Fundamental conceptions of psychoanalysis

Introduction

There are a number of misconceptions concerning psychoanalysis, some of which at least I would like to clear up. In 1908, when I first introduced psychoanalysis into this country, I addressed myself primarily to the medical profession, for psychoanalysis was developed by Prof. Freud while he studied the border-line cases of mental disturbances, and my interest was merely that of a psychiatrist who vainly tried to help such patients and finally found in psychoanalysis the most valuable instrument for the treatment and exploration of the mind. But even then it was realized that the subjects treated by psychoanalysis went far beyond pure medical spheres, for when a human mind was entered for the purpose of studying the origin of an abnormal manifestation, all his normal mental and emotional expressions had to be considered. In the course of many years Prof. Freud thus solved the mysteries of dreams, wit, mythology, fairy tales, and threw much light on the history of civilization and on the development of religion and philosophy, — subjects and phenomena which, strictly speaking, do not belong to abnormal states. It was therefore quite natural to expect that persons interested in the above mentioned subjects would be attracted also to psychoanalysis, and a review of the very extensive psychoanalytic literature shows that it not only drew to itself the attention of the medical profession br4: also that of the psychologist, educator, and serious minded lay-

iii iv INTRODUCTION

man, and notwithstanding some uninformed individuals to the contrary, much good has already been accomplished. Last but not least it has also attracted many charlatans and quacks who find in it a medium for the exploitation of the ignorant classes by promising to cure all their ailments by psychoanalysis. This, as everyone knows, is nothing new in medicine; there is no disease which is not cured by quacks. One could therefore easily remain silent and think that any person who is foolish enough to entrust his mind to quacks deserves no consideration, but as I feel somewhat responsible for psychoanalysis in this country, I merely wish to say that, whereas psychoanalysis is as wonderful a discovery in mental science as, let us say, the X-ray in surgery, it can be utilized only by persons who have been trained in anatomy and pathology. As a therapeutic agent psychoanalysis at best has a very limited field, it can only be used in the treatment of special cases. It cannot cure cancer, it cannot make an adjustable citizen out of a defective "radical," it cannot return an arrant young husband to a neurotic elderly lady, it has no more to do with the separation of mismated couples than the microscope with the dissolutions of tissues ; in fine it cannot make a normal person out of an idiot, and does not give a philosophy of life to a person who has not brains enough to formulate one himself. But it has already rewritten all the mental sciences, and in the hands of trained psychiatrists it can cure the most chronic psychoneurotic affections. Moreover, the knowledge gained through it is developing a prophylaxis, which will not only diminish nervous and mental diseases but will establish newer methods in our system of education. In brief, psychoanalysis aside from its therapeutic application, which is not the object of this work, is of interest to any person who wishes to

INTRODUCTION v

understand human nature and know himself in the Socratic sense.

The material found in this book is taken from the lectures given at my elementary course at the department of pedagogics of the New York University. This course is primarily intended for those who are occupying themselves with problems of education and psychology. But as it is impossible to talk about the normal individual without showing what would happen to a child if subjected to a peculiar or special kind of environment, I have given illustrative cases from abnormal spheres as well as brief, in no way technical, descriptions of some forms of mental derangements. I have also tried to avoid technical expressions as much as possible, and have not taken the trouble to clutter this volume with a lot of references, which a book intended for professional people would necessarily demand, but anyone knowing of my activities realizes that all my work is built on Prof. Freud's foundations, and are referred to his works for more detailed and more technical information.

Mr. Sydney M. Frankel, one of my former students, has given me very valuable suggestions, and relieved me of the task of indexing this book. I am very much indebted to him.

A. A. Brill November, 1921.

Contents

CHAPTER JAGB

I. The Cathartic Method ...... i

II. The Symptom : Its Nature and Function . 25

Chapter I

". . . It is by utterance that we live. . . ."

Psychoanalysis is a term that was fully developed by Professor Sigmund Freud and his pupils, and, etymologically, means mental analysis. We hear about all kinds of psychoanalysis, but the psychoanalysis that we are going to study is a mental analysis of a special kind that works with special instruments; it means the analysis of normal and abnormal activities by a certain definite method, — through the analysis of dreams, psychopathological actions, hallucinations, delusions, and psychic attacks of all kinds which we find in the abnormal spheres. It was originally developed by working with the so-called border-line cases of mental diseases ; that is to say, Professor Freud treated cases of so-called nervousness which the average physician puts under such headings as neurasthenia, hysteria, obsessions, and phobias. In order that we may understand fully how the subject of psychoanalysis was evolved, it seems to me desirable to say a few words about the early history of mental diseases.

