Freud - Complete Works (256 page)

Fragment Of An Analysis Of A Case Of Hysteria

1446

IV

POSTSCRIPT

It is true that I have introduced this paper
as a fragment of an analysis; but the reader will have discovered
that it is incomplete to a far greater degree than its title might
have led him to expect. It is therefore only proper that I should
attempt to give a reason for the omissions - which are by no means
accidental.

   A number of the results of the
analysis have been omitted, because at the time when work was
broken off they had either not been established with sufficient
certainty or they required further study before any general
statement could be made about them. At other points, where it
seemed to be permissible, I have indicated the direction along
which some particular solution would probably have been found to
lie. I have in this paper left entirely out of account the
technique, which does not at all follow as a matter of course, but
by whose means alone the pure metal of valuable unconscious
thoughts can be extracted from the raw material of the
patient’s associations. This brings with it the disadvantage
of the reader being given no opportunity of testing the correctness
of my procedure in the course of this exposition of the case. I
found it quite impracticable, however, to deal simultaneously with
the technique of analysis and with the internal structure of a case
of hysteria: I could scarcely have accomplished such a task, and if
I had, the result would have been almost unreadable. The technique
of analysis demands an entirely separate exposition, which would
have to be illustrated by numerous examples chosen from a very
great variety of cases and which would not have to take the results
obtained in each particular case into account. Nor have I attempted
in this paper to substantiate the psychological postulates which
will be seen to underlie my descriptions of mental phenomena. A
cursory attempt to do so would have effected nothing; an exhaustive
one would have been a volume in itself. I can only assure the
reader that I approached the study of the phenomena revealed by
observation of the psychoneuroses without being pledged to any
particular psychological system, and that I then proceeded to
adjust my views until they seemed adapted for giving an account of
the collection of facts which had been observed. I take no pride in
having avoided speculation; the material for my hypotheses was
collected by the most extensive and laborious series of
observations. The decidedness of my attitude on the subject of the
unconscious is perhaps specially likely to cause offence, for I
handle unconscious ideas, unconscious trains of thought, and
unconscious impulses as though they were no less valid and
unimpeachable psychological data than conscious ones. But of this I
am certain - that any one who sets out to investigate the same
region of phenomena and employs the same method will find himself
compelled to take up the same position, however much philosophers
may expostulate.

Fragment Of An Analysis Of A Case Of Hysteria

1447

   Some of my medical colleagues
have looked upon my theory of hysteria as a purely psychological
one, and have for that reason pronounced it
ipso facto
incapable of solving a pathological problem. They may perhaps
discover from this paper that their objection was based upon their
having unjustifiably transferred what is a characteristic of the
technique on to the theory itself. It is the therapeutic technique
alone that is purely psychological; the theory does not by any
means fail to point out that neuroses have an organic basis -
though it is true that it does not look for that basis in any
pathological anatomical changes, and provisionally substitutes the
conception of organic functions for the chemical changes which we
should expect to find but which we are at present unable to
apprehend. No one, probably, will be inclined to deny the sexual
function the character of an organic factor, and it is the sexual
function that I look upon as the foundation of hysteria and of the
psychoneuroses in general. No theory of sexual life will, I
suspect, be able to avoid assuming the existence of some definite
sexual substances having an excitant action. Indeed, of all the
clinical pictures which we meet with in clinical medicine, it is
the phenomena of intoxication and abstinence in connection with the
use of certain chronic poisons that most closely resemble the
genuine psychoneuroses.

   But, once again, in the present
paper I have not gone fully into all that might be said to-day
about ‘somatic compliance’, about the infantile germs
of perversion, about the erotogenic zones, and about our
predisposition towards bisexuality; I have merely drawn attention
to the points at which the analysis comes into contact with these
organic bases of the symptoms. More than this could not be done
with a single case. And I had the same reasons that I have already
mentioned for wishing to avoid a cursory discussion of these
factors. There is a rich opportunity here for further works, based
upon the study of a large number of analyses.

Fragment Of An Analysis Of A Case Of Hysteria

1448

   Nevertheless, in publishing this
paper, incomplete though it is, I had two objects in view. In the
first place, I wished to supplement my book on the interpretation
of dreams by showing how an art, which would otherwise be useless,
can be turned to account for the discovery of the hidden and
repressed parts of mental life. (Incidentally, in the process of
analysing the two dreams dealt with in the paper, the technique of
dream-interpretation, which is similar to that of psycho-analysis,
has come under consideration.) In the second place, I wished to
stimulate interest in a whole group of phenomena of which science
is still in complete ignorance to-day because they can only be
brought to light by the use of this particular method. No one, I
believe, can have had any true conception of the complexity of the
psychological events in a case of hysteria - the juxtaposition of
the most dissimilar tendencies, the mutual dependence of contrary
ideas, the repressions and displacements, and so on. The emphasis
laid by Janet upon the ‘
idée fixe
’ which
becomes transformed into a symptom amounts to no more than an
extremely meagre attempt at schematization. Moreover, it is
impossible to avoid the suspicion that, when the ideas attaching to
certain excitations are incapable of becoming conscious, those
excitations must act upon one another differently, run a different
course, and manifest themselves differently from those other
excitations which we describe as ‘normal’ and which
have ideas attaching to them of which we become conscious. When
once things have been made clear up to this point, no obstacle can
remain in the way of an understanding of a therapeutic method which
removes neurotic symptoms by transforming ideas of the former kind
into normal ones.

