Selected papers on hysteria and other psychoneuroses · Sigmund Freud
II.
On asking my patients during our first interview whether they remembered the first motive for the symptom in question, some said that they knew nothing, while others thought of something which they designated as an indistinct recollection, yet were unable to pursue it. I then followed Bernheim’s example of awakening the apparently forgotten impressions obtained during somnambulism (see the case of Miss Lucy). I urged them by assuring them that they did know it, and that they will recall it, etc., and thus some thought of something, while in others the recollections went further. I became still more pressing, I ordered the patient to lie down and voluntarily shut his eyes so as to “concentrate” his mind, causing thereby at least a certain similarity to hypnosis, and I then discovered that without any hypnosis there emerged new and retrospective reminiscences which probably belonged to our theme. Through such experiences I gained the impression that through urging alone it would really be possible to bring to light the definitely existing pathogenic series of ideas; and as this urging necessitated much exertion on my part, and showed me that I had to overcome a resistance, I, therefore, formulated this whole state of affairs into the following theory: _Through my psychic work I had to overcome a psychic force in the patient which opposed the pathogenic idea from becoming conscious_ (remembered). It then became clear to me that this must really be the same psychic force which assisted in the origin of the hysterical symptom, and at that time prevented the pathogenic idea from becoming conscious. What kind of effective force could here be assumed, and what motive could have brought it into activity? I could easily formulate an opinion, for I already had some complete analyses at my disposal in which I found examples of pathogenic, forgotten, and repressed ideas. From these I could judge the general character of such ideas. They were altogether of a painful nature, adapted to provoke the affects of shame, reproach, of psychic pain, and the feeling of injury; they were altogether of that kind which one would not like to experience and prefers to forget.
From all these the thought of defense resulted as if simultaneously. Indeed, it is generally admitted by all psychologists that the assumption of a new idea (assumption in the sense of belief, judgment of reality), depends on the mode and drift of the ideas already united in the ego. For the process of the censor, to which the newly formed ideas are subjected, special technical names have been created. An idea entered into the ego of the patient which proved to be unbearable and evoked a power of repulsion on the part of the ego, the purpose of which was a defense against this unbearable idea. This defense actually succeeded, and the idea concerned was crowded out of consciousness and out of the memory, so that its psychic trace could not apparently be found. Yet this trace must have existed. When I made the effort to direct the attention to it, I perceived as a resistance the same force which showed itself as repulsion in the genesis of the symptom. If I could now make it probable that the idea became pathogenic in consequence of the exclusion and repression, the chain would seem complete. In many epicrises of our histories, and in a small work concerning the defense neuropsychoses (1894), I have attempted to indicate the psychological hypotheses with the help of which this connection also—the fact of conversion—can be made clear.
Hence, a psychic force, the repugnance of the ego, has originally crowded the pathogenic idea from the association, and now opposes its return into the memory. The not knowing of the hysterics was really a—more or less conscious—not willing to know, and the task of the therapeutist was to overpower this resistance of association by psychic labor. Such accomplishment is, above all, brought about by “urging,” that is, by applying a psychic force in order to direct the attention of the patient on the desired traces of ideas. It does not, however, stop here, but as I will show, it assumes new forms in the course of the analysis, and calls to aid more psychic forces. I shall, above all, still linger at “the urging.” One cannot go very far with such simple assurances as, “You do know it, just say it,” or “It will soon come to your mind.” After a few sentences the thread breaks, even in the patient who is in a state of concentration. We must not, however, forget that we deal everywhere here with a quantitative comparison, with the struggle between motives of diverse force and intensity. The urging of the strange and inexperienced physician does not suffice for the “association resistance” in a grave hysteria. One must resort to more forceful means.
In the first place I make use of a small technical artifice. I inform the patient that I will in the next moment exert pressure on his forehead, I assure him that during this pressure he will see some reminiscence in the form of a picture, or some thought will occur to him, and I oblige him to communicate to me this picture or this thought, no matter what it may be. He is not supposed to hold it back because he may perhaps think that it is not the desired or the right thing, or because it is too disagreeable to say. There should be neither criticism nor reserve on account of affect or disregard. Only thus could we find the things desired, and only thus have we unfailingly found them. I then exert pressure for a few seconds on the forehead of the patient lying in front of me, and after stopping the pressure, I ask in a calm tone, as if any disappointment is out of the question, “What have you seen?” or, “What occurred to your mind?”
