Freud - Complete Works (45 page)

   I should not like it to be
wrongly thought that I do not wish to allow that hysteria is an
independent neurotic affection, that I regard it merely as a
psychical manifestation of anxiety neurosis and that I attribute to
it ‘ideogenic’ symptoms only and am transferring the
somatic symptoms (such as hyterogenic points and anaesthesias) to
anxiety neurosis. Nothing of the sort. In my opinion it is possible
to deal with hysteria, freed from any admixture, as something
independent; and to do so in every respect except in that of
therapeutics. For in therapeutics we are concerned with a practical
aim, with getting rid of the pathological state as a whole. And if
hysteria generally appears as a component of a mixed neurosis, the
situation resembles that in which there is a mixed infection, where
preserving life sets a problem which does not coincide with that of
combating the operation of one particular pathogenic agent.

   It is very important for me to
distinguish the part played by hysteria in the picture of the mixed
neuroses from that played by neurasthenia, anxiety neurosis and so
on, because, once I have made this distinction, I shall be able to
express concisely the therapeutic value of the cathartic method.
For I am inclined to venture the assertion that that method is - as
a matter of theory - very well able to get rid of any hysterical
symptom, whereas, as will be easily understood, it is completely
powerless against the phenomena of neurasthenia and is only able
rarely and in roundabout ways to influence the psychical effects of
anxiety neurosis. Its therapeutic effectiveness in any particular
case will accordingly depend on whether the hysterical components
of the clinical picture do or do not assume a position of practical
importance in comparison with the other neurotic components.

   There is another obstacle in the
way of the effectiveness of the cathartic method, which we have
already indicated in the ‘Preliminary Communication’.
It cannot affect the underlying causes of hysteria: thus it cannot
prevent fresh symptoms from taking the place of the ones which had
been got rid of. On the whole, then, I must claim a prominent place
for our therapeutic method as employed within the framework of a
therapy of the neuroses; but I should like to advise against
assessing its value or applying it outside this framework. Since,
however, I cannot in these pages offer a ‘therapy of the
neuroses’ of the sort needed by practitioners, what I have
just said is equivalent to postponing my account of the subject to
a possible later publication. But I am able, I think, to add the
following remarks by way of expansion and elucidation.

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232

   (1) I do not maintain that I have
actually got rid of all the hysterical symptoms that I have
undertaken to influence by the cathartic method. But it is my
opinion that the obstacles have lain in the personal circumstances
of the patients and have not been due to any question of theory. I
am justified in leaving these unsuccessful cases out of account in
arriving at a judgement, just as a surgeon disregards cases of
death which occur under anaesthesia, owing to post-operational
haemorrhage, accidental sepsis, etc., in making a decision about a
new technique. When I come to deal with the difficulties and
drawbacks of the procedure later on, I shall return to a
consideration of failures from this source.

   (2)  The cathartic method is
not to be regarded as worthless because it is a symptomatic and not
a causal one. For a causal therapy is in fact as a rule only a
prophylactic one; it brings to a halt any further effects of the
noxious agency, but does not therefore necessarily get rid of the
results which that agency has already brought about. As a rule a
second phase of treatment is required to perform this latter task,
and in cases of hysteria the cathartic method is quite invaluable
for this purpose.

   (3) Where a period of hysterical
production, an acute hysterical paroxysm, has been overcome and all
that is left over are hysterical symptoms in the shape of residual
phenomena, the cathartic method suffices for every indication and
brings about complete and permanent successes. A favourable
therapeutic constellation of this kind is not seldom to be found
precisely in the region of sexual life, owing to the wide
oscillations in the intensity of sexual needs and the complications
of the conditions necessary in order to bring about a sexual
trauma. Here the cathartic method does all that can be asked of it,
for the physician cannot set himself the task of altering a
constitution such as the hysterical one. He must content himself
with getting rid of the troubles to which such a constitution is
inclined and which may arise from it with the conjunction of
external circumstances. He will feel satisfied if the patient
regains her working capacity. Moreover, he is not without
consolation for the future when he considers the possibility of a
relapse. He is aware of the principal feature in the aetiology of
the neuroses - that their genesis is as a rule overdetermined, that
several factors must come together to produce this result; and he
may hope that this convergence will not be repeated at once, even
though a few individual aetiological factors remain operative.

   It might be objected that, in
cases of hysteria like this, in which the illness has run its
course, the residual symptoms in any case pass away spontaneously.
It may be said in reply, however, that a spontaneous cure of this
kind is very often neither rapid nor complete enough and that it
can be assisted to an extraordinary degree by our therapeutic
intervention. We may readily leave it for the moment as an
unresolved question whether by means of the cathartic therapy we
cure only what is capable of spontaneous cure or sometimes also
what would not have been cleared up spontaneously.

