[27] It is always a difficult and ungrateful task to discuss a theory which the author himself has not formulated in any final way. Freud has never propounded a cut-and-dried theory of hysteria; he has simply tried, from time to time, to formulate his theoretical conclusions in accordance with his experience at that moment. His theoretical formulations can claim the status of a working hypothesis that agrees with experience at all points. For the present, therefore, there can be no talk of a firmly-established Freudian theory of hysteria, but only of numerous experiences which have certain features in common. As we are not dealing with anything finished and conclusive, but rather with a process of development, an historical survey will probably be the form best suited to an account of Freud’s teachings.
[28] The theoretical presuppositions on which Freud bases his investigations are to be found in the experiments of Pierre Janet. Breuer and Freud, in their first formulation of the problem of hysteria, start from the fact of psychic dissociation and unconscious psychic automatisms. A further presupposition is the aetiological significance of affects, stressed among others by Binswanger.2 These two presuppositions, together with the findings reached by the theory of suggestion, culminate in the now generally accepted view that hysteria is a psychogenic neurosis.
[29] The aim of Freud’s research is to discover how the mechanism producing hysterical symptoms works. Nothing less is attempted, therefore, than to supply the missing link in the long chain between the initial cause and the ultimate symptom, a link which no one had yet been able to find. The fact, obvious enough to any attentive observer, that affects play an aetiologically decisive role in the formation of hysterical symptoms makes the findings of the first Breuer-Freud report, in the year 1893, immediately intelligible. This is especially true of the proposition advanced by both authors, that the hysteric suffers most of all from reminiscences, i.e., from feeling-toned complexes of ideas which, in certain exceptional conditions, prevent the initial affect from working itself out and finally disappearing.
[30] This view, presented only in broad outline at first, was reached by Breuer, who between the years 1880 and 1882 had the opportunity to observe and treat an hysterical woman patient of great intelligence. The clinical picture was characterized chiefly by a profound splitting of consciousness, together with numerous physical symptoms of secondary importance and constancy. Breuer, allowing himself to be guided by the patient, observed that in her twilight states complexes of reminiscences were reproduced which derived from the previous year. In these states she hallucinated a great many episodes that had had a traumatic significance for her. Further, he noticed that the reliving and retelling of these traumatic events had a marked therapeutic effect, bringing relief and an improvement in her condition. If he broke off the treatment, a considerable deterioration set in after a short time. In order to increase and accelerate the effect of the treatment, Breuer induced, besides the spontaneous twilight state, an artificially suggested one in which more material was “abreacted.” In this way he succeeded in effecting a substantial improvement. Freud, who at once recognized the extraordinary importance of these observations, thereupon furnished a number of his own which agreed with them. This material can be found in Studies on Hysteria, published in 1895 by Breuer and Freud.
[31] On this foundation was raised the original theoretical edifice constructed jointly by the two authors. They start with the symptomatology of affects in normal individuals. The excitation produced by affects is converted into a series of somatic innervations, thus exhausting itself and so restoring the “tonus of the nerve centres.” In this way the affect is “abreacted.” It is different in hysteria. Here the traumatic experience is followed—to use a phrase of Oppenheim’s—by an “abnormal expression of the emotional impulse.”3 The intracerebral excitation is not discharged directly, in a natural way, but produces pathological symptoms, either new ones or a recrudescence of old ones. The excitation is converted into abnormal innervations, a phenomenon which the authors call “conversion of the sum of excitation.” The affect is deprived of its normal expression, of its normal outlet in adequate innervations; it is not abreacted but remains “blocked.” The resulting hysterical symptoms can therefore be regarded as manifestations of the retention.
[32] This formulates the situation as we see it in the patient; but the important question as to why the affect should be blocked and converted still remains unanswered, and it was to this question that Freud devoted special attention. In “The Defence Neuro-psychoses,” published in 1894, he tried to analyse in great detail the psychological repercussions of the affect. He found two groups of psychogenic neuroses, different in principle because in one group the pathogenic affect is converted into somatic innervations, while in the other group it is displaced to a different complex of ideas. The first group corresponds to classic hysteria, the second to obsessional neurosis. He found the reason for the blocking of affect, or for its conversion or displacement, to be the incompatibility of the traumatic complex with the normal content of consciousness. In many cases he could furnish direct proof that the incompatibility had reached the consciousness of the patient, thus causing an active repression of the incompatible content. The patient did not wish to know anything about it and treated the critical complex as “non arrivé.” The result was a systematic circumvention or “repression” of the vulnerable spot, so that the affect could not be abreacted.
