The psycho-analytic VIew of psychogenic disturbance of VIsion 1 страница

(1910)

GENTLEMEN, - I propose to take the example of psychogenic disturbance of vision, in order to show you the modifications which have taken place in our view of the genesis of disorders of this kind under the influence of psycho-analytic methods of investigation. As you know, hysterical blindness is taken as the type of a psychogenic visual disturbance. It is generally believed, as a result of the researches of the French School (including such men as Charcot, Janet and Binet), that the genesis of these cases is understood. For we are in a position to produce blindness of this kind experimentally if we have at our disposal someone who is susceptible to somnambulism. If we put him into deep hypnosis and suggest the idea to him that he sees nothing with one of his eyes, he will in fact behave as though he had become blind in that eye, like a hysteric who has developed a visual disturbance spontaneously. We may thus construct the mechanism of spontaneous hysterical disturbances of vision on the model of suggested hypnotic ones. In a hysteric the idea of being blind arises, not from the prompting of a hypnotist, but spontaneously - by autosuggestion, as people say; and in both cases this idea is so powerful that it turns into reality, exactly like a suggested hallucination, paralysis, etc.

This seems perfectly sound and will satisfy anyone who can ignore the many enigmas that lie concealed behind the concepts of hypnosis, suggestion and autosuggestion. Autosuggestion in particular raises further questions. When and under what conditions does an idea become so powerful that it is able to behave like a suggestion and turn into reality without more ado? Closer investigation has taught us that we cannot answer this question without calling the concept of the ‘unconscious’ to our assistance. Many philosophers rebel against the assumption of a mental unconscious of this kind, because they have not concerned themselves with the phenomena which compel us to make that assumption. Psychopathologists have found that they cannot avoid working with such things as unconscious mental processes, unconscious ideas, and so on.

Appropriate experiments have shown that people who are hysterically blind do nevertheless see in some sense, though not in the full sense. Excitations of the blind eye may have certain psychical consequences (for instance, they may produce affects) even though they do not become conscious. Thus hysterically blind people are only blind as far as consciousness is concerned; in their unconscious they see. It is precisely observations such as this that compel us to distinguish between conscious and unconscious mental processes.

How does it happen that such people develop the unconscious ‘autosuggestion’ that they are blind, while nevertheless they see in their unconscious? The reply given by the French researches is to explain that in patients predisposed to hysteria there is an inherent tendency to dissociation - to a falling apart of the connections in their mental field - as a consequence of which some unconscious processes do not continue as far as into the conscious. Let us leave entirely on one side the value that this attempted explanation may have as regards an understanding of the phenomena in question, and let us look at the matter from another angle. As you see, Gentlemen, the identity of hysterical blindness with the blindness provoked by suggestion, on which so much stress was laid to begin with, has now been given up. The hysterical patient is blind, not as the result of an autosuggestive idea that he cannot see, but as the result of a dissociation between unconscious and conscious processes in the act of seeing; his idea that he does not see is the well-founded expression of the psychical state of affairs and not its cause.

If, Gentlemen, you complain of the obscurity of this exposition I shall not find it easy to defend. I have tried to give you a synthesis of the views of different investigators, and in doing so I have probably coupled them together too closely. I wanted to condense into a single composite whole the concepts that have been brought up to make psychogenic disturbances intelligible - their origin from excessively powerful ideas, the distinction between conscious and unconscious mental processes and the assumption of mental dissociation. And I have been no more successful in this than the French writers, at whose head stands Pierre Janet. I hope, therefore, that you will excuse not only the obscurity but the inaccuracy of my exposition, and will allow me to tell you how psycho-analysis has led us to a view of psychogenic disturbances of vision which is more self-consistent and probably closer to the facts.

Psycho-analysis, too, accepts the assumptions of dissociation and the unconscious, but relates them differently to each other. Its view is a dynamic one, which traces mental life back to an interplay between forces that favour or inhibit one another. If in any instance one group of ideas remains in the unconscious, psycho-analysis does not infer that there is a constitutional incapacity for synthesis which is showing itself in this particular dissociation, but maintains that the isolation and state of unconsciousness of this group of ideas have been caused by an active opposition on the part of other groups. The process owing to which it has met with this fate is known as ‘repression’ and we regard it as something analogous to a condemnatory judgement in the field of logic. Psycho-analysis points out that repressions of this kind play an extraordinarily important part in our mental life, but that they may also frequently fail and that such failures of repression are the precondition of the formation of symptoms.

