Psychanalysis; its theories and practical application;

Front matter

WELLESLEY COLLEGE LIBRARY PRESENTED BY

Its Theories and Practical Application

BY

Chapter I

The Development of Freud’s Conception of the Psychoneuroses and Psychoses, Their Relation to the Psychology of Dreams, Sex and the Psychopathology of Every-day Life

The psychoneuroses, the step-children of medicine, have of late received more attention in the literature than before. Both here and abroad it has been realized that there is a large group of diseases, the so-called border-line cases in mental diseases, the understanding and treatment of which has been sadly neglected, and it is gratifying to know that at least some steps have been taken to meet these deficiencies. The wave of psychotherapy which has swept the continent has also made its presence felt in this country through its numerous discussions in both lay and professional j oumals. Abroad its adherents claim brilliant results; one need only review the numerous works of the Nancy and other schools to be convinced that psychotherapy is no empty term, but an actual branch of

ll medicine, and that in the psychoneuroses it is the only effective remedial agent.

Yet, whereas all schools agree that the psychoneuroses should be treated by psychotherapy, they all disagree as to the nature of the psychoneuroses. One need only scan the recent works to see that diverse views are expressed by the different investigators on the subject. These diversities, in my opinion, are due to the fact that most of the investigators in question have ignored one important factor, namely, individual psychology. Without individual psychology the riddle of the neuroses, like the riddle of the psychoses, must remain unsolved.

Among the different views expressed on the neuroses those of Freud stand out most conspicuously. No recent theories in medicine or psychology have evoked so many controversies and discussions. After years of careful and painstaking labor Freud evolved not only a system of psychotherapy, but a new psychology. Unlike all other investigators he discarded all generalities and confined himself to the individual. The individual factors which had escaped the notice of other investigators he found to be of the utmost importance in the psychogenetic development of personality.

As early as 1895 Breuer and Freud published the “Studien iiber Hysterie.” They found that hysterical symptoms like neuralgias, paralyses, epileptiform attacks, etc., could be traced to actual psychic traumata which the patient could not consciously recall, but which could be readily demonstrated when the patient was put in the hypnotic state. In other words, they found that the hysterical manifestations were not accidental, but had an actual cause. The connection between cause and effect was often quite obvious; thus, “A very sick child falls asleep and the mother exerts all her will power to make no noise to awaken it, but just because she resolved to do so she emits a clicking sound with her tongue (hysterical counter-will) which was repeated on another occasion when she wished to be absolutely quiet. This developed into a regular tic which lasted for years/’1 In some cases the connection is not so simple, there being only a symbolic relation between the cause and the hysterical phenomena; thus, psychic pain may cause a neuralgia and moral disgust may cause vomiting. Breuer and Freud then concluded that these psychic traumata, or the memory of the same, act like foreign bodies in consciousness, and even long after their occurrence continue to influence like causative factors; to quote Freud, “The hysteric suffers mostly from reminiscences.’'2 Their symptoms are remnants and memory symbols for certain (traumatic) events. A deeper understanding of these symbolisms will perhaps be gained by comparing them with memory symbols of other spheres.

Thus the statues and monuments with which we embellish our big cities are such memory symbols. “ If you should take a walk through London you would find a richly decorated Gothic column in front of Charing Cross, one of the largest railroad stations of the city. On the occasion of removing to Westminster the remains of his beloved queen, Eleanor, one of the old Plantagenet kings in the XIII century ordered that Gothic crosses be erected at every station where the funeral procession halted, and Charing Cross is the last of the monuments commemorating this funeral procession. In another place in the city not far from London Bridge you will notice a modern lofty column which is briefly referred to as ‘ The Monument/ It is supposed to commemorate the big fire which started near there in 1666 and destroyed a large part of the city. These monuments, therefore, like the hysterical symptoms, are memory symbols. So far the comparison is justified. But what would you think of a Londoner who would even to-day halt in grief before the monument of the funeral procession of Queen Eleanor instead of continuing on his way with the required haste of modern business conditions? Or what would you think of another who would stop before ‘ The Monument ’ and bewail the conflagration of his beloved native city? Yet hysteric and neurotic individuals behave exactly like these two impractical Londoners. Not only do they recall the long forgotten painful events, but they stick to them with all their emotions. They cannot get away from the past and neglect for it reality and the present. This fixation of the psychic life on the pathogenic traumas is one of the most important, and, from a practical viewpoint, one of the most significant characters of the neurosis.”3

