Selected papers on hysteria and other psychoneuroses · Sigmund Freud
III.
In view of the discussions in the preceding section concerning the difficulty of my technique, which I have unreservedly exposed,—I have really collected them from my most difficult cases, though it will often be easier work—in view then of this state of affairs everybody will wish to ask whether it would not be more suitable, instead of all these tortures, to apply oneself more energetically to hypnosis, or to limit the application of the cathartic method to only such cases as can be placed in deep hypnosis. To the latter proposition I should have to answer that the number of patients available for my skill would shrink considerably; but to the former advice I will advance the supposition that even where hypnosis could be produced the resistance would not be very much lessened. My experiences in this respect are not particularly extensive, so that I am unable to go beyond this supposition, but wherever I achieved a cathartic cure in the hypnotic state I found that the work devolved upon me was not less than in the state of concentration. I have only recently finished such a treatment during which course I caused the disappearance of a hysterical paralysis of the legs.
The patient merged into a state, psychically very different from the conscious, and somatically distinguished by the fact that she was unable to open her eyes or rise without my ordering her to do so; and still I never had a case showing greater resistance than this one. I placed no value on these physical signs, and toward the end of the ten months’ treatment they really became imperceptible. The condition of the patient during our work has therefore lost nothing of its psychic peculiarities, such as the ability to recall the unconscious and its very peculiar relation to the person of the physician. To be sure, in the history of Mrs. Emmy v. N. I have described an example of a cathartic cure accomplished in a profound somnambulism in which the resistance played almost no part. But nothing that I obtained from this woman would have required any special effort; I obtained nothing that she could not have told me in her waking state after a longer acquaintanceship and some esteem. The real causes of her disease, which were surely identical with the causes of her relapses after my treatment, I have never found—it was my first attempt in this therapy—and when I once asked her accidentally for a reminiscence which contained a fragment of the erotic, I found her just as resistant and unreliable in her statements as any one of my later non-somnambulic patients. This patient’s resistance, even in the somnambulic state, against other requirements and exactions I have already discussed in her history. Since I have witnessed cases who, even in deep somnambulism were absolutely refractory therapeutically despite their obedience in everything else, I really became skeptical as to the value of hypnosis for the facilitation of the cathartic treatment. A case of this kind I have reported in brief,[32] and could still add others.
In our discussion thus far, the idea of resistance has thrust itself to the foreground. I have shown how, in the therapeutic work, one is led to the conception that hysteria originates through the repression of an unbearable idea from a motive of defense, that the repressed idea remains as a weak (mildly intensive) reminiscence, and that the affect snatched from it is used for a somatic innervation, that is, conversion of the excitement. By virtue of its repression the idea becomes the cause of morbid symptoms, that is pathogenic. A hysteria showing this psychic mechanism may be designated by the name of “defense hysteria,” but both Breuer and myself have repeatedly spoken of two other kinds of hysterias which we have named hypnoid and retention hysteria. The first to reveal itself to us was really the hypnoid-hysteria, for which I can mention no better example than Breuer’s case of Miss Anna O.[33] For this form of hysteria Breuer gives an essentially different psychic mechanism than for the form which is characterized by conversion. Here the idea becomes pathogenic through the fact that it is conceived in a peculiar psychic state, having remained from the very beginning external to the ego. It therefore needs no psychic force to keep it away from the ego, and it need not awaken any resistance when, with the help of the somnambulic psychic authority, it is initiated into the ego. The history of Anna O. really shows no such resistance.
I held this distinction as so essential that it has readily induced me to adhere to the formation of the hypnoid-hysteria. It is however remarkable that in my own experience I encountered no genuine hypnoid-hysteria, whatever I treated changed itself into a defense hysteria. Not that I have never dealt with symptoms which manifestly originated in separated conscious states, and therefore were excluded from being accepted into the ego. I found this also in my own cases, but I could show that the so called hypnoid state owed its separation to the fact that a split off psychic group originated before, through defense. In brief, I cannot suppress the suspicion that hypnoid and defense hysteria meet somewhere at their roots, and that the defense is the primary thing; but I know nothing about it. Equally uncertain is at present my opinion concerning the retention hysteria in which the therapeutic work is also supposed to follow without any resistance. I had a case which I took for a typical retention hysteria, and I was pleased over the anticipation of an easy and certain success; but this success did not come as easy as the work really was. I therefore presume, and again with all caution appropriate to ignorance, that in retention hysteria, too, we can find at its basis a fragment of defense which has thrust the whole process into hysteria. Let us hope that new experiences will soon decide whether I am running into the danger of one-sidedness and error in my tendency to spread the conception of defense for the whole of hysteria.
