On the occasion of the opening of the Hebrew University 2 страница

The patient had recovered and had remained well and, in fact, had become capable of doing serious work. But over the final stage of this hypnotic treatment there rested a veil of obscurity, which Breuer never raised for me; and I could not understand why he had so long kept secret what seemed to me an invaluable discovery instead of making science the richer by it. The immediate question, however, was whether it was possible to generalize from what he had found in a single case. The state of things which he had discovered seemed to me to be of so fundamental a nature that I could not believe it could fail to be present in any case of hysteria if it had been proved to occur in a single one. But the question could only be decided by experience. I therefore began to repeat Breuer’s investigations with my own patients and eventually, especially after my visit to Bernheim in 1889 had taught me the limitations of hypnotic suggestion, I worked at nothing else. After observing for several years that his findings were invariably confirmed in every case of hysteria that was accessible to such treatment, and after having accumulated a considerable amount of material in the shape of observations analogous to his, I proposed to him that we should issue a joint publication. At first he objected vehemently, but in the end he gave way, especially, since, in the meantime, Janet’s works had anticipated some of his results, such as the tracing back of hysterical symptoms to events in the patient’s life, and their removal by means of hypnotic reproduction in statu nascendi. In 1893 we issued a preliminary communication, ‘On the Psychical Mechanism of Hysterical Phenomena’, and in 1895 there followed our book, Studies on Hysteria.

If the account I have so far given has led the reader to expect that the Studies on Hysteria must, in all essentials of their material content, be the product of Breuer’s mind, that is precisely what I myself have always maintained and what it has been my aim to repeat here. As regards the theory put forward in the book, I was partly responsible, but to an extent which it is to-day no longer possible to determine. That theory was in any case unpretentious and hardly went beyond the direct description of the observations. It did not seek to establish the nature of hysteria but merely to throw light upon the origin of its symptoms. Thus it laid stress upon the significance of the life of the emotions and upon the importance of distinguishing between mental acts which are unconscious and those which are conscious (or rather capable of being conscious); it introduced a dynamic factor, by supposing that a symptom arises through the damming-up of an affect, and an economic factor, by regarding that same symptom as the product of the transformation of an amount of energy which would otherwise have been employed in some other way. (This latter process was described as conversion.) Breuer spoke of our method as cathartic; its therapeutic aim was explained as being to provide that the quota of affect used for maintaining the symptom, which had got on to the wrong lines and had, as it were, become strangulated there, should be directed on to the normal path along which it could obtain discharge (or abreaction). The practical results of the cathartic procedure were excellent. Its defects, which became evident later, were those of all forms of hypnotic treatment. There are still a number of psychotherapists who have not gone beyond catharsis as Breuer understood it and who still speak in its favour. Its value as an abridged method of treatment was shown afresh by Simmel in his treatment of war neuroses in the German army during the Great War. The theory of catharsis had not much to say on the subject of sexuality. In the case histories which I contributed to the Studies sexual factors played a certain part, but scarcely more attention was paid to them than to other emotional excitations. Breuer wrote of the girl, who has since become famous as his first patient, that her sexual side was extraordinarily undeveloped. It would have been difficult to guess from the Studies on Hysteria what an importance sexuality has in the aetiology of the neuroses.

The stage of development which now followed, the transition from catharsis to psycho-analysis proper, has been described by me several times already in such detail that I shall find it difficult to bring forward any new facts. The event which formed the opening of this period was Breuer’s retirement from our common work, so that I became the sole administrator of his legacy. There had been differences of opinion between us at quite an early stage, but they had not been a ground for our separating. In answering the question of when it is that a mental process becomes pathogenic - that is, when it is that it becomes impossible for it to be dealt with normally - Breuer preferred what might be called a physiological theory: he thought that the processes which could not find a normal outcome were such as had originated during unusual, ‘hypnoid’, mental states. This opened the further question of the origin of these hypnoid states. I, on the other hand, was inclined to suspect the existence of an interplay of forces and the operation of intentions and purposes such as are to be observed in normal life. Thus it was a case of ‘hypnoid hysteria’ versus ‘neuroses of defence’. But such differences as this would scarcely have alienated him from the subject if there had not been other factors at work. One of these was undoubtedly that his work as a physician and family doctor took up much of his time, and that he could not, like me, devote his whole strength to the work of catharsis. Again, he was affected by the reception which our book had received both in Vienna and in Germany. His self-confidence and powers of resistance were not developed so fully as the rest of his mental organization. When, for instance, the Studies met with a severe rebuff from Strümpell, I was able to laugh at the lack of comprehension which his criticism showed, but Breuer felt hurt and grew discouraged. But what contributed chiefly to his decision was that my own further work led in a direction to which he found it impossible to reconcile himself.