That the hysterical symptoms are only reminiscences was proven by the fact that the individual hysterical symptoms disappeared without returning if one succeeded in thoroughly awakening the memories of the causal process with its accompanying affects and if the patient circumstantially discussed the process, giving free play to the affect. The reason for the strangulation of the emotion was because at the time of its occurrence it could not be adequately worked off. We all know that it is not always possible to give vent to our feelings, and that an insult retaliated leaves quite a different impression than one that has to be swallowed.

The treatment called “catharsis” consisted in reconducting the sum of excitement from its false paths to the original conscious idea and then working it off by means of intellectual labor and speech. The patient was hypnotized and questioned about the origin of the symptoms and while recalling the original injuries, either in hypnosis or the normal state, the hemmed-in emotions were discharged and the symptoms disappeared. This is the so-called “abreagirung” — abreaction — which means to work off something by living through it again. It was noticed that the affect appeared with special intensity during the reproduction of the scenes which gave origin to the symptom and completely disappeared with their termination. On the other hand, no result was noticed when the scenes evoked were not accompanied by any emotional feeling.

This is rather a brief review of the conceptions originally expressed by Breuer and Freud. It is from these principles that Freud developed his present conceptions of the psychoneuroses and his revolutionary psychology.

When Freud continued to practice his cathartic treatment he was confronted with one special difficulty. He found that not all persons were hypnotizable and as hypnosis was absolutely essential for the broadening of the patient’s consciousness, many patients had to be given up as they could not be hypnotized. He even went so far as to take one of these patients to Nancy to Bernheim, but after applying all his skill Bernheim had to admit that he, too, could not hypnotize the patient.* This and a number of other reasons caused Freud to avoid hypnotism and to adopt a new procedure which he calls the psychoanalytic method. On asking the patients in the waking state whether they remembered the first motive of the symptom in question, some knew nothing while others recalled something rather vaguely. Freud then applied the same method which Bernheim used in awakening the manifestly forgotten impressions produced during somnambulism. He found that by urging and assuring the patients that they did remember and telling them that all they had to do was to concentrate their attention, and repeat the thoughts which would occur to them they finally recalled the pathogenic ideas without hypnotism. But as this urging necessitated much exertion on his part, and showed him that he had to overcome great resistance in the patient, he formulated the following theory: “Through my psychic work I had to overcome a psychic force in the patient which opposed the pathogenic idea from becoming conscious.”4 The resistance was due to the fact that the ideas which had to be disinterred were all of a nature adapted to provoke the affects of shame, reproach, mental pain and a feeling of injury — they were altogether -of that kind which one would not like to experience, and prefers to forget.

This gave rise to Freud's idea of repression; the pathogenic idea being of a painful nature is incompatible with the ego, and is therefore treated by it as non-arrive. The patient wishes to know nothing about it, he wishes

* That not every person can be hypnotized has been long acknowledged by all experienced observers of the subject.

