Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

I will now add to my former observations that in attempting to use Breuer’s method in greater latitude I met this difficulty—although the diagnosis was hysteria, and the probabilities spoke in favor of the prevalence of the psychic mechanism described by us, yet a number of patients could not be put into the hypnotic state. The hypnosis was necessary to broaden consciousness so as to find the pathogenic reminiscences which do not exist in the ordinary consciousness. I, therefore, was forced to either give up such patients, or to bring about this broadening by other means.

The reason why one person is hypnotizable and another not I could no more explain than others, and hence I could not start on a causal way towards the removal of the difficulties. I also observed that in some patients the obstacle was still more marked, as they even refused to submit to hypnosis. The idea then occurred to me that both cases might be identical, and that in both it might merely be an unwillingness. Those who entertain a psychic inhibition against hypnotism are not hypnotizable, it makes no difference whether they utter their unwillingness or not. It is not fully clear to me whether I can firmly adhere to this conception or not.

It was, therefore, important to avoid hypnotism and yet to obtain the pathogenic reminiscences. This I attained in the following manner:

On asking my patients during our first interview whether they remembered the first motive for the symptom in question, some said that they knew nothing, while others thought of something which they designated as an indistinct recollection, yet were unable to pursue it. I then followed Bernheim’s example of awakening the apparently forgotten impressions obtained during somnambulism (see the case of Miss Lucy). I urged them by assuring them that they did know it, and that they will recall it, etc., and thus some thought of something, while in others the recollections went further. I became still more pressing, I ordered the patient to lie down and voluntarily shut his eyes so as to “concentrate” his mind, causing thereby at least a certain similarity to hypnosis, and I then discovered that without any hypnosis there emerged new and retrospective reminiscences which probably belonged to our theme. Through such experiences I gained the impression that through urging alone it would really be possible to bring to light the definitely existing pathogenic series of ideas; and as this urging necessitated much exertion on my part, and showed me that I had to overcome a resistance, I, therefore, formulated this whole state of affairs into 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 (remembered). It then became clear to me that this must really be the same psychic force which assisted in the origin of the hysterical symptom, and at that time prevented the pathogenic idea from becoming conscious. What kind of effective force could here be assumed, and what motive could have brought it into activity? I could easily formulate an opinion, for I already had some complete analyses at my disposal in which I found examples of pathogenic, forgotten, and repressed ideas. From these I could judge the general character of such ideas. They were altogether of a painful nature, adapted to provoke the affects of shame, reproach, of psychic pain, and the feeling of injury; they were altogether of that kind which one would not like to experience and prefers to forget.

From all these the thought of defense resulted as if simultaneously. Indeed, it is generally admitted by all psychologists that the assumption of a new idea (assumption in the sense of belief, judgment of reality), depends on the mode and drift of the ideas already united in the ego. For the process of the censor, to which the newly formed ideas are subjected, special technical names have been created. An idea entered into the ego of the patient which proved to be unbearable and evoked a power of repulsion on the part of the ego, the purpose of which was a defense against this unbearable idea. This defense actually succeeded, and the idea concerned was crowded out of consciousness and out of the memory, so that its psychic trace could not apparently be found. Yet this trace must have existed. When I made the effort to direct the attention to it, I perceived as a resistance the same force which showed itself as repulsion in the genesis of the symptom. If I could now make it probable that the idea became pathogenic in consequence of the exclusion and repression, the chain would seem complete. In many epicrises of our histories, and in a small work concerning the defense neuropsychoses (1894), I have attempted to indicate the psychological hypotheses with the help of which this connection also—the fact of conversion—can be made clear.

Hence, a psychic force, the repugnance of the ego, has originally crowded the pathogenic idea from the association, and now opposes its return into the memory. The not knowing of the hysterics was really a—more or less conscious—not willing to know, and the task of the therapeutist was to overpower this resistance of association by psychic labor. Such accomplishment is, above all, brought about by “urging,” that is, by applying a psychic force in order to direct the attention of the patient on the desired traces of ideas. It does not, however, stop here, but as I will show, it assumes new forms in the course of the analysis, and calls to aid more psychic forces.

I shall, above all, still linger at “the urging.” One cannot go very far with such simple assurances as, “You do know it, just say it,” or “It will soon come to your mind.” After a few sentences the thread breaks, even in the patient who is in a state of concentration. We must not, however, forget that we deal everywhere here with a quantitative comparison, with the struggle between motives of diverse force and intensity. The urging of the strange and inexperienced physician does not suffice for the “association resistance” in a grave hysteria. One must resort to more forceful means.

In the first place I make use of a small technical artifice. I inform the patient that I will in the next moment exert pressure on his forehead, I assure him that during this pressure he will see some reminiscence in the form of a picture, or some thought will occur to him, and I oblige him to communicate to me this picture or this thought, no matter what it may be. He is not supposed to hold it back because he may perhaps think that it is not the desired or the right thing, or because it is too disagreeable to say. There should be neither criticism nor reserve on account of affect or disregard. Only thus could we find the things desired, and only thus have we unfailingly found them. I then exert pressure for a few seconds on the forehead of the patient lying in front of me, and after stopping the pressure, I ask in a calm tone, as if any disappointment is out of the question, “What have you seen?” or, “What occurred to your mind?”

This method[^[31]] taught me a great deal and led me to the goal every time. Of course I know that I can substitute this pressure on the forehead by any other sign, or any other physical influence, but as the patient lies before me the pressure on the forehead, or the grasping of his head between my two hands, is the most suggestive and most convenient thing that I could undertake for this end. To explain the efficacy of this artifice, I may perhaps say that it corresponds to a “momentary reinforced hypnosis”; but the mechanism of hypnosis is so enigmatical to me that I would not like to refer to it as an explanation. I rather think that the advantage of the process lies in the fact that through it I dissociate the attention of the patient from his conscious quest and reflection, in brief, from everything upon which his will can manifest itself. This resembles the process of staring at a crystal globe, etc. The fact, that under the pressure of my hand there always appears that which I am looking for, teaches that the supposedly forgotten pathogenic ideas always lie ready, “close by,” being attainable through easily approachable associations, and all that is necessary is to clear away some obstacle. This obstacle again seems to be the person’s will, and different persons learn to discard their premeditations, and to assume a perfectly objective attitude toward the psychic processes within them.

It is not always a “forgotten” reminiscence which comes to the surface under the pressure of the hand; in the rarest cases the real pathogenic reminiscences can be superficially discovered. More frequently an idea comes to the surface which is a link between the starting idea and the desired pathogenic one of the association chain, or it is an idea forming the starting point of a new series of thoughts and reminiscences, at the end of which the pathogenic idea exists. The pressure, therefore, has really not revealed the pathogenic idea, which, if torn from its connections without any preparation, would be incomprehensible; but it has shown the way to it, and indicated the direction towards which the investigation must proceed. The idea which is at first awakened through the pressure may correspond to a familiar reminiscence which was never repressed. If the connection becomes torn on the road to the pathogenic idea, all that is necessary for the reproduction of a new orientation and connection is a repetition of the procedure, that is, of the pressure.