I will still adhere for a moment to the last comparison in order to call attention to a point in which it does not do justice to the qualities of the thing compared. The logical connection corresponds not only to a zigzag-like devious line, but rather to a ramifying and especially to a converging system of lines. It has a junction in which two or more threads meet only to proceed thence united, and, as a rule, many threads running independently, or here and there connected by by-paths, open into the nucleus. To put it in different words, it is very remarkable how frequently a symptom is manifoldly determined, that is, over-determined.
I will introduce one more complication, and then my effort to illustrate the organization of the pathogenic psychic material will be achieved. It can happen that we may deal with more than one single nucleus in the pathogenic material, as, for example, when we have to analyze a second hysterical outbreak having its own etiology but which is still connected with the first outbreak of an acute hysteria which has been overcome years before. It can readily be imagined what strata and streams of thought must be added in order to produce a connection between the two pathogenic nuclei.
I will still add a few observations to the picture obtained of the organization of the pathogenic material. We have said of this material that it behaves like a foreign body, and that the therapy also acts like the removal of a foreign body from the living tissues. We are now in position to consider the shortcomings of this comparison. A foreign body does not enter into any connection with the layers of tissue surrounding it, although it changes them and produces in them a reactive inflammation. On the other hand, our pathogenic psychic group does not allow itself to be cleanly shelled out from the ego, its outer layers radiate in all directions into the parts of the normal ego, and really belong to the latter as much as to the pathogenic organization. The boundaries between both become purely conventional in the analysis, being placed now here, now there, and in certain locations no demarcation is possible. The inner layers become more and more estranged from the ego without showing a visible beginning of the pathogenic boundaries. The pathogenic organization really does not behave like a foreign body, but rather like an infiltration. The infiltrate must, in this comparison, be assumed to be the resistance. Indeed, the therapy does not consist in extirpating something—psychotherapy cannot do that at present—but it causes a melting of the resistance, and thus opens the way for the circulation into a hitherto closed territory.
(I make use here of a series of comparisons all of which have only a very limited resemblance to my theme, and do not even agree among themselves. I am aware of that, and I am not in danger of over-estimating their value; but, as it is my intention to illustrate the many sides of a most complicated and not as yet depicted idea, I therefore take the liberty of dealing also in thefollowing pages with comparisons which are not altogether free from objections.)
If, after a thorough adjustment, one could show to a third party the pathogenic material in its present recognized, complicated and multidimensional organization, he would justly propound the question, “How could such a camel go through the needle’s eye?” Indeed, one does not speak unjustly of a “narrowing of consciousness.” The term gains in sense and freshness for the physician who accomplishes such an analysis. Only one single reminiscence can enter into the ego consciousness; the patient occupied in working his way through this one sees nothing of that which follows, and forgets everything that has already wedged its way through. If the conquest of this one pathogenic reminiscence strikes against impediments, as for example, if the patient does not yield the resistance against it, but wishes to repress or distort it, the strait is, so to speak, blocked; the work comes to a standstill, it cannot advance, and the one reminiscence in the breach confronts the patient until he takes it up into the breadth of his ego. The whole spacially extended mass of the pathogenic material is thus drawn through a narrow fissure and reaches consciousness as if disjointed into fragments or strips, and it is the task of the psychotherapist to recompose it into the conjectured organization. He who desires still more comparisons may think here of a Chinese puzzle.
If one is about to begin an analysis in which one may expect such an organization of the pathogenic material, the following results of experience may be useful:It is perfectly hopeless to attempt to make any direct headway towards the nucleus of the pathogenic organization.Even if it could be guessed the patient would still not know what to start with the explanation given to him, nor would it change him psychically.
There is nothing left to do but follow up the periphery of the pathogenic psychic formation. One begins by allowing the patient to relate and recall what he knows, during which one can already direct his attention, and through the application of the pressure procedure slight resistances may be overcome. Whenever a new way is opened through pressure it can be expected that the patient will continue it for some distance without any new resistance.
