Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

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 not conjecture 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 the associative 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 historical case 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.”