Freud - Complete Works (278 page)

On Psychotherapy

1569

   (
d
) The conditions under
which this method is indicated, or contra-indicated, can scarcely
be definitely laid down as yet, because of the many practical
limitations to which my activities have been subjected.
Nevertheless, I will attempt to discuss a few of them here:

   (1) One should look beyond the
patient’s illness and form an estimate of his whole
personality; those patients who do not possess a reasonable degree
of education and a fairly reliable character should be refused. It
must not be forgotten that there are healthy people as well as
unhealthy ones who are good for nothing in life, and that there is
a temptation to ascribe to their illness everything that
incapacitates them, if they show any sign of neurosis. In my
opinion a neurosis is by no means a stamp of degeneracy, though it
may often enough be found in one person along with the signs of
degeneracy. Now analytic psychotherapy is not a process suited to
the treatment of neuropathic degeneracy; on the contrary,
degeneracy is a barrier to its effectiveness. Nor is the method
applicable to people who are not driven to seek treatment by their
own sufferings, but who submit to it only because they are forced
to by the authority of relatives. The qualification which is the
determining factor of fitness for psycho-analytic treatment - that
is, whether the patient is educable - must be discussed further
from another standpoint.

   (2) To be quite safe, one should
limit one’s choice of patients to those who possess a normal
mental condition, since in the psycho-analytic method this is used
as a foothold from which to obtain control of the morbid
manifestations. Psychoses, states of confusion and deeply-rooted (I
might say toxic) depression are therefore not suitable for
psycho-analysis; at least not for the method as it has been
practised up to the present. I do not regard it as by any means
impossible that by suitable changes in the method we may succeed in
overcoming this contraindication - and so be able to initiate a
psychotherapy of the psychoses.

   (3) The age of patients has this
much importance in determining their fitness for psycho-analytic
treatment, that, on the one hand, near or above the age of fifty
the elasticity of the mental processes, on which the treatment
depends, is as a rule lacking - old people are no longer educable -
and, on the other hand, the mass of material to be dealt with would
prolong the duration of the treatment indefinitely. In the other
direction the age limit can be determined only individually;
youthful persons under the age of adolescence are often exceedingly
amenable to influence.

   (4) Psycho-analysis should not be
attempted when the speedy removal of dangerous symptoms is
required, as, for example, in a case of hysterical anorexia.

On Psychotherapy

1570

   By this time you will have formed
an impression that the field of analytic psychotherapy is a very
narrow one, since you have in fact heard nothing from me except
indications that point against it. There remain, however, cases and
types of disease enough on which this therapy may be tested - as,
for instance, all chronic forms of hysteria with residual
manifestations, the broad field of obsessive conditions, aboulias,
and the like.

   It is gratifying that precisely
the most valuable and most highly developed persons are best suited
for this procedure; and one may also safely claim that in cases
where analytic psychotherapy has been able to achieve but little,
any other therapy would certainly not have been able to effect
anything at all.

   (
e
) You will no doubt wish
to enquire about the possibility of doing harm by undertaking a
psycho-analysis. In reply to this I may say that if you are willing
to judge impartially, if you will consider this procedure in the
same spirit of critical fairness that you show to our other
therapeutic methods, you will have to agree with me that no injury
to the patient is to be feared when the treatment is conducted with
comprehension. Anyone who is accustomed, like the lay public, to
blame the treatment for whatever happens during an illness will
doubtless judge differently. It is not so very long since the same
prejudice was directed against our hydropathic establishments. Many
patients who were advised to go into an establishment of that kind
hesitated because they had known someone who had entered the place
as a nervous invalid and had become insane there. As you may guess,
these were cases of early general paralysis that could still in
their first stage be sent to a hydropathic establishment; once
there, they had run their inevitable course until manifest mental
disorder supervened: but the public blamed the water for this
disastrous change. When it is a matter of new kinds of therapeutic
treatment even physicians are not always free from such errors of
judgement. I recall once making an attempt at psychotherapy with a
woman who had passed the greater part of her life in a state
alternating between mania and melancholia. I took on the case at
the close of a period of melancholia and for two weeks things
seemed to go smoothly; in the third week we were already at the
beginning of the next attack of mania. This was undoubtedly a
spontaneous transformation of the clinical picture, since in two
weeks analytic psychotherapy cannot accomplish anything. And yet
the eminent physician (now deceased) who saw the case with me could
not refrain from the remark that psychotherapy was probably to
blame for this ‘relapse’. I am quite convinced that in
other circumstances he would have shown a more critical
judgement.

