Freud - Complete Works (244 page)

Fragment Of An Analysis Of A Case Of Hysteria

1379

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.

Fragment Of An Analysis Of A Case Of Hysteria

1380

   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
.

Fragment Of An Analysis Of A Case Of Hysteria

1381

   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.

Fragment Of An Analysis Of A Case Of Hysteria

1382

   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.

Fragment Of An Analysis Of A Case Of Hysteria

1383

   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.