Freud - Complete Works (279 page)

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

1581

   I could not further elucidate
this part of my theory without a detailed discussion of my views on
repression. It will be enough here to refer to my
Three
Essays
(1905
d
), in which I have attempted to throw some
light - if only a feeble one - on the somatic processes in which
the essential nature of sexuality is to be looked for. I have there
shown that the constitutional sexual disposition of children is
incomparably more variegated than might have been expected, that it
deserves to be described as ‘polymorphously perverse’
and that what is spoken of as the normal behaviour of the sexual
function emerges from this disposition after certain of its
components have been repressed. By pointing out the infantile
elements in sexuality I was able to establish a simple correlation
between health, perversion and neurosis. I showed that
normality
is a result of the repression of certain component
instincts and constituents of the infantile disposition and of the
subordination of the remaining constituents under the primacy of
the genital zones in the service of the reproductive function. I
showed that
perversions
correspond to disturbances of this
coalescence owing to the overpowering and compulsive development of
certain of the component instincts, while
neuroses
can be
traced back to an excessive repression of the libidinal trends.
Since almost all the perverse instincts of the infantile
disposition can be recognized as the forces concerned in the
formation of symptoms in neuroses, though in a state of repression,
I was able to describe neurosis as being the ‘negative’
of perversion.

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

1582

   I think it is worth emphasizing
the fact that, whatever modifications my views on the aetiology of
the psychoneuroses have passed through, there are two positions
which I have never repudiated or abandoned - the importance of
sexuality and of infantilism. Apart from this, accidental
influences have been replaced by constitutional factors and
‘defence’ in the purely psychological sense has been
replaced by organic ‘sexual repression’. The question
may, however, be raised of where convincing evidence is to be found
in favour of the alleged aetiological importance of sexual factors
in the psychoneuroses, in view of the fact that the onset of these
illnesses may be observed in response to the most commonplace
emotions or even to somatic precipitating causes, and since I have
had to abandon a specific aetiology depending on the particular
form of the childhood experiences concerned. To such a question I
would reply that the psycho-analytic examination of neurotics is
the source from which this disputed conviction of mine is derived.
If we make use of that irreplaceable method of research, we
discover that
the patient’s symptoms constitute his sexual
activity
(whether wholly or in part), which arises from the
sources of the normal or perverse component instincts of sexuality.
Not only is a large part of the symptomatology of hysteria derived
directly from expressions of sexual excitement, not only do a
number of erotogenic zones attain the significance of genitals
during neuroses owing to an intensification of infantile
characteristics, but the most complicated symptoms are themselves
revealed as representing, by means of ‘conversion’,
phantasies which have a sexual situation as their subject-matter.
Anyone who knows how to interpret the language of hysteria will
recognize that the neurosis is concerned only with the
patient’s repressed sexuality. The sexual function must,
however, be understood in its true extent, as it is laid down by
disposition in infancy. Wherever some commonplace emotion must be
included among the determinants of the onset of the illness,
analysis invariably shows that it is the sexual component of the
traumatic experience - a component that is never lacking which has
produced the pathogenic result.

   We have been led on imperceptibly
from the question of the causation of the psychoneuroses to the
problem of their essential nature. If we are prepared to take into
account what has been learnt from psycho-analysis, we can only say
that the essence of these illnesses lies in disturbances of the
sexual processes, the processes which determine in the organism the
formation and utilization of sexual libido. It is scarcely possible
to avoid picturing these processes as being in the last resort of a
chemical nature; so that in what are termed the
‘actual’ neuroses we may recognize the
somatic
effects of disturbances of the sexual metabolism, and in the
psychoneuroses the
psychical
effects of those disturbances
as well. The similarity of the neuroses to the phenomena of
intoxication and abstinence after the use of certain alkaloids, as
well as to Graves’ disease and Addison’s disease, is
forced upon our notice clinically. And just as these last two
illnesses should no longer be described as ‘nervous
diseases’, so also the ‘neuroses’ proper, in
spite of their name, may soon have to be excluded from that
category as well.