   I was further anxious to show
that sexuality does not simply intervene, like a
deus ex
machina
, on one single occasion, at some point in the working
of the processes which characterize hysteria, but that it provides
the motive power for every single symptom, and for every single
manifestation of a symptom. The symptoms of the disease are nothing
else than
the patient’s sexual activity
. A single case
can never be capable of proving a theorem so general as this one;
but I can only repeat over and over again - for I never find it
otherwise - that sexuality is the key to the problem of the
psychoneuroses and of the neuroses in general. No one who disdains
the key will ever be able to unlock the door. I still await news of
the investigations which are to make it possible to contradict this
theorem or to limit its scope. What I have hitherto heard against
it have been expressions of personal dislike or disbelief. To these
it is enough to reply in the words of Charcot: ‘Ça
n’empêche pas d’exister
.
’

Fragment Of An Analysis Of A Case Of Hysteria

1449

   Nor is the case of whose history
and treatment I have published a fragment in these pages well
calculated to put the value of psycho-analytic therapy in its true
light. Not only the briefness of the treatment (which hardly lasted
three months) but another factor inherent in the nature of the case
prevented results being brought about such as are attainable in
other instances, where the improvement will be admitted by the
patient and his relatives and will approximate more or less closely
to a complete recovery. Satisfactory results of this kind are
reached when the symptoms are maintained solely by the internal
conflict between the impulses concerned with sexuality. In such
cases the patient’s condition will be seen improving in
proportion as he is helped towards a solution of his mental
problems by the translation of pathogenic into normal material. The
course of events is very different when the symptoms have become
enlisted in the service of external motives, as had happened with
Dora during the two preceding years. It is surprising, and might
easily be misleading, to find that the patient’s condition
shows no noticeable alteration even though considerable progress
has been made with the work of analysis. But in reality things are
not as bad as they seem. It is true that the symptoms do not
disappear while the work is proceeding; but they disappear a little
while later, when the relations between patient and physician have
been dissolved. The postponement of recovery or improvement is
really only caused by the physician’s own person.

Fragment Of An Analysis Of A Case Of Hysteria

1450

   I must go back a little, in order
to make the matter intelligible. It may be safely said that during
psycho-analytic treatment the formation of new symptoms is
invariably stopped. But the productive powers of the neurosis are
by no means extinguished; they are occupied in the creation of a
special class of mental structures, for the most part unconscious,
to which the name of ‘
transferences
’ may be
given.

   What are transferences? They are
new editions or facsimiles of the impulses and phantasies which are
aroused and made conscious during the progress of the analysis; but
they have this peculiarity, which is characteristic for their
species, that they replace some earlier person by the person of the
physician. To put it another way: a whole series of psychological
experiences are revived, not as belonging to the past, but as
applying to the person of the physician at the present moment. Some
of these transferences have a content which differs from that of
their model in no respect whatever except for the substitution.
These then - to keep to the same metaphor - are merely new
impressions or reprints. Others are more ingeniously constructed;
their content has been subjected to a moderating influence - to
sublimation
, as I call it - and they may even become
conscious, by cleverly taking advantage of some real peculiarity in
the physician’s person or circumstances and attaching
themselves to that. These, then, will no longer be new impressions,
but revised editions.

   If the theory of analytic
technique is gone into, it become, evident that transference is an
inevitable necessity. Practical experience, at all events, shows
conclusively that there is no means of avoiding it, and that this
latest creation of the disease must be combated like all the
earlier ones. This happens, however, to be by far the hardest part
of the whole task. It is easy to learn how to interpret dreams, to
extract from the patient’s associations his unconscious
thoughts and memories, and to practise similar explanatory arts:
for these the patient himself will always provide the text.
Transference is the one thing the presence of which has to be
detected almost without assistance and with only the slightest
clues to go upon, while at the same time the risk of making
arbitrary inferences has to be avoided. Nevertheless, transference
cannot be evaded, since use is made of it in setting up all the
obstacles that make the material inaccessible to treatment, and
since it is only after the transference has been resolved that a
patient arrives at a sense of conviction of the validity of the
connections which have been constructed during the analysis.

Fragment Of An Analysis Of A Case Of Hysteria

1451

   Some people may feel inclined to
look upon it as a serious objection to a method which is in any
case troublesome enough that it itself should multiply the labours
of the physician by creating a new species of pathological mental
products. They may even be tempted to infer from the existence of
transferences that the patient will be injured by analytic
treatment. Both these suppositions would be mistaken. The
physician’s labours are not multiplied by transference; it
need make no difference to him whether he has to overcome any
particular impulse of the patient’s in connection with
himself or with some one else. Nor does the treatment force upon
the patient, in the shape of transference, any new task which he
would not other wise have performed. It is true that neuroses may
be cured in institutions from which psycho-analytic treatment is
excluded, that hysteria may be said to be cured not by the method
but by the physician, and that there is usually a sort of blind
dependence and a permanent bond between a patient and the physician
who has removed his symptoms by hypnotic suggestion; but the
scientific explanation of all these facts is to be found in the
existence of ‘transferences’ such as are regularly
directed by patients on to their physicians. Psycho-analytic
treatment does not
create
transferences, it merely brings
them to light, like so many other hidden psychical factors. The
only difference is this - that spontaneously a patient will only
call up affectionate and friendly transferences to help towards his
recovery; if they cannot be called up, he feels the physician is
‘antipathetic’ to him, and breaks away from him as fast
as possible and without having been influenced by him. In
psycho-analysis, on the other hand, since the play of motives is
different, all the patient’s tendencies, including hostile
ones, are aroused; they are then turned to account for the purposes
of the analysis by being made conscious, and in this way the
transference is constantly being destroyed. Transference, which
seems ordained to be the greatest obstacle to psycho-analysis,
becomes its most powerful ally, if its presence can be detected
each time and explained to the patient.¹