Freud - Complete Works (46 page)

Studies On Hysteria

236

   There is one other advantage in
the use of this procedure which I must emphasize. I know of no
better way of getting to understand a severe case of complicated
neurosis with a greater or lesser admixture of hysteria than by
submitting it to an analysis by Breuer’s method. The first
thing that happens is the disappearance of whatever exhibits a
hysterical mechanism. In the meantime I have learnt in the course
of the analysis to interpret the residual phenomena and to trace
their aetiology; and in this way I have secured a firm basis for
deciding which of the weapons in the therapeutic armoury against
the neuroses is indicated in the case concerned. When I reflect on
the difference that I usually find between my judgement on a case
of neurosis
before
and
after
an analysis of this
kind, I am almost inclined to regard an analysis as essential for
the understanding of a neurotic illness. Moreover, I have adopted
the habit of combining cathartic psychotherapy with a rest-cure
which can, if need be, be extended into a complete treatment of
feeding-up on Weir Mitchell lines. This gives me the advantage of
being able on the one hand to avoid the very disturbing
introduction of new psychical impressions during a psychotherapy,
and on the other hand to remove the boredom of a rest-cure, in
which the patients not infrequently fall into the habit of harmful
day-dreaming. It might be expected that the often very considerable
psychical work imposed on the patients during a cathartic
treatment, and the excitations resulting from the reproduction of
traumatic experiences, would run counter to the intentions of the
Weir Mitchell rest cure and would hinder the successes which we are
accustomed to see it bring about. But the opposite is in fact the
case. A combination such as this between the Breuer and Weir
Mitchell procedures produces all the physical improvement that we
expect from the latter, as well as having a far-reaching psychical
influence such as never results from a rest-cure without
psychotherapy.

Studies On Hysteria

237

(2)

   I will now return to my earlier
remark that in my attempts to apply Breuer’s method more
extensively I came upon the difficulty that a number of patients
could not be hypnotized, although their diagnosis was one of
hysteria and it seemed probable that the psychical mechanism
described by us operated in them. I needed hypnosis to extend their
memory in order to find the pathogenic recollections which were not
present in their ordinary consciousness. I was obliged therefore
either to give up the idea of treating such patients or to
endeavour to bring about this extension in some other way.

   I was able as little as anyone
else to explain why it is that one person can be hypnotized and
another not, and thus I could not adopt a causal method of meeting
the difficulty. I noticed, however, that in some patients the
obstacle lay still further back: they refused even any
attempt
at hypnosis. The idea then occurred to me one day
that the two cases might be identical and that both might signify
an unwillingness; that people who were not hypnotizable were people
who had a psychical objection to hypnosis, whether their objection
was expressed as unwillingness or not. I am not clear in my mind
whether I can maintain this view.

   The problem was, however, how to
by-pass hypnosis and yet obtain the pathogenic recollections. This
I succeeded in doing in the following manner.

   When, at our first interview, I
asked my patients if they remembered what had originally occasioned
the symptom concerned, in some cases they said they knew nothing of
it, while in others they brought forward something which they
described as an obscure recollection and could not pursue further.
If, following the example of Bernheim when he awoke in his patients
impressions from their somnambulistic state which had ostensibly
been forgotten (
cf. p. 98 f.
), I now became
insistent - if I assured them that they
did
know it, that it
would occur to their minds, - then, in the first cases, something
did actually occur to them, and, in the others, their memory went a
step further. After this I became still more insistent; I told the
patients to lie down and deliberately close their eyes in order to
‘concentrate’ - all of which had at least some
resemblance to hypnosis. I then found that without any hypnosis new
recollections emerged which went further back and which probably
related to our topic. Experiences like this made me think that it
would in fact be possible for the pathogenic groups of ideas, that
were after all certainly present, to be brought to light by mere
insistence; and since this insistence involved effort on my part
and so suggested the idea that I had to overcome a resistance, the
situation led me at once to the theory that
by means of my
psychical work I had to overcome a psychical force in the patients
which was opposed to the pathogenic ideas becoming conscious (being
remembered)
. A new understanding seemed to open before my eyes
when it occurred to me that this must no doubt be the same
psychical force that had played a part in the generating of the
hysterical symptom and had at that time prevented the pathogenic
idea from becoming conscious. What kind of force could one suppose
was operative here, and what motive could have put it into
operation?  I could easily form an opinion on this. For I
already had at my disposal a few completed analyses in which I had
come to know examples of ideas that were pathogenic, and had been
forgotten and put out of consciousness. From these I recognized a
universal characteristic of such ideas: they were all of a
distressing nature, calculated to arouse the affects of shame, of
self-reproach and of psychical pain, and the feeling of being
harmed; they were all of a kind that one would prefer not to have
experienced, that one would rather forget. From all this there
arose, as it were automatically, the thought of
defence
. It
has indeed been generally admitted by psychologists that the
acceptance of a new idea (acceptance in the sense of believing or
of recognizing as real) is dependent on the nature and trend of the
ideas already united in the ego, and they have invented special
technical names for this process of censorship to which the new
arrival must submit. The patient’s ego had been approached by
an idea which proved to be incompatible, which provoked on the part
of the ego a repelling force of which the purpose was defence
against this incompatible idea. This defence was in fact
successful. The idea in question was forced out of consciousness
and out of memory. The psychical trace of it was apparently lost to
view. Nevertheless that trace must be there. If I endeavoured to
direct the patient’s attention to it, I became aware, in the
form of
resistance
, of the same force as had shown itself in
the form of
repulsion
when the symptom was generated. If,
now, I could make it appear probable that the idea had become
pathogenic precisely as a result of its expulsion and repression,
the chain would seem complete. In several of the discussions on our
case histories, and in a short paper on ‘The Neuro-Psychoses
of Defence’ (1894
a
), I have attempted to sketch out
the psychological hypotheses by the help of which this causal
connection - the fact of conversion - can be demonstrated.