The first scientific description of insanity dates back to 460 B. C. ; at that time Hippocrates considered mental disturbances as abnormalities due to some abnormal condition in the brain. Following him there was a long period of intermission, but one may find clinical descriptions by such men as Aretseus in 60 A. D., by Galen in 160 A. D.,

and by many others. During the middle ages survey the subject was not only neglected, but a great Nervous retrogression followed. Insane people were Mental treated most cruelly, and like criminals were

chained and put to death for being obsessed. But with the advance of civilization, the insane began to receive more and more attention, and in 1792 Professor Philippe Pinel of Paris brought about the abolition of chaining./ He was the first one to recognize that the insane person was a sick person and not a demon or criminal, Jand since his time there has been a gradual tendency toward both ameliorating the condition of the insane and understanding the nature of insanity generally.

Modern or present-day psychiatry dates back about twenty-five years or perhaps even less. But we may say that long before then individual efforts had been made to study the subject intelligently and scientifically, and we find accordingly a great many scientific contributions to catatonia and other diseases. But yet most of the text-books then current talked about mania and melancholia as if they were diseases by themselves. Nowadays we know, of course, that melancholia or mania are not diseases; it would be just as wrong to call coughing a disease. We all know that coughing is only a symptom of a disease; it is not an entity. That is to say, one may cough because he has tuberculosis, or perhaps an ordinary so-called cold. And so, too, with mania. Among the insane there is no form of insanity that may not show a period of that so-called mania. It is just a symptom. And so, as you see, symptoms were taken for diseases and there were a great many misunderstandings. I have seen on record at hospitals for the insane where a patient has been diagnosed, say in 1880, as a case of mania, two years later as a case of melancholia, three years later, again as a case of mania, and five years later the patient died of softening of the brain. This occurred simply because the doctors did not know any better, and this is still true of the ordinary practitioners, particularly of those doctors who have received their education under the old regime.

It was Professor Kraepelin, at that time of Heidelberg, who evolved modern mental science. He was a pupil of the great psychologist Wundt, and he discovered that the insane followed definite characteristics not only in the manifestations of their abnormal perceptions but also in the whole course of their disease. Kraepelin did for mental diseases what Virchow did for pathology. The latter held that we must know how the organs look in order to diagnose a disease. He examined diseased lungs, for instance, and found they showed certain characteristic features. But of course it was not until the microscope was used that real entities were established, for though a diseased lung may appear tubercular to the naked eye, it may not be that at all when studied and compared under the microscope. In mental diseases, the microscope is psychoanalysis. For years no effort was made to find out what the patient said, or, if he said anything at all, what it meant. It was sufficient when he was taken to the hospital, to write in our notes that he was dull, stupid, and demented. What all that really meant made little difference. When I came to the State Hospital, I examined a patient's record of twenty years. I would read, — 1882, patient dull, stupid, and demented; then a few years later, patient demented, dull, and stupid, and so on until they almost exhausted all possible permutations and combinations. Then "the patient suddenly died."

With Kraepelin's work, however, which was introduced here mainly through the efforts of Adolf Meyer, there was a marked improvement. Psychological entries were regularly made, every history was comprehensively noted, and particular attention was paid to the general behavior of the patient. We noted, for instance, what the patient said and did, whether he showed any hallucinatory and delusional trends, such as imagining that he is an emperor of Japan and that he was robbed of his throne, or whether he was just indifferent to his environments. His intelligence, memory and orientation were thoroughly tested, and last but not least he received a thorough physical and neurological examination. Only after such an examination did one venture the diagnosis. However, when one reads a number of histories of the same disease entity, say, dementia praecox, one will readily observe that there are no two cases exactly alike. And Kraepelin and his school never asked why it was that patient A had hallucinations of hearing a woman calling him endearing names, and why patient B heard a little child crying "mother," and why patient C heard a man speaking to her. No effort was made to find out why this was so, until Professor Freud published his original studies of the so-called border-line cases of mental diseases.