On Psychotherapy

1571

   (
f
) Finally, Gentlemen, I
must confess that it is hardly fair to take up your attention for
so long on the subject of psycho-analytic therapy without telling
you in what this treatment consists and on what it is based. Still,
as I am forced to be brief, I can only hint at this: This therapy,
then, is based on the recognition that unconscious ideas - or
better, the unconsciousness of certain mental processes - are the
direct cause of the morbid symptoms. We share this opinion with the
French school (Janet) who, by the way, owing to excessive
schematization, refer the cause of hysterical symptoms to an
unconscious
idée fixe
. Now please do not be afraid
that this is going to land us in the depths of philosophical
obscurities. Our unconscious is not quite the same thing as that of
philosophers and, moreover, the majority of philosophers will hear
nothing of ‘unconscious mental processes’. If, however,
you will look at the matter from our point of view, you will
understand that the transformation of this unconscious material in
the mind of the patient into conscious material must have the
result of correcting his deviation from normality and of lifting
the compulsion to which his mind has been subjected. For conscious
will-power governs only conscious mental processes, and every
mental compulsion is rooted in the unconscious. Nor need you ever
fear that the patient will be harmed by the shock accompanying the
introduction of the unconscious into consciousness, for you can
convince yourselves theoretically that the somatic and emotional
effect of an impulse that has become conscious can never be so
powerful as that of an unconscious one. It is only by the
application of our highest mental functions, which are bound up
with consciousness, that we can control all our impulses.

   There is, however, another angle
from which you may seek to understand the psycho-analytic method.
The uncovering and translating of the unconscious occurs in the
face of a continuous
resistance
on the part of the patient.
The process of bringing this unconscious material to light is
associated with unpleasure, and because of this the patient rejects
it again and again. It is for you then to interpose in this
conflict in the patient’s mental life. If you succeed in
persuading him to accept, by virtue of a better understanding,
something that up to now, in consequence of this automatic
regulation by unpleasure, he has rejected (repressed), you will
have accomplished something towards his education. For it is
education even to induce someone who dislikes getting up early to
do so all the same. Psycho-analytic treatment may in general be
conceived of as such a
re-education in overcoming internal
resistances
. Re-education of this kind is, however, in no
respect more necessary to nervous patients than in regard to the
mental element in their sexual life. For nowhere else have
civilization and education done so much harm as in this field, and
this is the point, as experience will show you, at which to look
for those aetiologies of the neuroses that are amenable to
influence; for the other aetiological factor, the constitutional
component, consists of something fixed and unalterable. And from
this it follows that one important qualification is required of the
physician in this work: not only must his own character be
irreproachable - ‘As to morals, that goes without
saying’, as the hero of Vischer’s novel
Auch
Einer
was in the habit of declaring - but he must also have
overcome in his own mind that mixture of prurience and prudery with
which, unfortunately, so many people habitually consider sexual
problems.

On Psychotherapy

1572

   At this juncture another remark
is perhaps not out of place. I know that the emphasis which I lay
upon the part played by sexuality in creating the psychoneuroses
has become generally known. But I know, too, that qualifications
and exact particularization are of little use with the general
public; there is very little room in the memory of the multitude;
it only retains the bare gist of any thesis and fabricates an
extreme version which is easy to remember. It may be, too, that
some physicians vaguely apprehend the content of my doctrine to be
that I regard sexual privation as the ultimate cause of the
neuroses. In the conditions of life in modern society there is
certainly no lack of sexual privation. On this basis, would it not
be simpler to aim directly at recovery by recommending sexual
activity as a therapeutic measure, instead of pursuing the
circuitous and laborious path of mental treatment?(I know of
nothing which could impel me to suppress such an inference if it
were justified. The real state of things, however, is otherwise.
Sexual need and privation are merely one factor at work in the
mechanism of neurosis; if there were no others the result would be
dissipation, not disease. The other, no less essential, factor,
which is all too readily forgotten, is the neurotic’s
aversion from sexuality, his incapacity for loving, that feature of
the mind which I have called ‘repression’. Not until
there is a conflict between the two tendencies does nervous illness
break out, and therefore to advise sexual activity in the
psychoneuroses can only very rarely be described as good
advice.