2 The theory which we had attempted to construct in the Studies remained, as I have said, very incomplete; and in particular we had scarcely touched on the problem of aetiology, on the question of the ground in which the pathogenic process takes root. I now learned from my rapidly increasing experience that it was not any kind of emotional excitation that was in action behind the phenomena of neurosis but habitually one of a sexual nature, whether it was a current sexual conflict or the effect of earlier sexual experiences. I was not prepared for this conclusion and my expectations played no part in it, for I had begun my investigation of neurotics quite unsuspectingly. While I was writing my ‘History of the Psycho-Analytic Movement’ in 1914, there recurred to my mind some remarks that had been made to me by Breuer, Charcot, and Chrobak, which might have led me to this discovery earlier. But at the time I heard them I did not understand what these authorities meant; indeed they had told me more than they knew themselves or were prepared to defend. What I heard from them lay dormant and inactive within me, until the chance of my cathartic experiments brought it out as an apparently original discovery. Nor was I then aware that in deriving hysteria from sexuality I was going back to the very beginnings of medicine and following up a thought of Plato’s. It was not until later that I learnt this from an essay by Havelock Ellis.

Under the influence of my surprising discovery, I now took a momentous step. I went beyond the domain of hysteria and began to investigate the sexual life of the so-called neurasthenics who used to visit me in numbers during my consultation hours. This experiment cost me, it is true, my popularity as a doctor, but it brought me convictions which to-day, almost thirty years later, have lost none of their force. There was a great deal of equivocation and mystery-making to be overcome, but, once that had been done, it turned out that in all of these patients grave abuses of the sexual function were present. Considering how extremely widespread are these abuses on the one hand and neurasthenia on the other, a frequent coincidence between the two would not have proved much; but there was more in it than that one bald fact. Closer observation suggested to me that it was possible to pick out from the confused jumble of clinical pictures covered by the name of neurasthenia two fundamentally different types, which might appear in any degree of mixture but which were nevertheless to be observed in their pure forms. In the one type the central phenomenon was the anxiety attack with its equivalents, rudimentary forms and chronic substitutive symptoms; I consequently gave it the name of anxiety neurosis, and limited the term neurasthenia to the other type. Now it was easy to establish the fact that each of these types had a different abnormality of sexual life as its corresponding aetiological factor: in the former, coitus interruptus, unconsummated excitation and sexual abstinence, and in the latter, excessive masturbation and too numerous nocturnal emissions. In a few specially instructive cases, which had shown a surprising alteration in the clinical picture from one type to the other, it could be proved that there had been a corresponding change in the underlying sexual régime. If it was possible to put an end to the abuse and allow its place to be taken by normal sexual activity, a striking improvement in the condition was the reward.

I was thus led into regarding the neuroses as being without exception disturbances of the sexual function, the so-called ‘actual neuroses’ being the direct toxic expression of such disturbances and the psychoneuroses their mental expression. My medical conscience felt pleased at my having arrived at this conclusion. I hoped that I had filled up a gap in medical science, which, in dealing with a function of such great biological importance, had failed to take into account any injuries beyond those caused by infection or by gross anatomical lesions. The medical aspect of the matter was, moreover, supported by the fact that sexuality was not something purely mental. It had a somatic side as well, and it was possible to assign special chemical processes to it and to attribute sexual excitation to the presence of some particular, though at present unknown, substances. There must also have been some good reason why the true spontaneous neuroses resembled no group of diseases more closely than the phenomena of intoxication and abstinence, which are produced by the administration or privation of certain toxic substances, or than exophthalmic goitre, which is known to depend upon the product of the thyroid gland.

Since that time I have had no opportunity of returning to the investigation of the ‘actual neuroses’; nor has this part of my work been continued by anyone else. If I look back to-day at my early findings, they strike me as being the first rough outlines of what is probably a far more complicated subject. But on the whole they seem to me still to hold good. I should have been very glad if I had been able, later on, to make a psycho-analytic examination of some more cases of simple juvenile neurasthenia, but unluckily the occasion did not arise. To avoid misconceptions, I should like to make it clear that I am far from denying the existence of mental conflicts and of neurotic complexes in neurasthenia. All that I am asserting is that the symptoms of these patients are not mentally determined or removable by analysis, but that they must be regarded as direct toxic consequences of disturbed sexual chemical processes.