to forget it. But as this repression, or forgetting, never succeeds completely, the pathogenic idea continues to strive to come to the surface, and is constantly inhibited by the psychic censor. This struggle of the two opposing forces results in a compromise. Each foregoes a part of the original demand, thus meeting the other half way, and the result of this mutual accommodation is then transformed into a hysterical symptom by the process of conversion. In this manner the ego frees itself from opposition, the original painful idea or unattainable wish is forgotten, and instead it becomes burdened with a memory symbol which remains in consciousness as an unadjusted motor or sensory innervation. We thus see that the main character of hysteria is not the splitting of consciousness as asserted by Janet and his school, but the ability of converting the sum of strangulated emotion either totally or partially, into that motor or sensory innervation which is more or less connected with the traumatic event. In brief the study of the psychoneuroses shows conclusively that there was a failure in the repression of the idea concerning the unattainable wish. To be sure the painful idea is crowded out of consciousness and memory and the individual thus spares himself a great deal of pain, but the repressed wish remains in the unconscious and lurks for an opportunity to become active. When it succeeds it brings to the surface a distorted and strange substitutive formation which soon becomes connected with the same pain the individual got rid of through the repression. This substitutive formation is the symptom and in hysteria it is produced by the process of conversion.

There are, however, predisposed persons in whom there 2 is no adaptation for conversion. Here, if an unbearable idea enters consciousness it meets with the same contrary forces as those mentioned above, the affect becomes detached from the idea, but instead of being converted into the physical, it remains in the psychic sphere. The weakened unbearable idea remains apart from all association in consciousness, but its detached affect or the sum of excitement allies itself to another indifferent idea,5 which on account of this “ false ” connection becomes an obsession; or the unbearable idea is so changed that the patient does not recognize it. He no longer thinks of the painful or disagreeable, but instead he is burdened with an obsession, the absurdity of which he realizes, but from which he cannot rid himself. The advantage thus gained by the ego in the transposition or dislocation of the affect is not as great as in the hysterical conversion of psychic excitement into somatic innervation. The affect remains unchanged and undiminished, but the unbearable idea is suppressed from memory.

The same mechanism holds true for the origin of phobias, and both come under the heading of compulsion neurosis. It was also found that the unbearable ideas underlying the compulsion neurosis (obsessions, doubts and phobias) have their origin in the sexual life. In the words of Freud, “the obsession represents a compensation or substitute for the unbearable sexual idea and takes its place in consciousness.”6

Both hysteria and compulsion neurosis belong to the defense neuropsychoses; their symptoms originate through the psychic mechanism of defense, that is through the attempt to repress a painful idea which was incompatible with the ego of the patient. In both neuroses the idea is robbed of its affect, and excluded from associative elaboration, remaining, however, in consciousness.

There is still another far more forceful and more successful form of defense, wherein the ego misplaces the incompatible idea with its emotion and acts as though the painful idea had never come to pass. When this occurs the person merges into a psychosis which may be called “ hallucinatory confusion.” To illustrate this form of defense I will cite a case which, through the kindness of Dr. M. S. Gregory, I saw in the psychopathic pavilion of Bellevue Hospital. It concerned a young married man of about thirty years, a New Yorker, who, being out of work, tried his fortune as a farm-hand up the state. Things did not go as smoothly as he expected, and one day the farmer gave him a rather severe thrashing, and dismissed him without paying him his salary. He sought redress, but could get none so that he had to walk to New York City penniless. When he returned home he made a number of attempts to obtain justice for himself, but was told that he could do nothing. He kept on brooding over it for some time, when one day he suddenly became excited and confused. He became boisterous, cursing the farmer, and accompanied his utterances by violently kicking the bedstead and the pillows. He imagined that he was punching the farmer. He was so excited and confused that his wife sent for the police who took him to the psychopathic pavilion of Bellevue Hospital.

Here the idea was so painful that the ego tore itself away from it, but as the painful idea was inseparably connected with reality the ego had to exclude itself wholly from reality. Such cases give us an insight into the psychoses. Thanks to the genius of Freud and the Zurich school7 we no longer fear to face the hitherto considered perplexities of the insane mind. As will be shown later every insane utterance, every morbid perception, has a definite meaning and a definite raison d'etre when analyzed. Truly there is method in madness.

