Contributions to the neue freie presse 16 страница

And here we have the domination of compulsion and doubt such as we meet with in the mental life of obsessional neurotics.

The doubt corresponds to the patient’s internal perception of his own indecision, which, in consequence of the inhibition of his love by his hatred, takes possession of him in the face of every intended action. The doubt is in reality a doubt of his own love - which ought to be the most certain thing in his whole mind; and it becomes diffused over everything else, and is especially apt to become displaced on to what is most insignificant and small.¹ A man who doubts his own love may, or rather must, doubt every lesser thing.²

¹ Compare the use of ‘representation by something very small’ as a technique in making jokes. Cf. Jokes and their Relation to the Unconscious.

² So in the love-verses addressed by Hamlet to Ophelia:

Doubt thou the stars are fire;

Doubt that the sun doth move;

Doubt truth to be a liar;

But never doubt I love.9

It is this same doubt that leads the patient to uncertainty about his protective measures, and to his continual repetition of them in order to banish that uncertainty; and it is this doubt, too, that eventually brings it about that the patient’s protective acts themselves become as impossible to carry out as his original inhibited decision in connection with his love. At the beginning of my investigations I was led to assume another and more general origin for the uncertainty of obsessional neurotics and one which seemed to be nearer the normal. If, for instance, while I am writing a letter some one interrupts me with questions, I afterwards feel a quite justifiable uncertainty as to what I may not have written under the influence of the disturbance, and, to make sure, I am obliged to read the letter over after I have finished it. In the same way I might suppose that the uncertainty of obsessional neurotics, when they are praying, for instance, is due to unconscious phantasies constantly mingling with their prayers and disturbing them. This hypothesis is correct, but it may be easily reconciled with what I have just said. It is true that the patient’s uncertainty whether he has carried through a protective measure is due to the disturbing effect of unconscious phantasies; but the content of these phantasies is precisely the contrary impulse - which it was the very aim of the prayer to ward off. This became clearly evident in our patient on one occasion, for the disturbing element did not remain unconscious but made its appearance openly. The words he wanted to use in his prayer were, ‘May God protect her’, but a hostile ‘not’ suddenly darted out of his unconscious and inserted itself into the sentence; and he understood that this was an attempt at a curse (p. 2152). If the ‘not’ had remained mute, he would have found himself in a state of uncertainty and would have kept on prolonging his prayers indefinitely. But since it became articulate he eventually gave up praying. Before doing so, however, he, like other obsessional patients, tried every kind of method for preventing the opposite feeling from insinuating itself. He shortened his prayers, for instance, or said them more rapidly. And similarly other patients will endeavour to ‘isolate’ all such protective acts from other things. But none of these technical procedures are of any avail in the long run. If the impulse of love achieves any success by displacing itself on to some trivial act, the impulse of hostility will very soon follow it on to its new ground and once more proceed to undo all that it has done.

And when the obsessional patient lays his finger on the weak spot in the security of our mental life - on the untrustworthiness of our memory - the discovery enables him to extend his doubt over everything, even over actions which have already been performed and which have so far had no connection with the love-hatred complex, and over the entire past. I may recall the instance of the woman who had just bought a comb for her little daughter in a shop, and, becoming suspicious of her husband, began to doubt whether she had not as a matter of fact been in possession of the comb for a long time. Was not this woman saying point-blank: ‘If I can doubt your love’ (and this was only a projection of her doubt of her own love for him), ‘then I can doubt this too, then I can doubt everything’ - thus revealing to us the hidden meaning of neurotic doubt?

The compulsion on the other hand is an attempt at a compensation for the doubt and at a correction of the intolerable conditions of inhibition to which the doubt bears witness. If the patient, by the help of displacement, succeeds at last in bringing one of his inhibited intentions to a decision, then the intention must be carried out. It is true that this intention is not his original one, but the energy dammed up in the latter cannot let slip the opportunity of finding an outlet for its discharge in the substitutive act. Thus this energy makes itself felt now in commands and now in prohibitions, according as the affectionate impulse or the hostile one snatches control of the pathway leading to discharge. If it happens that a compulsive command cannot be obeyed, the tension becomes intolerable and is perceived by the patient in the form of extreme anxiety.(But the pathway leading to a substitutive act, even where the displacement has been on to something very small, is so hotly contested, that such an act can as a rule be carried out only in the shape of a protective measure intimately associated with the very impulse which it is designed to ward off.