After having worked for a while in such manner a coöperating activity is usually manifested in the patient. A number of reminiscences now occur to him without any need of questioning or setting him a task. A way has thus been opened into an inner strata, within which the patient now spontaneously disposes of the material of equal resistance. It is well to allow him to reproduce for a while without being influenced; of course, he is unable to reveal important connections, but he may be allowed to clear things within the same stratum. The things which he thus reproduces often seem disconnected, but they give up the material which is later revived by the recognized connections.
One has to guard here in general against two things. If the patient is checked in the reproduction of the inflowing ideas, something is apt to be “buried” which must be uncovered later with great effort. On the other hand one must not overestimate his “unconscious intelligence,” and one must not allow it to direct the whole work. If I should wish to schematize the mode of labor, I could perhaps say that one should himself undertake the opening of the inner strata and the advancement in the radial direction, while the patient should take care of the peripheral extension.
The advancement is brought about by the fact that the resistance is overcome in the manner indicated above. As a rule, however, one must at first solve another problem. One must obtain a piece of a logical thread by which direction alone one can hope to penetrate into the interior. One should not expect that the voluntary information of the patient, the material which is mostly in the superficial strata, will make it easy for the analyzer to recognize the locations where it enters into the deep, and to which points the desired connections of thought are attached. On the contrary, just this is cautiously concealed, the assertion of the patient sounds perfect and fixed in itself. One is at first confronted, as it were, by a wall which shuts off every view, and gives no suggestion of anything hidden behind it.
If, however, one views with a critical eye the assertion obtained from the patient without much effort and resistance, one will unmistakably discover in it gaps and injuries. Here the connection is manifestly interrupted and is scantily completed by the patient by an expression conveying quite insufficient information. Hereone strikes against a motive which in a normal person would be designated as flimsy. The patient refuses to recognize these gaps when his attention is called to them. The physician, however, does well to seek under these weak points access to the material of the deeper layers and to hope to discover just here the threads of the connections which he traces by the pressure procedure. One, therefore, tells the patient, “You are mistaken, what you assert can have nothing to do with the thing in question; here we will have to strike against something which will occur to you under the pressure of my hand.”
The hysterical stream of thought, even if it reaches into the unconscious, may be expected to show the same logical connections and sufficient causations as those that would be formed in a normal individual. A looseness of these relationships does not lie within the sphere of influence of the neurosis. If the association of ideas of neurotics, and especially of hysterics, makes a different impression, if the relation of the intensities of different ideas does not seem to be explainable here on psychological determinants alone, we know that such manifestations are due to the existence of concealed unconscious motives. Such secret motives may be expected wherever such a deviation in the connection, or a transgression from the normally justified causations can be demonstrated.
To be sure one must free himself from the theoretical prejudice that one has to deal with abnormal brains of dégénerés and deséquilibrés, in whom the freedom of overthrowing the common psychological laws of the association of ideas is a stigma, or in whom a preferred idea without any motive may grow intensively excessive, and another without psychological motives may remain indestructible. Experience shows the contrary in hysteria; as soon as the hidden—often unconsciously remaining—motives have been revealed and brought to account there remains nothing in the hysterical thought connection that is enigmatical and anomalous.
Thus by tracing the breaches in the first statements of the patient, which are often hidden by “false connections,” one gets hold of a part of the logical thread at the periphery, and thereafter continues the route by the pressure procedure.
Very seldom do we succeed in working our way into the innerstrata by the same thread, usually it breaks on the way when the pressure fails, giving up either no experience, or one which cannot be explained or be continued despite all efforts. In such a case we soon learn how to protect ourselves from the obvious confusion. The expression of the patient must decide whether one really reached an end or encountered a case needing no psychic explanation, or whether it is the enormous resistance that halts the work. If the latter cannot soon be overcome, it may be assumed that the thread has been followed into a strata which is as yet impenetrable. One lets it fall in order to grasp another thread which may, perhaps, be followed up just as far. If one has followed all the threads into this strata, if the knottings have been reached through which no single isolated thread can be followed, it is well to think of seizing anew the resistances on hand.
One can readily imagine how complicated such a work may become. By constantly overcoming the resistance, one pushes his way into the inner strata, gaining knowledge concerning the accumulative themes and passing threads found in this layer; one examines as far as he can advance with the means at hand, and by means of the pressure procedure he gains first information concerning the content of the next strata.