In tracing the psychic traumas which are supposed to be at the basis of hysterical symptoms or compulsion neuroses, one invariably comes to sexual experiences of childhood. This is so conspicuous that it led Freud to lay great stress on the sexual and to formulate the following sentence: “In a normal vita sexualis no neurosis is possible.”8 This, I know, sounds rather strange, but I would like to call attention to the fact that the sexual impulse is one of our strongest impulses. It is the one impulse that is subjected to the greatest amount of repression and for that reason it has always been the weakest point in our cultural development. It must also be borne in mind that Freud’s conception of the sexual is very broad. It is just as broad as our English word “love” or the Greek word “eros,” and does not at all limit itself to the gross sexual. Moreover, it must be remembered that sexuality is more complicated than one thinks. Hypocrisy and prudishness have from time immemorial tabooed all things sexual; the word itself carries with it the ideas of lewdness and loathing. As a result of this the ignorance displayed in matters sexual is appalling. Thus we are led to believe that there is no sexuality before a certain age, the age of puberty, yet when we look back to our own youth we find that long before that age we were subjected to certain feelings which were unmistakably of a sexual nature. Freud maintains that the sexual is born with us and begins to manifest itself in infancy.

“It seems certain,” he says, “that the newborn child brings with it the germs of sexual feelings which continue to develop for some time and then succumb to a progressive suppression, which is, in turn, broken through by the proper advance of sexual development and which can be checked by individual idiosyncrasies.”9 He also tells us that the sexual impulse in man consists of many components and partial impulses. Many essential contributions to the sexual excitement are furnished by the peripheral excitement of certain parts of the body, such as the genitals, mouth, anus and bladder outlets. All these zones are active in infancy and only some of them go to make up the sexual life. The first libidinous manifestations are of an autoerotic character and the sexual manifestations displayed by the child are the almost universal infantile masturbation which serves to prepare the genitals for their future functions; thumbsucking, according to many observers, connects directly or indirectly with autoerotic sexual activities.10 I have studied a number of patients who retained this autoerotic sexual manifestation until late in life and I could definitely ascertain that it was a sexual activity pure and simple. In a number of cases thumbsucking continued until masturbation started and in a few cases both were practised synchronously. I know a young widow of thirty-five years who, in spite of all efforts to break herself of the habit, sucked her thumb until she married at twenty-five years and resumed it with the beginning of her widowhood. She told me she had no difficulty in stopping it soon after marriage, but that it returned a few weeks after her husband’s death. The anus and the bladder outlets are also erogenous zones of infantile life, and neurotics often retain them in later life.* Thus Z., twenty years old, had an uncontrolable desire to withhold his urine. He stated that there was much pleasure in the discomfort and that that was the reason for repeating it. His mother told me that he wet the bed to the age of fifteen and that as a child he would remain on the chamber for hours before be could be made to move his bowels. The child at first knows no other sexual object except itself. It is only in the later stages of development that it goes over to the love object.

Besides the erogenous zones the child shows those components which are designated as partial impulses. Among these we have the impulse for looking and showing and for cruelty which manifest themselves somewhat independently of the erogenous zones and later enter into intimate relationship with the sexual life; but along with the erogenous sexual activity they are noticeable even in the infantile years as separate and independent strivings. In later life they are repressed and subjected to the primacy of the genitals which serve the functions of procreation. The energies emanating from them are then deflected from the sexual and directed to important social aims. This is the so-called process of sublimation. Thus, sublimation of the homosexual com- * Cf. Chapter XI, on Anal Eroticism.

