Freud - Complete Works (378 page)

   The
compulsion
on the
other hand is an attempt at a compensation for the doubt and at a
correction of the intolerable conditions of inhibition to which the
doubt bears witness. If the patient, by the help of displacement,
succeeds at last in bringing one of his inhibited intentions to a
decision, then the intention
must
be carried out. It is true
that this intention is not his original one, but the energy dammed
up in the latter cannot let slip the opportunity of finding an
outlet for its discharge in the substitutive act. Thus this energy
makes itself felt now in commands and now in prohibitions,
according as the affectionate impulse or the hostile one snatches
control of the pathway leading to discharge. If it happens that a
compulsive command cannot be obeyed, the tension becomes
intolerable and is perceived by the patient in the form of extreme
anxiety.(But the pathway leading to a substitutive act, even where
the displacement has been on to something very small, is so hotly
contested, that such an act can as a rule be carried out only in
the shape of a protective measure intimately associated with the
very impulse which it is designed to ward off.

Notes Upon A Case Of Obsessional Neurosis

2191

   Furthermore, by a sort of
regression
, preparatory acts become substituted for the
final decision, thinking replaces acting, and, instead of the
substitutive act, some thought preliminary to it asserts itself
with all the force of compulsion. According as this regression from
acting to thinking is more or less marked, a case of obsessional
neurosis will exhibit the characteristics of obsessive thinking
(that is, of obsessional ideas) or of obsessive acting in the
narrower sense of the word. True obsessional acts such as these,
however, are only made possible because they constitute a kind of
reconciliation, in the shape of a compromise, between the two
antagonistic impulses. For obsessional acts tend to approximate
more and more - and the longer the disorder lasts the more evident
does this become - to infantile sexual acts of a masturbatory
character. Thus in this form of the neurosis acts of love are
carried out in spite of everything, but only by the aid of a new
kind of regression; for such acts no longer relate to another
person, the object of love and hatred, but are auto-erotic acts
such as occur in infancy.

   The first kind of regression,
that from acting to thinking, is facilitated by another factor
concerned in the production of the neurosis. The histories of
obsessional patients almost invariably reveal an early development
and premature repression of the sexual instinct of looking and
knowing; and, as we know, a part of the infantile sexual activity
of our present patient was governed by that instinct.¹

   We have already mentioned the
important part played by the sadistic instinctual components in the
genesis of obsessional neuroses. Where the epistemophilic instinct
is a preponderant feature in the constitution of an obsessional
patient, brooding becomes the principal symptom of the neurosis.
The thought-process itself becomes sexualized, for the sexual
pleasure which is normally attached to the content of thought
becomes shifted on to the act of thinking itself, and the
satisfaction derived from reaching the conclusion of a line of
thought is experienced as a
sexual
satisfaction. In the
various forms of obsessional neurosis in which the epistemophilic
instinct plays a part, its relation to thought-processes makes it
particularly well adapted to attract the energy which is vainly
endeavouring to make its way forward into action, and divert it
into the sphere of thought, where there is a possibility of its
obtaining pleasurable satisfaction of another sort. In this way,
with the help of the epistemophilic instinct, the substitutive act
may in its turn be replaced by preparatory acts of thought. But
procrastination in
action
is soon replaced by lingering over
thoughts
, and eventually the whole process, together with
all its peculiarities, is transferred into the new sphere, just as
in America an entire house will sometimes be shifted from one site
to another.

  
¹
The very high average of intellectual
capacity among obsessional patients is probably also connected with
this fact.

Notes Upon A Case Of Obsessional Neurosis

2192

   I may now venture, upon the basis
of the preceding discussion, to determine the psychological
characteristic, so long sought after, which lends to the products
of an obsessional neurosis their ‘obsessive’ or
compulsive quality. A thought-process is obsessive or compulsive
when, in consequence of an inhibition (due to a conflict of
opposing impulses) at the motor end of the psychical system, it is
undertaken with an expenditure of energy which (as regards both
quality and quantity) is normally reserved for actions alone; or,
in other words,
an obsessive or compulsive thought is one whose
function it is to represent an act regressively
. No one, I
think, will question my assumption that processes of thought are
ordinarily conducted (on grounds of economy) with smaller
displacements of energy, probably at a higher level, than are acts
intended to bring about discharge or to modify the external
world.