If, then, as we have learnt, psychogenic disturbances of vision depend on certain ideas connected with seeing being cut off from consciousness, we must, on the psycho-analytic view, assume that these ideas have come into opposition to other, more powerful ones, for which we use the collective concept of the ‘ego’- a compound which is made up variously at different times - and have for that reason come under repression. But what can be the origin of this opposition, which makes for repression, between the ego and various groups of ideas? You will no doubt notice that it was not possible to frame such a question before the advent of psycho-analysis, for nothing was known earlier of psychical conflict and repression. Our researches, however, have put us in a position to give us the desired answer. Our attention has been drawn to the importance of the instincts in ideational life. We have discovered that every instinct tries to make itself effective by activating ideas that are in keeping with its aims. These instincts are not always compatible with one another; their interests often come into conflict. Opposition between ideas is only an expression of struggles between the various instincts. From the point of view of our attempted explanation, a quite specially important part is played by the undeniable opposition between the instincts which subserve sexuality, the attainment of sexual pleasure, and those other instincts, which have as their aim the self-preservation of the individual - the ego-instincts. As the poet has said, all the organic instincts that operate in our mind may be classified as ‘hunger’ or ‘love’. We have traced the ‘sexual instinct’ from its first manifestations in children to its final form, which is described as ‘normal’. We have found that it is put together from numerous ‘component instincts’ which are attached to excitations of regions of the body; and we have come to see that these separate instincts have to pass through a complicated development before they can be brought effectively to serve the aims of reproduction. The light thrown by psychology on the evolution of our civilization has shown us that it originates mainly at the cost of the sexual component instincts, and that these must be suppressed, restricted, transformed and directed to higher aims, in order that the mental constructions of civilization may be established. We have been able to recognize as a valuable outcome of these researches something that our colleagues have not yet been willing to believe, namely that the human ailments known as ‘neuroses’ are derived from the many different ways in which these processes of transformation in the sexual component instincts may miscarry. The ‘ego’ feels threatened by the claims of the sexual instincts and fends them off by repressions; these, however, do not always have the desired result, but lead to the formation of dangerous substitutes for the repressed and to burdensome reactions on the part of the ego. From these two classes of phenomena taken together there emerge what we call the symptoms of neuroses.

We have apparently digressed widely from our problem, though in doing so we have touched on the manner in which neurotic pathological conditions are related to our mental life as a whole. But let us now return to the narrower question. The sexual and ego-instincts alike have in general the same organs and systems of organs at their disposal. Sexual pleasure is not attached merely to the function of the genitals. The mouth serves for kissing as well as for eating and communication by speech; the eyes perceive not only alterations in the external world which are important for the preservation of life, but also characteristics of objects which lead to their being chosen as objects of love - their charms. The saying that it is not easy for anyone to serve two masters is thus confirmed. The closer the relation into which an organ with a dual function of this kind enters with one of the major instincts, the more it with holds itself from the other. This principle is bound to lead to pathological consequences if the two fundamental instincts are disunited and if the ego maintains a repression of the sexual component instinct concerned. It is easy to apply this to the eye and to seeing. Let us suppose that the sexual component instinct which makes use of looking - sexual pleasure in looking - has drawn upon itself defensive action by the ego-instincts in consequence of its excessive demands, so that the ideas in which its desires are expressed succumb to repression and are prevented from becoming conscious; in that case there will be a general disturbance of the relation of the eye and of the act of seeing to the ego and consciousness. The ego will have lost its dominance over the organ, which will now be wholly at the disposal of the repressed sexual instinct. It looks as though the repression had been carried too far by the ego, as though it had emptied the baby out with the bath-water: the ego refuses to see anything at all any more, now that the sexual interest in seeing has made itself so prominent. But the alternative picture seems more to the point. This attributes the active role instead to the repressed pleasure in looking. The repressed instinct takes its revenge for being held back from further psychical expansion, by becoming able to extend its dominance over the organ that is in its service. The loss of conscious dominance over the organ is the detrimental substitute for the repression which had miscarried and was only made possible at that price.

This relation of an organ with a double claim on it - its relation to the conscious ego and to repressed sexuality - is to be seen even more clearly in motor organs than in the eye: as when, for instance, a hand which has tried to carry out an act of sexual aggression, and has become paralysed hysterically, is unable, after that act has been inhibited, to do anything else as though it were obstinately insisting on carrying out a repressed innervation; or as when the fingers of people who have given up masturbation refuse to learn the delicate movements required for playing the piano or the violin. As regards the eye, we are in the habit of translating the obscure psychical processes concerned in the repression of sexual scopophilia and in the development of the psychogenic disturbance of vision as though a punishing voice was speaking from within the subject, and saying: ‘Because you sought to misuse your organ of sight for evil sensual pleasures, it is fitting that you should not see anything at all any more’, and as though it was in this way approving the outcome of the process. The idea of talion punishment is involved in this, and in fact our explanation of psychogenic visual disturbance coincides with what is suggested by myths and legends. The beautiful legend of Lady Godiva tells how all the town’s inhabitants hid behind their shuttered windows, so as to make easier the lady’s task of riding naked through the streets in broad daylight, and how the only man who peeped through the shutters at her revealed loveliness was punished by going blind. Nor is this the only example which suggests that neurotic illness holds the hidden key to mythology as well.