ponent gives origin to the psychic process of loathing and morality; the sublimation of the infantile looking and exhibitionism gives rise to shame, and the sublimation of the sadistic and masochistic components to disgust, pity and similar feelings. These reactions formed during the sexual latency period — from the fourth year to the beginning of puberty, eleven — make up the character of the person and later give us a good indication of his early sexual life. I regret that I am unable to discuss here more fully the sexual theories expounded by Freud; those who are interested in the subject should study his interesting and profound book, “The Three Contributions to the Sexual Theory/ 7 I will merely add that after carefully studying the sexual development in its relation to the normal neurotic individuals, Freud concluded that the constitutional sexual predisposition of the child is “ polymorphous-perverse” and that from this constitution the so-called normal behavior of the sexual function results through a repression of certain components. The child has no conception of moral or esthetic feelings and it is only after the primitive impulses are repressed that the normal being evolves. By referring to the infantile character of sexuality the connection can be formed among the normal, perversions, and neuroses. The normal results through the repression of certain partial impulses and components of the infantile predisposition and through a subordination of the rest under the primacy of the genital zones. The perversions correspond to disturbances of this relationship due to a superior compulsive-like development of some of the partial impulses, while the neuroses can be traced to a marked repression of the libidinous strivings. However, it must be remembered that the symptoms do not by any means result at the expense only of the so-called normal sexual impulse (at least not exclusively or preponderately), but they represent the converted expression of impulses which might be designated as perverse if they could manifest themselves directly in phantasies and act without deviating from consciousness. The symptoms are therefore partially formed at the cost of abnormal sexuality. “The neurosis is, so to say, the negative of the perversion.”11

Moreover, there is a congenital variation in the sexual constitution, the existence of which can naturally only be established through its later manifestations. It manifests itself in a preponderance of one or another of the manifold sources of the sexual feeling and it must always come to expression in the final result even if it should remain within normal limits. To be sure, certain variations of the original disposition even without further aid must necessarily lead to the formation of an abnormal sexual life. This may be called “degenerative” and considered as an expression of hereditary deterioration. In this connection Freud states that in more than half of the severe cases of hysteria, compulsion neuroses, etc., treated by him by psychotherapy he positively succeeded in demonstrating syphilis in their fathers before marriage. The patients showed absolutely no sign of hereditary lues, so that the abnormal sexual constitution was to be considered as the last off-shoot of the luetic heredity. In my own cases I found even less than a third in which syphilis could be demonstrated in parents.

If in the course of development certain strong components experience a repression the following result takes place: the sexual excitations are produced as usual, but are prevented from attaining their aim by psychic hindrances and are driven off into many other paths until they express themselves in symptoms. The sexual life of such persons begins like that of perverts. A considerable part of their childhood is filled up with perverse sexual activity which occasionally extends far beyond the period of maturity, but owing to inner reasons a repressive change results before or after puberty and henceforth there appears a neurosis instead of a perversion12; and confining ourselves for the present to hysteria it may be said that hysteria is the result of a conflict between the libido and the sexual repression and that the hysterical symptoms have the value of a compromise between both psychic streams. We must bear in mind that it is the mental conflict which is the essential causative factor and not the sexual moment as such. The resultant compromise of such conflict generally causes the sexual wishes to be consciously rejected and unconsciously accepted. The wish is then repressed, but the sum of excitement finds its way into bodily innervation and forms the hysterical symptom.

Let me cite an example.

A married woman of forty-nine years who suffered from hysteria for more than twenty-two years showed as one of her symptoms a very painful contracted and paralyzed right arm which had been so for more than three years. The muscles of the arm and shoulder region were completely anesthetic and deep needle pricks were not perceived, but the slightest attempt to straighten out the member was most painful. Indeed the pain was the chief symptom. It would be impossible for me to give here the full analysis of the i symptom. I will merely mention some of the psychic constellations.