During the years that followed the publication of the Studies, having reached these conclusions upon the part played by sexuality in the aetiology of the neuroses, I read some papers on the subject before various medical societies, but was only met with incredulity and contradiction. Breuer did what he could for some time longer to throw the great weight of his personal influence into the scales in my favour, but he effected nothing and it was easy to see that he too shrank from recognizing the sexual aetiology of the neuroses. He might have crushed me or at least disconcerted me by pointing to his own first patient, in whose case sexual factors had ostensibly played no part whatever. But he never did so, and I could not understand why this was, until I came to interpret the case correctly and to reconstruct, from some remarks which he had made, the conclusion of his treatment of it. After the work of catharsis had seemed to be completed, the girl had suddenly developed a condition of ‘transference love’; he had not connected this with her illness, and had therefore retired in dismay. It was obviously painful to him to be reminded of this apparent contretemps. His attitude towards me oscillated for some time between appreciation and sharp criticism; then accidental difficulties arose, as they never fail to do in a strained situation, and we parted.

Another result of my taking up the study of nervous disorders in general was that I altered the technique of catharsis. I abandoned hypnotism and sought to replace it by some other method, because I was anxious not to be restricted to treating hysteriform conditions. Increasing experience had also given rise to two grave doubts in my mind as to the use of hypnotism even as a means to catharsis. The first was that even the most brilliant results were liable to be suddenly wiped away if my personal relation with the patient became disturbed. It was true that they would be re-established if a reconciliation could be effected; but such an occurrence proved that the personal emotional relation between doctor and patient was after all stronger than the whole cathartic process, and it was precisely that factor which escaped every effort at control. And one day I had an experience which showed me in the crudest light what I had long suspected. It related to one of my most acquiescent patients, with whom hypnotism had enabled me to bring about the most marvellous results, and whom I was engaged in relieving of her suffering by tracing back her attacks of pain to their origins. As she woke up on one occasion, she threw her arms round my neck. The unexpected entrance of a servant relieved us from a painful discussion, but from that time onwards there was a tacit understanding between us that the hypnotic treatment should be discontinued. I was modest enough not to attribute the event to my own irresistible personal attraction, and I felt that I had now grasped the nature of the mysterious element that was at work behind hypnotism. In order to exclude it, or at all events to isolate it, it was necessary to abandon hypnotism.

But hypnotism had been of immense help in the cathartic treatment, by widening the field of the patient’s consciousness and putting within his reach knowledge which he did not possess in his waking life. It seemed no easy task to find a substitute for it. While I was in this perplexity there came to my help the recollection of an experiment which I had often witnessed while I was with Bernheim. When the subject awoke from the state of somnambulism, he seemed to have lost all memory of what had happened while he was in that state. But Bernheim maintained that the memory was present all the same; and if he insisted on the subject remembering, if he asseverated that the subject knew it all and had only to say it, and if at the same time he laid his hand on the subject’s forehead, then the forgotten memories used in fact to return, hesitatingly at first, but eventually in a flood and with complete clarity. I determined that I would act in the same way. My patients, I reflected, must in fact ‘know’ all the things which had hitherto only been made accessible to them in hypnosis; and assurances and encouragement on my part, assisted perhaps by the touch of my hand, would, I thought, have the power of forcing the forgotten facts and connections into consciousness. No doubt this seemed a more laborious process than putting the patients into hypnosis, but it might prove highly instructive. So I abandoned hypnotism, only retaining my practice of requiring the patient to lie upon a sofa while I sat behind him, seeing him, but not seen myself.6

III

My expectations were fulfilled; I was set free from hypnotism. But along with the change in technique the work of catharsis took on a new complexion. Hypnosis had screened from view an interplay of forces which now came in sight and the understanding of which gave a solid foundation to my theory.

How had it come about that the patients had forgotten so many of the facts of their external and internal lives but could nevertheless recollect them if a particular technique was applied? Observation supplied an exhaustive answer to these questions. Everything that had been forgotten had in some way or other been distressing; it had been either alarming or painful or shameful by the standards of the subject’s personality. It was impossible not to conclude that that was precisely why it had been forgotten - that is, why it had not remained conscious. In order to make it conscious again in spite of this, it was necessary to overcome something that fought against one in the patient; it was necessary to make efforts on one’s own part so as to urge and compel him to remember. The amount of effort required of the physician varied in different cases; it increased in direct proportion to the difficulty of what had to be remembered. The expenditure of force on the part of the physician was evidently the measure of a resistance on the part of the patient. It was only necessary to translate into words what I myself had observed, and I was in possession of the theory of repression.