The threads are dropped, taken up again, and followed up until they reach the juncture; they are always retrieved, and by following a memory fascicle one reaches some by-way which finally opens again. In this manner it is possible to leave the work, layer by layer, and advance directly on the main road to the nucleus of the pathogenic organization. Thus the fight is won but not finished. One has to follow up the other threads and exhaust the material; but now the patient helps again energetically, for his resistance has mostly been broken.
In these later stages of the work it is of advantage if one can surmise the connection and tell it to the patient before it has been revealed. If the conjecture is correct the course of the analysis is accelerated, but even an incorrect hypothesis helps, for it urges the patient to participate and elicits from him energetic refutation, thus revealing that he surely knows better.
One, thereby, becomes astonishingly convinced,that it is not possible to press upon the patient things which he apparently does not know, or to influence the results of the analysis by excitinghis expectations. I have not succeeded a single time in altering or falsifying the reproductions of memory or the connections of events by my predictions; had I succeeded it surely would have been revealed in the end by a contradiction in the construction. If anything occurred as I predicted, the correctness of my conjecture was always attested by numerous trustworthy reminiscences. Hence, one must not fear to express his opinion to the patient concerning the connections which are to follow; it does no harm.
Another manifestation which can be repeatedly observed refers to the patient’s independent reproductions. It can be asserted that not a single reminiscence comes to the surface during such an analysis which has no significance. An interposition of irrelevant memory pictures having no connection with the important associations does not really occur. An exception not contrary to the rule may be postulated for those reminiscences which, though in themselves unimportant, are indispensable as intercalations, since the associations between two related reminiscences passed through them only.—As mentioned above, the period during which a reminiscence abides in the pass of the patient’s consciousness is directly proportionate to its significance. A picture which does not disappear requires further consideration; a thought which cannot be abolished must be followed further. A reminiscence never recurs if it has been adjusted, a picture spoken away cannot be seen again. However, if that does happen it can be definitely expected that the second time the picture will be joined by a new content of thought, that the idea will contain a new inference which will show that no perfect adjustment has taken place. On the other hand, a recurrence of different intensities, at first vaguely then quite plainly, often occurs, but it does not, however, contradict the assertion just advanced.
If the object of the analysis is to remove a symptom (pains, symptoms like vomiting, sensations and contractures) which is capable of aggravation or recurrence, the symptom shows during the work the interesting and not undesirable phenomenon of “joining in the discussion.” The symptom in question reappears, or appears with greater intensity, as soon as one penetrates into the region of the pathogenic organization containing the etiology of this symptom, and it continues to accompany the work withcharacteristic and instructive fluctuations. The intensity of the same (let us say of a nausea) increases the deeper one penetrates into its pathogenic reminiscence; it reaches its height shortly before the latter has been expressed, and suddenly subsides or disappears completely for a while after it has been fully expressed. If through resistance the patient delays the expression, the tension of the sensation of nausea becomes unbearable, and, if the expression cannot be forced, vomiting actually sets in. One thus gains a plastic impression of the fact that the vomiting takes the place of a psychic action (here that of speaking) just as was asserted in the conversion theory of hysteria.
The fluctuation of intensity on the part of the hysterical symptom recurs as often as one of its new and pathogenic reminiscences is attacked; the symptom remains, as it were, all the time the order of the day. If it is necessary to drop for awhile the thread upon which this symptom hangs, the symptom, too, merges into obscurity in order to emerge again at a later period of the analysis. This play continues until, through the completion of the pathogenic material, there occurs a definite adjustment of this symptom.
Strictly speaking the hysterical symptom does not behave here differently than a memory picture or a reproduced thought which is evoked by the pressure of the hand. Here, as there, the adjustment necessitates the same obsessing obstinacy of recurrence in the memory of the patient. The difference lies only in the apparent spontaneous appearance of the hysterical symptom, whereas one readily recalls having himself provoked the scenes and ideas. But in reality the memory symbols run in an uninterrupted series from the unchanged memory remnants of affectful experiences and thinking-acts to the hysterical symptoms.
