Selected papers on hysteria and other psychoneuroses · Sigmund Freud
CHAPTER VIII. ON PSYCHOTHERAPY.[53]
_Gentlemen_: It is almost eight years since, at the request of your deceased chairman, Prof. v. Reder, I had the pleasure of speaking in your midst on the subject of hysteria. Shortly before (1895) I had published the “Studien über Hysterie” together with Dr. J. Breuer, and on the basis of a new knowledge for which we are thankful to this investigator, I have attempted to introduce a new way of treating the neurosis. Fortunately, I can say that the endeavors of our “Studies” have met with success, and that the ideas which they advocate concerning the effects of psychic traumas through the restraint of affects and the conception of the hysterical symptom as a result of a displacement of excitement from the psychic to the physical—ideas for which we have created the terms “ab-reaction” and “conversion”—are today generally known and understood. At least in German-speaking countries there are no descriptions of hysteria which do not to a certain extent take cognizance of them, and no colleague who does not at least partially follow this theory. And yet as long as they were new these theories and these terms must have sounded strange enough!
I can not say the same thing about the therapeutic procedure which we have proposed to our colleagues together with our theory. It still struggles for recognition. This may have its special reasons. The technique of the procedure was at that time still rudimentary. I was unable to give those indications to the medical reader of the book which would enable him to perform such a treatment. But surely there were other causes of a general nature. To many physicians psychotherapy even today appears as a product of modern mysticism, and in comparison to our physico-chemical remedies the application of which is based on physiological insight, psychotherapy appears quite unscientific and unworthy of the interest of a natural philosopher. You will therefore allow me to present to you the subject of psychotherapy, and to point out to you what part of this verdict can be designated as unjust or erroneous. In the first place let me remind you that psychotherapy is not a modern therapeutic procedure. On the contrary it is one of the oldest remedies used in medicine. In Lëwenfeld’s instructive work (Lehrbuch der gesamten Psychotherapie) you can find the methods employed in primitive and ancient medicine. Most of them were of a psychotherapeutic nature. In order to cure a patient he was transferred into a state of “credulous expectation” which acts in a similar manner even today. Even after the doctors found other remedial agents psychotherapeutic endeavors never disappeared from this or that branch of medicine.
Secondly, I call your attention to the fact that we doctors really can not abandon psychotherapy if only because another very much to be considered party in the treatment—namely the patient—has no intention of abandoning it. You know how much we owe to the Nancy school (Liébault, Bernheim) for these explanations. Without our intention, an independent factor from the patient’s psychic disposition enters into the activity of every remedial agent introduced by the doctor, acting mostly in a favorable sense but often also in an inhibiting sense. We have learned to apply to this factor the word “suggestion,” and Moebius taught us that the failures of some of our remedies are to be ascribed to the disturbing influences of this very powerful moment. You doctors, all of you, constantly practice psychotherapy, even when you do not know it, or do not intend it, but it has one disadvantage, you leave entirely to the patient the psychic factor of your influence. It then becomes uncontrollable, it can not be divided into doses and can not be increased. Is it not a justified endeavor of the doctor to become master of this factor, to make use of it intentionally, to direct and enforce it? It is nothing other than that, that scientific psychotherapy expects of you.
In the third place, gentlemen, I wish to refer you to the well known experience, namely, that certain maladies and particularly the psychoneuroses, are more accessible to psychic influences than to any other medications. It is no modern talk but a dictum of old physicians that these diseases are not cured by the drug, but by the doctor, to wit, by the personality of the physician in so far as it exerts a psychic influence. I am well aware, gentlemen, that you like very much the idea which the aesthete Vischer, in his parody on Faust (Faust, der Tragödie, III Teil) endowed with a classical expression: “I know that the physical often acts on the moral.” But would it not be more adequate and frequently more correct to influence the moral part of the person with the moral, that is, with psychic means?
