Autobiographical note 75 страница

¹ This governess used to read every sort of book on sexual life and similar subjects, and talked to the girl about them, at the same time asking her quite frankly not to mention their conversations to her parents, as one could never tell what line they might take about them. For some time I looked upon this woman as the source of all Dora’s secret knowledge, and perhaps I was not entirely wrong in this.5

The poor woman had thrown a most unwelcome light on a part of Dora’s own behaviour. What the governess had from time to time been to Dora, Dora had been to Herr K.’s children. She had been a mother to them, she had taught them, she had gone for walks with them, she had offered them a complete substitute for the slight interest which their own mother showed in them. Herr K. and his wife had often talked of getting a divorce; but it never took place, because Herr K., who was an affectionate father, would not give up either of the two children. A common interest in the children had from the first been a bond between Herr K. and Dora. Her preoccupation with his children was evidently a cloak for something else that Dora was anxious to hide from herself and from other people.

The same inference was to be drawn both from her behaviour towards the children, regarded in the light of the governess’s behaviour towards herself, and from her silent acquiescence in her father’s relations with Frau K. - namely, that she had all these years been in love with Herr K. When I informed her of this conclusion she did not assent to it. It is true that she at once told me that other people besides (one of her cousins, for instance - a girl who had stopped with them for some time at B--) had said to her: ‘Why you’re simply wild about that man!’ But she herself could not be got to recollect any feelings of the kind. Later on, when the quantity of material that had come up had made it difficult for her to persist in her denial, she admitted that she might have been in love with Herr K. at B--' but declared that since the scene by the lake it had all been over.¹ In any case it was quite certain that the reproaches which she made against her father of having been deaf to the most imperative calls of duty and of having seen things in the light which was most convenient from the point of view of his own passions - these reproaches recoiled on her own head.²

¹ Compare the second dream.

² The question then arises: If Dora loved Herr K., what was the reason for her refusing him in the scene by the lake? Or at any rate, why did her refusal take such a brutal form, as though she were embittered against him? And how could a girl who was in love feel insulted by a proposal which was made in a manner neither tactless nor offensive?.6

Her other reproach against her father was that his ill-health was only a pretext and that he exploited it for his own purposes. This reproach, too, concealed a whole section of her own secret history. One day she complained of a professedly new symptom, which consisted of piercing gastric pains. ‘Whom are you copying now?’ I asked her, and found I had hit the mark. The day before she had visited her cousins, the daughters of the aunt who had died. The younger one had become engaged, and this had given occasion to the elder one for falling ill with gastric pains, and she was to be sent off to Semmering. Dora thought it was all just envy on the part of the elder sister; she always got ill when she wanted something, and what she wanted now was to be away from home so as not to have to look on at her sister’s happiness.¹ But Dora’s own gastric pains proclaimed the fact that she identified herself with her cousin, who, according to her, was a malingerer. Her grounds for this identification were either that she too envied the luckier girl her love, or that she saw her own story reflected in that of the elder sister, who had recently had a love-affair which had ended unhappily.² But she had also learned from observing Frau K. what useful things illnesses could become. Herr K. spent part of the year in travelling. Whenever he came back, he used to find his wife in bad health, although, as Dora knew, she had been quite well only the day before. Dora realized that the presence of the husband had the effect of making his wife ill, and that she was glad to be ill so as to be able to escape the conjugal duties which she so much detested. At this point in the discussion Dora suddenly brought in an allusion to her own alternations between poor and bad health during the first years of her girlhood at B--; and I was thus driven to suspect that her states of health were to be regarded as depending upon something else, in the same way as Frau K.’s. (It is a rule of psycho-analytic technique that an internal connection which is still undisclosed will announce its presence by means of a contiguity - a temporal proximity of associations; just as in writing, if ‘a’ and ‘b’ are put side by side, it means that the syllable ‘ab’ is to be formed out of them.) Dora had had a very large number of attacks of coughing accompanied by loss of voice. Could it be that the presence or absence of the man she loved had had an influence upon the appearance and disappearance of the symptoms of her illness? If this were so, it must be possible to discover some coincidence or other which would betray the fact. I asked her what the average length of these attacks had been. ‘From three to six weeks, perhaps.’ How long had Herr K.’s absences lasted? ‘Three to six weeks, too’, she was obliged to admit. Her illness was therefore a demonstration of her love for K., just as his wife’s was a demonstration of her dislike. It was only necessary to suppose that her behaviour had been the opposite of Frau K.’s and that she had been ill when he was absent and well when he had come back. And this really seemed to have been so, at least during the first period of the attacks. Later on it no doubt became necessary to obscure the coincidence between her attacks of illness and the absence of the man she secretly loved, lest its regularity should betray her secret. The length of the attacks would then remain as a trace of their original significance.