This method[31] taught me a great deal and led me to the goal every time. Of course I know that I can substitute this pressure on the forehead by any other sign, or any other physical influence, but as the patient lies before me the pressure on the forehead, or the grasping of his head between my two hands, is the most suggestive and most convenient thing that I could undertake for this end. To explain the efficacy of this artifice, I may perhaps say that it corresponds to a “momentary reinforced hypnosis”; but the mechanism of hypnosis is so enigmatical to me that I would not like to refer to it as an explanation. I rather think that the advantage of the process lies in the fact that through it I dissociate the attention of the patient from his conscious quest and reflection, in brief, from everything upon which his will can manifest itself. This resembles the process of staring at a crystal globe, etc. The fact, that under the pressure of my hand there always appears that which I am looking for, teaches that the supposedly forgotten pathogenic ideas always lie ready, “close by,” being attainable through easily approachable associations, and all that is necessary is to clear away some obstacle. This obstacle again seems to be the person’s will, and different persons learn to discard their premeditations, and to assume a perfectly objective attitude toward the psychic processes within them.
It is not always a “forgotten” reminiscence which comes to the surface under the pressure of the hand; in the rarest cases the real pathogenic reminiscences can be superficially discovered. More frequently an idea comes to the surface which is a link between the starting idea and the desired pathogenic one of the association chain, or it is an idea forming the starting point of a new series of thoughts and reminiscences, at the end of which the pathogenic idea exists. The pressure, therefore, has really not revealed the pathogenic idea, which, if torn from its connections without any preparation, would be incomprehensible; but it has shown the way to it, and indicated the direction towards which the investigation must proceed. The idea which is at first awakened through the pressure may correspond to a familiar reminiscence which was never repressed. If the connection becomes torn on the road to the pathogenic idea, all that is necessary for the reproduction of a new orientation and connection is a repetition of the procedure, that is, of the pressure. In still other cases the pressure of the hand awakens a reminiscence well known to the patient, which appearance, however, causes him surprise because he had forgotten its relation to the starting idea. In the further course of the analysis this relation becomes clear. From all these results of the pressure one receives a delusive impression of a superior intelligence external to the patient’s consciousness, which systematically holds a large psychic material for definite purposes, and has provided an ingenious arrangement for its return into consciousness. I presume, however, that this unconscious second intelligence is really only apparent.
In every complicated analysis one works repeatedly, nay continuously, with the help of this procedure (pressure on the forehead), which leads us from the place where the patient’s conscious reconductions become interrupted, showing us the way over reminiscences which remained known, and calling our attention to connections which have merged into forgetfulness. It also evokes and connects memories which have for years been withdrawn from the association, but can still be recognized as memories; and finally, as the highest performance of reproduction, it causes the appearance of thoughts which the patient never wishes to recognize as his own, which he does not remember, although he admits that they are inexorably demanded by the connection, and is convinced that just these ideas cause the termination of the analysis and the cessation of the symptoms.
I will now attempt to give a series of examples showing the excellent achievements of this procedure. I treated a young lady who suffered for six years from an intolerable and protracted nervous cough, which apparently was nurtured by every common catarrh, but must have had its strong psychic motives. Every other remedy had long since shown itself to be powerless, and I therefore attempted to remove the symptom by psychoanalysis. All that she could remember was that the nervous cough began at the age of fourteen while she boarded with her aunt. She remembered absolutely no psychic excitement during that time, and did not believe that there was a motive for her suffering. Under the pressure of my hand, she at first recalled a large dog. She then recognized the memory picture; it was her aunt’s dog which was attached to her, and used to accompany her everywhere, and without any further aid it occurred to her that this dog died and that the children buried it solemnly; and on the return from this funeral her cough appeared. I asked her why she began to cough, and after helping her with the pressure, the following thought occurred to her: “Now I am all alone in this world; no one loves me here; this animal was my only friend, and now I have lost it.” She then continued her story. “The cough disappeared when I left my aunt, but reappeared a year and a half later.”—“What was the reason for it?”—“I do not know.”—I again exerted some pressure on the forehead, and she recalled the news of her uncle’s death during which the cough again manifested itself, and also recalled a train of thought similar to the former. The uncle was apparently the only one in the family who sympathized with and loved her. That was, therefore, the pathogenic idea: “People do not love her; everybody else is preferred; she really does not deserve to be loved,” etc. To the idea of love there clung something which caused a marked resistance to the communication. The analysis was interrupted before this explanation.