There are many ways and means of psychotherapy. All methods are good which produce the aim of the therapy. Our usual consolation, “You will soon be well again,” with which we are so generous to our patients, corresponds to one of the psychotherapeutic methods, only that on gaining a profounder insight into the neuroses we are not forced to limit ourselves to this consolation alone. We have developed the technique of hypnotic suggestion, of psychotherapy through diversion, through practice, and through the evocation of serviceable affects. I do not disdain any of them, and would practice them all under suitable conditions. That I have in reality restricted myself to a single therapeutic procedure, to the method called by Breuer “cathartic,” which I prefer to call “analytic,” is simply due to subjective motives which guided me. Having participated in the elaboration of this therapy I feel it a personal duty to devote myself to its investigation, and to the final development of its technique. I maintain that the analytic method of psychotherapy is one which acts most penetratingly, and carries farthest; through it one can produce the most prolific changes in the patient. If I relinquish for a moment the therapeutic point of view, I can assert that it is the most interesting, and that it alone teaches us something concerning the origin and the connection of the morbid manifestations. Owing to insights which it opens for us into the mechanism of the psychic malady, it can even lead us beyond itself, and show us the way to still other kinds of therapeutic influences.
Allow me now to correct some errors, and furnish some explanations concerning this cathartic or analytic method of psychotherapy. (_a_) I notice that this method is often mistaken for the hypnotic suggestive treatment. I notice this by the fact that quite frequently colleagues whose confidant I am not by any means, send patients to me, refractory patients of course, with the request that I should hypnotize them. Now, for eight years I have not practiced hypnotism (individual cases excluded) as a therapeutic aim, and hence I used to return the patients with the advice that he who relies on hypnosis should do it himself. In truth, the greatest possible contrast exists between the suggestive and the analytic technique, that contrast which the great Leonardo da Vinci has expressed for the arts in the formulæ per via di porre and per via di levare. Said Leonardo, “the art of painting works per via di levare, that is to say, places little heaps of paint where they have not been before on the uncolored canvas; sculpturing, on the other hand, goes per via di levare, that is to say, it takes away from the stone as much as covers the surface of the statue therein contained.”
Quite similarly, gentlemen, the suggestive technique acts per via di porre, it does not concern itself about the origin, force, and significance of the morbid symptoms, but puts on something, to wit, the suggestion which it expects will be strong enough to prevent the pathogenic idea from expression. On the other hand the analytic therapy does not wish to put on anything, or introduce anything new, but to take away, and extract, and for this purpose it concerns itself with the genesis of the morbid symptoms, and the psychic connection of the pathogenic idea the removal of which is its aim. This manner of investigation has considerably furthered our understanding. I have so early given up the technique of suggestion, and with it hypnosis, because I despaired of making the suggestion as strong and persistent as would be necessary for a lasting cure. In all grave cases I noticed that the suggestions which were put on crumbled off again, and then the disease, or one replacing it, reappeared. Besides, I charge this technique with concealing from us the psychic play of forces, for example, it does not permit us to recognize the resistance with which the patients adhere to their malady, with which they also strive against the recovery, and which alone can give us an understanding of their behavior in life.
I should not wonder if the patient thus treated would rather be harmed than benefited. The mental instrument is really not at all easy to play. On such occasions I can not help but think of the speech of a world-renowned neurotic, who really never came under a doctor’s treatment, and only lived in the fancy of the poet. I mean Prince Hamlet of Denmark. The king has sent the two courtiers, Rosencrantz and Guildenstern, to investigate him and rob him of his secret. While he defended himself, pipes were brought on the stage. Hamlet took a pipe and requested one of his tormentors to play on it, saying that it is as easy to play as lying. The courtier hesitated because he knew no touch of it, and as he could not be moved to attempt to play the pipe, Hamlet finally burst forth: “Why, look you now, how unworthy a thing you make of me! You would play upon me; you would seem to know my stops; you would pluck out the heart of my mystery; you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice, in this little organ, yet you cannot make it speak. ’Sblood! do you think I am easier to be played on than a pipe? Call me what instrument you will, though you can fret me, you cannot play upon me.” (Act III, Scene 2.)