Furthermore, by a sort of regression, preparatory acts become substituted for the final decision, thinking replaces acting, and, instead of the substitutive act, some thought preliminary to it asserts itself with all the force of compulsion. According as this regression from acting to thinking is more or less marked, a case of obsessional neurosis will exhibit the characteristics of obsessive thinking (that is, of obsessional ideas) or of obsessive acting in the narrower sense of the word. True obsessional acts such as these, however, are only made possible because they constitute a kind of reconciliation, in the shape of a compromise, between the two antagonistic impulses. For obsessional acts tend to approximate more and more - and the longer the disorder lasts the more evident does this become - to infantile sexual acts of a masturbatory character. Thus in this form of the neurosis acts of love are carried out in spite of everything, but only by the aid of a new kind of regression; for such acts no longer relate to another person, the object of love and hatred, but are auto-erotic acts such as occur in infancy.

The first kind of regression, that from acting to thinking, is facilitated by another factor concerned in the production of the neurosis. The histories of obsessional patients almost invariably reveal an early development and premature repression of the sexual instinct of looking and knowing; and, as we know, a part of the infantile sexual activity of our present patient was governed by that instinct.¹

We have already mentioned the important part played by the sadistic instinctual components in the genesis of obsessional neuroses. Where the epistemophilic instinct is a preponderant feature in the constitution of an obsessional patient, brooding becomes the principal symptom of the neurosis. The thought-process itself becomes sexualized, for the sexual pleasure which is normally attached to the content of thought becomes shifted on to the act of thinking itself, and the satisfaction derived from reaching the conclusion of a line of thought is experienced as a sexual satisfaction. In the various forms of obsessional neurosis in which the epistemophilic instinct plays a part, its relation to thought-processes makes it particularly well adapted to attract the energy which is vainly endeavouring to make its way forward into action, and divert it into the sphere of thought, where there is a possibility of its obtaining pleasurable satisfaction of another sort. In this way, with the help of the epistemophilic instinct, the substitutive act may in its turn be replaced by preparatory acts of thought. But procrastination in action is soon replaced by lingering over thoughts, and eventually the whole process, together with all its peculiarities, is transferred into the new sphere, just as in America an entire house will sometimes be shifted from one site to another.

¹ The very high average of intellectual capacity among obsessional patients is probably also connected with this fact.2

I may now venture, upon the basis of the preceding discussion, to determine the psychological characteristic, so long sought after, which lends to the products of an obsessional neurosis their ‘obsessive’ or compulsive quality. A thought-process is obsessive or compulsive when, in consequence of an inhibition (due to a conflict of opposing impulses) at the motor end of the psychical system, it is undertaken with an expenditure of energy which (as regards both quality and quantity) is normally reserved for actions alone; or, in other words, an obsessive or compulsive thought is one whose function it is to represent an act regressively. No one, I think, will question my assumption that processes of thought are ordinarily conducted (on grounds of economy) with smaller displacements of energy, probably at a higher level, than are acts intended to bring about discharge or to modify the external world.