   Let me end upon this defensive
note. And let us hope that your interest in psychotherapy, when
freed from every hostile prejudice, may lend us support in our
endeavour to achieve success in treating even severe cases of
psychoneurosis.

1573

MY VIEWS ON THE PART PLAYED BY SEXUALITY

IN THE AETIOLOGY OF THE NEUROSES

(1906)

1574

Intentionally left blank

1575

MY VIEWS ON THE PART PLAYED BY SEXUALITY

IN THE AETIOLOGY OF THE NEUROSES

My theory of the aetiological importance of
the sexual factor in the neuroses can best be appreciated, in my
opinion, by following the history of its development. For I have no
desire whatever to deny that it has gone through a process of
evolution and been modified in the course of it. My professional
colleagues may find a guarantee in this admission that the theory
is nothing other than the product of continuous and ever
deeper-going experience. What is born of speculation, on the
contrary, may easily spring into existence complete and there after
remain unchangeable.

   Originally my theory related only
to the clinical pictures comprised under the term
‘neurasthenia’, among which I was particularly struck
by two, which occasionally appear as pure types and which I
described as ‘neurasthenia proper’ and ‘anxiety
neurosis’. It had, to be sure, always been a matter of common
knowledge that sexual factors
may
play a part in the
causation of these forms of illness; but those factors were not
regarded as invariably operative, nor was there any idea of giving
them precedence over other aetiological influences. I was surprised
to begin with at the frequency of gross disturbances in the
vita
sexualis
of nervous patients; the more I set about looking for
such disturbances - bearing in mind the fact that everyone hides
the truth in matters of sex - and the more skilful I became at
pursuing my enquiries in the face of a preliminary denial, the more
regularly was I able to discover pathogenic factors in sexual life,
till little seemed to stand in the way of my assuming their
universal occurrence. It was necessary, however, to presuppose from
the start that sexual irregularities occurred with similar
frequency in our ordinary society under the pressure of social
conditions; and a doubt might remain as to the degree of deviation
from normal sexual functioning which should be regarded as
pathogenic. I was therefore obliged to attach less importance to
the invariable evidence of sexual noxae than to a second discovery
which seemed to me less ambiguous. It emerged that the form taken
by the illness - neurasthenia or anxiety neurosis - bore a constant
relation to the nature of the sexual noxa involved. In typical
cases of neurasthenia a history of regular masturbation or
persistent emissions was found; in anxiety neurosis factors
appeared such as
coitus interruptus
, ‘unconsummated
excitation’, and other conditions - in all of which there
seemed to be the common element of an insufficient discharge of the
libido that had been produced. It was only after this discovery,
which was easy to make and could be confirmed as often as one
liked, that I had the courage to claim a preferential position for
sexual influences in the aetiology of the neuroses. Furthermore, in
the mixed forms of neurasthenia and anxiety neurosis which are so
common it was possible to trace a combination of the aetiologies
which I had assumed for the two pure forms. Moreover, this twofold
form assumed by the neurosis seemed to tally with the polar (i.e.
the masculine and feminine)  character of sexuality.

My Views On The Part Played By Sexuality In The Aetiology Of
The Neuroses

1576

   At the time at which I was
attributing to sexuality this important part in the production of
the
simple
neuroses,¹ I was still faithful to a purely
psychological theory in regard to the
psychoneuroses
  -
a theory in which the sexual factor was regarded as no more
significant than any other emotional source of feeling. On the
basis of some observations made by Josef Breuer on a hysterical
patient more than ten years earlier, I collaborated with him in a
study of the mechanism of the generation of hysterical symptoms,
using the method of awakening the patient’s memories in a
state of hypnosis; and we reached conclusions which enabled us to
bridge the gap between Charcot’s traumatic hysteria and
common non-traumatic hysteria (Breuer and Freud, 1895). We were led
to the assumption that hysterical symptoms are the permanent
results of psychical traumas, the sum of affect attaching to which
has, for particular reasons, been prevented from being worked over
consciously and has therefore found an abnormal path into somatic
innervation. The terms ‘strangulated affect’,
‘conversion’ and ‘abreaction’ cover the
distinctive features of this hypothesis.