Psycho-analysis is unjustly reproached, Gentlemen, for leading to purely psychological theories of pathological problems. The emphasis which it lays on the pathogenic role of sexuality, which, after all, is certainly not an exclusively psychical factor should alone protect it from this reproach. Psycho-analysts never forget that the mental is based on the organic, although their work can only carry them as far as this basis and no beyond it. Thus psycho-analysis is ready to admit, and indeed to postulate, that not all disturbances of vision need be psychogenic, like those that are evoked by the repression of erotic scopophilia. If an organ which serves the two sorts of instinct increases its erotogenic role, it is in general to be expected that this will not occur without the excitability and innervation of the organ undergoing changes which will manifest themselves as disturbances of its function in the service of the ego. Indeed, if we find that an organ normally serving the purpose of sense-perception begins to behave like an actual genital when its erotogenic role is increased, we shall not regard it as improbable that toxic changes are also occurring in it. For lack of a better name we must retain the old unsuitable term of ‘neurotic’ disturbances for both classes of functional disturbances - those of physiological as well as those of toxic origin - which follow from an increase in the erotogenic factor. Generally speaking, the neurotic disturbances of vision stand in the same relation to the psychogenic ones as the ‘actual neuroses’ do to the psychoneuroses: psychogenic visual disturbances can no doubt hardly ever appear without neurotic ones, but the latter can appear without the former. These neurotic symptoms are unfortunately little appreciated and understood even today; for they are not directly accessible to psycho-analysis, and other methods of research have left the standpoint of sexuality out of account.

Yet another line of thought extending into organic research branches off from psycho-analysis. We may ask ourselves whether the suppression of sexual component instincts which is brought about by environmental influences is sufficient in itself to call up functional disturbances in organs, or whether special constitutional conditions must be present in order that the organs may be led to an exaggeration of their erotogenic role and consequently provoke repression of the instincts. We should have to see in those conditions the constitutional part of the disposition to fall ill of psychogenic and neurotic disorders. This is the factor to which, as applied to hysteria, I gave the provisional name of ‘somatic compliance’.

‘WILD’ PSYCHO-ANALYSIS (1910)

A few days ago a middle-aged lady, under the protection of a female friend, called upon me for a consultation, complaining of anxiety-states. She was in the second half of her forties, fairly well preserved, and had obviously not yet finished with her womanhood. The precipitating cause of the outbreak of her anxiety-states had been a divorce from her last husband; but the anxiety had become considerably intensified, according to her account, since she had consulted a young physician in the suburb she lived in, for he had informed her that the cause of her anxiety was her lack of sexual satisfaction. He said that she could not tolerate the loss of intercourse with her husband, and so there were only three ways by which she could recover her health - she must either return to her husband, or take a lover, or obtain satisfaction from herself. Since then she had been convinced that she was incurable, for she would not return to her husband, and the other two alternatives were repugnant to her moral and religious feelings. She had come to me, however, because the doctor had said that this was a new discovery for which I was responsible, and that she had only to come and ask me to confirm what he said, and I should tell her that this and nothing else was the truth. The friend who was with her, an older, dried-up and unhealthy-looking woman, then implored me to assure the patient that the doctor was mistaken; it could not possibly be true, for she herself had been a widow for many years, and had nevertheless remained respectable without suffering from anxiety.

I will not dwell on the awkward predicament in which I was placed by this visit, but instead will consider the conduct of the practitioner who sent this lady to me. First, however, let us bear a reservation in mind which may possibly not be superfluous - indeed we will hope so. Long years of experience have taught me - as they could teach everyone else - not to accept straight away as true what patients, especially nervous patients, relate about their physician. Not only does a nerve-specialist easily become the object of many of his patients’ hostile feelings, whatever method of treatment he employs; he must also sometimes resign himself to accepting responsibility, by a kind of projection, for the buried repressed wishes of his nervous patients. It is a melancholy but significant fact that such accusations nowhere find credence more readily than among other physicians.