[33] The blocking of affect is due, therefore, not to a vaguely conceived “special disposition” but to a recognizable motive.
[34] To recapitulate what has been said: up to the year 1895 the Breuer-Freud investigations yielded the following results. Psychogenic symptoms arise from feeling-toned complexes of ideas that have the effect of a trauma, either
1. by conversion of the excitation into abnormal somatic innervations, or
2. by displacement of the affect to a less significant complex.
[35] The reason why the traumatic affect is not abreacted in a normal way, but is retained, is that its content is not compatible with the rest of the personality and must be repressed.
[36] The content of the traumatic affect provided the theme for Freud’s further researches. Already in the Studies on Hysteria and particularly in “The Defence Neuro-psychoses,” Freud had pointed out the sexual nature of the initial affect, whereas the first case history reported by Breuer skirts round the sexual element in a striking fashion, although the whole history not only contains a wealth of sexual allusions but, even for the expert, becomes intelligible and coherent only when the patient’s sexuality is taken into account. On the basis of thirteen careful analyses Freud felt justified in asserting that the specific aetiology of hysteria is to be found in the sexual traumata of early childhood, and that the trauma must have consisted in a “real irritation of the genitals.” The trauma works at first only preparatorily; it develops its real effect at puberty, when the old memory-trace is reactivated by nascent sexual feelings. Thus Freud tried to resolve the vague concept of a special disposition into quite definite, concrete events in the pre-pubertal period. At that time he did not attribute much significance to a still earlier inborn disposition.
[37] While the Breuer-Freud Studies enjoyed a certain amount of recognition (although, despite Raimann’s assurances,4 they have not yet become the common property of science), this theory of Freud’s met with general opposition. Not that the frequency of sexual traumata in childhood could be doubted, but rather their exclusively pathogenic significance for normal children. Freud certainly did not evolve this view out of nothing, he was merely formulating certain experiences which had forced themselves on him during analysis. To begin with, he found memory-traces of sexual scenes in infancy, which in many cases were quite definitely related to real happenings. Further, he found that though the traumata remained without specific effect in childhood, after puberty they proved to be determinants of hysterical symptoms. Freud therefore felt compelled to grant that the trauma was real. In my personal opinion he did this because at that time he was still under the spell of the original view that the hysteric “suffers from reminiscences,” for which reason the cause and motivation of the symptom must be sought in the past. Obviously such a view of the aetiological factors was bound to provoke opposition, especially among those with experience of hysteria, for the practitioner is accustomed to look for the driving forces of hysterical neurosis not so much in the past as in the present.
[38] This formulation of the theoretical standpoint in 1896 was no more than a transitional stage for Freud, which he has since abandoned. The discovery of sexual determinants in hysteria became the starting-point for extensive researches in the field of sexual psychology in general. Similarly, the problem of the determination of associative processes led his inquiry into the field of dream psychology. In 1900 he published his fundamental work on dreams, which is of such vital importance for the development of his views and his technique. No one who is not thoroughly acquainted with Freud’s method of dream interpretation will be able to understand the conceptions he has developed in recent years. The Interpretation of Dreams lays down the principles of Freudian theory and at the same time its technique. For an understanding of his present views and the verification of his results a knowledge of Freud’s technique is indispensable. This fact makes it necessary for me to go rather more closely into the nature of psychanalysis.
[39] The original cathartic method started with the symptoms and sought to discover the traumatic affect underlying them. The affect was thus raised to consciousness and abreacted in the normal manner; that is, it was divested of its traumatic potency. The method relied to a certain extent on suggestion—the analyst took the lead, while the patient remained essentially passive. Aside from this inconvenience, however, it was found that there were more and more cases in which no real trauma was present, and in which all the emotional conflicts seemed to derive exclusively from morbid fantasy activity. The cathartic method was unable to do justice to these cases.