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

1583

   Accordingly, the aetiology of the
neuroses comprises everything which can act in a detrimental manner
upon the processes serving the sexual function. In the forefront,
then, are to be ranked the noxae which affect the sexual function
itself - in so far as these are regarded as injurious by the sexual
constitution, varying as it does with different degrees of culture
and education. In the next place comes every other kind of noxa and
trauma which, by causing general damage to the organism, may lead
secondarily to injury to its sexual processes. It should not,
however, be forgotten that the aetiological problem in the case of
the neuroses is at least as complicated as the causative factors of
any other illness. A single pathogenic influence is scarcely ever
sufficient; in the large majority of cases a
number
of
aetiological factors are required, which support one another and
must therefore not be regarded as being in mutual opposition. For
this reason a state of neurotic illness cannot be sharply
differentiated from health. The onset of the illness is the product
of a summation and the necessary total of aetiological determinants
can be completed from any direction. To look for the aetiology of
the neuroses exclusively in heredity or in the constitution would
be just as one-sided as to attribute that aetiology solely to the
accidental influences brought to bear upon sexuality in the course
of the subject’s life - whereas better insight shows that the
essence of these illnesses lies solely in a disturbance of the
organism’s sexual processes.

VIENNA
,
June
1905.

1584

PSYCHICAL (OR MENTAL) TREATMENT

(1890)

1585

Intentionally left blank

1586

PSYCHICAL (OR MENTAL) TREATMENT

‘Psyche’ is a Greek word which may
be translated ‘mind’. Thus ‘psychical
treatment’ means ‘mental treatment’. The term
might accordingly be supposed to signify ‘treatment of the
pathological phenomena of mental life’. This, however, is
not
its meaning. ‘Psychical treatment’ denotes,
rather, treatment taking its start in the mind, treatment (whether
of mental or physical disorders) by measures which operate in the
first instance and immediately upon the human mind.

   Foremost among such measures is
the use of words; and words are the essential tool of mental
treatment. A layman will no doubt find it hard to understand how
pathological disorders of the body and mind can be eliminated by
‘mere’ words. He will feel that he is being asked to
believe in magic. And he will not be so very wrong, for the words
which we use in our everyday speech are nothing other than
watered-down magic. But we shall have to follow a roundabout path
in order to explain how science sets about restoring to words a
part at least of their former magical power.

   It is only comparatively
recently, too, that physicians with a scientific training have
learnt to appreciate the value of mental treatment. And we can
easily see why this was so when we reflect on the evolution of
medicine during the last half-century. After a somewhat unfruitful
period during which it was dependent on what was known as
‘Natural Philosophy’, it came under the happy influence
of the natural sciences and has achieved the greatest advances
alike as a science and as an art: it has shown that the organism is
built up from microscopically small elements (the cells), it has
learnt to understand the physics and chemistry of the various vital
processes (functions), it has distinguished the visible and
observable modifications which are brought about in the bodily
organs by different morbid processes, and has discovered, on the
other hand, the signs that reveal the operation of deep-lying
morbid processes in the living body; moreover it has identified a
great number of the micro-organisms which cause illness and, with
the help of its newly acquired knowledge, it has reduced to a quite
extraordinary degree the dangers arising from severe surgical
operations. All of these advances and discoveries were related to
the
physical
side of man, and it followed, as a result of an
incorrect though easily understandable trend of thought, that
physicians came to restrict their interest to the physical side of
things and were glad to leave the mental field to be dealt with by
the philosophers whom they despised.

Psychical (Or Mental) Treatment

1587

   Modern medicine, it is true, had
reason enough for studying the indisputable connection between the
body and the mind; but it never ceased to represent mental events
as determined by physical ones and dependent on them. Thus stress
was laid on the fact that intellectual functioning was conditional
upon the presence of a normally developed and sufficiently
nourished brain, that any disease of that organ led to disturbances
of intellectual functioning, that the introduction of toxic
substances into the circulation could produce certain states of
mental illness, or - to descend to more trivial matters - that
dreams could be modified by stimuli brought to bear upon a sleeper
for experimental purposes.

   The relation between body and
mind (in animals no less than in human beings) is a reciprocal one;
but in earlier times the other side of this relation, the effect of
the mind upon the body, found little favour in the eyes of
physicians. They seemed to be afraid of granting mental life any
independence, for fear of that implying an abandonment of the
scientific ground on which they stood.