   The obsessive thought which has
forced its way into consciousness with such excessive violence has
next to be secured against the efforts made by conscious thought to
resolve it. As we already know, this protection is afforded by the
distortion
which the obsessive thought has undergone before
becoming conscious. But this is not the only means employed. In
addition, each separate obsessional idea is almost invariably
removed from the situation in which it originated and in which, in
spite of its distortion, it would be most easily comprehensible.
With this end in view, in the first place
an interval of time is
inserted
between the pathogenic situation and the obsession
that arises from it, so as to lead astray any conscious
investigation of its causal connections, and in the second place
the content of the obsession is taken out of its particular setting
by being
generalized
. Our patient’s ‘obsession
for understanding’ is an example of this (
p. 2150
). But perhaps a better one is
afforded by another patient. This was a woman who prohibited
herself from wearing any sort of personal adornment, though the
exciting cause of the prohibition related only to one particular
piece of jewellery: she had envied her mother the possession of it
and had had hopes that one day she would inherit it. Finally, if we
care to distinguish verbal distortion from distortion of content,
there is yet another means by which the obsession is protected
against conscious attempts at solution. And that is the choice of
an indefinite or ambiguous wording. After being misunderstood, the
wording may find its way into the patient’s
‘deliria’, and whatever further processes of
development or substitution his obsession undergoes will then be
based upon the misunderstanding and not upon the proper sense of
the text. Observation will show, however, that the deliria
constantly tend to form new connections with that part of the
matter and wording of the obsession which is not present in
consciousness.

Notes Upon A Case Of Obsessional Neurosis

2193

   I should like to go back once
more to the instinctual life of obsessional neurotics and add one
more remark upon it. It turned out that our patient, besides all
his other characteristics, was a
renifleur
. By his own
account, when he was a child he had recognized every one by their
smell, like a dog; and even when he was grown up he was more
susceptible to sensations of smell than most people.¹ I have
met with the same characteristic in other neurotics, both in
hysterical and in obsessional patients, and I have come to
recognize that a tendency to taking pleasure in smell, which has
become extinct since childhood, may play a part in the genesis of
neurosis.² And here I should like to raise the general
question whether the atrophy of the sense of smell (which was an
inevitable result of man’s assumption of an erect posture)
and the consequent organic repression of his pleasure in smell may
not have had a considerable share in the origin of his
susceptibility to nervous disease. This would afford us some
explanation of why, with the advance of civilization, it is
precisely the sexual life that must fall a victim to repression.
For we have long known the intimate connection in the animal
organization between the sexual instinct and the function of the
olfactory organ.

  
¹
I may add that in his childhood he had been
subject to strong coprophilic propensities. In this connection his
anal erotism has already been noticed (
p. 2166
).

  
²
For instance, in certain forms of
fetishism.

Notes Upon A Case Of Obsessional Neurosis

2194

   In bringing this paper to a close
I may express a hope that, though my communication is incomplete in
every sense, it may at least stimulate other workers to throw more
light upon the obsessional neurosis by a deeper investigation of
the subject. What is characteristic of this neurosis - what
differentiates it from hysteria - is not, in my opinion, to be
found in instinctual life but in the psychological field. I cannot
take leave of my patient without putting on paper my impression
that he had, as it were, disintegrated into three personalities:
into one unconscious personality, that is to say, and into two
preconscious ones between which his consciousness could oscillate.
His unconscious comprised those of his impulses which had been
suppressed at an early age and which might be described as
passionate and evil impulses. In his normal state he was kind,
cheerful, and sensible - an enlightened and superior kind of person
- while in his third psychological organization he paid homage to
superstition and asceticism. Thus he was able to have two different
creeds and two different outlooks upon life. This second
preconscious personality comprised chiefly the reaction-formations
against his repressed wishes, and it was easy to foresee that it
would have swallowed up the normal personality if the illness had
lasted much longer. I have at present an opportunity of studying a
lady suffering severely from obsessional acts. She has become
similarly disintegrated into an easy-going and lively personality
and into an exceedingly gloomy and ascetic one. She puts forward
the first of them as her official ego, while in fact she is
dominated by the second. Both of these psychical organizations have
access to her consciousness, but behind her ascetic personality may
be discerned the unconscious part of her being - quite unknown to
her and composed of ancient and long-repressed wishful
impulses.¹