It was now easy to reconstruct the pathogenic process. Let us keep to a simple example, in which a particular impulsion had arisen in the subject’s mind but was opposed by other powerful impulsions. We should have expected the mental conflict which now arose to take the following course. The two dynamic quantities - for our present purposes let us call them ‘the instinct’ and ‘the resistance’ - would struggle with each other for some time in the fullest light of consciousness, until the instinct was repudiated and the cathexis of energy withdrawn from its impulsion. This would have been the normal solution. In a neurosis, however (for reasons which were still unknown), the conflict found a different outcome. The ego drew back, as it were, on its first collision with the objectionable instinctual impulse; it debarred the impulse from access to consciousness and to direct motor discharge, but at the same time the impulse retained its full cathexis of energy. I named this process repression; it was a novelty, and nothing like it had ever before been recognized in mental life. It was obviously a primary mechanism of defence, comparable to an attempt at flight, and was only a forerunner of the later-developed normal condemning judgement. The first act of repression involved further consequences. In the first place the ego was obliged to protect itself against the constant threat of a renewed advance on the part of the repressed impulse by making a permanent expenditure of energy, an anticathexis, and it thus impoverished itself. On the other hand, the repressed impulse, which was now unconscious, was able to find means of discharge and of substitutive satisfaction by circuitous routes and thus to bring the whole purpose of the repression to nothing. In the case of conversion hysteria the circuitous route led to the somatic innervation; the repressed impulse broke its way through at some point or other and produced symptoms. The symptoms were thus results of a compromise, for although they were substitutive satisfactions they were nevertheless distorted and deflected from their aim owing to the resistance of the ego.

The theory of repression became the corner-stone of our understanding of the neuroses. A different view had now to be taken of the task of therapy. Its aim was no longer to ‘abreact’ an affect which had got on to the wrong lines but to uncover repressions and replace them by acts of judgement which might result either in the accepting or in the condemning of what had formerly been repudiated. I showed my recognition of the new situation by no longer calling my method of investigation and treatment catharsis but psycho-analysis.

It is possible to take repression as a centre and to bring all the elements of psycho-analytic theory into relation with it. But before doing so I have a further comment of a polemical nature to make. According to Janet’s view a hysterical woman was a wretched creature who, on account of a constitutional weakness, was unable to hold her mental acts together, and it was for that reason that she fell a victim to a splitting of her mind and to a restriction of the field of her consciousness. The outcome of psycho-analytic investigations, on the other hand, showed that these phenomena were the result of dynamic factors - of mental conflict and of repression. This distinction seems to me to be far-reaching enough to put an end to the glib repetition of the view that whatever is of value in psycho-analysis is merely borrowed from the ideas of Janet. The reader will have learned from my account that historically psycho-analysis is completely independent of Janet’s discoveries, just as in its content it diverges from them and goes far beyond them. Janet’s works would never have had the implications which have made psycho-analysis of such importance to the mental sciences and have made it attract such universal interest. I always treated Janet himself with respect, since his discoveries coincided to a considerable extent with those of Breuer, which had been made earlier but were published later than his. But when in the course of time psycho-analysis became a subject of discussion in France, Janet behaved ill, showed ignorance of the facts and used ugly arguments. And finally he revealed himself to my eyes and destroyed the value of his own work by declaring that when he had spoken of ‘unconscious’ mental acts he had meant nothing by the phrase - it had been no more than a façon de parler.

8 But the study of pathogenic repressions and of other phenomena which have still to be mentioned compelled psycho-analysis to take the concept of the ‘unconscious’ seriously. Psycho-analysis regarded everything mental as being in the first instance unconscious; the further quality of ‘consciousness’ might also be present, or again it might be absent. This of course provoked a denial from the philosophers, for whom ‘conscious’ and ‘mental’ were identical, and who protested that they could not conceive of such an absurdity as the ‘unconscious mental’. There was no help for it, however, and this idiosyncrasy of the philosophers could only be disregarded with a shrug. Experience (gained from pathological material, of which the philosophers were ignorant) of the frequency and power of impulses of which one knew nothing directly, and whose existence had to be inferred like some fact in the external world, left no alternative open. It could be pointed out, incidentally, that this was only treating one’s own mental life as one had always treated other people’s. One did not hesitate to ascribe mental processes to other people, although one had no immediate consciousness of them and could only infer them from their words and actions. But what held good for other people must be applicable to oneself. Anyone who tried to push the argument further and to conclude from it that one’s own hidden processes belonged actually to a second consciousness would be faced with the concept of a consciousness of which one knew nothing, of an ‘unconscious consciousness’ - and this would scarcely be preferable to the assumption of an ‘unconscious mental’. If on the other hand one declared, like some other philosophers, that one was prepared to take pathological phenomena into account, but that the processes underlying them ought not to be described as mental but as ‘psychoid’, the difference of opinion would degenerate into an unfruitful dispute about words, though even so expediency would decide in favour of keeping the expression ‘unconscious mental’. The further question as to the ultimate nature of this unconscious is no more sensible or profitable than the older one as to the nature of the conscious.

