Among the intellectual motives employed for the overcoming of the resistance one can hardly dispense with one affective moment, that is, the personal equation of the doctor, and in a number of cases, this alone will be able to break the resistance. The conditions here do not differ from those found in any other branch of medicine, and one should not expect any therapeutic method to fully disclaim the assistance of this personal moment.
III.
In view of the discussions in the preceding section concerning the difficulty of my technique, which I have unreservedly exposed,—I have really collected them from my most difficult cases, though it will often be easier work—in view then of this state of affairs everybody will wish to ask whether it would not be more suitable, instead of all these tortures, to apply oneself more energetically to hypnosis, or to limit the application of the cathartic method to only such cases as can be placed in deep hypnosis. To the latter proposition I should have to answer that the number of patients available for my skill would shrink considerably; but to the former advice I will advance the supposition that even where hypnosis could be produced the resistance would not be very much lessened. My experiences in this respect are not particularly extensive, so that I am unable to go beyond this supposition, but wherever I achieved a cathartic cure in the hypnotic state I found that the work devolved upon me was not less than in the state of concentration. I have only recently finished such a treatment during which course I caused the disappearance of a hysterical paralysis of the legs. The patient merged into a state, psychically very different from the conscious, and somatically distinguished by the fact that she was unable to open her eyes or rise without my ordering her to do so; and still I never had a case showing greater resistance than this one. I placed no value on these physical signs, and toward the end of the ten months’ treatment they really became imperceptible. The condition of the patient during our work has therefore lost nothing of its psychic peculiarities, such as the ability to recall the unconscious and its very peculiar relation to the person of the physician. To be sure, in the history of Mrs. Emmy v. N. I have described an example of a cathartic cure accomplished in a profound somnambulism in which the resistance played almost no part. But nothing that I obtained from this woman would have required any special effort; I obtained nothing that she could not have told me in her waking state after a longer acquaintanceship and some esteem. The real causes of her disease, which were surely identical with the causes of her relapses after my treatment, I have never found—it was my first attempt in this therapy—and when I once asked her accidentally for a reminiscence which contained a fragment of the erotic, I found her just as resistant and unreliable in her statements as any one of my later non-somnambulic patients. This patient’s resistance, even in the somnambulic state, against other requirements and exactions I have already discussed in her history. Since I have witnessed cases who, even in deep somnambulism were absolutely refractory therapeutically despite their obedience in everything else, I really became skeptical as to the value of hypnosis for the facilitation of the cathartic treatment. A case of this kind I have reported in brief,[[32]] and could still add others.
In our discussion thus far, the idea of resistance has thrust itself to the foreground. I have shown how, in the therapeutic work, one is led to the conception that hysteria originates through the repression of an unbearable idea from a motive of defense, that the repressed idea remains as a weak (mildly intensive) reminiscence, and that the affect snatched from it is used for a somatic innervation, that is, conversion of the excitement. By virtue of its repression the idea becomes the cause of morbid symptoms, that is pathogenic. A hysteria showing this psychic mechanism may be designated by the name of “defense hysteria,” but both Breuer and myself have repeatedly spoken of two other kinds of hysterias which we have named hypnoid and retention hysteria. The first to reveal itself to us was really the hypnoid-hysteria, for which I can mention no better example than Breuer’s case of Miss Anna O.[[33]] For this form of hysteria Breuer gives an essentially different psychic mechanism than for the form which is characterized by conversion. Here the idea becomes pathogenic through the fact that it is conceived in a peculiar psychic state, having remained from the very beginning external to the ego. It therefore needs no psychic force to keep it away from the ego, and it need not awaken any resistance when, with the help of the somnambulic psychic authority, it is initiated into the ego. The history of Anna O. really shows no such resistance.
I held this distinction as so essential that it has readily induced me to adhere to the formation of the hypnoid-hysteria. It is however remarkable that in my own experience I encountered no genuine hypnoid-hysteria, whatever I treated changed itself into a defense hysteria. Not that I have never dealt with symptoms which manifestly originated in separated conscious states, and therefore were excluded from being accepted into the ego. I found this also in my own cases, but I could show that the so called hypnoid state owed its separation to the fact that a split off psychic group originated before, through defense. In brief, I cannot suppress the suspicion that hypnoid and defense hysteria meet somewhere at their roots, and that the defense is the primary thing; but I know nothing about it.