  
¹
(
Footnote added
1923:) The
patient’s mental health was restored to him by the analysis
which I have reported upon in these pages. Like so many other young
men of value and promise, he perished in the Great War.

2195

FIVE LECTURES ON PSYCHO-ANALYSIS

(1910)

2196

Intentionally left blank

2197

FIVE LECTURES ON PSYCHO-ANALYSIS

Delivered on the Occasion of the Celebration

of
the Twentieth Anniversary of the Foundation

of

CLARK
UNIVERSITY, WORCESTER

MASSACHUSETTS

September 1909

Five Lectures On Psycho-Analysis

2198

To

DR.
G. STANLEY HALL, PH.D., LL.D.

President of Clark University

Professor of Psychology and Pedagogics

This
Work is Gratefully Dedicated

Five Lectures On Psycho-Analysis

2199

FIRST
LECTURE

LADIES AND
GENTLEMEN
, - It is with novel and bewildering feelings that
I find myself in the New World, lecturing before an audience of
expectant enquirers. No doubt I owe this honour only to the fact
that my name is linked with the topic of psycho-analysis; and it is
of psycho-analysis, therefore, that I intend to speak to you. I
shall attempt to give you, as succinctly as possible, a survey of
the history and subsequent development of this new method of
examination and treatment.

   If it is a merit to have brought
psycho-analysis into being that merit is not mine.¹ I had no
share in its earliest beginnings. I was a student and working for
my final examinations at the time when another Viennese physician,
Dr. Josef Breuer,² first (in 1880-2) made use of this
procedure on a girl who was suffering from hysteria. Let us turn
our attention straightaway to the history of this case and its
treatment, which you will find set out in detail in the
Studies
on Hysteria
³ which were published later by Breuer and
myself.

   But I should like to make one
preliminary remark. It is not without satisfaction that I have
learnt that the majority of my audience are not members of the
medical profession. You have no need to be afraid that any special
medical knowledge will be required for following what I have to
say. It is true that we shall go along with the doctors on the
first stage of our journey, but we shall soon part company with
them and, with Dr. Breuer, shall pursue a quite individual
path.

  
¹
[
Footnote added
1923:] See, however,
in this connection my remarks in ‘A History of the
Psycho-Analytic Movement’ (1914
d
), where I assumed the
entire responsibility for psycho-analysis.

  
²
Dr. Josef Breuer, born in 1842, a
Corresponding Member of the Kaiserliche Akademie der
Wissenschaften, is well known for his work on respiration and on
the physiology of the sense of equilibrium.

  
³
Some of my contributions to this book have
been translated into English by Dr. A. A. Brill of New York:
Selected Papers on Hysteria
(New York, 1909).

Five Lectures On Psycho-Analysis

2200

   Dr. Breuer’s patient was a
girl of twenty-one, of high intellectual gifts. Her illness lasted
for over two years, and in the course of it she developed a series
of physical and psychological disturbances which decidedly deserved
to be taken seriously. She suffered from a rigid paralysis,
accompanied by loss of sensation, of both extremities on the right
side of her body; and the same trouble from time to time affected
her on her left side. Her eye movements were disturbed and her
power of vision was subject to numerous restrictions. She had
difficulties over the posture of her head; she had a severe nervous
cough. She had an aversion to taking nourishment, and on one
occasion she was for several weeks unable to drink in spite of a
tormenting thirst. Her powers of speech were reduced, even to the
point of her being unable to speak or understand her native
language. Finally, she was subject to conditions of
‘
absence
’,¹ of confusion, of delirium, and
of alteration of her whole personality, to which we shall have
presently to turn our attention.