[40] According to Freud’s statements in 1904,5 much has altered in the method since those early days. All suggestion is now discarded. The patients are no longer guided by the analyst; the freest rein is given to their associations, so that it is really the patients who conduct the analysis. Freud contents himself with registering, and from time to time pointing out, the connections that result. If an interpretation is wrong, it cannot be forced on the patient; if it is right, the result is immediately visible and expresses itself very clearly in the patient’s whole behaviour.
[41] The present psychanalytic method of Freud is much more complicated, and penetrates much more deeply, than the original cathartic method. Its aim is to bring to consciousness all the false associative connections produced by the complex, and in that way to resolve them. Thus the patient gradually gains complete insight into his illness, and also has an objective standpoint from which to view his complexes. The method could be called an educative one, since it changes the whole thinking and feeling of the patient in such a way that his personality gradually breaks free from the compulsion of the complexes and can take up an independent attitude towards them. In this respect Freud’s new method bears some resemblance to the educative method of Dubois,6 the undeniable success of which is due mainly to the fact that the instruction it imparts alters the patient’s attitude towards his complexes.
[42] Since it has grown entirely out of empirical practice, the theoretical foundations of the psychanalytic method are still very obscure. By means of my association experiments I think I have made at least a few points accessible to experimental investigation, though not all the theoretical difficulties have been overcome. It seems to me that the main difficulty is this. If, as psychanalysis presupposes, free association leads to the complex, Freud logically assumes that this complex is associated with the starting-point or initial idea. Against this it can be argued that it is not very difficult to establish the associative connection between a cucumber and an elephant. But that is to forget, first, that in analysis only the starting-point is given, and not the goal; and second, that the conscious state is not one of directed thinking but of relaxed attention. Here one might object that the complex is the point being aimed at and that, because of its independent feeling-tone, it possesses a strong tendency to reproduction, so that it “rises up” spontaneously and then, as though purely by chance, appears associated with the starting-point.
[43] This is certainly conceivable in theory, but in practice things generally look different. The complex, in fact, does not “rise up” freely but is blocked by the most intense resistances. Instead, what “rises up” often seems at first sight to be quite incomprehensible intermediate associations, which neither the analyst nor the patient recognizes as belonging in any way to the complex. But once the chain leading to the complex has been fully established, the meaning of each single link becomes clear, often in the most startling way, so that no special work of interpretation is needed. Anyone with enough practical experience of analysis can convince himself over and over again that under these conditions not just anything is reproduced, but always something that is related to the complex, though the relationship is, a priori, not always clear. One must accustom oneself to the thought that even in these chains of association chance is absolutely excluded. So if an associative connection is discovered in a chain of associations which was not intended—if, that is to say, the complex we find is associatively connected with the initial idea—then this connection has existed from the start; in other words, the idea we took as the starting-point was already constellated by the complex. We are therefore justified in regarding the initial idea as a sign or symbol of the complex.
[44] This view is in agreement with already known psychological theories which maintain that the psychological situation at a given moment is nothing but the resultant of all the psychological events preceding it. Of these the most predominant are the affective experiences, that is, the complexes, which for that reason have the greatest constellating power. If you take any segment of the psychological present, it will logically contain all the antecedent individual events, the affective experiences occupying the foreground, according to the degree of their actuality. This is true of every particle of the psyche. Hence it is theoretically possible to reconstruct the constellations from every particle, and that is what the Freudian method tries to do. During this work the probability is that you will come upon just the affective constellation lying closest to hand, and not merely on one but on many, indeed very many, each according to the degree of its constellating power. Freud has called this fact over-determination.
[45] Psychanalysis accordingly keeps within the bounds of known psychological facts. The method is extraordinarily difficult to apply, but it can be learnt; only, as Löwenfeld rightly emphasizes, one needs some years of intensive practice before one can handle it with any certainty. For this reason alone all over-hasty criticism of Freud’s findings is precluded. It also precludes the method from ever being used for mass therapy in mental institutions. Its achievements as a scientific instrument can be judged only by one who uses it himself.