I therefore have reason to hope that this lady gave me a tendentiously distorted account of what her doctor had said and that I do a man who is unknown to me an injustice by connecting my remarks about ‘wild’ psycho-analysis with this incident. But by doing so I may perhaps prevent others from doing harm to their patients.

Let us suppose, therefore, that her doctor spoke to the patient exactly as she reported. Everyone will at once bring us the criticism that if a physician thinks it necessary to discuss the question of sexuality with a woman he must do so with tact and consideration. Compliance with this demand, however, coincides with carrying out certain technical rules of psycho-analysis. Moreover, the physician in question was ignorant of a number of the scientific theories of psycho-analysis or had misapprehended them, and thus showed how little he had penetrated into an understanding of its nature and purposes.

Let us start with the latter, the scientific errors. The doctor’s advice to the lady shows clearly in what sense he understands the expression ‘sexual life’ - in the popular sense, namely, in which by sexual needs nothing is meant but the need for coitus or analogous acts producing orgasm and emission of the sexual substances. He cannot have remained unaware, however, that psycho-analysis is commonly reproached with having extended the concept of what is sexual far beyond its usual range. The fact is undisputed; I shall not discuss here whether it may justly be used as a reproach. In psycho-analysis the concept of what is sexual comprises far more; it goes lower and also higher than its popular sense. This extension is justified genetically; we reckon as belonging to ‘sexual life’ all the activities of the tender feelings which have primitive sexual impulses as their source, even when those impulses have become inhibited in regard to their original sexual aim or have exchanged this aim for another which is no longer sexual. For this reason we prefer to speak of psychosexuality, thus laying stress on the point that the mental factor in sexual life should not be overlooked or underestimated. We use the word ‘sexuality’ in the same comprehensive sense as that in which the German language uses the word lieben [‘to love’]. We have long known, too, that mental absence of satisfaction with all its consequences can exist where there is no lack of normal sexual intercourse; and as therapists we always bear in mind that the unsatisfied sexual trends (whose substitutive satisfactions in the form of nervous symptoms we combat) can often find only very inadequate outlet in coitus or other sexual acts.

Anyone not sharing this view of psychosexuality has no right to adduce psycho-analytic theses dealing with the aetiological importance of sexuality. By emphasizing exclusively the somatic factor in sexuality he undoubtedly simplifies the problem greatly, but he alone must bear the responsibility for what he does.

A second and equally gross misunderstanding is discernible behind the physician’s advice.

It is true that psycho-analysis puts forward absence of sexual satisfaction as the cause of nervous disorders. But does it not say more than this? Is its teaching to be ignored as too complicated when it declares that nervous symptoms arise from a conflict between two forces - on the one hand, the libido (which has as a rule become excessive), and on the other, a rejection of sexuality, or a repression which is over-severe? No one who remembers this second factor, which is by no means secondary in importance, can ever believe that sexual satisfaction in itself constitutes a remedy of general reliability for the sufferings of neurotics. A good number of these people are, indeed, either in their actual circumstances or in general incapable of satisfaction. If they were capable of it, if they were without their inner resistances, the strength of the instinct itself would point the way to satisfaction for them even though no doctor advised it. What is the good, therefore, of medical advice such as that supposed to have been given to this lady?

Even if it could be justified scientifically, it is not advice that she can carry out. If she had had no inner resistances against masturbation or against a liaison she would of course have adopted one of these measures long before. Or does the physician think that a woman of over forty is unaware that one can take a lover, or does he over-estimate his influence so much as to think that she could never decide upon such a step without medical approval?7

All this seems very clear, and yet it must be admitted the there is one factor which often makes it difficult to form a judgement. Some nervous states which we call the ‘actual neuroses’, such as typical neurasthenia and pure anxiety neurosis, obviously depend on the somatic factor in sexual life, while we have no certain picture as yet of the part played in them by the psychical factor and by repression. In such cases it is natural that the physician should first consider some ‘actual’ therapy, some alteration in the patient’s somatic sexual activity, and he does so with perfect justification if his diagnosis is correct. The lady who consulted the young doctor complained chiefly of anxiety-states, and so he probably assumed that she was suffering from an anxiety neurosis, and felt justified in recommending a somatic therapy to her. Again a convenient misapprehension! A person suffering from anxiety is not for that reason necessarily suffering from anxiety neurosis; such a diagnosis of it cannot be based on the name; one has to know what signs constitute an anxiety neurosis, and be able to distinguish it from other pathological states which are also manifested by anxiety. My impression was that the lady in question was suffering from anxiety hysteria, and the whole value of such nosographical distinctions, one which quite justifies them, lies in the fact that they indicate a different aetiology and a different treatment. No one who took into consideration the possibility of anxiety hysteria in this case would have fallen into the error of neglecting the mental factors, as this physician did with his three alternatives.