The obsessive thought which has forced its way into consciousness with such excessive violence has next to be secured against the efforts made by conscious thought to resolve it. As we already know, this protection is afforded by the distortion which the obsessive thought has undergone before becoming conscious. But this is not the only means employed. In addition, each separate obsessional idea is almost invariably removed from the situation in which it originated and in which, in spite of its distortion, it would be most easily comprehensible. With this end in view, in the first place an interval of time is inserted between the pathogenic situation and the obsession that arises from it, so as to lead astray any conscious investigation of its causal connections, and in the second place the content of the obsession is taken out of its particular setting by being generalized. Our patient’s ‘obsession for understanding’ is an example of this (p. 2150). But perhaps a better one is afforded by another patient. This was a woman who prohibited herself from wearing any sort of personal adornment, though the exciting cause of the prohibition related only to one particular piece of jewellery: she had envied her mother the possession of it and had had hopes that one day she would inherit it. Finally, if we care to distinguish verbal distortion from distortion of content, there is yet another means by which the obsession is protected against conscious attempts at solution. And that is the choice of an indefinite or ambiguous wording. After being misunderstood, the wording may find its way into the patient’s ‘deliria’, and whatever further processes of development or substitution his obsession undergoes will then be based upon the misunderstanding and not upon the proper sense of the text. Observation will show, however, that the deliria constantly tend to form new connections with that part of the matter and wording of the obsession which is not present in consciousness.

I should like to go back once more to the instinctual life of obsessional neurotics and add one more remark upon it. It turned out that our patient, besides all his other characteristics, was a renifleur. By his own account, when he was a child he had recognized every one by their smell, like a dog; and even when he was grown up he was more susceptible to sensations of smell than most people.¹ I have met with the same characteristic in other neurotics, both in hysterical and in obsessional patients, and I have come to recognize that a tendency to taking pleasure in smell, which has become extinct since childhood, may play a part in the genesis of neurosis.² And here I should like to raise the general question whether the atrophy of the sense of smell (which was an inevitable result of man’s assumption of an erect posture) and the consequent organic repression of his pleasure in smell may not have had a considerable share in the origin of his susceptibility to nervous disease. This would afford us some explanation of why, with the advance of civilization, it is precisely the sexual life that must fall a victim to repression. For we have long known the intimate connection in the animal organization between the sexual instinct and the function of the olfactory organ.

¹ I may add that in his childhood he had been subject to strong coprophilic propensities. In this connection his anal erotism has already been noticed.

² For instance, in certain forms of fetishism.4 In bringing this paper to a close I may express a hope that, though my communication is incomplete in every sense, it may at least stimulate other workers to throw more light upon the obsessional neurosis by a deeper investigation of the subject. What is characteristic of this neurosis - what differentiates it from hysteria - is not, in my opinion, to be found in instinctual life but in the psychological field. I cannot take leave of my patient without putting on paper my impression that he had, as it were, disintegrated into three personalities: into one unconscious personality, that is to say, and into two preconscious ones between which his consciousness could oscillate. His unconscious comprised those of his impulses which had been suppressed at an early age and which might be described as passionate and evil impulses. In his normal state he was kind, cheerful, and sensible - an enlightened and superior kind of person - while in his third psychological organization he paid homage to superstition and asceticism. Thus he was able to have two different creeds and two different outlooks upon life. This second preconscious personality comprised chiefly the reaction-formations against his repressed wishes, and it was easy to foresee that it would have swallowed up the normal personality if the illness had lasted much longer. I have at present an opportunity of studying a lady suffering severely from obsessional acts. She has become similarly disintegrated into an easy-going and lively personality and into an exceedingly gloomy and ascetic one. She puts forward the first of them as her official ego, while in fact she is dominated by the second. Both of these psychical organizations have access to her consciousness, but behind her ascetic personality may be discerned the unconscious part of her being - quite unknown to her and composed of ancient and long-repressed wishful impulses.¹

¹ (Footnote added 1923:) The patient’s mental health was restored to him by the analysis which I have reported upon in these pages. Like so many other young men of value and promise, he perished in the Great War.5

FIVE LECTURES ON PSYCHO-ANALYSIS (1910)

Delivered on the Occasion of the Celebration

of the Twentieth Anniversary of the Foundation of CLARK UNIVERSITY, WORCESTER

MASSACHUSETTSSeptember 1909

To D^R. G. STANLEY HALL, PH.D., LL.D.President of Clark UniversityProfessor of Psychology and PedagogicsThis Work is Gratefully Dedicated9

FIRST LECTURE

LADIES AND GENTLEMEN, - It is with novel and bewildering feelings that I find myself in the New World, lecturing before an audience of expectant enquirers. No doubt I owe this honour only to the fact that my name is linked with the topic of psycho-analysis; and it is of psycho-analysis, therefore, that I intend to speak to you. I shall attempt to give you, as succinctly as possible, a survey of the history and subsequent development of this new method of examination and treatment.