[46] Freud applied his method first of all to the investigation of dreams, refining and perfecting it in the process. Here he found, it appears, all those surprising associative connections which play such an important role in the neuroses. I would mention, as the most important discovery, the significant role which feeling-toned complexes play in dreams and their symbolical mode of expression. Freud attaches great significance to verbal expression—one of the most important components of our thinking–because the double meaning of words is a favourite channel for the displacement and improper expression of affects. I mention this point because it is of fundamental importance in the psychology of neurosis. For anyone who is familiar with these matters, which are everyday occurrences with normal people too, the interpretations given in the “Fragment of an Analysis of a Case of Hysteria,” however strange they may sound, will contain nothing unexpected, but will fit smoothly into his general experience. Unfortunately I must refrain from a detailed discussion of Freud’s findings and must limit myself to a few hints. These latest investigations are required reading for Freud’s present view of hysterical illnesses. Judging by my own experience, it is impossible to understand the meaning of the Three Essays and of the “Fragment” without a thorough knowledge of The Interpretation of Dreams.
[47] By “thorough knowledge” I naturally do not mean the cheap philological criticism which many writers have levelled at this book, but a patient application of Freud’s principles to psychic processes. Here lies the crux of the whole problem. Attack and defence both miss the mark so long as the discussion proceeds only on theoretical ground. Freud’s discoveries do not, at present, lend themselves to the framing of general theories. For the present the only question is: do the associative connections asserted by Freud exist or not? Nothing is achieved by thoughtless affirmation or negation; one should look at the facts without prejudice, carefully observing the rules laid down by Freud. Nor should one be put off by the obtrusion of sexuality, for as a rule you come upon many other, exceedingly interesting things which, at least to begin with, show no trace of sex. An altogether harmless but most instructive exercise, for instance, is the analysis of constellations indicating a complex in the association experiment. With the help of this perfectly harmless material a great many Freudian phenomena can be studied without undue difficulty. The analysis of dreams and hysteria is considerably more difficult and therefore less suitable for a beginner. Without a knowledge of the ground-work Freud’s more recent teachings are completely incomprehensible, and, as might be expected, they have remained misunderstood.
[48] It is with the greatest hesitation, therefore, that I make the attempt to say something about the subsequent development of Freud’s views. My task is rendered especially difficult by the fact that actually we have only two publications to go on: they are the above-mentioned Three Essays on the Theory of Sexuality and the “Fragment of an Analysis of a Case of Hysteria.” There is as yet no attempt at a systematic exposition and documentation of Freud’s more recent views. Let us first try to come closer to the argument of the Three Essays.
[49] These essays are extremely difficult to understand, not only for one unaccustomed to Freud’s way of thinking but also for those who have already worked in this special field. The first thing to be considered is that Freud’s conception of sexuality is uncommonly wide. It includes not only normal sexuality but all the perversions, and extends far into the sphere of psychosexual derivates. When Freud speaks of sexuality, it must not be understood merely as the sexual instinct.7 Another concept which Freud uses in a very wide sense is “libido.” This concept, originally borrowed from “libido sexualis,” denotes in the first place the sexual components of psychic life so far as they are volitional, and then any inordinate passion or desire.
[50] Infantile sexuality, as Freud understands it, is a bundle of possibilities for the application or “investment” of libido. A normal sexual goal does not exist at that stage, because the sexual organs are not yet fully developed. But the psychic mechanisms are probably already in being. The libido is distributed among all the possible forms of sexual activity, and also among all the perversions—that is, among all the variants of sexuality which, if they become fixed, later turn into real perversions. The progressive development of the child gradually eliminates the libidinal investment of perverse tendencies and concentrates on the growth of normal sexuality. The investments set free during this process are used as driving-forces for sublimations, that is, for the higher mental functions. At or after puberty the normal individual seizes on an objective sexual goal, and with this his sexual development comes to an end.