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233

   (4) Where we meet with an acute
hysteria, a case which is passing through the period of the most
active production of hysterical symptoms and in which the ego is
being constantly overwhelmed by the products of the illness (i.e.
during a hysterical psychosis), even the cathartic method will make
little change in the appearance and course of the disorder. In such
circumstances we find ourselves in the same position as regards the
neurosis as a physician faced by an acute infectious disease. The
aetiological factors have performed their work sufficiently, at a
time which has now passed and is beyond the reach of any influence;
and now, after the period of incubation has elapsed, they have
become manifest. The illness cannot be broken off short. We must
wait for it to run its course and in the mean time make the
patient’s circumstances as favourable as possible. If, during
an acute period like this, we get rid of the products of the
illness, the freshly generated hysterical symptoms, we must also be
prepared to find that those that have been got rid of will promptly
be replaced by others. The physician will not be spared the
depressing feeling of being faced by a Sisyphean task. The immense
expenditure of labour, and the dissatisfaction of the
patient’s family, to whom the inevitable length of an acute
neurosis is not likely to be as familiar as the analogous case of
an acute infectious disease - these and other difficulties will
probably make a systematic application of the cathartic method as a
rule impossible in any given case. Nevertheless, it remains a
matter for serious consideration whether it may not be true that
even in an acute hysteria the regular clearing up of the products
of the illness exercises a curative influence, by supporting the
patient’s normal ego which is engaged in the work of defence,
and by preserving it from being overwhelmed and falling into a
psychosis and even perhaps into a permanent state of confusion.

   What the cathartic method is able
to accomplish even in acute hysteria, and how it even restricts the
fresh production of pathological symptoms in a manner that is of
practical importance, is quite clearly revealed by the case history
of Anna O., in which Breuer first learnt to employ this
psychotherapeutic procedure.

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   (5) Where it is a question of
hysterias which run a chronic course, accompanied by a moderate but
constant production of hysterical symptoms, we find the strongest
reason for regretting our lack of a therapy which is effective
causally, but we also have most ground for the appreciation of the
value of the cathartic procedure as a
symptomatic
therapy.
In such cases we have to do with the mischief produced by an
aetiology that persists chronically. Everything depends on
reinforcing the patient’s nervous system in its capacity to
resist; and we must reflect that the existence of a hysterical
symptom means a weakening of the resistance of that nervous system
and represents a factor predisposing to hysteria. As can be seen
from the mechanism of monosymptomatic hysteria, a new hysterical
symptom is most easily formed in connection with, and on the
analogy of, one that is already present. The point at which a
symptom has already broken through once (see 
p. 181
) forms a weak spot at which it
will break through again the next time. A psychical group that has
once been split off plays the part of a ‘provoking’
crystal from which a crystallization which would otherwise not have
occurred will start with the greatest facility. To get rid of the
symptoms which are already present, to undo the psychical changes
which underlie them, is to give back to patients the whole amount
of their capacity for resistance, so that they can successfully
withstand the effects of the noxious agency. A very great deal can
be done for such patients by means of prolonged supervision and
occasional ‘chimney-sweeping’ (
p. 29
).

   (6) It remains for me to mention
the apparent contradiction between the admission that not all
hysterical symptoms are psychogenic and the assertion that they can
all be got rid of by a psychotherapeutic procedure. The solution
lies in the fact that some of these non-psychogenic symptoms
(stigmata, for instance) are, it is true, indications of illness,
but cannot be described as ailments; and consequently it is not of
practical importance if they persist after the successful treatment
of the illness. As regards other such symptoms, it seems to be the
case that in some roundabout way they are carried off along with
the psychogenic symptoms, just as, perhaps, in some roundabout way
they are after all dependent on a psychical causation.

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235

   I must now consider the
difficulties and disadvantages of our therapeutic procedure, so far
as they do not become obvious to everyone from the case histories
reported above or from the remarks on the technique of the method
which follow later. I will enumerate and indicate these
difficulties rather that elaborate them.

   The procedure is laborious and
time-consuming for the physician. It presupposes great interest in
psychological happenings, but personal concern for the patients as
well. I cannot imagine bringing myself to delve into the psychical
mechanism of a hysteria in anyone who struck me as low-minded and
repellent, and who, on closer acquaintance, would not be capable of
arousing human sympathy; whereas I can keep the treatment of a
tabetic or rheumatic patient apart from personal approval of this
kind. The demands made on the patient are not less. The procedure
is not applicable at all below a certain level of intelligence, and
it is made very much more difficult by any trace of feebleness of
mind. The complete consent and complete attention of the patients
are needed, but above all their confidence, since the analysis
invariably leads to the disclosure of the most intimate and secret
psychical events. A good number of the patients who would be
suitable for this form of treatment abandon the doctor as soon as
the suspicion begins to dawn on them of the direction in which the
investigation is leading. For patients such as these the doctor has
remained a stranger. With others, who have decided to put
themselves in his hands and place their confidence in him - a step
which in other such situations is only taken voluntarily and never
at the doctor’s request - with these other patients, I say,
it is almost inevitable that their personal relation to him will
force itself, for a time at least, unduly into the foreground. It
seems, indeed, as though an influence of this kind on the part of
the doctor is a
sine qua non
to a solution of the problem. I
do not think any essential difference is made in this respect
whether hypnosis can be used or whether it has to be by-passed and
replaced by something else. But reason demands that we should
emphasize the fact that these drawbacks, though they are
inseparable from our procedure, cannot be laid at its door. On the
contrary, it is quite clear that they are based on the
predetermining conditions of the neuroses that are to be cured and
that they must attach to any medical activity which involves
intense preoccupation with the patient and leads to a psychical
change in him. I have not been able to attribute any deleterious
effects or danger to the employment of hypnosis, though I made
copious use of it in some of my cases. Where I caused damage, the
reasons lay elsewhere and deeper. If I survey my therapeutic
efforts during the last few years since the communications made by
my honoured teacher and friend Josef Breuer showed me the use of
the cathartic method, I believe that in spite of everything, I have
done much more, and more frequent, good than harm and have
accomplished some things which no other therapeutic procedure could
have achieved. It has on the whole, as the ‘Preliminary
Communication’ put it, brought ‘considerable
therapeutic advantages’.