Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

After months I again saw the patient who said that “the former pain disappeared after following the treatment and remained away a long time, but now it has reappeared as a nervous pain. I recognize it by the fact that I do not perceive it now on motion as before, but only during certain hours, as for example, in the morning on awakening, and during certain excitements.” The patient’s diagnosis was quite correct. It was now important to discover the cause of this pain, but in this she could not assist me in her uninfluenced state. When, in a state of concentration and under the pressure of my hand, I asked her whether anything occurred to her, or whether she saw anything, she began to describe her visual pictures. She saw something like a sun with rays, which I naturally had to assume to be a phosphene produced by pressure on the eyes. I expected that the useful pictures would follow, but she continued to see stars of a peculiar pale blue light, like moonlight, etc., and I believed that she merely saw glittering, shining, and twinkling spots before the eyes. I was already prepared to add this attempt to the failures, and I was thinking how I could quietly withdraw from this affair, when my attention was called to one of the manifestations which she described. She saw a big black cross which was inclined, the edges of which were surrounded by a subdued moonlike light in which all the pictures thus far seen were shining, and upon the arm there flickered a little flame that was apparently no longer a phosphene. I continued to listen. She saw numerous pictures in the same light, peculiar signs resembling somewhat sanscrit. She also saw figures like triangles, among which there was one big triangle, and again the cross. I now thought of an allegorical interpretation, and asked, “What does this cross mean?”—“It is probably meant to interpret pain,” she answered. I argued, saying, that “by cross one usually understands a moral burden,” and asked her what was hidden behind that pain. She could not explain that and continued looking. She saw a sun with golden rays which she interpreted as God, the primitive force; she then saw a gigantic lizard which she examined quizzically but without fear; then a heap of snakes, then another sun but with mild silvery rays, and in front of it, between her own person and this source of light, there was a barrier which concealed from her the center of the sun.

I knew for some time that we dealt here with allegories, and I immediately asked for an explanation of the last picture. Without reflecting she answered: “The sun is perfection, the ideal, and the barrier represents my weaknesses and failings which stand between me and the ideal.”—“Indeed, do you reproach yourself? Are you dissatisfied with yourself?”—“Yes.”—“Since when?”—“Since I became a member of the Theosophical Society and read the writings edited by it. I have always had a poor opinion of myself.” “What was it that made the last strongest impression upon you?”—“A translation from the sanscrit which now appears in serial numbers.” A minute later I was initiated into her mental conflicts, and into her self reproaches. She related a slight incident which gave occasion for a reproach, and in which, as a result of an inciting conversion, the former organic pain at first appeared.—The pictures which I had at first taken for phosphenes were symbols of occultistic streams of thought, perhaps plain emblems from the title pages of occultistic books.

I have thus far so warmly praised the achievements of the pressure procedure, and have so entirely neglected the aspect of the defense or the resistance, that I certainly must have given the impression that by means of this small artifice one is placed in position to become master of the psychic resistances against the cathartic cure. But to believe this would be a gross mistake. Such advantages do not exist in the treatment so far as I can see; here, as everywhere else, great change requires much effort. The pressure procedure is nothing but a trick serving to surprise for awhile the defensive ego, which in all graver cases recalls its intentions and continues its resistance.

I need only recall the various forms in which this resistance manifested itself. In the first place, the pressure experiment usually fails the first or second time. The patient then expresses himself disappointed, saying, “I believed that some idea would occur to me, but I only thought so; as attentive as I was nothing came.” Such attitudes assumed by the patient are not yet to be counted as a resistance; we usually answer to that, “You were really too anxious, the second time things will come.” And they really come. It is remarkable how completely the patients—even the most tractable and the most intelligent—can forget the agreement which they have previously entered into. They have promised to tell everything that occurs to them under the pressure of the hand, be it closely related to them or not, and whether it is agreeable to them to say it or not; that is, they are to tell everything without any choice, or influence by critique or affect. Yet they do not keep their promise, it is apparently beyond their powers. The work repeatedly stops, they continue to assert that this time nothing came to their mind. One needs not believe them, and one must always assume, and also say, that they hold back something because they believe it to be unimportant, or perceive it as painful. One must insist, repeat the pressure, and assume an assured attitude until one really hears something. The patient then adds, “I could have told you that the first time.”—“Why did you not say it?”—“I could not believe that that could be it. Only after it returned repeatedly have I decided to tell it;” or, “I had hoped that it would not be just that, that I could spare myself from saying it, but only after it could not be repressed have I noticed that I could not avoid it.”—Thus the patient subsequently betrays the motives of a resistance which he did not at first wish to admit. He apparently could not help offering resistances.

It is remarkable under what subterfuges these resistances are frequently hidden. “I am distracted today”; “the clock or the piano playing in the next room disturbs me,” they say. I became accustomed to answer to that, “Not at all, you simply struck against something that you do not willingly wish to say. That does not help you at all. Just stick to it.”—The longer the pause between the pressure of my hand and the utterance of the patient, the more suspicious I become, and the more is it to be feared that the patient arranges what comes to his mind, and distorts it in the reproduction. The most important explanations are frequently ushered in as superfluous accessories, just as the princes of the opera who are dressed as beggars. “Something now occurred to me, but it has nothing to do with it. I only tell it to you because you wish to know everything.” With this introduction we usually obtain the long desired solution. I always listen when I hear a patient talk so lightly of an idea. That the pathogenic idea should appear of so little importance on its reappearance is a sign of the successful defense. One can infer from this of what the process of defense consisted. Its object was to make a weak out of a strong idea, that is, to rob it of its affect.