[51] In Freud’s view, it is characteristic of hysteria that the infantile sexual development takes place under difficult conditions, since the perverse investments of libido are much less easily discarded than with normal individuals and therefore last longer. If the real sexual demands of later life impinge in any form on a morbid personality, its inhibited development shows itself in the fact that it is unable to satisfy the demand in the proper way, because the demand comes up against an unprepared sexuality. As Freud says, the individual predisposed to hysteria brings a “bit of sexual repression” with him from his childhood. Instead of the sexual excitation, in the widest sense of the word, being acted out in the sphere of normal sexuality, it is repressed and causes a reactivation of the original infantile sexual activity. This is expressed above all in the fantasy-activity so characteristic of hysterics. The fantasies develop along the line already traced by the special kind of infantile sexual activity. The fantasies of hysterics are, as we know, boundless; hence, if the psychic balance is in some measure to be preserved, equivalent inhibiting mechanisms are needed or, as Freud calls them, resistances. If the fantasies are of a sexual nature, then the corresponding resistances will be shame and disgust. As these affective states are normally associated with physical manifestations, the appearance of physical symptoms is assured.
[52] I think a concrete example from my own experience will illustrate the meaning of Freud’s teachings better than any theoretical formulations, which, because of the complexity of the subject, are all apt to sound uncommonly ponderous.
[53] The case is one of psychotic hysteria in an intelligent young woman of twenty. The earliest symptoms occurred between the third and fourth year. At that time the patient began to keep back her stool until pain compelled her to defecate. Gradually she began to employ the following auxiliary procedure: she seated herself in a crouching position on the heel of one foot, and in this position tried to defecate, pressing the heel against the anus. The patient continued this perverse activity until her seventh year. Freud calls this infantile perversion anal eroticism.
[54] The perversion stopped with the seventh year and was replaced by masturbation. Once, when her father smacked her on the bare buttocks, she felt distinct sexual excitement. Later she became sexually excited when she saw her younger brother being disciplined in the same way. Gradually she developed a markedly negative attitude towards her father.
[55] Puberty started when she was thirteen. From then on fantasies developed of a thoroughly perverse nature which pursued her obsessively. These fantasies had a compulsive character: she could never sit at table without thinking of defecation while she was eating, nor could she watch anyone else eating without thinking of the same thing, and especially not her father. In particular, she could not see her father’s hands without feeling sexual excitement; for the same reason she could no longer bear to touch his right hand. Thus it gradually came about that she could not eat at all in the presence of other people without continual fits of compulsive laughter and cries of disgust, because the defecation fantasies finally spread to all the persons in her environment. If she was corrected or even reproached in any way, she answered by sticking out her tongue, or with convulsive laughter, cries of disgust, and gestures of horror, because each time she had before her the vivid image of her father’s chastising hand, coupled with sexual excitement, which immediately passed over into ill-concealed masturbation.
[56] At the age of fifteen, she felt the normal urge to form a love relationship with another person. But all attempts in this direction failed, because the morbid fantasies invariably thrust themselves between her and the very person she most wanted to love. At the same time, because of the disgust she felt, any display of affection for her father had become impossible. Her father had been the object of her infantile libido transference, hence the resistances were directed especially against him, whereas her mother was not affected by them. About this time she felt a stirring of love for her teacher, but it quickly succumbed to the same overpowering disgust. In a child so much in need of affection this emotional isolation was bound to have the gravest consequences, which were not long in coming.
[57] At eighteen, her condition had got so bad that she really did nothing else than alternate between deep depressions and fits of laughing, crying, and screaming. She could no longer look anyone in the face, kept her head bowed, and when anybody touched her stuck her tongue out with every sign of loathing.
[58] This short history demonstrates the essentials of Freud’s view. First we find a fragment of perverse infantile sexual activity—anal eroticism—replaced in the seventh year by masturbation. At this period the administering of corporal punishment, affecting the region of the anus, produced sexual excitement. Here we have the determinants for the later psychosexual development. Puberty, with its physical and spiritual upheavals, brought a marked increase in fantasy activity. This seized on the sexual activity of childhood and modulated it in endless variations. Perverse fantasies of this kind were bound to act as moral foreign bodies, so to speak, in an otherwise sensitive person, and had to be repressed by means of defence mechanisms, particularly shame and disgust. This readily accounts for all those fits of disgust, loathing, exclamations of horror, sticking out the tongue, etc.