   When you hear such an enumeration
of symptoms, you will be inclined to think it safe to assume, even
though you are not doctors, that what we have before us is a severe
illness, probably affecting the brain, that it offers small
prospect of recovery and will probably lead to the patient’s
early decease. You must be prepared to learn from the doctors,
however, that, in a number of cases which display severe symptoms
such as these, it is justifiable to take a different and a far more
favourable view. If a picture of this kind is presented by a young
patient of the female sex, whose vital internal organs (heart,
kidneys, etc.) are shown on objective examination to be normal, but
who has been subjected to violent
emotional
shocks - if,
moreover, her various symptoms differ in certain matters of detail
from what would have been expected - then doctors are not inclined
to take the case too seriously. They decide that what they have
before them is not an organic disease of the brain, but the
enigmatic condition which, from the time of ancient Greek medicine,
has been known as ‘hysteria’ and which has the power of
producing illusory pictures of a whole number of serious diseases.
They consider that there is then no risk to life but that a return
to health - even a complete one - is probable. It is not always
quite easy to distinguish a hysteria like this from a severe
organic illness. There is no need for us to know, however, how a
differential diagnosis of that kind is made; it will suffice to
have an assurance that the case of Breuer’s patient was
precisely of a kind in which no competent physician could fail to
make a diagnosis of hysteria. And here we may quote from the report
of the patient’s illness the further fact that it made its
appearance at a time when she was nursing her father, of whom she
was devotedly fond, through the grave illness which led to his
death, and that, as a result of her own illness, she was obliged to
give up nursing him.

  
¹
[The French term.]

Five Lectures On Psycho-Analysis

2201

   So far it has been an advantage
to us to accompany the doctors; but the moment of parting is at
hand. For you must not suppose that a patient’s prospects of
medical assistance are improved in essentials by the fact that a
diagnosis of hysteria has been substituted for one of severe
organic disease of the brain. Medical skill is in most cases
powerless against severe diseases of the brain; but neither can the
doctor do anything against hysterical disorders. He must leave it
to kindly Nature to decide when and how his optimistic prognosis
shall be fulfilled.¹

   Thus the recognition of the
illness as hysteria makes little difference to the patient; but to
the doctor quite the reverse. It is noticeable that his attitude
towards hysterical patients is quite other than towards sufferers
from organic diseases. He does not have the same sympathy for the
former as for the latter: for the hysteric’s ailment is in
fact far less serious and yet it seems to claim to be regarded as
equally so. And there is a further factor at work. Through his
studies, the doctor has learnt many things that remain a sealed
book to the layman: he has been able to form ideas on the causes of
illness and on the changes it brings about - e.g. in the brain of a
person suffering from apoplexy or from a malignant growth - ideas
which must to some degree meet the case, since they allow him to
understand the details of the illness. But all his knowledge - his
training in anatomy, in physiology and in pathology - leaves him in
the lurch when he is confronted by the details of hysterical
phenomena. He cannot understand hysteria, and in the face of it he
is himself a layman. This is not a pleasant situation for anyone
who as a rule sets so much store by his knowledge. So it comes
about that hysterical patients forfeit his sympathy. He regards
them as people who are transgressing the laws of his science - like
heretics in the eyes of the orthodox. He attributes every kind of
wickedness to them, accuses them of exaggeration, of deliberate
deceit, of malingering. And he punishes them by withdrawing his
interest from them.

  
¹
I am aware that this is no longer the case;
but in my lecture I am putting myself and my hearers back into the
period before 1880. If things are different now, that is to a great
extent the result of the activities whose history I am now
sketching.

Five Lectures On Psycho-Analysis

2202

   Dr. Breuer’s attitude
towards his patient deserved no such reproach. He gave her both
sympathy and interest, even though, to begin with, he did not know
how to help her. It seems likely that she herself made his task
easier by the admirable qualities of intellect and character to
which he has testified in her case history. Soon, moreover, his
benevolent scrutiny showed him the means of bringing her a first
instalment of help.

