FREUD HAD OPENED HIS practice in April 1886 and married Martha in September. Its romantic and sexual satisfactions waned rapidly for Freud, but marriage proved a satisfying domestic arrangement. The Freuds had their first child after thirteen months together, and then five more children in eight years. Martha would manage the household and shield her husband from interruption in his long work hours. Freud had dreaded patient care, considering it drudgery. In the early years, it was a source of inspiration.
Although Freud continued work in mainstream neurology—his well-respected book on the aphasias appeared in 1891—his clinical practice was increasingly devoted to mental illness. Freud diagnosed the bulk of his patients with such labels as hysteria, neurasthenia, and neurosis, poorly bounded categories that covered a wide range of severity of impairment. Freud treated patients with muscular exercise, hydrotherapy, and electrotherapy. He also employed hypnosis, putting patients in a trance and telling them that their symptoms would disappear. In Freud’s hands, these interventions were not especially effective. He later wrote, cynically, “If one wanted to make a living from the treatment of nervous ailments, one had to do something for them.”
Still focused on the bold stroke that would make his name, Freud put his hopes in a collaboration with Breuer, a careful clinician who had achieved some success with his treatment for hysteria. In 1880, Breuer had been consulted by Bertha Pappenheim, then twenty-one years old and a friend of Martha Bernays. Pappenheim—in his case report, Breuer would give her the pseudonym “Anna O.”—was an imaginative young woman who had felt constrained by the demands of her upbringing in a wealthy orthodox Jewish family. She was close to her father and succumbed to hysteria while she nursed him during a fatal illness. Her symptoms began with a cough and moved on to paralyses, anesthesias, mood swings, hallucinations, and an alteration in personality. Soon she was bedridden. Breuer attended her each evening, when she would enter a hypnotic trance and tell fanciful stories. These discussions brought relief. Pappenheim called the method the “talking cure.”
The breakthrough came as Pappenheim discussed a particular symptom, difficulty drinking. She recalled seeing a woman let a dog lap from her glass. Naming the source of the disgust caused the symptom to disappear. Breuer took Pappenheim’s cue and had her explore memories related to her symptoms, a process to which she gave the name “chimney sweeping.”
Breuer’s method was hardly original. In the 1850s, a Dutch physician, Andries Hoek, had treated a young woman with “uncovering hypnotherapy,” in which he provided relief by letting her talk about early traumatic experiences, including sexual abuse, that had sensitized her to strains in adult life. Closer to home, the senior Viennese colleague who had recommended Freud to Charcot, Moritz Benedikt, had been treating hysterics without hypnosis, using a method that involved recollection and narrative. Benedikt believed that hysteria arose from psychological effects of shameful sexual ideas and memories. He countered it by encouraging patients to reveal their “second life”—that is, fantasies—and “pathogenic secrets.”
This method drifted beyond the consulting room. In 1880s Vienna, “catharsis” was in the air. Martha Bernays’s uncle, the philologist Jakob Bernays, had proposed that for playgoers, the revelatory moment of tragedy had the power to free sufferers from the noxious influence of excess emotion. Pappenheim and Breuer seem to have taken this notion to heart.
Breuer was an extremely patient man or a highly interested one. Each session with Pappenheim lasted hours. Sometimes, Breuer traced back a symptom through a hundred prior occurrences before a root emerged. After weeks of this vigorous collaboration, every one of Pappenheim’s complaints had disappeared.
In 1882 and 1883, Breuer discussed the case with Freud, who in turn tried to discuss it with Charcot. Breuer’s observation was that, at least for Pappenheim, hysterical symptoms could be cured through the discussion of memories. But for some years, Breuer did not publish his case. Freud later wrote that the reason was what happened next. On the evening of the day of her cure, Pappenheim developed abdominal cramps and said, “Now comes Dr. B’s child.” Pappenheim was experiencing a hysterical pregnancy.
Whether this episode ever occurred is uncertain. Breuer made no note of it. Freud first mentioned it many years later, when it was convenient for him to attack Breuer and support his own subsequent theory about the sexual origins of hysteria. What is known is that Breuer referred Pappenheim to a Swiss sanatorium. At a distance from Breuer, Pappenheim experienced improvement, but she suffered for another six years and was hospitalized at least three more times. A reasonable explanation for Breuer’s reluctance to publish is that Pappenheim’s relapse and extended illness were evident to members of the Viennese Jewish community.