When we began to examine the nature of hallucinations and delusions,': we found for example that there is a definite reason why such and such a woman sat in a corner of the room at the hospital and fondled a doll made of rags and newspapers, talking to it as though it were her baby. When we investigate this woman's life, we find that she had an only child and lost it, and thus became insane. When a woman talks to herself, as it were, we find upon examination that she misses that person to whom she talks. I have in mind at present a woman who continually converses with her imaginary bridegroom. Upon investigation it is found that on her wedding day, when all the guests and relatives were assembled, he took short leave and did not come. Everybody, of course, went home and bitterly inveighed against him ; she alone tried to defend him. She was stupefied and could not imagine that he would not come; she begged the people to wait, and they continued to wait for hours, but the man never appeared. Then suddenly she ran to the door and exclaimed that she heard him talking to her, and since then she has been at the hospital for the insane.

Before Freud developed psychoanalysis, it was commonly held that if a person is nervous, there must be something wrong with his physical make-up, though this could not be substantiated by examination. Such patients have always formed a very large class of cases, complaining of all sorts of aches and pains, peculiar feelings, morbid fears and obsessive thoughts, for which there was no physical basis. Dr. Beard, an American physician, concluded that as nothing wrong could be ascertained in the physical examination of such cases, there was necessarily something wrong with their nerves, and he therefore designated this whole class of cases as neurasthenia, which means a weakness of nerves. As a matter of fact, these cases really show no more "weakness of nerves" than people who have no such complaints to offer. But Dr. Beard thought that the nerve fibers must be weak, for apparently there was no heart trouble, nor lung trouble, nor anything else that was organically wrong, to account for the patients' complaints. Various remedies were used in neurasthenia but the treatment was purely symptomatic. Thus if the patients were excited the medicine quieted them, if dull or depressed they were stimulated. But whatever was the remedy, they did not recover; they kept on taking these drugs and continually returning to the doctor, much to the disgust of both physician and patient. I may say that fully eighty percent of patients that consult doctors suffer from such complaints, as has been shown by the experience of numbers of consultants. They represent the largest class of patients that we find in clinics, dispensaries, and private practice. Of course, they may be helped somewhat, but that only temporarily. Years ago, when I worked in five different clinics and dispensaries in New York, I would come in touch with patients who had made the acquaintance of all of them. I would treat a woman in the Vanderbilt Clinic and then meet her in the Bellevue dispensary; she looked quite abashed and sorry, and declared apologetically that the medicine she received from me in the first clinic no longer did her any good. And so these patients kept on moving from one hospital to another, and as a matter of fact, they still do to this day.

About 1880 Professor Heinrich Erb of the University of Heidelberg discovered the therapeutic value of electricity. It soon became the rage ; it was used in the diagnosis as well as in the treatment. Every nervous person was sooner or later initiated into the mystery of electrical shocks; when the ordinary ones proved ineffective, new forms of electrical sparks were invented. But at best such treatment only served as a form of suggestion. In a few weeks the patient would come back with some new ailment. Electricity may do some temporary good, but it never cures. A little electricity, a dose of medicine, or a cold bath or massage may help a little, but I do not hesitate to say that I have never seen a chronic case that was cured by such means. Like the other practitioners of his time, Professor Freud resorted to all the remedies at his disposal but the results were very discouraging.

It was at this time that Freud read about Professor Charcot of Paris, who was experimenting with hypnotism. Charcot found that he could hypnotize a hysterical person and suggest to her the symptom of another person and the patient would have this symptom. In other words, he maintained that hysterical symptoms can be suggested through hypnotism, and if they can be suggested, they can also be removed by hypnotism. Let me say, in passing, that hypnotism is nothing quite as strange and mysterious as you generally imagine. Do not think that a person can be hypnotized volcns nolens in the manner shown on the vaudeville stage. No one can be hypnotized against his will. But there is no doubt that if people are willing, they can usually be hypnotized. Charcot's experiments soon became widely known in the scientific world. As soon as Freud heard about these new studies, he left his practice, went to Paris, and became one of Charcot's favorite pupils. He worked with him for about two years.