   It was observed that, while the
patient was in her states of ‘
absence
(altered
personality accompanied by confusion), she was in the habit of
muttering a few words to herself which seemed as though they arose
from some train of thought that was occupying her mind. The doctor,
after getting a report of these words, used to put her into a kind
of hypnosis and then repeat them to her so as to induce her to use
them as a starting point. The patient complied with the plan, and
in this way reproduced in his presence the mental creations which
had been occupying her mind during the
‘
absences
’ and which had betrayed their
existence by the fragmentary words which she had uttered. They were
profoundly melancholy phantasies - ‘day dreams’ we
should call them - sometimes characterized by poetic beauty, and
their starting-point was as a rule the position of a girl at her
father’s sick-bed. When she had related a number of these
phantasies, she was as if set free, and she was brought back to
normal mental life. The improvement in her condition, which would
last for several hours, would be succeeded next day by a further
attack of ‘
absence
’; and this in turn would be
removed in the same way by getting her to put into words her
freshly constructed phantasies. It was impossible to escape the
conclusion that the alteration in her mental state which was
expressed in the ‘
absences
’ was a result of the
stimulus proceeding from these highly emotional phantasies. The
patient herself, who, strange to say, could at this time only speak
and understand English, christened this novel kind of treatment the
‘talking cure’¹ or used to refer to it jokingly as
‘chimney sweeping’.¹

  
¹
[In English in the original.]

Five Lectures On Psycho-Analysis

2203

   It soon emerged, as though by
chance, that this process of sweeping the mind clean could
accomplish more than the merely temporary relief of her
ever-recurring mental confusion. It was actually possible to bring
about the disappearance of the painful symptoms of her illness, if
she could be brought to remember under hypnosis, with an
accompanying expression of affect, on what occasion and in what
connection the symptom had first appeared. ‘It was in the
summer during a period of extreme heat, and the patient was
suffering very badly from thirst; for, without being able to
account for it in any way, she suddenly found it impossible to
drink. She would take up the glass of water that she longed for,
but as soon as it touched her lips she would push it away like
someone suffering from hydrophobia. As she did this, she was
obviously in an
absence
for a couple of seconds. She lived
only on fruit, such as melons, etc., so as to lessen her tormenting
thirst. This had lasted for some six weeks, when one day during
hypnosis she grumbled about her English "lady-companion",
whom she did not care for, and went on to describe, with every sign
of disgust, how she had once gone into this lady’s room and
how her little dog - horrid creature! - had drunk out of a glass
there. The patient had said nothing, as she had wanted to be
polite. After giving further energetic expression to the anger she
had held back, she asked for something to drink, drank a large
quantity of water without any difficulty, and awoke from her
hypnosis with the glass at her lips; and thereupon the disturbance
vanished, never to return.’¹

   With your permission, I should
like to pause a moment over this event. Never before had anyone
removed a hysterical symptom by such a method or had thus gained so
deep an insight into its causation. It could not fail to prove a
momentous discovery if the expectation were confirmed that others
of the patient’s symptoms - perhaps the majority of them -
had arisen and could be removed in this same manner. Breuer spared
no pains in convincing himself that this was so, and he proceeded
to a systematic investigation of the pathogenesis of the other and
more serious symptoms of the patient’s illness. And it really
was
so. Almost all the symptoms had arisen in this way as
residues - ‘precipitates’ they might be called - of
emotional experiences. To these experiences, therefore, we later
gave the name of ‘psychical traumas’, while the
particular nature of the symptoms was explained by their relation
to the traumatic scenes which were their cause. They were, to use a
technical term, ‘determined’ by the scenes of whose
recollection they represented residues, and it was no longer
necessary to describe them as capricious or enigmatic products of
the neurosis. One unexpected point, however, must be noticed. What
left the symptom behind was not always a
single
experience.
On the contrary, the result was usually brought about by the
convergence of several traumas, and often by the repetition of a
great number of similar ones. Thus it was necessary to reproduce
the whole chain of pathogenic memories in chronological order, or
rather in reversed order, the latest ones first and the earliest
ones last; and it was quite impossible to jump over the later
traumas in order to get back more quickly to the first, which was
often the most potent one.