1. The former value of the person should not be overlooked in the disease, and you should refuse a patient who does not possess a certain degree of education, and whose character is not in a measure reliable. We must not forget that there are also healthy persons who are good for nothing, and that if they only show a mere touch of the neurosis, one is only too much inclined to blame the disease for incapacitating such inferior persons. I maintain that the neurosis does not in any way stamp its bearer as a dégéneré, but that frequently enough it is found in the same individual associated with the manifestations of degeneration. The analytic psychotherapy is therefore no procedure for the treatment of neuropathic degeneration, on the contrary it is limited by it. It is also not to be applied in persons who are not prompted by their own suffering to seek the treatment, but subject themselves to it by order of their relatives. The characteristic feature upon which the usefulness of the psychoanalytic treatment depends, the educability, we will still have to consider from another point of view. 2. If one wishes to take a safe course he should limit his selection to persons of a normal state, for, in psychoanalytic procedures, it is from the normal that we seize upon the morbid. Psychoses, confusional states, and marked (I might say toxic) depressions, are unsuitable for analysis, at least as it is practiced today. I do not think it at all impossible that with the proper changes in the procedure it will be possible to disregard this contraindication, and thus claim a psychotherapy for the psychoses.
3. The age of the patient also plays a part in the selection for the psychoanalytic treatment. Persons near or over the age of fifty lack, on the one hand, the plasticity of the psychic processes upon which the therapy depends—old people are no longer educable—and on the other hand, the material which has to be elaborated, and the duration of the treatment is immensely increased. The earliest age limit is to be individually determined; youthful persons, even before puberty, are excellent subjects for influence. 4. One should not attempt psychoanalysis when it is a question of rapidly removing a threatening manifestation, as, for example, in the case of an hysterical anorexia. You have now gained the impression that the sphere of application of the analytic psychotherapy is a very limited one, for you really heard me enumerate nothing but contraindications. Nevertheless, there remain sufficient cases and morbid states, such as all chronic forms of hysteria with remnant manifestations, the extensive realms of compulsive states, abulias, etc., on which this therapy can be tried. It is pleasing that particularly the worthiest and highest developed persons can thus be most helped. Where the analytic psychotherapy has accomplished but little one can cheerfully assert that any other treatment would have certainly resulted in nothing.
We can still choose another point of view for the understanding of the psychoanalytic treatment. The revealing and interpreting of the unconscious takes place under constant resistance on the part of the patient. The emerging of the unconscious is connected with displeasure and owing to this displeasure it is continuously repulsed by the patient. It is upon this conflict in the patient’s psychic life that you encroach, and if you succeed in prevailing upon him to accept something, for motives of better insight, which he has thus far repulsed (repressed) on account of the automatic adjustment of displeasure, you have achieved in him a piece of educational work. For it is really an education if you can induce a person to leave his bed early in the morning despite his unwillingness to do so. As such an after training for the overcoming of inner resistances you can conceive the psychoanalytic treatment in quite a general manner. But in no sphere of the nervous patients is such an after training so essential as in the psychic elements of their sexual life. For nowhere have culture and education produced as much harm as here, and it is here, as experience will show you, that the controlling etiologies of the neuroses are found. The other etiological element, the constitutional contribution, is really given to us as something immutable. But this gives rise to an important demand on the doctor. Not only must he be of unblemished character—“morality is really a matter of course” as the principal person in Th. Vischer’s “Auch Einer” used to say—but he must have overcome in his own personality the mixture of lewdness and prudishness with which so many others are wont to meet the sexual problems.