Studies On Hysteria

238

   Thus a psychical force, aversion
on the part of the ego, had originally driven the pathogenic idea
out of association and was now opposing its return to memory. The
hysterical patient’s ‘not knowing’ was in fact a
‘not wanting to know’ - a not wanting which might be to
a greater or less extent conscious. The task of the therapist,
therefore, lies in overcoming by his psychical work this resistance
to association. He does this in the first place by
‘insisting’, by making use of psychical compulsion to
direct the patients’ attention to the ideational traces of
which he is in search. His efforts, however, are not exhausted by
this, but, as I shall show, they take on other forms in the course
of an analysis and call in other psychical forces to assist
them.

   I must dwell on the question of
insistence a little longer, Simple assurances such as ‘of
course you know it’, ‘tell me all the same’,
‘you’ll think of it in a moment’ do not carry us
very far. Even with patients in a state of
‘concentration’ the thread breaks off after a few
sentences. It should not be forgotten, however, that it is always a
question here of a
quantitative
comparison, of a struggle
between motive forces of different degrees of strength or
intensity. Insistence on the part of a strange doctor who is
unfamiliar with what is happening is not powerful enough to deal
with the resistance to association in a serious case of hysteria.
We must think of stronger means.

   In these circumstances I make use
in the first instance of a small technical device. I inform the
patient that, a moment later, I shall apply pressure to his
forehead, and I assure him that, all the time the pressure lasts,
he will see before him a recollection in the form of a picture or
will have it in his thoughts in the form of an idea occurring to
him; and I pledge him to communicate this picture or idea to me,
whatever it may be. He is not to keep it to himself because he may
happen to think it is not, or because it would be too disagreeable
for him to say it. There is to be no criticism of it, no reticence,
either for emotional reasons or because it is judged unimportant.
Only in this manner can we find what we are in search of, but in
this manner we shall find it infallibly. Having said this, I press
for a few seconds on the forehead of the patient as he lies in
front of me; I then leave go and ask quietly, as though there were
no question of a disappointment: ‘What did you see?’ or
‘ What occurred to you?’

Studies On Hysteria

239

   This procedure has taught me much
and has also invariably achieved its aim. To-day I can no longer do
without it. I am of course aware that a pressure on the forehead
like this could be replaced by any other signal or by some other
exercise of physical influence on the patient; but since the
patient is lying in front of me, pressure on his forehead, or
taking his head between my two hands, seems to be the most
convenient way of applying suggestion for the purpose I have in
view. It would be possible for me to say by way of explaining the
efficacy of this device that it corresponded to a
‘momentarily intensified hypnosis’; but the mechanism
of hypnosis is so puzzling to me that I would rather not make use
of it as an explanation. I am rather of opinion that the advantage
of the procedure lies in the fact that by means of it I dissociate
the patient’s attention from his conscious searching and
reflecting - from everything, in short, on which he can employ his
will - in the same sort of way in which this is effected by staring
into a crystal ball, and so on. The conclusion which I draw from
the fact that what I am looking for always appears under the
pressure of my hand is as follows. The pathogenic idea which has
ostensibly been forgotten is always lying ready ‘close at
hand’ and can be reached by associations that are easily
accessible. It is merely a question of getting some obstacle out of
the way. This obstacle seems once again to be the subject’s
will, and different people can learn with different degrees of ease
to free themselves from their intentional thinking and to adopt an
attitude of completely objective observation towards the psychical
processes taking place in them.

   What emerges under the pressure
of my hand is not always a ‘forgotten’ recollection; it
is only in the rarest cases that the actual pathogenic
recollections lie so easily to hand on the surface. It is much more
frequent for an idea to emerge which is an intermediate link in the
chain of associations between the idea from which we start and the
pathogenic idea which we are in search of; or it may be an idea
which forms the starting point of a new series of thoughts and
recollections at the end of which the pathogenic idea will be
found. It is true that where this happens my pressure has not
revealed the pathogenic idea - which would in any case be
incomprehensible, torn from its context and without being led up to
- but it has pointed the way to it and has shown the direction in
which further investigation is to be made. The idea that is first
provoked by the pressure may in such cases be a familiar
recollection which has never been repressed. If on our way to the
pathogenic idea the thread is broken off once more, it only needs a
repetition of the procedure, of the pressure, to give us fresh
bearings and a fresh starting-point.

Studies On Hysteria

240

   On yet other occasions the
pressure of the hand provokes a memory which is familiar in itself
to the patient, but the appearance of which astonishes him because
he has forgotten its relation to the idea from which we started.
This relation is then confirmed in the further course of the
analysis. All these consequences of the pressure give one a
deceptive impression of there being a superior intelligence outside
the patient’s consciousness which keeps a large amount of
psychical material arranged for particular purposes and has fixed a
planned order for its return to consciousness. I suspect, however,
that this unconscious second intelligence is no more than an
appearance.

   In every fairly complicated
analysis the work is carried on by the repeated, indeed continuous,
use of this procedure of pressure on the forehead. Sometimes this
procedure, starting from where the patient’s waking
retrospection breaks off, points the further path through memories
of which he has remained aware; sometimes it draws attention to
connections which have been forgotten; sometimes it calls up and
arranges recollections which have been withdrawn from association
for many years but which can still be recognized as recollections;
and sometimes, finally, as the climax of its achievement in the way
of reproductive thinking, it causes thoughts to emerge which the
patient will never recognize as his own, which he never
remembers
, although he admits that the context calls for
them inexorably, and while he becomes convinced that it is
precisely these ideas that are leading to the conclusion of the
analysis and the removal of his symptoms.