Among other signs the pathogenic memories can also be recognized by the fact that they are designated by the patient as unessential, and yet are only uttered with resistance. There are also cases where the patient seeks to disavow the recollections, even while they are being reproduced, with such remarks as these: “Now something occurred to me, but apparently you talked it into me;” or, “I know what you expect to this question, you surely think that I thought of this and that.” An especially clever way of shifting is found in the following expression: “Now something really occurred to me, but it seems to me as if I added it, and that it is not a reproduced thought.”—In all these cases I remain inflexibly firm, I admit none of these distinctions, but explain to the patient that these are only forms and subterfuges of the resistance against the reproduction of a recollection which in spite of all we are forced to recognize.

One generally experiences less trouble in the reproduction of pictures than thoughts. Hysterical patients who are usually visual are easier to manage than patients suffering from obsessions. Once the picture emerges from the memory we can hear the patient state that as he proceeds to describe it, it proportionately fades away and becomes indistinct; the patient wears it out, so to speak, by transforming, it into words. We then orient ourselves through the memory picture itself in order to find the direction towards which the work should be continued. We say to the patient, “Just look again at the picture, has it disappeared?”—“As a whole, yes, but I still see this detail.”—“Then this must have some meaning, you will either see something new, or this remnant will remind you of something.” When the work is finished the visual field becomes free again, and a new picture can be called forth; but at other times such a picture, in spite of its having been described, remains persistently before the inner eye of the patient, and I take this as a sign that he still has something important to tell me concerning its theme. As soon as this has been accomplished, the picture disappears like a wandering spirit returning to rest.

It is naturally of great value for the progress of the analysis to carry our point with the patient, otherwise we have to depend on what he thinks is proper to impart. It, therefore, will be pleasant to hear that the pressure procedure never failed except in a single case which I shall discuss later, but which I can now characterize by the fact that there was a special motive for the resistance. To be sure, it may happen under certain conditions that the procedure may be applied without bringing anything to light; as, for example, we may ask for the further etiology of a symptom when the same has already been exhausted; or, we may investigate for the psychic genealogy of a symptom, perhaps a pain, which really was of somatic origin. In these cases the patient equally insists that nothing occurred to him, and he is right. We should strive to avoid doing an injustice to the patient by making it a general rule not to lose sight of his features while he calmly lies before us during the analysis. One can then learn to distinguish, without any difficulty, the psychic calm in the real non appearance of a reminiscence from the tension and emotional signs under which the patient labors in trying to disavow the emerging reminiscences for the purpose of defense. The differential diagnostic application of the pressure procedure is really based on such experiences.

We can see, therefore, that even with the help of the pressure procedure the task is not an easy one. The only advantage gained is the fact that we have learned from the results of this method in what direction to investigate, and what things we have to force upon the patient. For some cases that suffices, for the question is really to find the secret, and tell it to the patient, so that he is usually then forced to relinquish his resistance. In other cases more is necessary; here the surviving resistance of the patient manifests itself by the fact that the connections become torn, the solutions do not appear, and the recalled pictures come indistinctly and incompletely. On reviewing, at a later period, the earlier results of an analysis, we are often surprised at the distorted aspects of all the occurrences and scenes which we have snatched from the patient by the pressure procedure. It usually lacks the essential part, the relations to the person or to the theme, and for that reason the picture remained incomprehensible. I will now give one or two examples showing the effects of such a censoring during the first appearance of the pathogenic memories. The patient sees the upper part of a female body on which a loose covering fits carelessly, only much later he adds to this torso the head, and thereby betrays a person and a relationship. Or, he relates a reminiscence of his childhood about two boys whose forms are very indistinct, and to whom a certain mischievousness was attributed. It required many months and considerable progress in the course of the analysis before he again saw this reminiscence and recognized one of the children as himself and the other as his brother. What means have we now at our disposal to overcome this continued resistance?

We have but few, yet we have almost all those by which one person exerts a psychic influence on the other. In the first place we must remember that psychic resistance, especially of long continuance, can only be broken slowly, gradually, and with much patience. We can also count on the intellectual interest which manifests itself in the patient after a brief period of the analysis. On explaining and imparting to him the knowledge of the marvelous world of psychic processes, which we have gained only through such analysis, we obtain his collaboration, causing him to view himself with the objective interest of the investigator, and we thus drive back the resistance which rests on an affective basis. But finally—and this remains the strongest motive force—after the motives for the defense have been discovered, we must make the attempt to reduce or even substitute them by stronger ones. Here the possibility of expressing the therapeutic activity in formulæ ceases. One does as well as he can as an explainer where ignorance has produced timorousness, as a teacher, as a representative of a freer and more superior world-conception, and as confessor, who through the continuance of his sympathy and his respect, imparts, so to say, absolution after the confession. One endeavors to do something humane for the patient in so far as the range of one’s own personality and the measure of sympathy which one can set apart for the case allows. It is an indispensable prerequisite for such psychic activities to have approximately discovered the nature of the case and the motives of the defense here effective. Fortunately the technique of the urging and the pressure procedure take us just so far. The more we have solved such enigmas the easier will we discover new ones, and the earlier will we be able to manage the actual curative psychic work. For it is well to bear in mind that although the patient can rid himself of an hysterical symptom only after reproducing and uttering under emotion its causal pathogenic impressions, yet the therapeutic task merely consists in inducing him to do it, and once the task has been accomplished there remains nothing for the doctor to correct or abolish. All the contrary suggestions necessary have already been employed during the struggle carried on against the resistance. The case may be compared to the unlocking of a closed door, where, as soon as the door knob has been pressed downward, no other difficulties are encountered in opening the door.