This is perhaps the place for another observation. I know that the emphasis which I laid on the sexual rôle in the origin of the psychoneuroses has become widely known. But I also know that restriction and nearer determinations are of little use with the great public; the multitude has little room in its memory, and generally retains from a statement the bare nucleus, thus creating for itself an easily remembered extreme. The same might also have happened to some physicians when the faint notion that they have of my theory is that I trace back the neurosis in the last place to sexual privation. Of such there is surely no dearth under the vital conditions of our society. But if that supposition were true would it not seem obvious that in order to avoid the roundabout way of the psychic treatment and tend directly towards the cure, we should directly recommend sexual participation as the remedy? I really do not know what could induce me to suppress these conclusions if they were justified. But the state of affairs is different. The sexual need or privation is merely one of the factors playing a part in the mechanism of the neurosis, and if it alone existed the result would not be a disease but a dissipation. The other equally indispensable factor, which one is only too ready to forget, is the sexual repugnance of neurotics, their inability to love; it is that psychic feature which I have designated as “repression.” It is only from the conflict between the two strivings that the neurotic malady originates, and it is for this reason that the advice for sexual participation in the psychoneuroses can really only seldom be designated as good.
Allow me to conclude with this guarded remark. Let us hope that with an interest for psychotherapy, purified of all hostile prejudice, you will help us to do some good in the treatment of the severe cases of psychoneuroses. CHAPTER IX. MY VIEWS ON THE RÔLE OF SEXUALITY IN THE ETIOLOGY OF THE NEUROSES.[54] I am of the opinion that my theory on the etiological significance of the sexual moment in the neuroses can be best appreciated by following its development. I will by no means make any effort to deny that it passed through an evolution during which it underwent a change. My colleagues can find the assurance in this admission that this theory is nothing other than the result of continued and painstaking experiences. In contradistinction to this whatever originates from speculation can certainly appear complete at one go and continue unchanged.
Originally the theory had reference only to the morbid pictures comprehended as “neurasthenia,” among which I found two types which occasionally appeared pure, and which I described as “actual neurasthenia” and “anxiety neurosis.” For it was always known that sexual moments could play a part in the causation of these forms, but they were found neither regularly effective, nor did one think of conceding to them a precedence over other etiological influences. I was above all surprised at the frequency of coarse disturbances in the vita sexualis of nervous patients. The more I was in quest of such disturbances, during which I remembered that all men conceal the truth in things sexual, and the more skilful I became in continuing the examination despite the incipient negation, the more regularly such disease-forming moments were discovered in the sexual life, until it seemed to me that they were but little short of universal. But one must from the first be prepared for similar frequent occurrences of sexual irregularities under the stress of the social relations of our society, and one could therefore remain in doubt as to what part of the deviation from the normal sexual function is to be considered as a morbid cause.
I could therefore only place less value on the regular demonstration of sexual noxas than on other experiences which appeared to me to be less equivocal. It was found that the form of the malady, be it neurasthenia or anxiety neurosis, shows a constant relation to the form of the sexual injury. In the typical cases of neurasthenia we could always demonstrate masturbation or accumulated pollutions, while in anxiety neurosis we could find such factors as coitus interruptus, “frustrated excitement,” etc. The moment of insufficient discharge of the generated libido seemed to be common to both. Only after this experience, which is easy to gain and very often confirmed, had I the courage to claim for the sexual influences a prominent place in the etiology of the neurosis. It also happened that the mixed forms of neurasthenia and anxiety neurosis occurring so often, showed the admixture of the etiologies accepted for both, and that such a bipartition in the form of the manifestations of the neurosis seemed to accord well with the polar characters of sexuality (male and female).
At the same time, while I assigned to sexuality this significance in the origin of the simple neurosis, I still professed for the psychoneuroses (hysteria and obsessions) a purely psychological theory in which the sexual moment was no differently considered than any other emotional sources. Together with J. Breuer, and in addition to observations which he has made on his hysterical patients fully a decade before, I have studied the mechanism of the origin of hysterical symptoms by the awakening of memories in hypnotic states. We obtained information which permitted us to cross the bridge from Charcot’s traumatic hysteria to the common non-traumatic hysteria. We reached the conception that the hysterical symptoms are permanent results of psychic traumas, and that the amount of affect belonging to them was pushed away from conscious elaboration by special determinations, thus forcing an abnormal road into bodily innervation. The terms “strangulated affect,” “conversion,” and “ab-reaction,” comprise the distinctive characteristics of this conception.