Thus far I have dealt with the difficulties and technique of the cathartic method, I would now like to add a few indications showing how one makes an analysis with technique. For me this is a very interesting theme, but I do not expect that it will excite similar interest in others who have not practiced such analyses. Properly speaking we shall again deal with the technique, but this time with those difficulties concerning which the patient cannot be held responsible, and which must in part be the same in a hypnoid and a retention hysteria as well as in the defense hysteria which I have in mind as a model. I start on this last fragment of discussion with the expectation that the psychic peculiarities revealed here might sometime attain a certain value as raw material for an intellectual dynamics.
The first and strongest impression which one gains through such an analysis is surely the fact that the pathogenic psychic material, apparently forgotten and not at the disposal of the ego, playing no rôle in the association and in memory, still lies ready in some manner and in proper and good order. All that is necessary is to remove the resistances blocking the way. Barring that, everything is known as we know anything else, the proper connections of the individual ideas among themselves and with the nonpathogenic are frequently recalled and are present; they have been produced in their time and retained in memory. The pathogenic psychic material appears as the property of an intelligence which is not necessarily inferior to the normal ego. The semblance of a second personality is often most delusively produced. Whether this impression is justified, whether the arrangements of the psychic material resulting after the adjustment is not transferred back into the time of the disease, these are questions which I do not like to consider in this place. One cannot easily and intuitively describe the experiences resulting from these analyses as if he placed himself in the position, which one can only take a survey of after their disappearance.
The condition is usually not so simple as one represents it in special cases, as, for example, in a single case in which a symptom originates through a serious trauma. We frequently deal not with a single hysterical symptom but with a number of the same which are partially independent of one another and partially connected. We must not expect a single traumatic reminiscence whose nucleus is a single pathogenic idea, but we must be ready to assume a series of partial traumas and a concatenation of pathogenic streams of thought. The monosymptomatic traumatic hysteria is, as it were, an elementary organism, it is a single being in comparison to the complicated structure of a grave hysterical neurosis as is generally encountered.
The psychic material of such hysteria presents itself as a multidimensional formation of at least triple stratification. I hope to be able to soon justify this figurative expression. First of all there is a nucleus of such reminiscences (either experiences or streams of thought) in which the traumatic moment culminated, or in which the pathogenic idea has found its purest formation. Around this nucleus we often find an incredibly rich mass of other memory material which we have to elaborate by the analysis in the triple arrangement mentioned before. In the first place, there is an unmistakable linear chronological arrangement which takes place within every individual theme. As an example of this I can only cite the arrangements in Breuer’s analysis of Anna O. The theme is that of becoming deaf, of not hearing,[34] which then becomes differentiated according to seven determinants, and under each heading there were from ten to one hundred single reminiscences in chronological order. It was as if one should take up an orderly kept record. In the analysis of my patient, Emmy v. N., there were similar if not so many memory sub-divisions; they formed quite a general event in every analysis. They always occurred in a chronological order which was as definitely reliable as the serial sequences of the days of the week or the names of the months in psychically normal individuals. They increased the work of the analysis through the peculiarity of reversing the series of their origin in the reproduction; the freshest and the most recent occurrence of the accumulation occurred first as a “wrapper,” and that with which the series really began gave the impression of the conclusion.
The grouping of similar reminiscences in a multiplicity of linear stratifications, as represented in a bundle of documents, in a package, etc., I have designated as the formation of a theme. These themes now show a second form of arrangement. I cannot express it differently than by saying that they are concentrically stratified around the pathogenic nucleus. It is not difficult to say what determines these strata, and according to what decreasing or increasing magnitude this arrangement follows. They are layers of equal resistance tending towards the nucleus, accompanied by zones of similar alteration of consciousness into which the individual themes extend. The most peripheral layers contain those reminiscences (or fascicles) of the different themes which can readily be recalled and were always perfectly conscious. The deeper one penetrates the more difficult it becomes to recognize the emerging reminiscences until one strikes those near the nucleus which the patient disavows, even at the reproduction.