Due to a number of sexual traumas sustained in childhood all sexual feelings were repressed and, as a result, she was totally frigid when she was married. Indeed coitus was both painful and disgusting to her. This produced marked marital unhappiness, her husband failed to understand her condition, and what made matters worse was the fact that he found her masturbating in her sleep. When he first noticed it he was very indignant and tried to call her to account for it, but she continued to sleep; he tried to arouse her, but she did not respond. He thought at first that she was shamming, but finally concluded that “she had a fit” and reported the matter to the family physician. This somnambulistic state during which she masturbated was repeated on an average of five to six times a week. There was complete amnesia for this action. She at first refused to believe it, but she was finally convinced of it by her own sister, who saw her do it on the occasion of sleeping with her. She then sought the aid of a physician who gave her large doses of bromide and advised her to wear a sock over her hand and firmly tie her arm in complete flexion While she was being treated for her masturbation it was reported to her that her husband carried on some illicit relations with one of the girls she employed. She absolutely refused to believe this, and no amount of urging on the part of her husband’s own relatives could induce her to dismiss this girl. This girl was the daughter of a very poor woman and it was out of compassion that she took her into her millinery establishment and taught her the profession. This state of affairs continued for months. She was extremely jealous, yet her pride would not allow her to take any action in the matter. It was after a quarrel about some other matters, during which her husband grasped her by the right arm that it became painful and developed into the condition noted above. As she was the moving spirit in the millinery establishment the business had to be given up, as she was totally incapacitated by her malady.

Here we see the conflict was between the libido and the repression. The repressed sexual feelings made her consciously frigid, but unconsciously passionate. When her masturbation was brought to her consciousness she took all the precautions to prevent it, but as usual she was unsuccessful. Her husband’s faithlessness gave rise to another conflict. Her pride gained the upper hand and she absolutely refused to believe what everyone else saw and what she herself could not fail to see. When her husband grasped her by this arm, which was the cause of so much mental pain — it was the one with which she masturbated — the conversion took place. The symptom, as Freud puts it, was the result of a compromise between two opposing affects, one of which strove to bring to a realization a partial impulse or a component of the sexual constitution, while the other strove to suppress the same.13 This symptom, as we see, served a double purpose. It stopped the masturbation and incapacitated her to such an extent that the business had to be given up and the girl who caused her so many pangs had to go. The pain was also the punishment for the underlying sexual desire. She never masturbated with her left hand, nor has she ever been seen masturbating since she was cured by psychanalysis.

In analyzing neurotic symptoms Freud found that the dream played a great part in the individual’s life. This gave origin to the epoch-making book, “ The Interpretation of Dreams.”* The dream is not at all absurd and senseless, but has a definite meaning when analyzed, and in the experienced hand it is the most valuable instrument for penetrating the mind. In the neurotic patient the subject of the dream generally refers to the origin of the neurosis, i.e., to the repressed material, but due to the many distortions and transformations only few and

* Translated by A. A. Brill. George Allen, London, and the Macmillan Co., New York.

hidden associations show allusions to the repressed experience. Psychanalysis explains the different components of the dream and thus reveals the repressed ideas which are at the basis of the neurosis. The dream is divided into the manifest and latent thoughts. The former are remembered by the dreamer on awakening, while the latter represent the thoughts of the dream before they were subjected to the distortion. When the translation is complete we find that the latent thoughts of the dream contain the fulfilment of a repressed wish.14 The same holds true in the psychoneurotic symptoms. In the words of Freud, “The hysterical symptom, like all other psychic formations, is the expression of a wish fulfilment.” 15

In the same way the repression continues to evince itself in normal conscious life; in other words, the wish fulfilment normally manifests itself during the waking state just as it does in the dream and in the neurotic symptoms. This can be readily seen if we analyze the abnormal or the so-called accidental actions of every-day life. In his very interesting and instructive book, “The Psychopathology of Every Day Life,”16 Freud shows that mere lapses of memory, speech and writing, as well as the common mistakes are not at all accidental, but when analyzed have a reason. Thus the forgetting of a name which we have once known implies that either directly or indirectly there is something painful or disagreeable connected with it. A mistake in talking is usually what the speaker really means. In other words, the repression influences our waking state just as it does the dream and the psychoneurotic symptoms. Just as the latent thought of the dream, the psychoneurotie symptom represents a fulfilled wish and both the dream and the neurosis seem incomprehensible until explained by psychanalysis.