When Freud came back to Vienna, he at once decided to utilize his knowledge on cases of neurasthenia. He had a friend older than himself, Dr. Breuer, a man of TIie great learning, and recognized in Europe for his "£2°*' attainments in medical and scientific subjects, who cure" took considerable interest in his career. Naturally he was very eager to know all about Charcot's work and after Freud explained to him what the noted neurologist was doing in hysteria, Breuer began to describe what he considered an unusually interesting case. He told his younger friend about a woman whom he thought to be intelligent and refined and who was suffering from a severe case of hysteria. She had been treated by some of the most prominent neurologists in Europe and finally came back to Breuer, her family physician. One day she said to him: "Dr. Breuer, if you would only let me talk to you and if I could tell you how my difficulties started, I think we could do something." Dr. Breuer was sympathetic and told her to go right ahead. She began to tell him of a paralysis she had, and presently she went into an intimate account of her life; she talked on and on with much feeling, and when he reminded her, in a f rank and friendly way, that he could give her no more time, she asked him for an appointment to come again. Every time she came and talked for an hour she felt appreciably better ; she called it the "talking cure." She insisted upon calling on him just to talk. She would tell him when a certain symptom came, how she suffered, about her intimate affairs, and about such and such a dream. She spoke about things that a doctor would not generally think of listening to. It meant quite a tax on his time, but he was anxious to help her. He became attached to her and sympathized with her emotional difficulties; and gradually she was losing one symptom after another. It seemed strange to Breuer; he had given this woman all sorts of medicines, another doctor had given her hot and cold baths, and another electricity; and now she came merely to tell him stories and was getting well.

To Freud this story was full of significance ; it opened up problems to him that he had been pondering for years. He asked himself why this woman should be getting well by merely talking. As he went deeper and deeper into the problem, he became more and more convinced of one fundamental principle. He began to see more and more clearly that the whole idea was, that if the patient could go back to the origin of the symptom, then the symptom would disappear. The great difficulty, however, was that it took so much time. When a person comes to you and tells you about his or her life and you have to be a sympathetic listener and live through that life, as it were, you cannot go through with it in the twinkling of an eye; life is long, and it takes time to track its undercurrents, and a person's thoughts do not run in seconds ; it is not a matter of feeling a pulse. Freud suggested that hypnotism be used in conjunction with this "talking cure," for hypnotism is supposed to broaden consciousness; it opens up the whole mind; no resistances or inhibitions are offered; things come into the mind and take root. A patient in the waking state will not be able to answer questions, unless you give him a long time to think and recall. Freud thought accordingly that it would be a splendid idea to hypnotize her and ask her how and when she got her symptom; this would save so much time. And so he and Breuer took the patient's history first, then hypnotized her and asked her about her painful condition. The patient would recall and tell everything, and gradually the symptom disappeared.

Freud and Breuer worked together for some time and got wonderful results; they were so impressed with this new procedure that they called it the "Cathartic Method," which means the purging of the mind, a^ort of unburdening of the mind. In every-day life, we all know the therapeutic value of expression; when a person tells you his troubles he begins to feel better ; we say a weight has been removed from his heart. They took cases that had been resisting treatment for years and cured them. They finally reported some of them and formulated various theories. In the first place, they found that all hysterics suffer from the past. Every hysterical symptom represents some mental or emotional disturbance that has taken place in the person's life in the past; there were occurrences of a disagreeable and painful nature which every individual likes to forget. The idea was that if a patient can recall an unpleasant situation and live it over, so to say, he loses the symptom ; that words are almost equivalent to the action, and that in going over some painful experience in the past, there is what is called an dbreaction, German, "Abreagierung" in which the painful emotions associated with the experience are liberated and thus cease to create physical disturbances. When the patient had a pain in the face it was treated as neuralgia; of course, it may have been that or not. If it is neuralgia it will usually yield to treatment, if not it is a psychic pain, a functional pain. It io PSYCHOANALYSIS

represents, in concrete form, the expression: "I felt as though she slapped me in the face." When the painful situation is brought back to the patient and explained to him, the symptom disappears.

Let me make all this a little clearer by an example. A woman has a pain in her arm ; she consults the doctor, who examines her and asks her whether she was out yesterday.

She says she was, and that the weather was bad and she caught cold. He prescribes a medicine, but the pain continues. She returns to the doctor, he tries some other remedy, but the pain grows worse. The patient is discouraged and consults another physician; she now merely tells him she has rheumatism in her arm ; she gives him the symptoms ; he takes it for granted that she has rheumatism and treats her accordingly. She goes from doctor to doctor until some diagnostician pronounces it hysterical and not rheumatism. She consults a neurologist and we find this story : She is a young woman who had made the acquaintance of a college student. As time went on, they became more and more intimate and it was rumored that they were to be married; in fact she thought so too. Upon graduating, he left the city and kept up a long correspondence with her. He came and spent his vacations with her; but he did not propose. The general impression was that, as he was a young man, he wished to make his way in the world before he married. Thus for years he came, spent his vacations with her, and left without proposing. The last year he wrote her with manifest enthusiasm that at last he had reached the goal of his ambition: he had received an appointment with such and such a salary. All the relatives heard about the letter and were now quite sure he would marry her. He came for his vacation, as usual, spent some time with her and took her out for a long walk the night before he left. But he did not propose. Everybody was disappointed ; the mother was

