PSYCHOANALYSIS

[1]     If he wants to help his patient, the doctor and above all the “specialist for nervous diseases” must have psychological knowledge; for nervous disorders and all that is embraced by the terms “nervousness,” hysteria, etc. are of psychic origin and therefore logically require psychic treatment. Cold water, light, fresh air, electricity, and so forth have at best a transitory effect and sometimes none at all. The patient is sick in mind, in the highest and most complex of the mind’s functions, and these can hardly be said to belong any more to the province of medicine. Here the doctor must also be a psychologist, which means that he must have knowledge of the human psyche.

[2]     In the past, that is to say up to fifty years ago, the doctor’s psychological training was still very bad. His psychiatric textbooks were wholly confined to clinical descriptions and the systematization of mental diseases, and the psychology taught in the universities was either philosophy or the so-called “experimental psychology” inaugurated by Wundt.1 The first moves towards a psychotherapy of the neuroses came from the Charcot school, at the Salpetrière in Paris; Pierre Janet2 began his epoch-making researches into the psychology of neurotic states, and Bernheim3 in Nancy took up with great success Liébeault’s4 old and forgotten idea of treating the neuroses by suggestion. Sigmund Freud translated Bernheim’s book and also derived valuable inspiration from it. At that time there was still no psychology of the neuroses and psychoses. To Freud belongs the undying merit of having laid the foundations of a psychology of the neuroses. His teachings sprang from his experience in the practical treatment of the neuroses, that is, from the application of a method which he called psychoanalysis.

[3]     Before we enter upon a closer presentation of our subject, something must be said about its relation to science as known hitherto. Here we encounter a curious spectacle which proves yet again the truth of Anatole France’s remark: “Les savants ne sont pas curieux.” The first work of any magnitude5 in this field awakened only the faintest echo, in spite of the fact that it introduced an entirely new conception of the neuroses. A few writers spoke of it appreciatively and then, on the next page, proceeded to explain their hysterical cases in the same old way. They behaved very much like a man who, having eulogized the idea or fact that the earth was a sphere, calmly continues to represent it as flat. Freud’s next publications remained absolutely unnoticed, although they put forward observations which were of incalculable importance for psychiatry. When, in the year 1900, Freud wrote the first real psychology of dreams6 (a proper Stygian darkness had hitherto reigned over this field), people began to laugh, and when he actually started to throw light on the psychology of sexuality in 1905,7 laughter turned to insult. And this storm of learned indignation was not behindhand in giving Freudian psychology an unwanted publicity, a notoriety that extended far beyond the confines of scientific interest.

[4]     Accordingly we must look more closely into this new psychology. Already in Charcot’s time it was known that the neurotic symptom is “psychogenic,” i.e., originates in the psyche. It was also known, thanks mainly to the work of the Nancy school, that all hysterical symptoms can be produced through suggestion. Equally, something was known, thanks to the researches of Janet, about the psychological mechanisms that produce such hysterical phenomena as anaesthesia, paresia, paralysis, and amnesia. But it was not known how an hysterical symptom originates in the psyche; the psychic causal connections were completely unknown. In the early eighties Dr. Breuer, an old Viennese practitioner, made a discovery which became the real starting-point for the new psychology. He had a young, very intelligent woman patient suffering from hysteria, who manifested the following symptoms among others: she had a spastic (rigid) paralysis of the right arm, and occasional fits of absentmindedness or twilight states; she had also lost the power of speech inasmuch as she could no longer command her mother tongue but could only express herself in English (systematic aphasia). They tried at that time to account for these disorders with anatomical theories, although the cortical centre for the arm function was as little disturbed here as with a normal person. The symptomatology of hysteria is full of anatomical impossibilities. One lady, who had completely lost her hearing because of an hysterical affection, often used to sing. Once, when she was singing, her doctor seated himself unobserved at the piano and softly accompanied her. In passing from one stanza to the next he made a sudden change of key, whereupon the patient, without noticing it, went on singing in the changed key. Thus she hears—and does not hear. The various forms of systematic blindness offer similar phenomena: a man suffering from total hysterical blindness recovered his power of sight in the course of treatment, but it was only partial at first and remained so for a long time. He could see everything with the exception of people’s heads. He saw all the people round him without heads. Thus he sees—and does not see. From a large number of like experiences it had been concluded that only the conscious mind of the patient does not see and hear, but that the sense function is otherwise in working order. This state of affairs directly contradicts the nature of an organic disorder, which always affects the actual function as well.