¹ An event of everyday occurrence between sisters.

² I shall discuss later on what further conclusion I drew from these gastric pains.7

I remembered that long before, while I was working at Charcot’s clinic, I had seen and heard how in cases of hysterical mutism writing operated vicariously in the place of speech. Such patients were able to write more fluently, quicker, and better than others did or than they themselves had done previously. The same thing had happened with Dora. In the first days of her attacks of aphonia ‘writing had always come specially easy to her’. No psychological elucidation was really required for this peculiarity, which was the expression of a physiological substitutive function enforced by necessity; it was noticeable, however, that such an elucidation was easily to be found. Herr K. used to write to her at length while he was travelling and to send her picture post-cards. It used to happen that she alone was informed as to the date of his return, and that his arrival took his wife by surprise. Moreover, that a person will correspond with an absent friend whom he cannot talk to is scarcely less obvious than that if he has lost his voice he will try to make himself understood in writing. Dora’s aphonia, then, allowed of the following symbolic interpretation. When the man she loved was away she gave up speaking; speech had lost its value since she could not speak to him. On the other hand, writing gained in importance, as being the only means of communication with him in his absence.

8 Am I now going on to assert that in every instance in which there are periodical attacks of aphonia we are to diagnose the existence of a loved person who is at times away from the patient? Nothing could be further from my intention. The determination of Dora’s symptoms is far too specific for it to be possible to expect a frequent recurrence of the same accidental aetiology. But, if so, what is the value of our elucidation of the aphonia in the present case? Have we not merely allowed ourselves to become the victims of a jeu d’esprit? I think not. In this connection we must recall the question which has so often been raised, whether the symptoms of hysteria are of psychical or of somatic origin, or whether, if the former is granted, they are necessarily all of them psychically determined. Like so many other questions to which we find investigators returning again and again without success, this question is not adequately framed. The alternatives stated in it do not cover the real essence of the matter. As far as I can see, every hysterical symptom involves the participation of both sides. It cannot occur without the presence of a certain degree of somatic compliance offered by some normal or pathological process in or connected with one of the bodily organs. And it cannot occur more than once - and the capacity for repeating itself is one of the characteristics of a hysterical symptom - unless it has a psychical significance, a meaning. The hysterical symptom does not carry this meaning with it, but the meaning is lent to it, soldered to it, as it were; and in every instance the meaning can be a different one, according to the nature of the suppressed thoughts which are struggling for expression. However, there are a number of factors at work which tend to make less arbitrary the relations between the unconscious thoughts and the somatic processes that are at their disposal as a means of expression, and which tend to make those relations approximate to a few typical forms. For therapeutic purposes the most important determinants are those given by the fortuitous psychical material; the clearing-up of the symptoms is achieved by looking for their psychical significance. When everything that can be got rid of by psycho-analysis has been cleared away, we are in a position to form all kinds of conjectures, which probably meet the facts, as regards the somatic basis of the symptoms - a basis which is as a rule constitutional and organic. Thus in Dora’s case we shall not content ourselves with a psycho-analytic interpretation of her attacks of coughing and aphonia; but we shall also indicate the organic factor which was the source of the ‘somatic compliance’ that enabled her to express her love for a man who was periodically absent. And if the connection between the symptomatic expression and the unconscious mental content should strike us as being in this case a clever tour de force, we shall be relieved to hear that it succeeds in creating the same impression in every other case and in every other instance.