If it is a merit to have brought psycho-analysis into being that merit is not mine.¹ I had no share in its earliest beginnings. I was a student and working for my final examinations at the time when another Viennese physician, Dr. Josef Breuer,² first (in 1880-2) made use of this procedure on a girl who was suffering from hysteria. Let us turn our attention straightaway to the history of this case and its treatment, which you will find set out in detail in the Studies on Hysteria³ which were published later by Breuer and myself.

But I should like to make one preliminary remark. It is not without satisfaction that I have learnt that the majority of my audience are not members of the medical profession. You have no need to be afraid that any special medical knowledge will be required for following what I have to say. It is true that we shall go along with the doctors on the first stage of our journey, but we shall soon part company with them and, with Dr. Breuer, shall pursue a quite individual path.

¹ [Footnote added 1923:] See, however, in this connection my remarks in ‘A History of the Psycho-Analytic Movement’ (1914d), where I assumed the entire responsibility for psycho-analysis.

² Dr. Josef Breuer, born in 1842, a Corresponding Member of the Kaiserliche Akademie der Wissenschaften, is well known for his work on respiration and on the physiology of the sense of equilibrium.

³ Some of my contributions to this book have been translated into English by Dr. A. A. Brill of New York: Selected Papers on Hysteria (New York, 1909).

Dr. Breuer’s patient was a girl of twenty-one, of high intellectual gifts. Her illness lasted for over two years, and in the course of it she developed a series of physical and psychological disturbances which decidedly deserved to be taken seriously. She suffered from a rigid paralysis, accompanied by loss of sensation, of both extremities on the right side of her body; and the same trouble from time to time affected her on her left side. Her eye movements were disturbed and her power of vision was subject to numerous restrictions. She had difficulties over the posture of her head; she had a severe nervous cough. She had an aversion to taking nourishment, and on one occasion she was for several weeks unable to drink in spite of a tormenting thirst. Her powers of speech were reduced, even to the point of her being unable to speak or understand her native language. Finally, she was subject to conditions of ‘absence’,¹ of confusion, of delirium, and of alteration of her whole personality, to which we shall have presently to turn our attention.

When you hear such an enumeration of symptoms, you will be inclined to think it safe to assume, even though you are not doctors, that what we have before us is a severe illness, probably affecting the brain, that it offers small prospect of recovery and will probably lead to the patient’s early decease. You must be prepared to learn from the doctors, however, that, in a number of cases which display severe symptoms such as these, it is justifiable to take a different and a far more favourable view. If a picture of this kind is presented by a young patient of the female sex, whose vital internal organs (heart, kidneys, etc.) are shown on objective examination to be normal, but who has been subjected to violent emotional shocks - if, moreover, her various symptoms differ in certain matters of detail from what would have been expected - then doctors are not inclined to take the case too seriously. They decide that what they have before them is not an organic disease of the brain, but the enigmatic condition which, from the time of ancient Greek medicine, has been known as ‘hysteria’ and which has the power of producing illusory pictures of a whole number of serious diseases. They consider that there is then no risk to life but that a return to health - even a complete one - is probable. It is not always quite easy to distinguish a hysteria like this from a severe organic illness. There is no need for us to know, however, how a differential diagnosis of that kind is made; it will suffice to have an assurance that the case of Breuer’s patient was precisely of a kind in which no competent physician could fail to make a diagnosis of hysteria. And here we may quote from the report of the patient’s illness the further fact that it made its appearance at a time when she was nursing her father, of whom she was devotedly fond, through the grave illness which led to his death, and that, as a result of her own illness, she was obliged to give up nursing him.