Oddly enough, the three therapeutic alternatives of this so-called psycho-analyst leave no room for - psycho-analysis! This woman could apparently only be cured of her anxiety by returning to her husband, or by satisfying her needs by masturbation or with a lover. And where does analytic treatment come in, the treatment which we regard as the main remedy in anxiety-states?

This brings us to the technical errors which are to be seen in the doctor’s procedure in this alleged case. It is a long superseded idea, and one derived from superficial appearances, that the patient suffers from a sort of ignorance, and that if one removes this ignorance by giving him information (about the causal connection of his illness with his life, about his experiences in childhood, and so on) he is bound to recover. The pathological factor is not his ignorance in itself, but the root of this ignorance in his inner resistances; it was they that first called this ignorance into being, and they still maintain it now. The task of the treatment lies in combating these resistances. Informing the patient of what he does not know because he has repressed it is only one of the necessary preliminaries to the treatment. If knowledge about the unconscious were as important for the patient as people inexperienced in psycho-analysis imagine, listening to lectures or reading books would be enough to cure him. Such measures, however, have as much influence on the symptoms of nervous illness as a distribution of menu-cards in a time of famine has upon hunger. The analogy goes even further than its immediate application; for informing the patient of his unconscious regularly results in an intensification of the conflict in him and an exacerbation of his troubles.

Since, however, psycho-analysis cannot dispense with giving this information, it lays down that this shall not be done before two conditions have been fulfilled. First, the patient must, through preparation, himself have reached the neighbourhood of what he has repressed, and secondly, he must have formed a sufficient attachment (transference) to the physician for his emotional relationship to him to make a fresh flight impossible.

Only when these conditions have been fulfilled is it possible to recognize and to master the resistances which have led to the repression and the ignorance. Psycho-analytic intervention, therefore, absolutely requires a fairly long period of contact with the patient. Attempts to ‘rush’ him at first consultation, by brusquely telling him the secrets which have been discovered by the physician, are technically objectionable. And they mostly bring their own punishment by inspiring a hearty enmity towards the physician on the patient’s part and cutting him off from having any further influence.

Besides all this, one may sometimes make a wrong surmise, and one is never in a position to discover the whole truth. Psycho-analysis provides these definite technical rules to replace the indefinable ‘medical tact’ which is looked upon as some special gift.

It is not enough, therefore, for a physician to know a few of the findings of psycho-analysis; he must also have familiarized himself with its technique if he wishes his medical procedure to be guided by a psycho-analytic point of view. This technique cannot yet be learnt from books, and it certainly cannot be discovered independently without great sacrifices of time, labour and success. Like other medical techniques, it is to be learnt from those who are already proficient in it. It is a matter of some significance, therefore, in forming a judgement on the incident which I took as a starting-point for these remarks, that I am not acquainted with the physician who is said to have given the lady such advice and have never heard his name.

Neither I myself nor my friends and co-workers find it agreeable to claim a monopoly in this way in the use of a medical technique. But in face of the dangers to patients and to the cause of psycho-analysis which are inherent in the practice that is to be foreseen of a ‘wild’ psycho-analysis, we have had no other choice. In the spring of 1910 we founded an International Psycho-Analytical Association, to which its members declare their adherence by the publication of their names, in order to be able to repudiate responsibility for what is done by those who do not belong to us and yet call their medical procedure ‘psycho-analysis’. For as a matter of fact ‘wild’ analysts of this kind do more harm to the cause of psycho-analysis than to individual patients. I have often found that a clumsy procedure like this, even if at first it produced an exacerbation of the patient’s condition, led to a recovery in the end. Not always but still often. When he has abused the physician enough and feels far enough away from his influence, his symptoms give way, or he decides to take some step which leads along the path to recovery. The final improvement then comes about ‘of itself’, or is ascribed to some totally indifferent treatment by some other doctor to whom the patient has later turned. In the case of the lady whose complaint against her physician we have heard, I should say that, despite everything, the ‘wild’ psycho-analyst did more for her than some highly respected authority who might have told her she was suffering from a ‘vasomotor neurosis’. He forced her attention to the real cause of her trouble, or in that direction, and in spite of all her opposition this intervention of his cannot be without some favourable results. But he has done himself harm and helped to intensify the prejudices which patients feel, owing to their natural affective resistances, against the methods of psycho-analysis. And this can be avoided.

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