As we shall hear later it is the peculiarity of the concentric stratification of the pathogenic psychic material which gives to the course of such an analysis its characteristic features. We must now mention the third and most essential arrangement concerning which a general statement can hardly be made. It is the arrangement according to the content of thought, the connection through the logical thread reaching to the nucleus which might in each case correspond to a special, irregular, and manifoldly devious road. This arrangement has a dynamic character in contradistinction to both morphological stratifications mentioned before. Whereas, in a spacially formed scheme the latter would be represented by rigid, arched, and straight lines, the course of the logical concatenation would have to be followed with a wand, over the most tortuous route, from the superficial into the deep layers and back, generally, however, progressing from the peripheral to the central nucleus, and touching thereby all stations; that is, its movement is similar to the zigzag movement of the knight in the solution of a chess problem. I will still adhere for a moment to the last comparison in order to call attention to a point in which it does not do justice to the qualities of the thing compared. The logical connection corresponds not only to a zigzag-like devious line, but rather to a ramifying and especially to a converging system of lines. It has a junction in which two or more threads meet only to proceed thence united, and, as a rule, many threads running independently, or here and there connected by by-paths, open into the nucleus. To put it in different words, it is very remarkable how frequently a symptom is manifoldly determined, that is, over-determined.
I will introduce one more complication, and then my effort to illustrate the organization of the pathogenic psychic material will be achieved. It can happen that we may deal with more than one single nucleus in the pathogenic material, as, for example, when we have to analyze a second hysterical outbreak having its own etiology but which is still connected with the first outbreak of an acute hysteria which has been overcome years before. It can readily be imagined what strata and streams of thought must be added in order to produce a connection between the two pathogenic nuclei. I will still add a few observations to the picture obtained of the organization of the pathogenic material. We have said of this material that it behaves like a foreign body, and that the therapy also acts like the removal of a foreign body from the living tissues. We are now in position to consider the shortcomings of this comparison. A foreign body does not enter into any connection with the layers of tissue surrounding it, although it changes them and produces in them a reactive inflammation. On the other hand, our pathogenic psychic group does not allow itself to be cleanly shelled out from the ego, its outer layers radiate in all directions into the parts of the normal ego, and really belong to the latter as much as to the pathogenic organization. The boundaries between both become purely conventional in the analysis, being placed now here, now there, and in certain locations no demarcation is possible. The inner layers become more and more estranged from the ego without showing a visible beginning of the pathogenic boundaries. The pathogenic organization really does not behave like a foreign body, but rather like an infiltration. The infiltrate must, in this comparison, be assumed to be the resistance. Indeed, the therapy does not consist in extirpating something—psychotherapy cannot do that at present—but it causes a melting of the resistance, and thus opens the way for the circulation into a hitherto closed territory.
(I make use here of a series of comparisons all of which have only a very limited resemblance to my theme, and do not even agree among themselves. I am aware of that, and I am not in danger of over-estimating their value; but, as it is my intention to illustrate the many sides of a most complicated and not as yet depicted idea, I therefore take the liberty of dealing also in the following pages with comparisons which are not altogether free from objections.) If, after a thorough adjustment, one could show to a third party the pathogenic material in its present recognized, complicated and multidimensional organization, he would justly propound the question, “How could such a camel go through the needle’s eye?” Indeed, one does not speak unjustly of a “narrowing of consciousness.” The term gains in sense and freshness for the physician who accomplishes such an analysis. Only one single reminiscence can enter into the ego consciousness; the patient occupied in working his way through this one sees nothing of that which follows, and forgets everything that has already wedged its way through. If the conquest of this one pathogenic reminiscence strikes against impediments, as for example, if the patient does not yield the resistance against it, but wishes to repress or distort it, the strait is, so to speak, blocked; the work comes to a standstill, it cannot advance, and the one reminiscence in the breach confronts the patient until he takes it up into the breadth of his ego. The whole spacially extended mass of the pathogenic material is thus drawn through a narrow fissure and reaches consciousness as if disjointed into fragments or strips, and it is the task of the psychotherapist to recompose it into the conjectured organization. He who desires still more comparisons may think here of a Chinese puzzle.
If one is about to begin an analysis in which one may expect such an organization of the pathogenic material, the following results of experience may be useful: _It is perfectly hopeless to attempt to make any direct headway towards the nucleus of the pathogenic organization._ Even if it could be guessed the patient would still not know what to start with the explanation given to him, nor would it change him psychically. There is nothing left to do but follow up the periphery of the pathogenic psychic formation. One begins by allowing the patient to relate and recall what he knows, during which one can already direct his attention, and through the application of the pressure procedure slight resistances may be overcome. Whenever a new way is opened through pressure it can be expected that the patient will continue it for some distance without any new resistance. After having worked for a while in such manner a coöperating activity is usually manifested in the patient. A number of reminiscences now occur to him without any need of questioning or setting him a task. A way has thus been opened into an inner strata, within which the patient now spontaneously disposes of the material of equal resistance. It is well to allow him to reproduce for a while without being influenced; of course, he is unable to reveal important connections, but he may be allowed to clear things within the same stratum. The things which he thus reproduces often seem disconnected, but they give up the material which is later revived by the recognized connections.