   This one-sided attitude of
medicine towards the body has undergone a gradual change in the
course of the last decade and a half, a change brought about
directly by clinical experience. There are a large number of
patients, suffering from affections of greater or less severity,
whose disorders and complaints make great demands on the skill of
their physicians, but in whom no visible or observable signs of a
pathological process can be discovered either during their life or
after their death, in spite of all the advances in the methods of
investigation made by scientific medicine. One group of these
patients are distinguished by the copiousness and variety of their
symptoms: they are incapable of intellectual work because of
headaches or inability to concentrate their attention, their eyes
ache when they read, their legs become fatigued when they walk,
develop dull pains or go to sleep, their digestion is disturbed by
distressing sensations, by eructations or gastric spasms, they
cannot defaecate without aperients, they are subject to
sleeplessness, and so on. They may suffer from all these disorders
simultaneously or in succession, or from only a selection of them;
but in every case the illness is evidently the same. Moreover, its
signs are often variable and replace one another. A patient who has
hitherto been incapacitated by headaches but has had a fairly good
digestion may next day enjoy a clear head but may thenceforward be
unable to manage most kinds of food. Again, his sufferings may
suddenly cease if there is a marked change in the circumstances of
his existence. If he is travelling he may feel perfectly well and
be able to enjoy the most varied diet without any ill effects, but
when he gets home he may once more have to restrict himself to sour
milk. In a few cases the disorder - whether it is a pain or a
weakness resembling a paralysis - may suddenly pass from one side
of the body to the other: it may jump from his right side to the
corresponding part of the body on his left side. But in every
instance it is to be observed that the symptoms are very clearly
influenced by excitement, emotion, worry, etc., and also that they
can disappear and give place to perfect health without leaving any
traces, even if they have persisted over a long period.

   Medical research has at last
shown that people of this kind are not to be looked upon as
suffering from a disease of the stomach or of the eyes or whatever
it may be, but that it must be a question in their case of an
illness of the nervous system as a whole. Examination of the brain
and nerves of these patients has so far, however, revealed no
perceptible changes; and, indeed, some of the features of their
symptomatology prohibit any expectation that even more accurate
methods of investigation could ever discover changes of a sort that
would throw light upon the illness. This condition has been
described as ‘nervousness’ (neurasthenia or hysteria)
and has been characterized as a merely ‘functional’
disorder of the nervous system.¹ Incidentally, an exhaustive
examination of the brain (after the patient’s death) has been
equally without results in the case of many more permanent nervous
disorders, as well as in illnesses with exclusively mental
symptoms, such as what are known as obsessions and delusional
insanity.

  
¹
See Volume II, Part X, Chapter 4 [of the
work,
Die Gesundheit
, in which this paper of Freud’s
first appeared.]

Psychical (Or Mental) Treatment

1588

   Physicians were thus faced by the
problem of investigating the nature and origin of the symptoms
shown by these nervous or neurotic patients. In the course of this
investigation it was found that in some at least of these patients
the signs of their illness originate from nothing other than
a
change in the action of their minds upon their bodies
and that
the immediate cause of their disorder is to be looked for in their
minds. What may be the remoter causes of the disturbance which
affects their minds is another question, with which we need not now
concern ourselves. But medical science was here provided with an
opportunity for directing its full attention to what had previously
been the neglected side of the mutual relation between body and
mind.

   It is not until we have studied
pathological phenomena that we can get an insight into normal ones.
Many things which had long been known of the influence of the mind
on the body were only now brought into their true perspective. The
commonest, everyday example of the mind’s action on the body,
and one that is to be observed in everyone, is offered by what is
known as the ‘expression of the emotions’. A
man’s states of mind are manifested, almost without
exception, in the tensions and relaxations of his facial muscles,
in the adaptations of his eyes, in the amount of blood in the
vessels of his skin, in the modifications in his vocal apparatus
and in the movements of his limbs and in particular of his hands.
These concomitant physical changes are for the most part of no
advantage to the person concerned; on the contrary, they often
stand in his way if he wishes to conceal his mental processes from
other people. But they serve these other people as trustworthy
indications from which his mental processes can be inferred and in
which more confidence can be placed than in any simultaneous verbal
expressions that may be made deliberately. If we are able to submit
anyone to a more accurate examination during certain of his mental
activities, we come upon further physical consequences, in the
shape of changes in his heart-action, alterations in the
distribution of blood in his body, and so on.