I am prepared to be told at this point that there is no very great advantage in having been taught by psycho-analysis that the clue to the problem of hysteria is to be found not in ‘a peculiar instability of the molecules of the nerves’ or in a liability to ‘hypnoid states’ - but in a ‘somatic compliance’. But in reply to the objection I may remark that this new view has not only to some extent pushed the problem further back, but has also to some extent diminished it. We have no longer to deal with the whole problem, but only with the portion of it involving that particular characteristic of hysteria which differentiates it from other psychoneuroses. The mental events in all psycho-neuroses proceed for a considerable distance along the same lines before any question arises of the ‘somatic compliance’ which may afford the unconscious mental processes a physical outlet. When this factor is not forthcoming, something other than a hysterical symptom will arise out of the total situation; yet it will still be something of an allied nature, a phobia, perhaps, or an obsession - in short, a psychical symptom.

I now return to the reproach of malingering which Dora brought against her father. It soon became evident that this reproach corresponded to self-reproaches not only concerning her earlier states of ill-health but also concerning the present time. At such points the physician is usually faced by the task of guessing and filling in what the analysis offers him in the shape only of hints and allusions. I was obliged to point out to the patient that her present ill-health was just as much actuated by motives and was just as tendentious as had been Frau K.’s illness, which she had understood so well. There could be no doubt, I said, that she had an aim in view which she hoped to gain by her illness. That aim could be none other than to detach her father from Frau K. She had been unable to achieve this by prayers or arguments; perhaps she hoped to succeed by frightening her father (there was her farewell letter), or by awakening his pity (there were her fainting-fits), or if all this was in vain, at least she would be taking her revenge on him. She knew very well, I went on, how much he was attached to her, and that tears used to come into his eyes whenever he was asked after his daughter’s health. I felt quite convinced that she would recover at once if only her father were to tell her that he had sacrificed Frau K, for the sake of her health. But, I added, I hoped he would not let himself be persuaded to do this, for then she would have learned what a powerful weapon she had in her hands, and she would certainly not fail on every future occasion to make use once more of her liability to ill health. Yet if her father refused to give way to her, I was quite sure she would not let herself be deprived of her illness so easily.

0 I will pass over the details which showed how entirely correct all of this was, and I will instead add a few general remarks upon the part played in hysteria by the motives of illness. A motive for being ill is sharply to be distinguished as a concept from a potentiality for illness - from the material out of which symptoms are formed. The motives have no share in the formation of symptoms, and indeed are not present at the beginning of the illness. They only appear secondarily to it; but it is not until they have appeared that the disease is fully constituted.¹ Their presence can be reckoned upon in every case in which there is real suffering and which is of fairly long standing. A symptom comes into the patient’s mental life at first as an unwelcome guest; it has everything against it; and that is why it may vanish so easily, apparently of its own accord, under the influence of time. To begin with there is no use to which it can be put in the domestic economy of the mind; but very often it succeeds in finding one secondarily. Some psychical current or other finds it convenient to make use of it, and in that way the symptom manages to obtain a secondary function and remains, as it were, anchored fast in the patient’s mental life. And so it happens that any one who tries to make him well is to his astonishment brought up against a powerful resistance, which teaches him that the patient’s intention of getting rid of his complaint is not so entirely and completely serious as it seemed.² Let us imagine a workman, a bricklayer, let us say, who has fallen off a house and been crippled, and now earns his livelihood by begging at the street-corner. Let us then suppose that a miracle-worker comes along and promises him to make his crooked leg straight and capable of walking. It would be unwise, I think, to look forward to seeing an expression of peculiar bliss upon the man’s features. No doubt at the time of the accident he felt he was extremely unlucky, when he realized that he would never be able to do any more work and would have to starve or live upon charity. But since then the very thing which in the first instance threw him out of employment has become his source of income: he lives by his disablement. If that is taken from him he may become totally helpless. He has in the meantime forgotten his trade and lost his habits of industry; he has grown accustomed to idleness, and perhaps to drink as well.