Some time ago I attempted to relieve an elderly lady of her anxiety attacks, which considering their characteristic qualities, were hardly adapted to such influence. Since her menopause she had become extremely religious, and always received me as if I were the Devil. She was always armed with a small ivory crucifix which she hid in her hand. Her attacks of anxiety, which bore the hysterical character, could be traced to her early girlhood, and were supposed to have originated from the application of an iodine preparation used to reduce a moderate swelling of the thyroid. I naturally repudiated this origin, and sought to substitute it by another which was in better harmony with my views concerning the etiology of neurotic symptoms. To the first question for an impression of her youth which would stand in causal connection to the attacks of anxiety, there appeared under the pressure of my hand the reminiscence of reading a so called devotional book wherein piously enough there was some mention of the sexual processes. The passage in question made an impression on this girl, which was contrary to the intention of the author. She burst into tears and flung the book away. That was before the first attack of anxiety. A second pressure on the forehead of the patient evoked the next reminiscence, it referred to her brother’s teacher who showed her great respect, and for whom she entertained a warmer feeling. This reminiscence culminated in the reproduction of an evening in her parents’ home, during which they all sat around the table with the young man, and delightfully enjoyed themselves in a lively conversation. During the night following this evening she was awakened by the first attack of anxiety which surely had more to do with some resistance against a sensual feeling than perhaps with the coincidently used iodine. In what other way could I have succeeded in revealing in this obstinate patient, prejudiced against me and every worldly remedy, such a connection contrary to her own opinion and assertion?
On another occasion I had to deal with a young happily married woman, who as early as in the first years of her girlhood, was found every morning for some time in a state of lethargy, with rigid members, opened mouth, and protruding tongue. Similar attacks, though not so marked, recurred at the present time on awakening. A deep hypnosis could not be produced, so that I began my investigation in a state of concentration, and assured her during the first pressure that she would see something that would be directly connected with the cause of her condition during her childhood. She acted calmly and willingly, she again saw the residence in which she had passed her early girlhood, her room, the position of her bed, the grandmother who lived with them at the time, and one of her governesses whom she dearly loved. There was then a succession of small, quite indifferent scenes, in these rooms, and among these persons, the conclusion of which was the leave taking of the governess who married from the home. I did not know what to start with these reminiscences; I could not bring about any connection between them and the etiology of the attacks. To be sure the various circumstances were recognized as having occurred at the same time at which the attacks first appeared.
Before I could continue the analysis, I had occasion to talk to a colleague, who, in former years, was my patient’s family physician. From him I obtained the following explanation: At the time that he treated the mature and physically very well developed girl for these first attacks, he was struck by the excessive affection in the relations between her and her governess. He became suspicious and caused the grandmother to watch these relations. After a short while the old lady informed him that the governess was wont to pay nightly visits to the child’s bed, and that quite regularly after such visits the child was found in the morning in an attack. She did not hesitate to bring about the quiet removal of this corruptress of youth. The children, as well as the mother, were made to believe that the governess left the house in order to get married. The treatment, which was above all successful, consisted in informing the young woman of the explanations given to me. Occasionally the explanations, which one obtains by the pressure procedure, follow in very remarkable form, and under circumstances which make the assumption of an unconscious intelligence appear even more alluring. Thus I recall a lady who suffered for years from obsessions and phobias, and who referred the origin of her trouble to her childhood, but could mention nothing to which it could have been attributed. She was frank and intelligent, and evinced only a very slight conscious resistance. I will add here that the psychic mechanism of obsessions is very closely related to that of hysterical symptoms, and that the technique of the analysis in both is the same.
On asking the lady whether she had seen or recalled anything under the pressure of my hand, she answered, “Neither, but a word suddenly occurred to me.”—“A single word?”—“Yes, but it is too foolish.”—“Just tell it.”—“Teacher.”—“Nothing more?”—“No.” I exerted pressure a second time, and again a single word flashed through her mind: “Shirt.”—I now observed that we have dealt with a new mode of replying, and by repeated pressure I evoked the following apparently senseless series of words: Teacher—shirt—bed—city—wagon. I asked, “What does all that mean?” She reflected for a moment, and it then occurred to her that “it can only refer to this one incident which now comes to my mind. When I was ten years old my older sister of twelve had an attack of frenzy one night, and had to be bound, put in a wagon and taken to the city. I remember distinctly that it was the teacher who overpowered her and accompanied her to the asylum.”—We then continued this manner of investigation, and received from our oracle another series of words which, though we could not altogether interpret, could nevertheless be used as a continuation of this story, and as an appendix to a second. The significance of this reminiscence was soon clear. The reason why her sister’s illness made such an impression on her was because they both shared a common secret. They slept in the same room, and one night they both submitted to a sexual assault by a certain man. In discovering this sexual trauma of early youth, we revealed not only the origin of the first obsession but also the trauma which later acted pathogenically.—The peculiarity of this case lies only in the appearance of single catch words which we had to elaborate into sentences, for the irrelevance and incoherence found in these oracle like uttered words adhere to all ideas and scenes which generally occur as a result of pressure. On further investigation it is regularly found that the seemingly disconnected reminiscences are connected by close streams of thought, and that they lead quite directly to the desired pathogenic moment.