One has to guard here in general against two things. If the patient is checked in the reproduction of the inflowing ideas, something is apt to be “buried” which must be uncovered later with great effort. On the other hand one must not overestimate his “unconscious intelligence,” and one must not allow it to direct the whole work. If I should wish to schematize the mode of labor, I could perhaps say that one should himself undertake the opening of the inner strata and the advancement in the radial direction, while the patient should take care of the peripheral extension. The advancement is brought about by the fact that the resistance is overcome in the manner indicated above. As a rule, however, one must at first solve another problem. One must obtain a piece of a logical thread by which direction alone one can hope to penetrate into the interior. One should not expect that the voluntary information of the patient, the material which is mostly in the superficial strata, will make it easy for the analyzer to recognize the locations where it enters into the deep, and to which points the desired connections of thought are attached. On the contrary, just this is cautiously concealed, the assertion of the patient sounds perfect and fixed in itself. One is at first confronted, as it were, by a wall which shuts off every view, and gives no suggestion of anything hidden behind it.
If, however, one views with a critical eye the assertion obtained from the patient without much effort and resistance, one will unmistakably discover in it gaps and injuries. Here the connection is manifestly interrupted and is scantily completed by the patient by an expression conveying quite insufficient information. Here one strikes against a motive which in a normal person would be designated as flimsy. The patient refuses to recognize these gaps when his attention is called to them. The physician, however, does well to seek under these weak points access to the material of the deeper layers and to hope to discover just here the threads of the connections which he traces by the pressure procedure. One, therefore, tells the patient, “You are mistaken, what you assert can have nothing to do with the thing in question; here we will have to strike against something which will occur to you under the pressure of my hand.” The hysterical stream of thought, even if it reaches into the unconscious, may be expected to show the same logical connections and sufficient causations as those that would be formed in a normal individual. A looseness of these relationships does not lie within the sphere of influence of the neurosis. If the association of ideas of neurotics, and especially of hysterics, makes a different impression, if the relation of the intensities of different ideas does not seem to be explainable here on psychological determinants alone, we know that such manifestations are due to the existence of concealed unconscious motives. Such secret motives may be expected wherever such a deviation in the connection, or a transgression from the normally justified causations can be demonstrated.
To be sure one must free himself from the theoretical prejudice that one has to deal with abnormal brains of dégénerés and deséquilibrés, in whom the freedom of overthrowing the common psychological laws of the association of ideas is a stigma, or in whom a preferred idea without any motive may grow intensively excessive, and another without psychological motives may remain indestructible. Experience shows the contrary in hysteria; as soon as the hidden—often unconsciously remaining—motives have been revealed and brought to account there remains nothing in the hysterical thought connection that is enigmatical and anomalous. Thus by tracing the breaches in the first statements of the patient, which are often hidden by “false connections,” one gets hold of a part of the logical thread at the periphery, and thereafter continues the route by the pressure procedure. Very seldom do we succeed in working our way into the inner strata by the same thread, usually it breaks on the way when the pressure fails, giving up either no experience, or one which cannot be explained or be continued despite all efforts. In such a case we soon learn how to protect ourselves from the obvious confusion. The expression of the patient must decide whether one really reached an end or encountered a case needing no psychic explanation, or whether it is the enormous resistance that halts the work. If the latter cannot soon be overcome, it may be assumed that the thread has been followed into a strata which is as yet impenetrable. One lets it fall in order to grasp another thread which may, perhaps, be followed up just as far. If one has followed all the threads into this strata, if the knottings have been reached through which no single isolated thread can be followed, it is well to think of seizing anew the resistances on hand.
One can readily imagine how complicated such a work may become. By constantly overcoming the resistance, one pushes his way into the inner strata, gaining knowledge concerning the accumulative themes and passing threads found in this layer; one examines as far as he can advance with the means at hand, and by means of the pressure procedure he gains first information concerning the content of the next strata. The threads are dropped, taken up again, and followed up until they reach the juncture; they are always retrieved, and by following a memory fascicle one reaches some by-way which finally opens again. In this manner it is possible to leave the work, layer by layer, and advance directly on the main road to the nucleus of the pathogenic organization. Thus the fight is won but not finished. One has to follow up the other threads and exhaust the material; but now the patient helps again energetically, for his resistance has mostly been broken. In these later stages of the work it is of advantage if one can surmise the connection and tell it to the patient before it has been revealed. If the conjecture is correct the course of the analysis is accelerated, but even an incorrect hypothesis helps, for it urges the patient to participate and elicits from him energetic refutation, thus revealing that he surely knows better.
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