In the close relations of the psychoneuroses to the simple neuroses, which can go so far that the diagnostic distinction is not always easy for the unpracticed, it could happen that the cognition gained from one sphere has also taken effect in the other. Leaving such influences out of the question, the deep study of the psychic traumas also leads to the same results. If by the “analytic” method we continue to trace the psychic traumas from which the hysterical symptoms are derived, we finally reach to experiences which belong to the patient’s childhood, and concern his sexual life. This can be found even in such cases where a banal emotion of a non-sexual nature has occasioned the outburst of the disease. Without taking into account these sexual traumas of childhood we could neither explain the symptoms, find their determination intelligible, nor guard against their recurrence. The incomparable significance of sexual experiences in the etiology of the psychoneuroses seems therefore firmly established, and this fact remains until today one of the main supports of the theory. If we represent this theory by saying that the course of the life long hysterical neurosis lies in the sexual experiences of early childhood which are usually trivial in themselves, it surely would sound strange enough. But if we take cognizance of the historical development of the theory, and transfer the main content of the same into the sentence: hysteria is the expression of a special behavior of the sexual function of the individual, and that this behavior was already decisively determined by the first effective influences and experiences of childhood, we will perhaps be poorer in a paradox but richer in a motive for directing our attention to a hitherto very neglected and most significant aftereffect of infantile impressions in general.
As I reserve the question whether the etiology of hysteria (and compulsion neurosis) is to be found in the sexual infantile experiences for a later more thorough discussion, I now return to the construction of the theory expressed in some small preliminary publications in the years 1895–1896.[55] The bringing into prominence of the assumed etiological moments permitted us at the time to contrast the common neuroses which are maladies with an actual etiology, with the psychoneuroses which etiology was in the first place to be sought in the sexual experiences of remote times. The theory culminates in the sentence: In a normal vita sexualis no neurosis is possible. If I still consider today this sentence as correct it is really not surprising that after ten years labor on the knowledge of these relations I passed a good way beyond my former point of view, and that I now think myself in a position to correct by detailed experience the imperfections, the displacements, and the misconceptions, from which this theory then suffered. By chance my former rather meagre material furnished me with a great number of cases in which infantile histories, sexual seduction by grown-up persons or older children, played the main rôle. I overestimated the frequency of these (otherwise not to be doubted) occurrences, the more so because I was then in no position to distinguish definitely the deceptive memories of hysterical patients concerning their childhood, from the traces of the real processes, whereas, I have since then learned to explain many a seduction fancy as an attempt at defense against the reminiscence of their own sexual activity (infantile masturbation). The emphasis laid on the “traumatic” element of the infantile sexual experience disappeared with this explanation, and it remained obvious that the infantile sexual activities (be they spontaneous or provoked) dictate the course of the later sexual life after maturity. The same explanation which really corrects the most significant of my original errors perforce also changed the conception of the mechanism of the hysterical symptoms. These no longer appeared as direct descendants of repressed memories of sexual infantile experiences, but between the symptoms and the infantile impressions there slipped in the fancies (confabulations of memory) of the patients which were mostly produced during the years of puberty and which on the one hand, are raised from and over the infantile memories, and on the other, are immediately transformed into symptoms. Only after the introduction of the element of hysterical fancies did the structure of the neurosis and its relation to the life of the patient become transparent. It also resulted in a veritable surprising analogy between these unconscious hysterical fancies and the romances which became conscious as delusions in paranoia.
Ideas discussed in this chapter
Text from Project Gutenberg, public domain in the United States.