   But in view of the close
connections between the psychoneuroses and the simple neuroses,
which go so far, indeed, that a differential diagnosis is not
always easy for inexperienced observers, it could not be long
before the knowledge arrived at in the one field was extended to
the other. Moreover, apart from this consideration, a deeper
investigation of the psychical mechanism of hysterical symptoms led
to the same result. For if the psychical traumas from which the
hysterical symptoms were derived were pursued further and further
by means of the ‘cathartic’ procedure initiated by
Breuer and me, experiences were eventually reached which belonged
to the patient’s childhood and related to his sexual life.
And this was so, even in cases in which the onset of the illness
had been brought about by some commonplace emotion of a non-sexual
kind. Unless these sexual traumas of childhood were taken into
account it was impossible either to elucidate the symptoms (to
understand the way in which they were determined) or to prevent
their recurrence. In this way the unique significance of sexual
experiences in the aetiology of the psychoneuroses seemed to be
established beyond a doubt; and this fact remains to this day one
of the corner-stones of my theory.

  
¹
In my paper on anxiety neurosis
(1895
b
).

My Views On The Part Played By Sexuality In The Aetiology Of
The Neuroses

1577

   This theory might be expressed by
saying that the cause of life-long hysterical neuroses lies in what
are in themselves for the most part the trivial sexual experiences
of early childhood; and, put in this way, it might no doubt sound
strange. But if we take the historical development of the theory
into account, and see as its essence the proposition that hysteria
is the expression of a particular behaviour of the
individual’s sexual function and that this behaviour is
decisively determined by the first influences and experiences
brought to bear in childhood, we shall be a paradox the poorer but
the richer by a motive for turning our attention to something of
the highest importance (though it has hitherto been grossly
neglected) - the after-effects of the impressions of childhood.

   I will postpone until later in
this paper a more thorough going discussion of the question whether
we are to regard the sexual experiences of childhood as the causes
of hysteria (and obsessional neurosis), and I will now return to
the form taken by the theory in some of my shorter preliminary
publications during the years 1895 and 1896 (Freud, 1896
b
and 1896
c
). By laying stress on the supposed aetiological
factors it was possible at that time to draw a contrast between the
common neuroses as disorders with a
contemporary
aetiology
and psychoneuroses whose aetiology was chiefly to be looked for in
the sexual experiences of the remote past. The theory culminated in
this thesis: if the
vita sexualis
is normal, there can be no
neurosis.

My Views On The Part Played By Sexuality In The Aetiology Of
The Neuroses

1578

   Though even to-day I do not
consider these assertions incorrect, it is not to be wondered at
that, in the course of ten years of continuous effort at reaching
an understanding of these phenomena, I have made a considerable
step forward from the views I then held, and now believe that I am
in a position, on the basis of deeper experience, to correct the
insufficiencies, the displacements and the misunderstandings under
which my theory then laboured. At that time my material was still
scanty, and it happened by chance to include a disproportionately
large number of cases in which sexual seduction by an adult or by
older children played the chief part in the history of the
patient’s childhood. I thus over-estimated the frequency of
such events (though in other respects they were not open to doubt).
Moreover, I was at that period unable to distinguish with certainty
between falsifications made by hysterics in their memories of
childhood and traces of real events. Since then I have learned to
explain a number of phantasies of seduction as attempts at fending
off memories of the subject’s
own
sexual activity (
infantile masturbation). When this point had been clarified, the
‘traumatic’ element in the sexual experiences of
childhood lost its importance and what was left was the realization
that infantile sexual activity (whether spontaneous or provoked )
prescribes the direction that will be taken by later sexual life
after maturity. The same clarification (which corrected the most
important of my early mistakes) also made it necessary to modify my
view of the mechanism of hysterical symptoms. They were now no
longer to be regarded as direct derivatives of the repressed
memories of childhood experiences; but between the symptoms and the
childish impressions there were inserted the patient’s
phantasies
(or imaginary memories), mostly produced during
the years of puberty, which on the one side were built up out of
and over the childhood memories and on the other side were
transformed directly into the symptoms. It was only after the
introduction of this element of hysterical phantasies that the
texture of the neurosis and its relation to the patient’s
life became intelligible; a surprising analogy came to light, too,
between these unconscious phantasies of hysterics and the imaginary
creations of paranoics which become conscious as delusions.

