Freud - Complete Works (48 page)

Studies On Hysteria

246

   Hitherto I have been so warm in
my praises of the achievements of pressure as an auxiliary
procedure, and I have the whole time so greatly neglected the
aspect of defence or resistance, that I may no doubt have created
an impression that this little device has put us in a position to
master the psychical obstacles to a cathartic treatment. But to
believe this would be to make a serious mistake. Gains of this
kind, so far as I can see, are not to be looked for in treatment.
Here, as elsewhere, a large change requires a large amount of work.
The procedure by pressure is no more than a trick for temporarily
taking unawares an ego which is eager for defence. In all fairly
serious cases the ego recalls its aims once more and proceeds with
its resistance.

   I must mention the different
forms in which this resistance appears. One is that, as a rule, the
pressure procedure fails on the first or second occasion. The
patient then declares, very disappointedly: ‘I expected
something would occur to me, but all I thought was how tensely I
was expecting it. Nothing came.’ The fact of the patient
putting himself on his guard like this does not yet amount to an
obstacle. We can say in reply: ‘It’s precisely because
you were too curious; it will work next time.’ And in fact it
does work. It is remarkable how often patients, even the most
docile and intelligent, can completely forget their undertaking,
though they had agreed to it beforehand. They promised to say
whatever occurred to them under the pressure of my hand,
irrespectively of whether it seemed to them relevant or not, and of
whether it was agreeable to them to say it or not - to say it, that
is, without selecting and without being influenced by criticism or
affect. But they do not keep this promise; it is evidently beyond
their strength to do so. The work keeps on coming to a stop and
they keep on maintaining that this time nothing has occurred to
them. We must not believe what they say, we must always assume, and
tell them, too, that they have kept something back because they
thought it unimportant or found it distressing. We must insist on
this, we must repeat the pressure and represent ourselves as
infallible, till at last we are really told something. The patient
then adds: ‘I could have told you that the first time.’
‘Why didn’t you say it?’ ‘I couldn’t
believe it could be that. It was only when it came back every time
that I made up my mind to say it.’ Or else: ‘I hoped it
wouldn’t be that of all things. I could well do without
saying that. It was only when it refused to be repressed that I saw
I shouldn’t be let off.’ Thus after the event the
patient betrays the motives for a resistance which he refused to
admit to begin with. He is evidently quite unable to do anything
but put up resistance.

Studies On Hysteria

247

   This resistance often conceals
itself behind some remarkable excuses. ‘My mind is distracted
to-day; the clock (or the piano in the next room) is disturbing
me.’ I have learned to answer such remarks: ‘Not at
all. You have at this moment come up against something that you had
rather not say. It won’t do any good. Go on thinking about
it.’ The longer the pause between my hand-pressure and the
patient’s beginning to speak, the more suspicious I become
and the more it is to be feared that the patient is re-arranging
what has occurred to him and is mutilating it in his reproduction
of it. A most important piece of information is often announced as
being a redundant accessory, like an opera prince disguised as a
beggar. ‘Something has occurred to me now, but it has nothing
to do with the subject. I’m only saying it because you want
to know every thing.’ Accompanying words such as these
usually introduce the long-sought solution. I always prick up my
ears when I hear a patient speak so disparagingly of something that
has occurred to him. For it is an indication that defence has been
successful if the pathogenic ideas seem, when they re-emerge, to
have so little importance. From this we can infer in what the
process of defence consisted: it consisted in turning a strong idea
into a weak one, in robbing it of its affect.

   A pathogenic recollection is thus
recognizable, among other things, by the fact that the patient
describes it as unimportant and nevertheless only utters it under
resistance. There are cases, too, in which the patient tries to
disown it even after its return. ‘Something has occurred to
me now, but you obviously put it into my head.’ Or, ‘I
know what you expect me to answer. Of course you believe I’ve
thought this or that.’ A particularly clever method of
disavowal lies in saying: ‘Something has occurred to me now,
it’s true, but it seems to me as if I’d put it in
deliberately. It doesn’t seem to be a reproduced thought at
all.’ In all such cases, I remain unshakeably firm. I avoid
entering into any of these distinctions but explain to the patient
that they are only forms of his resistance and pretexts raised by
it against reproducing this particular memory, which we must
recognize in spite of all this.

   When memories return in the form
of pictures our task is in general easier than when they return as
thoughts. Hysterical patients, who are as a rule of a
‘visual’ type, do not make such difficulties for the
analyst as those with obsessions.