With pleasure do I therefore recall a case of analysis in which my confidence in the results of pressure was splendidly justified. A very intelligent, and apparently very happy, young woman consulted me for persistent pain in her abdomen which yielded to no treatment. I found that the pain was situated in the abdominal wall and was due to palpable muscular hardening, and I ordered local treatment. After months I again saw the patient who said that “the former pain disappeared after following the treatment and remained away a long time, but now it has reappeared as a nervous pain. I recognize it by the fact that I do not perceive it now on motion as before, but only during certain hours, as for example, in the morning on awakening, and during certain excitements.” The patient’s diagnosis was quite correct. It was now important to discover the cause of this pain, but in this she could not assist me in her uninfluenced state. When, in a state of concentration and under the pressure of my hand, I asked her whether anything occurred to her, or whether she saw anything, she began to describe her visual pictures. She saw something like a sun with rays, which I naturally had to assume to be a phosphene produced by pressure on the eyes. I expected that the useful pictures would follow, but she continued to see stars of a peculiar pale blue light, like moonlight, etc., and I believed that she merely saw glittering, shining, and twinkling spots before the eyes.
I was already prepared to add this attempt to the failures, and I was thinking how I could quietly withdraw from this affair, when my attention was called to one of the manifestations which she described. She saw a big black cross which was inclined, the edges of which were surrounded by a subdued moonlike light in which all the pictures thus far seen were shining, and upon the arm there flickered a little flame that was apparently no longer a phosphene. I continued to listen. She saw numerous pictures in the same light, peculiar signs resembling somewhat sanscrit. She also saw figures like triangles, among which there was one big triangle, and again the cross. I now thought of an allegorical interpretation, and asked, “What does this cross mean?”—“It is probably meant to interpret pain,” she answered. I argued, saying, that “by cross one usually understands a moral burden,” and asked her what was hidden behind that pain. She could not explain that and continued looking. She saw a sun with golden rays which she interpreted as God, the primitive force; she then saw a gigantic lizard which she examined quizzically but without fear; then a heap of snakes, then another sun but with mild silvery rays, and in front of it, between her own person and this source of light, there was a barrier which concealed from her the center of the sun.
I knew for some time that we dealt here with allegories, and I immediately asked for an explanation of the last picture. Without reflecting she answered: “The sun is perfection, the ideal, and the barrier represents my weaknesses and failings which stand between me and the ideal.”—“Indeed, do you reproach yourself? Are you dissatisfied with yourself?”—“Yes.”—“Since when?”—“Since I became a member of the Theosophical Society and read the writings edited by it. I have always had a poor opinion of myself.” “What was it that made the last strongest impression upon you?”—“A translation from the sanscrit which now appears in serial numbers.” A minute later I was initiated into her mental conflicts, and into her self reproaches. She related a slight incident which gave occasion for a reproach, and in which, as a result of an inciting conversion, the former organic pain at first appeared.—The pictures which I had at first taken for phosphenes were symbols of occultistic streams of thought, perhaps plain emblems from the title pages of occultistic books. I have thus far so warmly praised the achievements of the pressure procedure, and have so entirely neglected the aspect of the defense or the resistance, that I certainly must have given the impression that by means of this small artifice one is placed in position to become master of the psychic resistances against the cathartic cure. But to believe this would be a gross mistake. Such advantages do not exist in the treatment so far as I can see; here, as everywhere else, great change requires much effort. The pressure procedure is nothing but a trick serving to surprise for awhile the defensive ego, which in all graver cases recalls its intentions and continues its resistance.
I need only recall the various forms in which this resistance manifested itself. In the first place, the pressure experiment usually fails the first or second time. The patient then expresses himself disappointed, saying, “I believed that some idea would occur to me, but I only thought so; as attentive as I was nothing came.” Such attitudes assumed by the patient are not yet to be counted as a resistance; we usually answer to that, “You were really too anxious, the second time things will come.” And they really come. It is remarkable how completely the patients—even the most tractable and the most intelligent—can forget the agreement which they have previously entered into. They have promised to tell everything that occurs to them under the pressure of the hand, be it closely related to them or not, and whether it is agreeable to them to say it or not; that is, they are to tell everything without any choice, or influence by critique or affect. Yet they do not keep their promise, it is apparently beyond their powers. The work repeatedly stops, they continue to assert that this time nothing came to their mind. One needs not believe them, and one must always assume, and also say, that they hold back something because they believe it to be unimportant, or perceive it as painful. One must insist, repeat the pressure, and assume an assured attitude until one really hears something. The patient then adds, “I could have told you that the first time.”—“Why did you not say it?”—“I could not believe that that could be it. Only after it returned repeatedly have I decided to tell it;” or, “I had hoped that it would not be just that, that I could spare myself from saying it, but only after it could not be repressed have I noticed that I could not avoid it.”—Thus the patient subsequently betrays the motives of a resistance which he did not at first wish to admit. He apparently could not help offering resistances.
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