Recently, diagnosticians have speculated that when she was seeing Breuer, Pappenheim was in the midst of a pathological grief reaction, in the context of an underlying propensity to manic depression. Whatever her ailment, eventually it remitted, and Pappenheim went on to a distinguished career as a social activist on behalf of women, children, the poor, and Jews.
In retrospect, Pappenheim has about her something of Blanche Wittmann, the talented woman able to perform for her doctor. Pappenheim had tried at one point to indicate that she had feigned certain symptoms. For Pappenheim, the reward was not notoriety but intimacy with a kindly figure and escape from a stultifying social environment.
Martha Bernays assumed that the relationship turned on Pappenheim’s sexual attractiveness. It was, Martha wrote, “curious that no man other than her physician of the moment got close to poor Bertha,” since even at a young age she had the power “to turn the head of the most sensible of men.” Like Scheherazade, to whom Breuer compared her, Pappenheim assured her audience’s nightly presence, via her symptom-by-symptom recovery. The philosopher Jonathan Lear, overall a defender of Freud, has characterized the daily improvements as Pappenheim’s “gifts” to Breuer. Lear adds that her “cure” may have been “the greatest hysterical symptom of all.” Arguably, the progressive if temporary improvement had no special relationship to the means of treatment, tracing symptoms to their root.
Though Breuer and Freud would emphasize the role of the talking cure, Pappenheim’s recovery was complicated. Breuer had administered the medications chloral hydrate and morphine, to which Pappenheim then became addicted. (Perhaps Freud’s recent cocaine fiasco made mention of this fact impossible.) Pappenheim had responded better to a “moral treatment,” improving when she took responsibility for a dog and for other sick patients. She was given exercise and baths. In this swirl of interventions, remissions, and relapses, there would seem to be no basis for drawing conclusions of any sort. Breuer’s early report about the case makes the modest claim that speaking about its associated fantasies weakens a symptom.
In the 1880s, many doctors were writing thoughtfully about hysteria. In particular, Charcot’s student Pierre Janet was outlining a comprehensive approach to causation and treatment. He saw some symptoms as arising from the social surround, with patients adopting postures featured in romantic novels. Other symptoms might be related to recent traumatic memories, such as sexual infidelities; inherited tendencies, such as suggestibility; past bodily illnesses, such as infectious diseases; and early losses or abuse. Certain symptoms seemed to point symbolically to their cause—as when a woman who had felt guilty satisfaction when her father’s coffin was mistakenly draped in red became phobic over the color. Janet considered hysteria to constitute a splitting of consciousness arising in response to psychic shocks.
A number of interventions seemed helpful, including an exploration of symptoms in the reverse order of their appearance and a practical discussion, much like today’s cognitive therapy, of the relationship of fixed beliefs to the realities of daily life. Janet called his approach “psychological analysis.” Nor was the process original to him. Psychological analysis was an integration of the medical methods of the time.
Janet was aware of hysterics’ tendency to try to please their doctors and so took precautions to avoid “leading the witness.” He recognized, too, that patients were not always respectful but might instead be jealous, loving, rebellious, or overly dependent. He saw the rapport between doctor and patient as a critical therapeutic tool.
A century later, we do not have a solid explanation of hysterical symptoms or related phenomena such as multiple personality disorder and mood disorders. But current findings, derived through the statistical tools of behavioral genetics, correspond to what Janet believed. Within the bounds of what was discoverable using only observation and interviews with patients, late nineteenth-century physicians knew what could be known about hysteria. Breuer understood his own work as an incremental contribution within a vigorous tradition of research.
In the late 1880s, Freud adopted Breuer’s chimney-sweeping approach to hysteria. In the early 1890s, the two began writing joint reports on their results. Only once Freud became involved did Breuer’s conclusions become more decided: “[W]e found, to our great surprise at first, that each individual hysterical symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect…” This claim justified the “cathartic method.” Moving from cure to causation, the two doctors arrived at their famous summation: “Hysterics suffer mainly from reminiscences.” Further, they concluded that symptoms are a form of storytelling. Their form contains hints about their origin.
In 1895, Freud and Breuer collaborated in the publication of Studies on Hysteria, a report of their theories about the cause and cure of the illness. The book was built around a handful of case histories. An illustrative vignette involves a thirty-year-old governess, “Miss Lucy R.,” whom Freud treated for a mild case of hysteria. While in the employ of a widower, the young woman developed symptoms. Her spirits were uncharacteristically subdued, and she perceived odd odors, of burnt pudding and cigar smoke.