[5]     After this digression, let us come back to the Breuer case. There were no organic causes for the disorder, so it had to be regarded as hysterical, i.e., psychogenic. Breuer had observed that if, during her twilight states (whether spontaneous or artificially induced), he got the patient to tell him of the reminiscences and fantasies that thronged in upon her, her condition was eased for several hours afterwards. He made systematic use of this discovery for further treatment. The patient devised the name “talking cure” for it or, jokingly, “chimney-sweeping.”

[6]     The patient had become ill when nursing her father in his fatal illness. Naturally her fantasies were chiefly concerned with these disturbing days. Reminiscences of this period came to the surface during her twilight states with photographic fidelity; so vivid were they, down to the last detail, that we can hardly assume the waking memory to have been capable of such plastic and exact reproduction. (The name “hypermnesia” has been given to this intensification of the powers of memory which not infrequently occurs in restricted states of consciousness.) Remarkable things now came to light. One of the many stories told ran somewhat as follows:

One night, watching by the sick man, who had a high fever, she was tense with anxiety because a surgeon was expected from Vienna to perform an operation. Her mother had left the room for a while, and Anna, the patient, sat by the sick-bed with her right arm hanging over the back of the chair. She fell into a sort of waking dream in which she saw a black snake coming, apparently out of the wall, towards the sick man as though to bite him. (It is quite likely that there really were snakes in the meadow at the back of the house, which had already given the girl a fright and which now provided the material for the hallucination.) She wanted to drive the creature away, but felt paralysed; her right arm, hanging over the back of the chair, had “gone to sleep”: it had become anaesthetic and paretic, and, as she looked at it, the fingers changed into little serpents with death’s-heads. Probably she made efforts to drive away the snake with her paralysed right hand, so that the anaesthesia and paralysis became associated with the snake hallucination. When the snake had disappeared, she was so frightened that she wanted to pray; but all speech failed her, she could not utter a word until finally she remembered an English nursery rhyme, and then she was able to go on thinking and praying in English.8

[7]     Such was the scene in which the paralysis and the speech disturbance originated, and with the narration of this scene the disturbance itself was removed. In this manner the case is said to have been finally cured.

[8]     I must content myself with this one example. In the book I have mentioned by Breuer and Freud there is a wealth of similar examples. It can readily be understood that scenes of this kind make a powerful impression, and people are therefore inclined to impute causal significance to them in the genesis of the symptom. The view of hysteria then current, which derived from the English theory of the “nervous shock” energetically championed by Charcot, was well qualified to explain Breuer’s discovery. Hence there arose the so-called trauma theory, which says that the hysterical symptom, and, in so far as the symptoms constitute the illness, hysteria in general, derive from psychic injuries or traumata whose imprint persists unconsciously for years. Freud, now collaborating with Breuer, was able to furnish abundant confirmation of this discovery. It turned out that none of the hundreds of hysterical symptoms arose by chance—they were always caused by psychic occurrences. So far the new conception opened up an extensive field for empirical work. But Freud’s inquiring mind could not remain long on this superficial level, for already deeper and more difficult problems were beginning to emerge. It is obvious enough that moments of extreme anxiety such as Breuer’s patient experienced may leave an abiding impression. But how did she come to experience them at all, since they already clearly bear a morbid stamp? Could the strain of nursing bring this about? If so, there ought to be many more occurrences of the kind, for there are unfortunately very many exhausting cases to nurse, and the nervous health of the nurse is not always of the best. To this problem medicine gives an excellent answer: “The in the calculation is predisposition.” One is just “predisposed” that way. But for Freud the problem was: what constitutes the predisposition? This question leads logically to an examination of the previous history of the psychic trauma. It is a matter of common observation that exciting scenes have quite different effects on the various persons involved, or that things which are indifferent or even agreeable to one person arouse the greatest horror in others—witness frogs, snakes, mice, cats, etc. There are cases of women who will assist at bloody operations without turning a hair, while they tremble all over with fear and loathing at the touch of a cat. I remember a young woman who suffered from acute hysteria following a sudden fright.9 She had been to an evening party and was on her way home about midnight in the company of several acquaintances, when a cab came up behind them at full trot. The others got out of the way, but she, as though spellbound with terror, kept to the middle of the road and ran along in front of the horses. The cabman cracked his whip and swore; it was no good, she ran down the whole length of the road, which led across a bridge. There her strength deserted her, and to avoid being trampled on by the horses she would in her desperation have leapt into the river had not the passers-by prevented her. Now, this same lady had happened to be in St. Petersburg on the bloody twenty-second of January [1905], in the very street which was cleared by the volleys of the soldiers. All round her people were falling to the ground dead or wounded; she, however, quite calm and clear-headed, espied a gate leading into a yard through which she made her escape into another street. These dreadful moments caused her no further agitation. She felt perfectly well afterwards—indeed, rather better than usual.