Psychical (Or Mental) Treatment

1589

   In certain mental states
described as ‘affects’, the part played by the body is
so obvious and on so large a scale that some psychologists have
even adopted the view that the essence of these affects consists
only in their physical manifestations. It is a matter of common
knowledge that extraordinary changes occur in the facial
expression, in the circulation, in the excretions and in the state
of tension of the voluntary muscles under the influence of fear, of
rage, of mental pain and of sexual delight. What is less well
known, though equally well established, is the occurrence of other
physical results of the affects which cannot be counted as their
expression. Persistent affective states of a distressing or
‘depressive’ nature (as they are called), such as
sorrow, worry or grief, reduce the state of nourishment of the
whole body, cause the hair to turn white, the fat to disappear and
the walls of the blood-vessels to undergo morbid changes. On the
other hand, under the influence of feelings of joy, of
‘happiness’, we find that the whole body blossoms out
and shows signs of a renewal of youth. The major affects evidently
have a large bearing on the capacity to resist infectious illness;
a good example of this is to be seen in the medical observation
that there is a far greater liability to contract such diseases as
typhus and dysentery in defeated armies than in victorious ones.
The affects, moreover, - this applies almost exclusively to
depressive affects - are often sufficient in themselves to bring
about both diseases of the nervous system accompanied by manifest
anatomical changes and also diseases of other organs. In such cases
it must be assumed that the patient already had a predisposition,
though hitherto an inoperative one, to the disease in question.

   States of illness that are
already present can be very considerably influenced by violent
affects. Such changes are usually for the worse; but there is no
lack of instances in which a severe shock or a sudden bereavement
brings about a peculiar alteration in the tone of the organism
which may have a favourable influence on some well-established
pathological condition or may even bring it to an end. Finally,
there can be no doubt that the duration of life can be appreciably
shortened by depressive affects and that a violent shock, or a deep
humiliation or disgrace, may put a sudden end to life. Strange to
say, this same result may be found to follow too from the
unexpected impact of a great joy.

Psychical (Or Mental) Treatment

1590

   The affects in the narrower sense
are, it is true, characterized by a quite special connection with
somatic processes; but, strictly speaking, all mental states,
including those that we usually regard as ‘processes of
thought’, are to some degree ‘affective’, and not
one of them is without its physical manifestations or is incapable
of modifying somatic processes. Even when a person is engaged in
quietly thinking in a string of ‘ideas’, there are a
constant series of excitations, corresponding to the content of
these ideas, which are discharged into the smooth or striated
muscles. These excitations can be made apparent if they are
appropriately reinforced, and certain striking and, indeed,
ostensibly ‘supernatural’ phenomena can be explained by
this means. Thus, what is known as ‘thought-reading’
[
Gedanken erraten
] may be explained by small, involuntary
muscular movements carried out by the ‘medium’ in the
course of an experiment - when, for instance, he has to make
someone discover a hidden object. The whole phenomenon might more
suitably be described as ‘thought-betraying’
[
Gedanken verraten
].

   The processes of volition and
attention are also capable of exercising a profound effect on
somatic processes and of playing a large part in promoting or
hindering physical illnesses. A famous English physician has
reported that he can succeed in producing a great variety of
sensations and pains in any part of his body to which he may choose
to direct his attention, and the majority of people appear to
behave similarly. It is in general true that in forming a judgement
of pains (which are usually regarded as physical phenomena) we must
bear in mind their unmistakable dependence upon mental
determinants. Laymen, who like to sum up mental influences of this
kind under the name of ‘imagination’, are inclined to
have little respect for pains that are due to imagination as
contrasted with those caused by injury, illness or inflammation.
But this is clearly unjust. However pains may be caused - even by
imagination - they themselves are no less real and no less
violent on that account.