The phenomenon of “joining in the discussion” of the hysterical symptom during the analysis carries with it a practical inconvenience to which the patient should be reconciled. It is quite impossible to undertake the analysis of a symptom in one stretch or to divide the pauses in the work in such a manner as to precisely coincide with the resting point in the adjustment. Furthermore, the interruption which is categorically dictated by the accessory circumstances of the treatment, like the late hour, etc., often occurs in the most awkward locations, just when somecritical point could be approached or when a new theme comes to light. These are the same inconveniences which every newspaper reader experiences in reading the daily fragments of his newspaper romance, when, immediately after the decisive speech of the heroine, or after the report of a shot, etc., he reads, “To be continued.” In our case the raked-up but unabolished theme, the at first strengthened but not yet explained symptom, remains in the patient’s psyche, and troubles him perhaps more than before.
But the patient must understand this as it cannot be differently arranged. Indeed, there are patients who during such an analysis are unable to get rid of the theme once touched; they are obsessed by it even during the interval between the two treatments, and as they are unable to advance alone with the adjustment, they suffer more than before. Such patients, too, finally learn to wait for the doctor, postponing all interest which they have in the adjustment of the pathogenic material for the hours of the treatment, and they then begin to feel freer during the intervals.
The general condition of the patient during such an analysis seems also worthy of consideration. For a while it remains uninfluenced by the treatment expressing the former effective factors. But then a moment comes in which the patient is seized, and his interest chained and from that time his general condition becomes more and more dependent on the condition of the work. Whenever a new explanation is gained and an important contribution in the chain of the analysis is reached, the patient feels relieved and experiences a presentiment of the approaching deliverance; but at each standstill of the work, at each threatening entanglement, the psychic burden which oppresses him grows, and the unhappy sensation of his incapacity increases. To be sure, both conditions are only temporary, for the analysis continues disdaining to boast of a moment of wellbeing, and continues regardlessly over the period of gloominess. One is generally pleased if it is possible to substitute the spontaneous fluctuations in the condition of the patient by such as one himself provokes and understands, just as one prefers to see in place of the spontaneous discharge of the symptoms that order of the day which corresponds to the condition of the analysis.
Usually the deeper one penetrates into the above described layers of the psychic structure the more obscure and difficult the work will at first become. But once the nucleus is reached light ensues, and there is no more fear that a marked gloom will be cast over the condition of the patient. However, the reward of the labor, the cessation of the symptoms of the disease can only be expected when the full analysis of every individual symptom has been accomplished; indeed where the individual symptoms are connected through many junctures one is not even encouraged by partial successes during the work. By virtue of the great number of existing causal connections every unadjusted pathogenic idea acts as a motive for the complete creation of the neurosis, and only with the last word of the analysis does the whole picture of the disease disappear, just as happens in the behavior of the individual reproduced reminiscence.
If a pathogenic reminiscence or a pathogenic connection which was previously withdrawn from the ego consciousness is revealed by the work of the analysis and inserted into the ego, one can observe in the psychic personality which was thus enriched the many ways in which it gives utterance to its gain. Especially does it frequently happen that after the patients have been painstakingly forced to a certain knowledge, they say: “Why I have known that all the time, I could have told you that before.” Those who have more insight recognize this afterwards as a self deception and accuse themselves of ungratefulness. In general the position that the ego takes towards the new acquisition depends upon the strata of the analysis from which the latter originates. Whatever belongs to the outermost layers is recognized without any difficulty, for it always remained in the possession of the ego, and the only thing that was new to the ego was its connection with the deeper layers of the pathogenic material. Whatever is brought to light from these deeper layers also finds appreciation and recognition, but frequently only after long hesitation and reflection. Of course, visual memory pictures are here more difficult to deny than reminiscences of mere streams of thought. Not very seldom the patient will at first say, “It is possible that I thought of that, but I cannot recall it,” and only after a longer familiarity with this supposition recognition will appear. He then recalls and even verifies by sightassociations that he once really had this thought. During the analysis I make it a point of holding the value of an emerging reminiscence independent of the patient’s recognition. I am not tired of repeating that we are obliged to accept everything that we bring to light with our means. Should there be anything unreal or incorrect in the material thus revealed, the connection will later teach us to separate it. I may add that I rarely ever have occasion to subsequently withdraw the recognition from a reminiscence which I had preliminarily admitted. In spite of the deceptive appearance of an urgent contradiction, whatever came to the surface finally proved itself correct.