THE CATHARTIC METHOD n

disgusted; her brother threatened to punch him in the face when he came again ; and the poor girl was terribly grieved. She was told to drop him and think no more of him ; she was willing to do so but claimed that it was much easier said than done. She argued that he must love her or else he would not write and spend his vacations with her ; she felt that she was his only confidante. She did not realize that there are men who are so inhibited in their love life that they cannot propose. She was experiencing a mental conflict. She wanted to drop him; but there was no mistake about his loving her. He was a serious, quiet, well-behaved man who came from a very fine family and whom no one could accuse of being a trifler. "He certainly is not an adventurer, because he does not act like one," she would think to herself ; "but why, then, does he not propose?" [I would like you to notice the human, emotional element that enters into all these cases.; Gradually, however, she made up her mind that he did not love her and that she would have nothing more to do with him. In time she was even ready to write to him not to correspond with her, but she could not gather sufficient strength to do so. Gradually there came on that pain in her arm.

When we go beyond the superficial aspects of this case, we find that it goes back to a fundamental condition in the past. We discover that the patient is suffering from the past, that the pain in her arm is only a monument of the past ; it is a memento, one might say, of her mental conflict. In other words, when she was emotionally arguing with herself whether he loved her or not and when she had to repress all talk about him, and make herself believe that she did not love him, her feelings, her emotions became converted into that of pain. The arm was the arm that he pressed on the night before he left. She would say to herself : "But what about that feeling ? He pressed my arm" ; for then she had hoped that he would say the expected words. Analysis reveals that it is that feeling that she wished to retain in memory that became a pain ; it was a symbolic form of expression, for she could not talk about it in any other way. Without having to speak about the young man she could now unconsciously retain this episode through the pain in the arm. There was in a sense, a morbid gain. She could now talk and complain about her pain and thus have some form of expression, though the fundamental and deeper phase of her condition was submerged and she knew nothing about it. We see here a conversion of past emotion into something physical.1 When the patient realized this deeper aspect of her condition and when the painful past experience was brought to her consciousness she was cured. It was after careful study and observation of such cases that the idea was postulated, then, first, that one can convert psychic energy into physical manifestations, and secondly that a cure is effected by bringing the submerged painful experience to consciousness, thus releasing the strangulated emotions. This new viewpoint meant an enormous step forward.

We may see from the above case that what Breuer and Freud brought to the surface by the Cathartic Method were those things that the patient found disagreeable con- and painful, things that the patient could not talk

pore- ' about. This young woman could not complain of

scious the fact that the young man did not propose to

uncon- her for so many years; and of course, if it is

essentially a sexual situation, no sensitive person can speak about it openly, particularly a woman. In

1 This conversion of mental into physical elements takes place in a certain definite way. This particular patient had the reminiscence of the arm, so it was in the arm; sometimes it is in the nose, hair or any other organ or bodily function. It is hard to realize how many different complaints one hears from patients of this type.

other words, they formulated the theory that the patient suffers from what we call strangulated emotions, certain feelings and ideas which we would like to give vent to, but cannot. We say they are finally pushed into the unconscious, and we postulate such a thing as unconscious, that is, something of which the person is absolutely unaware and which he cannot, through any effort of his own, bring to consciousness. In the Zurich school, which I shall have occasion to speak about later, we thought of the emotions thus associated with a painful experience as forming a complex. We defined it as an idea or group of ideas accentuated and colored over by profound emotional feelings which was gradually relegated to the unconscious for the very reason that it was of a distinctly painful nature and so could not be kept in consciousness. We unconsciously run away from distressing thoughts : we say we wish to forget them. These strangulated ideas and emotions remain in the unconscious in a dormant state, and any association may bring them to the surf ace v

A woman, for instance, gets up one morning, feeling perfectly well ; she sits down to her desk to write a note to her friend. She writes the date and stops ; a feeling of sadness gradually grows upon her, and she decides not to write. All day she feels depressed ; it so happens that she comes to see me and tells me about it. Upon talking to her, I find that the moment she took her pen and wrote the date the latter struck a complex in her mind which evoked a certain date that went back a great many years to a day when something extremely disagreeable happened to her. When she became depressed, she knew nothing about it. She did not consciously recall the original painful experience. She merely experienced the emotion that went with the episode. In this pushing out of what is painful from the field of consciousness, we have an unconscious protective mechanism.