¹ [The French term.]1

So far it has been an advantage to us to accompany the doctors; but the moment of parting is at hand. For you must not suppose that a patient’s prospects of medical assistance are improved in essentials by the fact that a diagnosis of hysteria has been substituted for one of severe organic disease of the brain. Medical skill is in most cases powerless against severe diseases of the brain; but neither can the doctor do anything against hysterical disorders. He must leave it to kindly Nature to decide when and how his optimistic prognosis shall be fulfilled.¹

Thus the recognition of the illness as hysteria makes little difference to the patient; but to the doctor quite the reverse. It is noticeable that his attitude towards hysterical patients is quite other than towards sufferers from organic diseases. He does not have the same sympathy for the former as for the latter: for the hysteric’s ailment is in fact far less serious and yet it seems to claim to be regarded as equally so. And there is a further factor at work. Through his studies, the doctor has learnt many things that remain a sealed book to the layman: he has been able to form ideas on the causes of illness and on the changes it brings about - e.g. in the brain of a person suffering from apoplexy or from a malignant growth - ideas which must to some degree meet the case, since they allow him to understand the details of the illness. But all his knowledge - his training in anatomy, in physiology and in pathology - leaves him in the lurch when he is confronted by the details of hysterical phenomena. He cannot understand hysteria, and in the face of it he is himself a layman. This is not a pleasant situation for anyone who as a rule sets so much store by his knowledge. So it comes about that hysterical patients forfeit his sympathy. He regards them as people who are transgressing the laws of his science - like heretics in the eyes of the orthodox. He attributes every kind of wickedness to them, accuses them of exaggeration, of deliberate deceit, of malingering. And he punishes them by withdrawing his interest from them.

¹ I am aware that this is no longer the case; but in my lecture I am putting myself and my hearers back into the period before 1880. If things are different now, that is to a great extent the result of the activities whose history I am now sketching.2

Dr. Breuer’s attitude towards his patient deserved no such reproach. He gave her both sympathy and interest, even though, to begin with, he did not know how to help her. It seems likely that she herself made his task easier by the admirable qualities of intellect and character to which he has testified in her case history. Soon, moreover, his benevolent scrutiny showed him the means of bringing her a first instalment of help.

It was observed that, while the patient was in her states of ‘absence (altered personality accompanied by confusion), she was in the habit of muttering a few words to herself which seemed as though they arose from some train of thought that was occupying her mind. The doctor, after getting a report of these words, used to put her into a kind of hypnosis and then repeat them to her so as to induce her to use them as a starting point. The patient complied with the plan, and in this way reproduced in his presence the mental creations which had been occupying her mind during the ‘absences’ and which had betrayed their existence by the fragmentary words which she had uttered. They were profoundly melancholy phantasies - ‘day dreams’ we should call them - sometimes characterized by poetic beauty, and their starting-point was as a rule the position of a girl at her father’s sick-bed. When she had related a number of these phantasies, she was as if set free, and she was brought back to normal mental life. The improvement in her condition, which would last for several hours, would be succeeded next day by a further attack of ‘absence’; and this in turn would be removed in the same way by getting her to put into words her freshly constructed phantasies. It was impossible to escape the conclusion that the alteration in her mental state which was expressed in the ‘absences’ was a result of the stimulus proceeding from these highly emotional phantasies. The patient herself, who, strange to say, could at this time only speak and understand English, christened this novel kind of treatment the ‘talking cure’¹ or used to refer to it jokingly as ‘chimney sweeping’.¹

