It is left for me to utilize the explanations gained in this case of paranoia for the comparison of paranoia with compulsion neurosis. Here, as there, the repression was shown to be the nucleus of the psychic mechanism, and in both cases the repression is a sexual experience of childhood. The origin of every compulsion in this paranoia is in the repression, and the symptoms of paranoia allow a similar classification as the one found justified in compulsion neurosis. Some symptoms also originate from the primary defense among which are all delusions of distrust, suspicion and persecution by others. In the compulsion neurosis the initial reproach became repressed through the formation of the primary symptom of defense, self-distrust, moreover, the reproach was recognized as justified, and for the purpose of adjustment the validity acquired by the scrupulousness during the normal interval now guards against giving credence to the returning reproach in the form of an obsession. By the formation of the defense symptom of distrust in others, the reproach in paranoia is repressed in a way which may be designated as projection; the reproach is also deprived of recognition, and as a retaliation there is no protection against the returning reproaches contained in the delusions.
The other symptoms in my case of paranoia are therefore to be designated as symptoms of the return of the repression, and as in the compulsion neurosis they show the traces of the compromise which alone permits an entrance into consciousness. Such are the delusions of being observed while undressing, the visual hallucinations, the perceptual hallucinations and the hearing of voices. The memory content existing in the delusion mentioned is almost unchanged and appears only uncertain through utterance. The return of the repression into visual pictures comes nearer to the character of hysteria than to the character of compulsion neurosis; still, hysteria is wont to repeat its memory symbols without modification, whereas the paranoiac memory hallucination undergoes a distortion similar to those in compulsion neurosis. An analogous modern picture takes the place of the one repressed (instead of a child’s lap it was the lap of a woman upon which the hairs were particularly distinct because they were absent in the original impression). Quite peculiar to paranoia but no further elucidated in this comparison is the fact that the repressed reproaches return as loud thoughts, this must yield to a double distortion: (1) a censor, which either leads to a replacement through other associated thoughts or to a concealment by indefinite expressions, and (2) the reference to the modern which is merely analogous to the old.
The third group of symptoms found in compulsion neurosis, the symptoms of the secondary defense, cannot exist as such in paranoia, for no defense asserts itself against the returning symptoms which really find credence. As a substitute for this we find in paranoia another source of symptom formation; the delusions (symptoms of return) reaching consciousness through the compromise demand a great deal of the thinking work of the ego until they can be unconditionally accepted. As they themselves are not to be influenced the ego must adapt itself to them, and hence the combining delusional formation, the delusion of interpretation which results in the transformation of the ego, corresponds here to the symptoms of secondary defense of compulsion neurosis. In this respect my case was imperfect as it did not at that time show any attempt at interpretation, this only appeared later. I do not doubt, however that if psychoanalysis were also applied to that stage of paranoia, another important result would be established. It would probably be found that even the so called weakness of memory in paranoiacs is purposeful, that is, it depends on the repression and serves its purpose. Subsequently even those nonpathogenic memories which stand in opposition to the transformation of the ego become repressed and replaced; this the symptoms of return imperatively demand.
CHAPTER VIII.
On Psychotherapy.[[53]]
Gentlemen:
It is almost eight years since, at the request of your deceased chairman, Prof. v. Reder, I had the pleasure of speaking in your midst on the subject of hysteria. Shortly before (1895) I had published the “Studien über Hysterie” together with Dr. J. Breuer, and on the basis of a new knowledge for which we are thankful to this investigator, I have attempted to introduce a new way of treating the neurosis. Fortunately, I can say that the endeavors of our “Studies” have met with success, and that the ideas which they advocate concerning the effects of psychic traumas through the restraint of affects and the conception of the hysterical symptom as a result of a displacement of excitement from the psychic to the physical—ideas for which we have created the terms “ab-reaction” and “conversion”—are today generally known and understood. At least in German-speaking countries there are no descriptions of hysteria which do not to a certain extent take cognizance of them, and no colleague who does not at least partially follow this theory. And yet as long as they were new these theories and these terms must have sounded strange enough!
I can not say the same thing about the therapeutic procedure which we have proposed to our colleagues together with our theory. It still struggles for recognition. This may have its special reasons. The technique of the procedure was at that time still rudimentary. I was unable to give those indications to the medical reader of the book which would enable him to perform such a treatment. But surely there were other causes of a general nature. To many physicians psychotherapy even today appears as a product of modern mysticism, and in comparison to our physico-chemical remedies the application of which is based on physiological insight, psychotherapy appears quite unscientific and unworthy of the interest of a natural philosopher. You will therefore allow me to present to you the subject of psychotherapy, and to point out to you what part of this verdict can be designated as unjust or erroneous.
In the first place let me remind you that psychotherapy is not a modern therapeutic procedure. On the contrary it is one of the oldest remedies used in medicine. In Lëwenfeld’s instructive work (Lehrbuch der gesamten Psychotherapie) you can find the methods employed in primitive and ancient medicine. Most of them were of a psychotherapeutic nature. In order to cure a patient he was transferred into a state of “credulous expectation” which acts in a similar manner even today. Even after the doctors found other remedial agents psychotherapeutic endeavors never disappeared from this or that branch of medicine.
Secondly, I call your attention to the fact that we doctors really can not abandon psychotherapy if only because another very much to be considered party in the treatment—namely the patient—has no intention of abandoning it. You know how much we owe to the Nancy school (Liébault, Bernheim) for these explanations. Without our intention, an independent factor from the patient’s psychic disposition enters into the activity of every remedial agent introduced by the doctor, acting mostly in a favorable sense but often also in an inhibiting sense. We have learned to apply to this factor the word “suggestion,” and Moebius taught us that the failures of some of our remedies are to be ascribed to the disturbing influences of this very powerful moment. You doctors, all of you, constantly practice psychotherapy, even when you do not know it, or do not intend it, but it has one disadvantage, you leave entirely to the patient the psychic factor of your influence. It then becomes uncontrollable, it can not be divided into doses and can not be increased. Is it not a justified endeavor of the doctor to become master of this factor, to make use of it intentionally, to direct and enforce it? It is nothing other than that, that scientific psychotherapy expects of you.
In the third place, gentlemen, I wish to refer you to the well known experience, namely, that certain maladies and particularly the psychoneuroses, are more accessible to psychic influences than to any other medications. It is no modern talk but a dictum of old physicians that these diseases are not cured by the drug, but by the doctor, to wit, by the personality of the physician in so far as it exerts a psychic influence. I am well aware, gentlemen, that you like very much the idea which the aesthete Vischer, in his parody on Faust (Faust, der Tragödie, III Teil) endowed with a classical expression: “I know that the physical often acts on the moral.”