Freud set aside hypnosis and instead pressed his hand on his patient’s forehead as a way of eliciting memories. (Soon he dropped this method in favor of having the patient lie quietly and report her thoughts.) He then caused Miss Lucy R. to recall incidents leading up to the hallucinated smells.
But in practice, the case flows from Freud’s dramatic pronouncement midway through treatment: “I believe that really you are in love with your employer, the Director, though perhaps without being aware of it yourself, and that you have a secret hope of taking [his late wife’s] place in actual fact.” With her wish in the open, the governess was able to link an event at which cigars were smoked with an occasion when the director reprimanded her violently for allowing her charges to be kissed on the lips by a visitor. When her situation had been clarified—to the Director, she was not a marriage prospect—Miss Lucy R. renounced her unreasonable hopes and returned to her customary cheerful state, although her nasal functioning remained impaired.
Freud is an inspired storyteller. The case report may remind readers of a Sherlock Holmes tale or a chapter from Jane Eyre. But then, in Conan Doyle and Brontë, the attractiveness of employers to governesses is a commonplace, as it is in household management guides of the era, which include advice to employers about how to minimize these complications. Stepping back from the narrative, a reader may be surprised that it takes Freud some time to understand what is troubling his patient. The key to the case seems to be reconciling a lovestruck young woman to her circumstances, never mind the tracing of distinctive symptoms to their origins. Nor is it clear that the olfactory disturbance, which plays the dramatic role in the detective work, really did resolve.
We may want to complicate this account in one way. Perhaps it would have been humiliating for Miss Lucy R. to find relief immediately on being confronted with the difficult truth, that she loved a man beyond her station who was, moreover, cruel and keenly aware of social distinctions. As a matter of courtesy, Freud might have needed to engage in a ritual with her, one that allowed Miss Lucy R. to move from the position of victim to that of conqueror. In eliciting one more story involving the smells of the household, Freud shared with his patient the mantle of brave explorer. Extending the methods of Breuer, Janet, Benedikt, and others, Freud was developing a socially acceptable way for doctors to spend time with patients and engage their predicaments.
Freud would later be celebrated as the discoverer of the unconscious. But at the end of the nineteenth century, the unconscious was a central topic for students of mind. A contemporary of Freud’s termed it “less a psychological problem than the problem of psychology.” In the course of elaborating a philosophy in which man’s irrationality and sexual drives play central roles, Arthur Schopenhauer, in the 1850s, had linked unconscious conflict to mental illness. Schopenhauer observed, “The Will’s opposition to let what is repellent to it come to the knowledge of the intellect is the spot through which insanity can break through into the spirit.” Similarly, the notion that mental afflictions speak through translatable symbols has roots in 1850s psychiatry. In the subsequent half century, books with titles like The Philosophy of the Unconscious and The Double Ego were popular. By 1889, a leading scientific review concluded that the existence of an unconscious had been well established. According to the monograph, health was characterized by an accord between layers of mind, illness by conflict, and extreme illness by a dominance of the unconscious. In intellectual salons, the unconscious was an obsessive topic.
Breuer introduces his and Freud’s theories by remarking, “It hardly seems necessary any longer to argue in favour of the existence of current ideas that are unconscious or subconscious. They are among the commonest facts of everyday life. If I have forgotten to make one of my medical visits, I have feelings of lively unrest.” The anxiety is a sign that at some level Breuer is aware of the obligation after all.
But Breuer and Freud make special claims about the contents of the unconscious. They argue that complicated ideas can remain inadmissible to ordinary thought and that these forbidden ideas give rise to specific effects. It is this connection that distinguishes Breuer’s and Freud’s reports. They want to make the unconscious out as witty, mordant, and creative—a part of the mind that speaks through clever puzzles.
That is why, in the Miss Lucy R. case, Freud focused on the smells of cigar smoke and burnt pudding. The existence of an emotional unconscious—one that might cause a romantic girl to become dispirited when brought up short by her employer—was a common fact of life. Freud needed to demonstrate that symptoms symbolize unacceptable ideas that remain split off from awareness. By tracing the hallucinated smells to their origins in particular scenes, Freud hoped to describe the transformation of thought into symptom and thus to define the specific workings of the unconscious mind.