Those ideas which originate in the deepest layer, and from the nucleus of the pathogenic organization, are only with the greatest difficulty recognized by the patient as reminiscences. Even after everything is accomplished, when the patients are overcome by the logical force and are convinced of the curative effect accompanying the emerging of this idea—I say even if the patients themselves assume that they have thought “so” and “so” they often add, “but to recall, that I have thought so, I cannot.” One readily comes to an understanding with them by saying that these were unconscious thoughts. But how should we note this state of affairs in our own psychological views? Should we pay no heed to the patient’s demurring recognition which has no motive after the work has been completed; should we assume that it was really a question of thoughts which never occurred, and for which there is only a possibility of existence so that the therapy would consist in the consummation of a psychic act which at that time never took place? It is obviously impossible to state anything about it, that is, to state anything concerning the condition of the pathogenic material previous to the analysis, before one has thoroughly explained his psychological views especially concerning the essence of consciousness. It is a fact worthy of reflection that in such analyses one can follow a stream of thought from the conscious into the unconscious (that is, absolutely not recognized as a reminiscence) thence draw it for some distance through the consciousness, and again see it end in the unconscious; and still this variation of the psychic elucidation would change nothing in it, in its logicalness, and in a single part of its connection. Should I then have this stream of thought freely before me, I could notconjecture what part was, and what part was not recognized by the patient as a reminiscence. In a measure I see only the points of the stream of thought merging into the unconscious, just the reverse of that which has been claimed for our normal psychic processes.
I still have another theme to treat which plays an undesirably great part in the work of such a cathartic analysis. I have already admitted the possibility that the pressure procedure may fail and despite all assurance and urging it may evoke no reminiscences. I also stated that two possibilities are to be considered, there is really nothing to evoke in the place where we investigate—that can be recognized by the perfectly calm expression of the patient—or, we have struck against a resistance to be overcome only at some future time. We are confronted with a new layer into which we cannot as yet penetrate, and this can again be read from the drawn and psychic exertion of the patient’s expression. A third cause may be possible which also indicates an obstacle, not as to the purport, but externally. This cause occurs when the relation of the patient to the physician is disturbed, and signifies the worst obstacle that can be encountered. One may consider that in every more serious analysis.
I have already alluded to the important rôle falling to the personality of the physician in the creation of motives which are to overcome the psychic force of the resistance. In not a few cases, especially in women and where we deal with the explanation of erotic streams of thought, the cooperation of the patient becomes a personal sacrifice which must be recompensed by some kind of a substitute of love. The great effort and the patient friendliness for the physician suffice as such substitutes. If this relation of the patient to the physician is disturbed the readiness of the patient fails; if the physician desires information concerning the next pathogenic idea, the patient is confronted by the consciousness of the unpleasantness which has accumulated in her against the physician. As far as I have discovered this obstacle occurs in three principal cases:
1. In personal estrangement, if the patient believes herself slighted, disparaged and insulted, or if she hears unfavorable accounts concerning the physician and his methods of treatment.This is the least serious case. The obstacle can readily be overcome by discussion and explanation, although the sensitiveness and the suspicion of hysterics can occasionally manifest itself in unsuspected dimensions.
2. If the patient is seized with the fear that she becomes too accustomed to her physician, that in his presence she loses her independence and could even become sexually dependent upon him; this case is more significant because it is less determined individually. The occasion for this obstacle lies in the nature of the therapeutic distress. The patient has now a new motive to resist which manifests itself, not only in a certain reminiscence but at each attempt of the treatment. Whenever the pressure procedure is started the patient usually complains of headache. Her new motive for the resistance remains to her for the most part unconscious, and she manifests it by a newly created hysterical symptom. The headache signifies the aversion towards being influenced.