   Once a picture has emerged from
the patient’s memory, we may hear him say that it becomes
fragmentary and obscure in proportion as he proceeds with his
description of it.
The patient is, as it were, getting rid of it
by turning it into words
. We go on to examine the memory
picture itself in order to discover the direction in which our work
is to proceed.  ‘Look at the picture once more. Has it
disappeared?’ ‘Most of it, yes, but I still see this
detail.’ ‘Then this residue must still mean something.
Either you will see something new in addition to it, or something
will occur to you in connection with it.’ When this work has
been accomplished, the patient’s field of vision is once more
free and we can conjure up another picture. On other occasions,
however, a picture of this kind will remain obstinately before the
patient’s inward eye, in spite of his having described it;
and this is an indication to me that he still has something
important to tell me about the topic of the picture. As soon as
this has been done the picture vanishes, like a ghost that has been
laid.

Studies On Hysteria

248

   It is of course of great
importance for the progress of the analysis that one should always
turn out to be in the right
vis-à-vis
the patient,
otherwise one would always be dependent on what he chose to tell
one. It is therefore consoling to know that the pressure technique
in fact never fails, apart from a single case, which I shall have
to discuss later but of which I can at once say that it corresponds
to a particular motive for resistance. It can of course happen that
one makes use of the procedure in circumstances in which there is
nothing for it to reveal. For instance, we may ask for the further
aetiology of a symptom when we already have it completely before
us, or we may investigate a psychical genealogy of a symptom, such
as a pain, which is in fact a somatic one. In such cases the
patient will equally assert that nothing has occurred to him and
this time he will be in the right. We can avoid doing the patient
an injustice if we make it a quite general rule all through the
analysis to keep an eye on his facial expression as he lies quietly
before us. We can then learn to distinguish without any difficulty
the restful state of mind that accompanies the real absence of a
recollection from the tension and signs of emotion with which he
tries to disavow the emerging recollection, in obedience to
defence. Moreover, experiences like these make it possible also to
use the pressure technique for purposes of differential
diagnosis.

   Thus even with the assistance of
the pressure technique the work is by no means easy. The one
advantage that we gain is of learning from the results of this
procedure the direction in which we have to conduct our enquiries
and the things that we have to insist upon to the patient. With
some cases this suffices. The principal point is that I should
guess the secret and tell it to the patient straight out; and he is
then as a rule obliged to abandon his rejection of it. In other
cases more is required. The patient’s persisting resistance
is indicated by the fact that connections are broken, solutions
fail to appear, the pictures are recalled indistinctly and
incompletely. Looking back from a later period of an analysis to an
earlier one, we are often astonished to realize in what a mutilated
manner all the ideas and scenes emerged which we extracted from the
patient by the procedure of pressing. Precisely the essential
elements of the picture were missing - its relation to himself or
to the main contents of his thoughts - and that is why it remained
unintelligible.

Studies On Hysteria

249

   I will give one or two examples
of the way in which a censoring of this kind operates when
pathogenic recollections first emerge. For instance, the patient
sees the upper part of a woman’s body with the dress not
properly fastened - out of carelessness, it seems. It is not until
much later that he fits a head to this torso and thus reveals a
particular person and his relation to her. Or he brings up a
reminiscence from his childhood of two boys. What they look like is
quite obscure to him, but they are said to have been guilty of some
misdeed. It is not until many months later and after the analysis
has made great advances that he sees this reminiscence once more
and recognizes himself in one of the children and his brother in
the other.