It is perhaps worth a detour to say a word about the fate of the unconscious after Freud. The best-publicized challenge to Freud’s account occurred in the context of the “recovered memory” debate in the 1980s and 1990s. In the course of that controversy, experimental psychologists questioned the idea that traumatic events are repressed. Complex, emotional memories tend to be conscious, even when the underlying events are experienced as shameful.
But the demurrals have been much more general. Psychoanalysts have pulled back from the claim that the unconscious is something like a complete second brain, one that fashions astonishing condensations of conflicting ideas. By the 1940s, Harry Stack Sullivan, an influential American analyst, was referring to “selective inattention” as a psychological mechanism. Often what emerge in therapy are inconvenient thoughts (like Lucy R.’s awareness of her employer’s social rigidity) that have been registered but then set aside. Object relations, an analytic theory elaborated in the 1970s, holds that the unconscious contains templates of emotionally salient relationships. If a woman’s father was undermining, for her a demanding employer may elicit old feelings that mix comfort with fear. Most recently, researchers have identified an evaluative component in the unconscious mind. Outside awareness, we assess whether a situation is threatening. The resulting “affective learning” corresponds to the sort of experience Breuer mentions in connection with the forgotten medical visit, signal anxiety that warns of a task overlooked.
These views of mind, in which consciousness attends selectively to information and the unconscious sets the emotional tone, correspond to the psychology that Breuer said was unarguable in the 1890s. There is, today, little scientific or clinical support for the additional claim that the unconscious speaks through symptoms that contain complex narrative content.
But Freud’s distinctive contribution, in the 1890s, was the extension of the principle, advanced in simpler form by others, that symptoms reveal hints of thoughts and feelings pushed out of awareness. For Freud, symptoms were symbols. The relationship of cause to effect might not be strictly imitative (odors causing imagined odors) but abstract. Freud made this point in discussing a patient he would call his master teacher, “Frau Cäcelie M.”
Frau M. was the Baroness Anna von Lieben, a noblewoman married to a Jewish banker, and one of the richest women in Europe. (To give a sense of the closeness of the circles in which Freud operated: The banker’s sister was the wife of Freud’s teacher Brentano; Breuer was the von Lieben family doctor; and Charcot had treated Anna von Lieben as well.) Von Lieben suffered absence attacks, feelings of worthlessness, wandering pains, and memory loss. For Freud, von Lieben’s intelligence, her skill as a poet, and her lineage argued against hysteria’s being, as Charcot had sometimes proposed, a hereditary illness based on progressive degradation of mental functions over generations.
But then, genetics may well have influenced von Lieben’s condition. She was a vigorous producer of symptoms, which she described in long speeches. She hired a chess player to spend the night outside her bedroom because she was an insomniac and might find herself in need of a late-night game. As with Pappenheim, looking at the available information about von Lieben, a modern diagnostician might wonder whether bipolar affective disorder, a disease with high heritability, played a role in the chronic mental illness.
Freud worked with von Lieben twice daily for three years. He began with hypnosis but apparently moved to an early form of the “free association” method, in which the patient is instructed to say the next thing that comes to her mind, without censoring her thoughts. The physical form of psychoanalysis, the doctor sitting at the head of a couch on which the patient reclines, may owe something to von Lieben’s preference for the chaise longue. By Freud’s account, von Lieben helped to direct the therapy, pointing out meaning in symptoms that then resolved, only to be replaced by others.
The therapy yielded limited results. Family members expressed skepticism about the unestablished doctor’s intense involvement with his patient. Von Lieben’s uncle wrote his wife (also a patient of Freud’s): “Only and always only ear-confession and hypnosis—from that we have seen no wonders….” In a letter probably dating from a year after Freud’s treatment ended, a friend summarized the ups and downs of von Lieben’s condition: “On the whole a depressing picture, and I am gripped with a deep melancholy when I see her like that, lying before me covered with plaids [i.e., blankets] on the chaise longue.” Like Pappenheim’s, von Lieben’s analysis was complicated by a morphine addiction. She moved on to work with another doctor.
Again, this treatment hardly offers a clear field for research. Hundreds of topics must have been discussed as symptoms waxed and waned. What Freud believed he learned from von Lieben is that symbolization governs the connection between symptom and cause. He traced a stabbing sensation in the forehead to a memory of a “piercing” glance from a censorious relative. Pain in the heel related to worries about being on “the right footing” with strangers. Freud did not attribute these associations to von Lieben’s artistic bent. On the contrary, he concluded that such connections arose from the natural expression of emotions, along lines suggested by Darwin. For example, “swallowing something,” a phrase that refers to a repressed reaction to insult, arises from “innervatory sensations” from the pharynx. It is, then, no coincidence that hysteria draws on figures of speech. Thus, Freud concluded, even when concrete causes of symptoms (actual odors from cigars) cannot be found, metaphorical ones can be adduced.