¹ [Footnote added 1923:] This is not quite right. The statement that the motives of illness are not present at the beginning of the illness, but only appear secondarily to it, cannot be maintained. In the very next paragraph motives for being ill are mentioned which were in existence before the outbreak of illness, and were partly responsible for that outbreak. I subsequently found a better way of meeting the facts, by introducing a distinction between the primary advantage derived from the illness and the secondary one. The motive for being ill is, of course, invariably the gaining of some advantage. What follows in the later sentences of this paragraph applies to the secondary gain. But in every neurotic illness a primary gain has also to be recognized. In the first place, falling ill involves a saving of psychical effort; it emerges as being economically the most convenient solution where there is a mental conflict (we speak of a ‘flight into illness’), even though in most cases the ineffectiveness of such an escape becomes manifest at a later stage. This element in the primary gain may be described as the internal or psychological one, and it is, so to say, a constant one. But beyond this, external factors (such as in the instance given of the situation of a woman subjugated by her husband) may contribute motives for falling ill; and these will constitute the external element in the primary gain.

² A man of letters, who incidentally is also a physician - Arthur Schnitzler - has expressed this piece of knowledge very correctly in his Paracelsus.1

The motives for being ill often begin to be active even in childhood. A little girl in her greed for love does not enjoy having to share the affection of her parents with her brothers and sisters; and she notices that the whole of their affection is lavished on her once more whenever she arouses their anxiety by falling ill. She has now discovered a means of enticing out her parents’ love, and will make use of that means as soon as she has the necessary psychical material at her disposal for producing an illness. When such a child has grown up to be a woman she may find all the demands she used to make in her childhood countered owing to her marriage with an inconsiderate husband, who may subjugate her will, mercilessly exploit her capacity for work, and lavish neither his affection nor his money upon her. In that case ill-health will be her one weapon for maintaining her position. It will procure her the care she longs for; it will force her husband to make pecuniary sacrifices for her and to show her consideration, as he would never have done while she was well; and it will compel him to treat her with solicitude if she recovers, for otherwise a relapse will threaten. Her state of ill-health will have every appearance of being objective and involuntary - the very doctor who treats her will bear witness to the fact; and for that reason she will no need to feel any conscious self-reproaches at making such successful use of a means which she had found effective in her years of childhood.

And yet illnesses of this kind are the result of intention for the purposes they serve. They are as a rule levelled at a particular person, and consequently vanish with that person’s departure. The crudest and most commonplace views on the character of hysterical disorder - such as are to be heard from uneducated relatives or nurses - are in a certain sense right. It is true that the paralysed and bedridden woman would spring to her feet if a fire were to break out in her room, and that the spoiled wife would forget all her sufferings if her child were to fall dangerously ill or if some catastrophe were to threaten the family circumstances. People who speak of the patients in this way are right except upon a single point: they overlook the psychological distinction between what is conscious and what is unconscious. This may be permissible where children are concerned, but with adults it is no longer possible. That is why all these asseverations that it is ‘only a question of willing’ and all the encouragements and abuse that are addressed to the patient are of no avail. An attempt must first be made by the roundabout methods of analysis to convince the patient herself of the existence in her of an intention to be ill.