   What means have we at our
disposal for overcoming this continual resistance?  Few, but
they include almost all those by which one man can ordinarily exert
a psychical influence on another. In the first place, we must
reflect that a psychical resistance, especially one that has been
in force for a long time, can only be resolved slowly and by
degrees, and we must wait patiently. In the next place, we may
reckon on the intellectual interest which the patient begins to
feel after working for a short time. By explaining things to him,
by giving him information about the marvellous world of psychical
processes into which we ourselves only gained insight by such
analyses, we make him himself into a collaborator, induce him to
regard himself with the objective interest of an investigator, and
thus push back his resistance, resting as it does on an affective
basis. But lastly - and this remains the strongest lever - we must
endeavour, after we have discovered the motives for his defence, to
deprive them of their value or even to replace them by more
powerful ones. This no doubt is where it ceases to be possible to
state psychotherapeutic activity in formulas. One works to the best
of one’s power, as an elucidator (where ignorance has given
rise to fear), as a teacher, as the representative of a freer or
superior view of the world, as a father confessor who gives
absolution, as it were, by a continuance of his sympathy and
respect after the confession has been made. One tries to give the
patient human assistance, so far as this is allowed by the capacity
of one’s own personality and by the amount of sympathy that
one can feel for the particular case. It is an essential
precondition for such psychical activity that we should have more
or less divined the nature of the case and the motives of the
defence operating in it, and fortunately the technique of
insistence and pressure takes us as far as this. The more such
riddles we have already solved, the easier we may find it to guess
a new one and the sooner we shall be able to start on the truly
curative psychical work. For it is well to recognize this clearly:
the patient only gets free from the hysterical symptom by
reproducing the pathogenic impressions that caused it and by giving
utterance to them with an expression of affect, and thus the
therapeutic task
consists solely in inducing him to do so
;
when once this task has been accomplished there is nothing left for
the physician to correct or to remove. Whatever may be required for
this purpose in the way of counter-suggestions has already been
expended during the struggle against the resistance. The situation
may be compared with the unlocking of a locked door, after which
opening it by turning the handle offers no further difficulty.

   Besides the intellectual motives
which we mobilize to overcome the resistance, there is an affective
factor, the personal influence of the physician, which we can
seldom do without, and in a number of cases the latter alone is in
a position to remove the resistance. The situation here is no
different from what it is elsewhere in medicine and there is no
therapeutic procedure of which one may say that it can do entirely
without the co-operation of this personal factor.

Studies On Hysteria

250

(3)

   In view of what I have said in
the preceding section about the difficulties of my technique, which
I have unsparingly exposed (I brought them together, incidentally,
from the severest cases; things often turn out very much more
conveniently) - in view of all this, then, everyone will no doubt
feel inclined to ask whether it would not be more expedient,
instead of putting up with all these troubles, to make a more
energetic use of hypnosis or to restrict the use of the cathartic
method to patients who can be put under deep hypnosis. As regards
the latter proposal I should have to answer that in that case the
number of suitable patients, so far as
my
skill is
concerned, would dwindle far too much; and I would meet the first
piece of advice with the suspicion that the forcible imposition of
hypnosis might not spare us much resistance. My experiences on this
point, oddly enough, have not been numerous, and I cannot,
therefore, go beyond a suspicion. But where I have carried out a
cathartic treatment under hypnosis instead of under concentration,
I did not find that this diminished the work I had to do. Not long
ago I completed a treatment of this kind in the course of which I
caused a hysterical paralysis of the legs to clear up. The patient
passed into a state which was very different psychically from
waking and which was characterized physically by the fact that it
was impossible for her to open her eyes or get up till I had called
out to her: ‘Now wake up!’ None the less I have never
come across greater resistance than in this case. I attached no
importance to these physical signs, and towards the end of the
treatment, which lasted ten months, they had ceased to be
noticeable. But in spite of this the patient’s state while we
were working lost none of its psychical characteristics - the
capacity she possessed for remembering unconscious material and her
quite special relation to the figure of the physician. On the other
hand, I have given an example in the case history of Frau Emmy von
N. of a cathartic treatment in the deepest somnambulism in which
resistance played scarcely any part. But it is also true that I
learnt from that lady nothing whose telling might have called for
any special overcoming of objections, nothing that she could not
have told me even in a waking state, supposing we had been
acquainted for some time and she had thought fairly highly of me. I
never reached the true causes of her illness, which were no doubt
identical with the causes of her relapse after my treatment (for
this was my first attempt with this method); and the only occasion
on which I happened to ask her for a reminiscence which involved an
erotic element I found her just as reluctant and untrustworthy in
what she told me as I did later with any of my non-somnambulistic
patients. I have already spoken in that lady’s case history
of the resistance which she put up even during somnambulism to
other requests and suggestions of mine. I have become altogether
sceptical about the value of hypnosis in facilitating cathartic
treatments, since I have experienced instances in which during deep
somnambulism there has been absolute
therapeutic
recalcitrance, where in other respects the patient has been
perfectly obedient. I reported a case of this kind briefly on
p. 90 
n
.
, and I could add
others. I may admit, too, that this experience has corresponded
pretty well to the requirement I insist upon that there shall be a
quantitative relation between cause and effect in the psychical
field as well.