[9]     This failure to react to an apparent shock can frequently be observed. Hence it necessarily follows that the intensity of a trauma has very little pathogenic significance in itself, but it must have a special significance for the patient. That is to say, it is not the shock as such that has a pathogenic effect under all circumstances, but, in order to have an effect, it must impinge on a special psychic disposition, which may, in certain circumstances, consist in the patient’s unconsciously attributing a specific significance to the shock. Here we have a possible key to the “predisposition.” We have therefore to ask ourselves: what are the particular circumstances of the scene with the cab? The patient’s fear began with the sound of the trotting horses; for an instant it seemed to her that this portended some terrible doom—her death, or something as dreadful; the next moment she lost all sense of what she was doing.

[10]     The real shock evidently came from the horses. The patient’s predisposition to react in so unaccountable a way to this unremarkable incident might therefore consist in the fact that horses have some special significance for her. We might conjecture, for instance, that she once had a dangerous accident with horses. This was actually found to be the case. As a child of about seven she was out for a drive with her coachman, when suddenly the horses took fright and at a wild gallop made for the precipitous bank of a deep river-gorge. The coachman jumped down and shouted to her to do likewise, but she was in such deadly fear that she could hardly make up her mind. Nevertheless she jumped in the nick of time, while the horses crashed with the carriage into the depths below. That such an event would leave a very deep impression scarcely needs proof. Yet it does not explain why at a later date such an insensate reaction should follow the perfectly harmless hint of a similar situation. So far we know only that the later symptom had a prelude in childhood, but the pathological aspect of it still remains in the dark. In order to penetrate this mystery, further knowledge is needed. For it had become clear with increasing experience that in all the cases analysed so far, there existed, apart from the traumatic experiences, another, special class of disturbances which lie in the province of love. Admittedly “love” is an elastic concept that stretches from heaven to hell and combines in itself good and evil, high and low. With this discovery Freud’s views underwent a considerable change. If, more or less under the spell of Breuer’s trauma theory, he had formerly sought the cause of neurosis in traumatic experiences, now the centre of gravity of the problem shifted to an entirely different point. This is best illustrated by our case: we can understand well enough why horses should play a special part in the life of the patient, but we do not understand the later reaction, so exaggerated and uncalled for. The pathological peculiarity of this story lies in the fact that she is frightened of quite harmless horses. Remembering the discovery that besides the traumatic experience there is often a disturbance in the province of love, we might inquire whether perhaps there is something peculiar in this connection.

[11]     The lady knows a young man to whom she thinks of becoming engaged; she loves him and hopes to be happy with him. At first nothing more is discoverable. But it would never do to be deterred from investigation by the negative results of the preliminary questioning. There are indirect ways of reaching the goal when the direct way fails. We therefore return to that singular moment when the lady ran headlong in front of the horses. We inquire about her companions and what sort of festive occasion it was in which she had just taken part. It had been a farewell party for her best friend, who was going abroad to a health resort on account of her nerves. This friend is married and, we are told, happily; she is also the mother of a child. We may take leave to doubt the statement that she is happy; for, were she really so, she would presumably have no reason to be “nervous” and in need of a cure. Shifting my angle of approach, I learned that after her friends had rescued her they brought the patient back to the house of her host—her best friend’s husband—as this was the nearest shelter at that late hour of night. There she was hospitably received in her exhausted state. At this point the patient broke off her narrative, became embarrassed, fidgeted, and tried to change the subject. Evidently some disagreeable reminiscence had suddenly bobbed up. After the most obstinate resistance had been overcome, it appeared that yet another very remarkable incident had occurred that night: the amiable host had made her a fiery declaration of love, thus precipitating a situation which, in the absence of the lady of the house, might well be considered both difficult and distressing. Ostensibly this declaration of love came to her like a bolt from the blue, but these things usually have their history. It was now the task of the next few weeks to dig out bit by bit a long love story, until at last a complete picture emerged which I attempt to outline somewhat as follows:

As a child the patient had been a regular tomboy, caring only for wild boys’ games, scorning her own sex, and avoiding all feminine ways and occupations. After puberty, when the erotic problem might have come too close, she began to shun all society, hated and despised everything that even remotely reminded her of the biological destiny of woman, and lived in a world of fantasies which had nothing in common with rude reality. Thus, until about her twenty-fourth year, she evaded all those little adventures, hopes, and expectations which ordinarily move a girl’s heart at this age. Then she got to know two men who were destined to break through the thorny hedge that had grown up around her. Mr. A was her best friend’s husband, and Mr. B was his bachelor friend. She liked them both. Nevertheless it soon began to look as though she liked Mr. B a vast deal better. An intimacy quickly sprang up between them and before long there was talk of a possible engagement. Through her relations with Mr. B and through her friend she often came into contact with Mr. A, whose presence sometimes disturbed her in the most unaccountable way and made her nervous. About this time the patient went to a large party. Her friends were also there. She became lost in thought and was dreamily playing with her ring when it suddenly slipped off her finger and rolled under the table. Both gentlemen looked for it and Mr. B succeeded in finding it. He placed the ring on her finger with an arch smile and said, “You know what that means!” Overcome by a strange and irresistible feeling, she tore the ring from her finger and flung it through the open window. A painful moment ensued, as may be imagined, and soon she left the party in deep dejection. Not long after this, so-called chance brought it about that she should spend her summer holidays at a health resort where Mr. and Mrs. A were also staying. Mrs. A then began to grow visibly nervous, and frequently stayed indoors because she felt out of sorts. The patient was thus in a position to go out for walks alone with Mr. A. On one occasion they went boating. So boisterous was she in her merriment that she suddenly fell overboard. She could not swim, and it was only with great difficulty that Mr. A pulled her half-unconscious into the boat. And then it was that he kissed her. With this romantic episode the bonds were tied fast. But the patient would not allow the depths of this passion to come to consciousness, evidently because she had long habituated herself to pass over such things or, better, to run away from them. To excuse herself in her own eyes she pursued her engagement to Mr. B all the more energetically, telling herself every day that it was Mr. B whom she loved. Naturally this curious little game had not escaped the keen glances of wifely jealousy. Mrs. A, her friend, had guessed the secret and fretted accordingly, so that her nerves only got worse. Hence it became necessary for Mrs. A to go abroad for a cure. At the farewell party the evil spirit stepped up to our patient and whispered in her ear, “Tonight he is alone. Something must happen to you so that you can go to his house.” And so indeed it happened: through her own strange behaviour she came back to his house, and thus she attained her desire.

[12]     After this explanation everyone will probably be inclined to assume that only a devilish subtlety could devise such a chain of circumstances and set it to work. There is no doubt about the subtlety, but its moral evaluation remains a doubtful matter, because I must emphasize that the motives leading to this dramatic dénouement were in no sense conscious. To the patient, the whole story seemed to happen of itself, without her being conscious of any motive. But the previous history makes it perfectly clear that everything was unconsciously directed to this end, while the conscious mind was struggling to bring about the engagement to Mr. B. The unconscious drive in the other direction was stronger.

[13]     So once more we return to our original question, namely, whence comes the pathological (i.e., peculiar or exaggerated) nature of the reaction to the trauma? On the basis of a conclusion drawn from analogous experiences, we conjectured that in this case too there must be, in addition to the trauma, a disturbance in the erotic sphere. This conjecture has been entirely confirmed, and we have learnt that the trauma, the ostensible cause of the illness, is no more than an occasion for something previously not conscious to manifest itself, i.e., an important erotic conflict. Accordingly the trauma loses its exclusive significance, and is replaced by a much deeper and more comprehensive conception which sees the pathogenic agent as an erotic conflict.

[14]     One often hears the question: why should the erotic conflict be the cause of the neurosis rather than any other conflict? To this we can only answer: no one asserts that it must be so, but in point of fact it frequently is so. In spite of all indignant protestations to the contrary, the fact remains that love,10 its problems and its conflicts, is of fundamental importance in human life and, as careful inquiry consistently shows, is of far greater significance than the individual suspects.

[15]     The trauma theory has therefore been abandoned as antiquated; for with the discovery that not the trauma but a hidden erotic conflict is the root of the neurosis, the trauma loses its causal significance.11