It would be more difficult to explain concisely how it came about that psycho-analysis made a further distinction in the unconscious, and separated it into a preconscious and an unconscious proper. It will be sufficient to say that it appeared a legitimate course to supplement the theories that were a direct expression of experience with hypotheses that were designed to facilitate the handling of the material and related to matters which could not be a subject of immediate observation. The very same procedure is adopted by the older sciences. The subdivision of the unconscious is part of an attempt to picture the apparatus of the mind as being built up of a number of agencies or systems whose relations to one another are expressed in spatial terms, without, however, implying any connection with the actual anatomy of the brain. (I have described this as the topographical method of approach.) Such ideas as these are part of a speculative superstructure of psycho-analysis, any portion of which can be abandoned or changed without loss or regret the moment its inadequacy has been proved. But there is still plenty to be described that lies closer to actual experience.

9 I have already mentioned that my investigation of the precipitating and underlying causes of the neuroses led me more and more frequently to conflicts between the subject’s sexual impulses and his resistances to sexuality. In my search for the pathogenic situations in which the repressions of sexuality had set in and in which the symptoms, as substitutes for what was repressed, had had their origin, I was carried further and further back into the patient’s life and ended by reaching the first years of his childhood. What poets and students of human nature had always asserted turned out to be true: the impressions of that early period of life, though they were for the most part buried in amnesia, left ineradicable traces upon the individual’s growth and in particular laid down the disposition to any nervous disorder that was to follow. But since these experiences of childhood were always concerned with sexual excitations and the reaction against them, I found myself faced by the fact of infantile sexuality - once again a novelty and a contradiction of one of the strongest of human prejudices. Childhood was looked upon as ‘innocent’ and free from the lusts of sex, and the fight with the demon of ‘sensuality’ was not thought to begin until the troubled age of puberty. Such occasional sexual activities as it had been impossible to overlook in children were put down as signs of degeneracy or premature depravity or as a curious freak of nature. Few of the findings of psycho-analysis have met with such universal contradiction or have aroused such an outburst of indignation as the assertion that the sexual function starts at the beginning of life and reveals its presence by important signs even in childhood. And yet no other finding of analysis can be demonstrated so easily and so completely.

Before going further into the question of infantile sexuality I must mention an error into which I fell for a while and which might well have had fatal consequences for the whole of my work. Under the influence of the technical procedure which I used at that time, the majority of my patients reproduced from their childhood scenes in which they were sexually seduced by some grown-up person. With female patients the part of seducer was almost always assigned to their father. I believed these stories, and consequently supposed that I had discovered the roots of the subsequent neurosis in these experiences of sexual seduction in childhood. My confidence was strengthened by a few cases in which relations of this kind with a father, uncle, or elder brother had continued up to an age at which memory was to be trusted. If the reader feels inclined to shake his head at my credulity, I cannot altogether blame him; though I may plead that this was at a time when I was intentionally keeping my critical faculty in abeyance so as to preserve an unprejudiced and receptive attitude towards the many novelties which were coming to my notice every day. When, however, I was at last obliged to recognize that these scenes of seduction had never taken place, and that they were only phantasies which my patients had made up or which I myself had perhaps forced on them, I was for some time completely at a loss. My confidence alike in my technique and in its results suffered a severe blow; it could not be disputed that I had arrived at these scenes by a technical method which I considered correct, and their subject-matter was unquestionably related to the symptoms from which my investigation had started. When I had pulled myself together, I was able to draw the right conclusions from my discovery: namely, that the neurotic symptoms were not related directly to actual events but to wishful phantasies, and that as far as the neurosis was concerned psychical reality was of more importance than material reality. I do not believe even now that I forced the seduction-phantasies on my patients, that I ‘suggested’ them. I had in fact stumbled for the first time upon the Oedipus complex, which was later to assume such an overwhelming importance, but which I did not recognize as yet in its disguise of phantasy. Moreover, seduction during childhood retained a certain share, though a humbler one, in the aetiology of neuroses. But the seducers turned out as a rule to have been older children.

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