3. If the patient fears lest the painful ideas emerging from the content of the analysis would be transferred to the physician. This happens frequently, and, indeed, in many analyses it is a regular occurrence. The transference to the physician occurs through false connections.[35]I must here give an example. The origin of a certain hysterical symptom in one of my hysterical patients was the wish she entertained years ago which was immediately banished into the unconscious, that the man with whom she at that time conversed would heartily grasp her and force a kiss on her. After the ending of a session such a wish occurred to the patient in reference to me. She was horrified and spent a sleepless night, and at the next session, although she did not refuse the treatment she was totally unfit for the work. After I had discovered the obstacle and removed it, the work continued. The wish that so frightened the patient appeared as the next pathogenic reminiscence, that is, as the one now required by the logical connection. It came about in the following manner: The content of the wish at first appeared in the patient’s consciousness without the recollection of the accessory circumstances which would have transferred this wish into the past. By theassociative force prevailing in consciousness the existing wish became connected with my own person, with which the patient could naturally occupy herself, and in this mesalliance—which I call a false connection—the same affect became reawakened which originally urged the patient to banish this clandestine wish. As soon as I discovered this I could presuppose every similar claim on my personality to be another transference and false connection. It is remarkable how the patient falls a victim to deception on every new occasion.
No analysis can be brought to an end if one does not know how to meet the resistances resulting from the causes mentioned. The way can be found if one bears in mind that the new symptom produced after the old model should be treated like the old symptoms. In the first place it is necessary to make the patient conscious of the obstacle. In one of my patients, in whom the pressure symptoms suddenly failed and I had cause to assume an unconscious idea like the one mentioned in 2, I met it for the first time with an unexpected attack. I told her that there must have originated some obstacle against the continuation of the treatment and that the pressure procedure has at least the power to show her the obstacle, and then pressed her head. She then said, surprisingly, “I see you sitting here on the chair, but that is nonsense, what can that mean?”—But now I could explain it.
In another patient the obstacle did not usually show itself directly on pressure, but I could always demonstrate it by taking the patient back to the moment in which it originated. The pressure procedure never failed to bring back this moment. By discovering and demonstrating the obstacle, the first difficulty was removed, but a greater one still remained. The difficulty lay in inducing the patient to give information where there was an obvious personal relation and where the third person coincided with the physician. At first I was very much annoyed about the increase of this psychic work until I had learned to see the lawful part of this whole process, and I then also noticed that such a transference does not cause any considerable increase in the work. The work of the patient remained the same, she perhaps had to overcome the painful affect of having entertained such a wish, and it seemed to be the same for the success whether she took this psychic repulsion as a theme of the work in the historicalcase or in the recent case with me. The patients also gradually learned to see that in such transferences to the person of the physician they generally dealt with a force or a deception which disappeared when the analysis was accomplished. I believe, however, that if I should have delayed in making clear to them the nature of the obstacle, I would have given them a new, though a milder, hysterical symptom for another spontaneously developed.
I now believe that I have sufficiently indicated how such analyses should be executed, and the experiences connected with them. They perhaps make some things appear more complicated than they are, for many things really result by themselves during such work. I have not enumerated the difficulties of the work in order to give the impression that in view of such requirements it pays for the physician and patient to undertake a cathartic analysis only in the rarest cases. I allow my medical activities to be inflected by the contrary suppositions.—To be sure I am unable to formulate the most definite indications for the application of the here discussed therapeutic method without entering into the valuation of the more significant and more comprehensive theme of the therapy of the neuroses in general. I have often compared the cathartic psychotherapy to surgical measures, and designated my cures as psychotherapeutic operations; the analogies follow the opening of a pus pocket, the curetting of a carious location, etc. Such an analogy finds its justification, not so much in the removal of the morbid as in the production of better curative conditions for the issue of the process.
When I promised my patients help and relief through the cathartic method, I was often obliged to hear the following objections: “You say, yourself, that my suffering has probably to do with my own relation and destinies. You cannot change any of that. In what manner, then, can you help me?” To this I could always answer: “I do not doubt at all that it would be easier for destiny than for me to remove your sufferings, but you will be convinced that much will be gained if we succeed in transforming your hysterical misery into everyday unhappiness, against which you will be better able to defend yourself with a restored nervous system.”