¹ [In English in the original.]3

It soon emerged, as though by chance, that this process of sweeping the mind clean could accomplish more than the merely temporary relief of her ever-recurring mental confusion. It was actually possible to bring about the disappearance of the painful symptoms of her illness, if she could be brought to remember under hypnosis, with an accompanying expression of affect, on what occasion and in what connection the symptom had first appeared. ‘It was in the summer during a period of extreme heat, and the patient was suffering very badly from thirst; for, without being able to account for it in any way, she suddenly found it impossible to drink. She would take up the glass of water that she longed for, but as soon as it touched her lips she would push it away like someone suffering from hydrophobia. As she did this, she was obviously in an absence for a couple of seconds. She lived only on fruit, such as melons, etc., so as to lessen her tormenting thirst. This had lasted for some six weeks, when one day during hypnosis she grumbled about her English "lady-companion", whom she did not care for, and went on to describe, with every sign of disgust, how she had once gone into this lady’s room and how her little dog - horrid creature! - had drunk out of a glass there. The patient had said nothing, as she had wanted to be polite. After giving further energetic expression to the anger she had held back, she asked for something to drink, drank a large quantity of water without any difficulty, and awoke from her hypnosis with the glass at her lips; and thereupon the disturbance vanished, never to return.’¹

With your permission, I should like to pause a moment over this event. Never before had anyone removed a hysterical symptom by such a method or had thus gained so deep an insight into its causation. It could not fail to prove a momentous discovery if the expectation were confirmed that others of the patient’s symptoms - perhaps the majority of them - had arisen and could be removed in this same manner. Breuer spared no pains in convincing himself that this was so, and he proceeded to a systematic investigation of the pathogenesis of the other and more serious symptoms of the patient’s illness. And it really was so. Almost all the symptoms had arisen in this way as residues - ‘precipitates’ they might be called - of emotional experiences. To these experiences, therefore, we later gave the name of ‘psychical traumas’, while the particular nature of the symptoms was explained by their relation to the traumatic scenes which were their cause. They were, to use a technical term, ‘determined’ by the scenes of whose recollection they represented residues, and it was no longer necessary to describe them as capricious or enigmatic products of the neurosis. One unexpected point, however, must be noticed. What left the symptom behind was not always a single experience. On the contrary, the result was usually brought about by the convergence of several traumas, and often by the repetition of a great number of similar ones. Thus it was necessary to reproduce the whole chain of pathogenic memories in chronological order, or rather in reversed order, the latest ones first and the earliest ones last; and it was quite impossible to jump over the later traumas in order to get back more quickly to the first, which was often the most potent one.

¹ Studies on Hysteria.4

No doubt you will now ask me for some further instances of the causation of hysterical symptoms besides the one I have already given you of a fear of water produced by disgust at a dog drinking out of a glass. But if I am to keep to my programme I shall have to restrict myself to very few examples. In regard to the patient’s disturbances of vision, for instance, Breuer describes how they were traced back to occasions such as one on which, ‘when she was sitting by her father’s bedside with tears in her eyes, he suddenly asked her what time it was. She could not see clearly; she made a great effort, and brought her watch near to her eyes. The face of the watch now seemed very big - thus accounting for her macropsia and convergent squint. Or again, she tried hard to suppress her tears so that the sick man should not see them.’¹ Moreover, all of the pathogenic impressions came from the period during which she was helping to nurse her sick father. ‘She once woke up during the night in great anxiety about the patient, who was in a high fever; and she was under the strain of expecting the arrival of a surgeon from Vienna who was to operate. Her mother had gone away for a short time and Anna was sitting at the bedside with her right arm over the back of her chair. She fell into a waking dream and saw a black snake coming towards the sick man from the wall to bite him. (It is most likely that there were in fact snakes in the field behind the house and that these had previously given the girl a fright; they would thus have provided the material for her hallucination.) She tried to keep the snake off, but it was as though she was paralysed. Her right arm, over the back of the chair, had gone to sleep, and had become anaesthetic and paretic; and when she looked at it the fingers turned into little snakes with death’s heads (the nails). (It seems probable that she had tried to use her paralysed right hand to drive off the snake and that its anaesthesia and paralysis has consequently become associated with the hallucination of the snake.) When the snake vanished, in her terror she tried to pray. But language failed her: she could find no tongue in which to speak, till at last she thought of some children’s verses in English and then found herself able to think and pray in that language.’¹ When the patient had recollected this scene in hypnosis, the rigid paralysis of her left arm, which had persisted since the beginning of her illness, disappeared, and the treatment was brought to an end.

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