It is in combating the motives of illness that the weak point in every kind of therapeutic treatment of hysteria lies. This in quite generally true, and it applies equally to psycho-analysis. Destiny has an easier time of it in this respect: it need not concern itself either with the patient’s constitution or with his pathogenic material; it has only to take away a motive for being ill, and the patient is temporarily or perhaps even permanently freed from his illness. How many fewer miraculous cures and spontaneous disappearances of symptoms should we physicians have to register in cases of hysteria, if we were more often given a sight of the human interests which the patient keeps hidden from us! In one case, some stated period of time has elapsed; in a second, consideration for some other person has ceased to operate; in a third, the situation has been fundamentally changed by some external event - and the whole disorder which up till then had shown the greatest obstinacy, vanishes at a single blow, apparently of its own accord, but really because it has been deprived of its most powerful motive, one of the uses to which it has been put in the patient’s life.

Motives that support the patient in being ill are probably to be found in all fully developed cases. But there are some in which the motives are purely internal - such as desire for self-punishment, that is, penitence and remorse. It will be found much easier to solve the therapeutic problem in such cases than in those in which the illness is related to the attainment of some external aim. In Dora’s case that aim was clearly to touch her father’s heart and to detach him from Frau K.

None of her father’s actions seemed to have embittered her so much as his readiness to consider the scene by the lake as a product of her imagination. She was almost beside herself at the idea of its being supposed that she had merely fancied something on that occasion. For a long time I was in perplexity as to what the self-reproach could be which lay behind her passionate repudiation of this explanation of the episode. It was justifiable to suspect that there was something concealed, for a reproach which misses the mark gives no lasting offence. On the other hand, I came to the conclusion that Dora’s story must correspond to the facts in every respect. No sooner had she grasped Herr K.’s intention than, without letting him finish what he had to say, she had given him a slap in the face and hurried away. Her behaviour must have seemed as incomprehensible to the man after she had left him as to us, for he must long before have gathered from innumerable small signs that he was secure of the girl’s affections. In our discussion of Dora’s second dream we shall come upon the solution of this riddle as well as upon the self-reproach which we have hitherto failed to discover.

As she kept on repeating her complaints against her father with a wearisome monotony, and as at the same time her cough continued, I was led to think that this symptom might have some meaning in connection with her father. And apart from this, the explanation of the symptom which I had hitherto obtained was far from fulfilling the requirements which I am accustomed to make of such explanations. According to a rule which I had found confirmed over and over again by experience, though I had not yet ventured to erect it into a general principle, a symptom signifies the representation - the realization - of a phantasy with a sexual content, that is to say, it signifies a sexual situation. It would be better to say that at least one of the meanings of a symptom is the representation of a sexual phantasy, but that no such limitation is imposed upon the content of its other meanings. Any one who takes up psycho-analytic work will quickly discover that a symptom has more than one meaning and serves to represent several unconscious mental processes simultaneously. And I should like to add that in my estimation a single unconscious mental process or phantasy will scarcely ever suffice for the production of a symptom.

An opportunity very soon occurred for interpreting Dora’s nervous cough in this way by means of an imagined sexual situation. She had once again been insisting that Frau K. only loved her father because he was ‘ein vermögender Mann [‘a man of means’]. Certain details of the way in which she expressed herself (which I pass over here, like most other purely technical parts of the analysis) led me to see that behind this phrase its opposite lay concealed, namely, that her father was ‘ein unvermögender Mann’ [‘a man without means’]. This could only be meant in a sexual sense - that her father, as a man, was without means, was impotent.¹ Dora confirmed this interpretation from her conscious knowledge; whereupon I pointed out the contradiction she was involved in if on the one hand she continued to insist that her father’s relation with Frau K. was a common love-affair, and on the other hand maintained that her father was impotent, or in other words incapable of carrying on an affair of such a kind. Her answer showed that she had no need to admit the contradiction. She knew very well, she said, that there was more than one way of obtaining sexual gratification. (The source of this piece of knowledge, however, was once more untraceable.) I questioned her further, whether she referred to the use of organs other than the genitals for the purpose of sexual intercourse, and she replied in the affirmative. I could then go on to say that in that case she must be thinking of precisely those parts of the body which in her case were in a state of irritation, - the throat and the oral cavity. To be sure, she would not hear of going so far as this in recognizing her own thoughts; and indeed, if the occurrence of the symptom was to be made possible at all, it was essential that she should not be completely clear on the subject. But the conclusion was inevitable that with her spasmodic cough, which, as is usual, was referred for its exciting stimulus to a tickling in her throat, she pictured to herself a scene of sexual gratification per os between the two people whose love-affair occupied her mind so incessantly. A very short time after she had tacitly accepted this explanation her cough vanished - which fitted in very well with my view; but I do not wish to lay too much stress upon this development, since her cough had so often before disappeared spontaneously.