Looking backward, it is hard to know what to make of this contention. Our patients are not Freud’s patients. We do still recognize certain symptoms that bear the mark of their cause. A soldier who has been fired on when driving in a battle zone may startle in response to sudden noises when on the roadway at home. But this correspondence is direct, not distorted by a mind intent on repressing shameful thoughts. And most symptoms of mental illness have no such meaningful content. Contemporary medicine—and the norm was similar a century ago—takes diseases to be syndromal. Their symptoms come in predictable clusters. If you are depressed, and on that basis you have disordered mood, sleep, and cognition, the odds are good that you will have altered appetite as well—never mind whether you are “starved for attention” or “sick to your stomach” over a life circumstance.
As for diseases with diverse, fluctuating symptoms—hysteria in Freud’s day or borderline personality disorder in our own—psychiatry sees the temporary manifestations as epiphenomena. They may have functions, if they help a patient to gain attention or avoid obligations, or they may represent a general flailing about, in panic. Insofar as we can trace their causes, these ailments, the ones whose sufferers have a flamboyant quality, arise from a combination of personality and mood disorder. Both the impulsive, grandiose style and the vulnerability to depression or mania have complex causes: genetics, prenatal events, early trauma, chronic stress, and acute losses, in combination. Often symptoms are understandable—a child with an unpredictable parent may grow up anxious and afraid of intimacy. But we no longer expect a creatively disguised one-to-one correspondence between symptom and thought or event—nor is it credible that Freud would have consistently found such a relationship, except by forcing the issue.
Freud used his new theory, that symptoms always symbolize causes, to support his authoritarian tendencies with patients. Where Breuer was cautious, Freud became peremptory, insisting on acceptance of his interpretations. He saw himself as a battlefield general, opposing the objections of his patients and his critics alike, declaring, “We shall in the end conquer every resistance by emphasizing the unshakeable nature of our convictions.”
Freud was always intent on expanding the reach of his theories, applying them to cases far afield from those in which he made his original observations. Soon, Freud would claim that when people become paranoid it is because they are repressing the wish to engage in the very acts they fear, the ones they say others will perform on them. The patients’ apparent anxieties symbolize real and unacceptable desires. Then followers, with Freud’s approval, suggested that infertile young women are ambivalent about motherhood and that men with ulcers are exhibiting the inner bite of ambition. Patients suffering disease were now also imputed to cowardice, for failing to examine the difficult truths that their symptoms clearly expressed.
The evidence developed by skeptics over the past forty years—inquiries into the identity of patients and the outcome of their treatments—has changed the grounds of the debate over Freud’s work. For years, critics had said that psychoanalysis was not science because its observations could not be disproved through experiments. Freud’s supporters replied that neutral observation that leads to hypothesis building is a form of science. Freud had listened to patients, built interpretations on their free associations, seen symptoms remit, and then reported his conclusions.
The new findings showed that Freud’s early work did not meet even the most generous, minimal criteria for scientific inquiry. If Breuer and Freud were supplying morphine to their hysterical patients, all bets are off as to what caused these women’s reports of symptoms to fluctuate. The patients had too much incentive to enter into the game the doctors were proposing. There is no evidence that the retrieval of unconscious memories cured hysterical patients—indeed, no evidence that the memories were unconscious and no evidence that the patients were cured. It is unclear whether Freud and Breuer had made any progress in elucidating the causes of disease or the workings of the mind. In Freud’s work, theory guided interactions with patients and not the reverse.
All the same, the publication of the Studies is a signal moment in the history of medicine. Freud may not have discovered the unconscious or invented psychological analysis, but he made the unconscious and analysis interesting. He did so first in the consulting room—perhaps by seeing patterns when there were none, perhaps through his decisiveness and frankness about difficult matters. He then detailed his findings in beautifully crafted reports that mimic (and would soon inspire) the fiction of the era. Freud gave hope, to patients and to readers, at a time when mental illnesses seemed epidemic. And then, the intervention that Freud championed proved extremely useful—not the pressing of the head or the triumphant interpretations, but the process of collaborative inquiry that became psychotherapy, the leading treatment for mental illness for the subsequent half century and one that remains extremely important today.