[59] At the time when the ordinary longings of puberty for the love of other people were beginning to stir, the pathological symptoms increased, because the fantasies were now directed most intensively to the very people who seemed most worthy of love. This naturally led to a violent psychic conflict, which fully explains the deterioration that then set in, ending in hysterical psychosis.
[60] We now understand why Freud can say that hysterics bring with them “a bit of sexual repression from childhood.” For constitutional reasons they are probably ready for sexual or quasi-sexual activities earlier than other people. In keeping with their constitutional emotivity, the infantile impressions go deeper and last longer, so that later, at puberty, they have a constellating effect on the trend of the first really sexual fantasies. Again in keeping with their constitutional emotivity, all affective impulses are much stronger than in normal persons. Hence, to counteract the intensity of their abnormal fantasies, correspondingly strong feelings of shame and disgust are bound to appear. When real sexual demands are made, requiring the transference of libido to the love-object, all the perverse fantasies are transferred to him, as we have seen. Hence the resistance against the object of love. The patient could not transfer her libido to him without inhibitions, and this precipitated the great emotional conflict. Her libido exhausted itself in struggling against her feelings of defence, which grew ever stronger, and which then produced the symptoms. Thus Freud can say that the symptoms represent nothing but the sexual activity of the patient.
[61] Summing up, we can formulate Freud’s present view of hysteria as follows:
a. Certain precocious sexual activities of a more or less perverse nature grow up on a constitutional basis.
b. These activities do not lead at first to real hysterical symptoms.
c. At puberty (which psychologically sets in earlier than physical maturity) the fantasies tend in a direction constellated by the infantile sexual activity.
d. The fantasies, intensified for constitutional (affective) reasons, lead to the formation of complexes of ideas that are incompatible with the other contents of consciousness and are therefore repressed, chiefly by shame and disgust.
e. This repression takes with it the transference of libido to a love-object, thus precipitating the great emotional conflict which then provides occasion for the outbreak of actual illness.
f. The symptoms of the illness owe their origin to the struggle of the libido against the repression; they therefore represent nothing but an abnormal sexual activity.
[62] How far does the validity of Freud’s view go? This question is exceedingly difficult to answer. Above all, it must be emphatically pointed out that cases which conform exactly to Freud’s schema really do exist. Anyone who has learnt the technique knows this. But no one knows whether Freud’s schema is applicable to all forms of hysteria (in any case, hysteria in children and the psychotraumatic neuroses form a group apart). For ordinary cases of hysteria, such as the nerve-specialist meets by the dozen, Freud asserts the validity of his views; my own experience, which is considerably less than his, has yielded nothing that would argue against this assertion. In the cases of hysteria which I have analysed, the symptoms were extraordinarily varied, but they all showed a surprising similarity in their psychological structure. The outward appearance of a case loses much of its interest when it is analysed, because one then sees how the same complex can produce apparently very far-fetched and very remarkable symptoms. For this reason it is impossible to say whether Freud’s schema applies only to certain groups of symptoms. At present we can only affirm that his findings are true of an indefinitely large number of cases of hysteria which till now could not be delimited as clinical groups.
[63] As to the detailed results of Freud’s analyses, the violent opposition they have met with is due simply to the fact that practically no one has followed the development of Freud’s theory since 1896. Had his dream-analyses been tested and his rules observed, Freud’s latest publications, particularly the “Fragment of an Analysis of a Case of Hysteria,” would not have been so difficult to understand. The only disconcerting thing about these reports is their frankness. The public can forgive Freud least of all for his sexual symbolism. In my view he is really easiest to follow here, because this is just where mythology, expressing the fantasy-thinking of all races, has prepared the ground in the most instructive way. I would only mention the writings of Steinthal8 in the 1860’s, which prove the existence of a widespread sexual symbolism in the mythological records and the history of language. I also recall the eroticism of our poets and their allegorical or symbolical expressions. No one who considers this material will be able to conceal from himself that there are uncommonly far-reaching and significant analogies between the Freudian symbolisms and the symbols of poetic fantasy in individuals and in whole nations. The Freudian symbol and its interpretation is therefore nothing unheard of, it is merely something unusual for us psychiatrists. But these difficulties should not deter us from going more deeply into the problems raised by Freud, for they are of extraordinary importance for psychiatry no less than for neurology.