Equally uncertain is at present my opinion concerning the retention hysteria in which the therapeutic work is also supposed to follow without any resistance. I had a case which I took for a typical retention hysteria, and I was pleased over the anticipation of an easy and certain success; but this success did not come as easy as the work really was. I therefore presume, and again with all caution appropriate to ignorance, that in retention hysteria, too, we can find at its basis a fragment of defense which has thrust the whole process into hysteria. Let us hope that new experiences will soon decide whether I am running into the danger of one-sidedness and error in my tendency to spread the conception of defense for the whole of hysteria.
Thus far I have dealt with the difficulties and technique of the cathartic method, I would now like to add a few indications showing how one makes an analysis with technique. For me this is a very interesting theme, but I do not expect that it will excite similar interest in others who have not practiced such analyses. Properly speaking we shall again deal with the technique, but this time with those difficulties concerning which the patient cannot be held responsible, and which must in part be the same in a hypnoid and a retention hysteria as well as in the defense hysteria which I have in mind as a model. I start on this last fragment of discussion with the expectation that the psychic peculiarities revealed here might sometime attain a certain value as raw material for an intellectual dynamics.
The first and strongest impression which one gains through such an analysis is surely the fact that the pathogenic psychic material, apparently forgotten and not at the disposal of the ego, playing no rôle in the association and in memory, still lies ready in some manner and in proper and good order. All that is necessary is to remove the resistances blocking the way. Barring that, everything is known as we know anything else, the proper connections of the individual ideas among themselves and with the nonpathogenic are frequently recalled and are present; they have been produced in their time and retained in memory. The pathogenic psychic material appears as the property of an intelligence which is not necessarily inferior to the normal ego. The semblance of a second personality is often most delusively produced. Whether this impression is justified, whether the arrangements of the psychic material resulting after the adjustment is not transferred back into the time of the disease, these are questions which I do not like to consider in this place. One cannot easily and intuitively describe the experiences resulting from these analyses as if he placed himself in the position, which one can only take a survey of after their disappearance.
The condition is usually not so simple as one represents it in special cases, as, for example, in a single case in which a symptom originates through a serious trauma. We frequently deal not with a single hysterical symptom but with a number of the same which are partially independent of one another and partially connected. We must not expect a single traumatic reminiscence whose nucleus is a single pathogenic idea, but we must be ready to assume a series of partial traumas and a concatenation of pathogenic streams of thought. The monosymptomatic traumatic hysteria is, as it were, an elementary organism, it is a single being in comparison to the complicated structure of a grave hysterical neurosis as is generally encountered.
The psychic material of such hysteria presents itself as a multidimensional formation of at least triple stratification. I hope to be able to soon justify this figurative expression. First of all there is a nucleus of such reminiscences (either experiences or streams of thought) in which the traumatic moment culminated, or in which the pathogenic idea has found its purest formation. Around this nucleus we often find an incredibly rich mass of other memory material which we have to elaborate by the analysis in the triple arrangement mentioned before. In the first place, there is an unmistakable linear chronological arrangement which takes place within every individual theme. As an example of this I can only cite the arrangements in Breuer’s analysis of Anna O. The theme is that of becoming deaf, of not hearing,[[34]] which then becomes differentiated according to seven determinants, and under each heading there were from ten to one hundred single reminiscences in chronological order. It was as if one should take up an orderly kept record. In the analysis of my patient, Emmy v. N., there were similar if not so many memory sub-divisions; they formed quite a general event in every analysis. They always occurred in a chronological order which was as definitely reliable as the serial sequences of the days of the week or the names of the months in psychically normal individuals. They increased the work of the analysis through the peculiarity of reversing the series of their origin in the reproduction; the freshest and the most recent occurrence of the accumulation occurred first as a “wrapper,” and that with which the series really began gave the impression of the conclusion.