My Views On The Part Played By Sexuality In The Aetiology Of
The Neuroses

1579

   After I had made this correction,
‘infantile sexual traumas’ were in a sense replaced by
the ‘infantilism of sexuality’. A second modification
of the original theory lay not far off. Along with the supposed
frequency of seduction in childhood, I ceased also to lay
exaggerated stress on the
accidental
influencing of
sexuality on to which I had sought to thrust the main
responsibility for the causation of the illness, though I had not
on that account denied the constitutional and hereditary factors. I
had even hoped to solve the problem of choice of neurosis (the
decision to which form of psychoneurosis the patient is to fall a
victim) by reference to the details of the sexual experiences of
childhood. I believed at that time - though with reservations -
that a passive attitude in these scenes produced a predisposition
to hysteria and, on the other hand, an active one a predisposition
to obsessional neurosis. Later on I was obliged to abandon this
view entirely, even though some facts demand that in some way or
other the supposed correlation between passivity and hysteria and
between activity and obsessional neurosis shall be maintained.
Accidental influences derived from experience having thus receded
into the background, the factors of constitution and heredity
necessarily gained the upper hand once more; but there was this
difference between my views and those prevailing in other quarters,
that on my theory the ‘sexual constitution’ took the
place of a ‘general neuropathic disposition’. In my
recently published
Three Essays on the Theory of Sexuality
(1905
d
) I have tried to give a picture of the variegated
nature of this sexual constitution as well as of the composite
character of the sexual instinct in general and its derivation from
contributory sources from different parts of the organism.

My Views On The Part Played By Sexuality In The Aetiology Of
The Neuroses

1580

   As a further corollary to my
modified view of  ‘sexual traumas in childhood’,
my theory now developed further in a direction which had already
been indicated in my publications between 1894 and 1896. At that
time, and even before sexuality had been given its rightful place
as an aetiological factor, I had maintained that no experience
could have a pathogenic effect unless it appeared intolerable to
the subject’s ego and gave rise to efforts at defence (Freud,
1894
a
). It was to this defence that I traced back the split
in the psyche (or, as we said in those days, in consciousness)
which occurs in hysteria. If the defence was successful, the
intolerable experience with its affective consequences was expelled
from consciousness and from the ego’s memory. In certain
circumstances, however, what had been expelled pursued its
activities in what was now an unconscious state, and found its way
back into consciousness by means of symptoms and the affects
attaching to them, so that the illness corresponded to a failure in
defence. This view had the merit of entering into the interplay of
the psychical forces and of thus bringing the mental processes in
hysteria nearer to normal ones, instead of characterizing the
neurosis as nothing more than a mysterious disorder insusceptible
to further analysis.

   Further information now became
available relating to people who had remained normal; and this led
to the unexpected finding that the sexual history of
their
childhood did not necessarily differ in essentials from that of
neurotics, and, in particular, that the part played by seduction
was the same in both cases. As a consequence, accidental influences
receded still further into the background as compared with
‘repression’ (as I now began to say instead of
‘defence’). Thus it was no longer a question of what
sexual experiences a particular individual had had in his
childhood, but rather of his reaction to those experiences - of
whether he had reacted to them by ‘repression’ or not.
It could be shown how in the course of development a spontaneous
infantile sexual activity was often broken off by an act of
repression. Thus a mature neurotic individual was invariably
pursued by a certain amount of ‘sexual repression’ from
his childhood; this found expression when he was faced by the
demands of real life, and the psycho-analyses of hysterics showed
that they fell ill as a result of the conflict between their libido
and their sexual repression and that their symptoms were in the
nature of compromises between the two mental currents.