¹ [‘Unvermögend’ means literally ‘unable’, and is commonly used in the sense of both ‘not rich’ and ‘impotent’.]5 This short piece of the analysis may perhaps have excited in the medical reader - apart from the scepticism to which he is entitled - feelings of astonishment and horror; and I am prepared at this point to look into these two reactions so as to discover whether they are justifiable. The astonishment is probably caused by my daring to talk about such delicate and unpleasant subjects to a young girl - or, for that matter, to any woman who is sexually active. The horror is aroused, no doubt, by the possibility that an inexperienced girl could know about practices of such a kind and could occupy her imagination with them. I would advise recourse to moderation and reasonableness upon both points. There is no cause for indignation either in the one case or in the other. It is possible for a man to talk to girls and women upon sexual matters of every kind without doing them harm and without bringing suspicion upon himself, so long as, in the first place, he adopts a particular way of doing it, and, in the second place, can make them feel convinced that it is unavoidable. A gynaecologist, after all, under the same conditions, does not hesitate to make them submit to uncovering every possible part of their body. The best way of speaking about such things is to be dry and direct; and that is at the same time the method furthest removed from the prurience with which the same subjects are handled in ‘society’, and to which girls and women alike are so thoroughly accustomed. I call bodily organs and processes by their technical names, and I tell these to the patient if they - the names, I mean - happen to be unknown to her. J’appelle un chat un chat. I have certainly heard of some people - doctors and laymen - who are scandalized by a therapeutic method in which conversations of this sort occur, and who appear to envy either me or my patients the titillation which, according to their notions, such a method must afford. But I am too well acquainted with the respectability of these gentry to excite myself over them. I shall avoid the temptation of writing a satire upon them. But there is one thing that I will mention: often, after I have for some time treated a patient who had not at first found it easy to be open about sexual matters, I have had the satisfaction of hearing her exclaim: ‘Why, after all, your treatment is far more respectable than Mr. X.’s conversation!’

No one can undertake the treatment of a case of hysteria until he is convinced of the impossibility of avoiding the mention of sexual subjects, or unless he is prepared to allow himself to be convinced by experience. The right attitude is: ‘pour faire une omlette il faut casser des oeufs.’ The patients themselves are easy to convince; and there are only too many opportunities of doing so in the course of the treatment. There is no necessity for feeling any compunction at discussing the facts of normal or abnormal sexual life with them. With the exercise of a little caution all that is done is to translate into conscious ideas what was already known in the unconscious; and, after all, the whole effectiveness of the treatment is based upon our knowledge that the affect attached to an unconscious idea operates more strongly and, since it cannot be inhibited, more injuriously than the affect attached to a conscious one. There is never any danger of corrupting an inexperienced girl. For where there is no knowledge of sexual processes even in the unconscious, no hysterical symptom will arise; and where hysteria is found there can no longer be any question of ‘innocence of mind’ in the sense in which parents and educators use the phrase. With children of ten, of twelve, or of fourteen, with boys and girls alike, I have satisfied myself that the truth of this statement can invariably be relied upon.

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