Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

4. One should not attempt psychoanalysis when it is a question of rapidly removing a threatening manifestation, as, for example, in the case of an hysterical anorexia.

You have now gained the impression that the sphere of application of the analytic psychotherapy is a very limited one, for you really heard me enumerate nothing but contraindications. Nevertheless, there remain sufficient cases and morbid states, such as all chronic forms of hysteria with remnant manifestations, the extensive realms of compulsive states, abulias, etc., on which this therapy can be tried.

It is pleasing that particularly the worthiest and highest developed persons can thus be most helped. Where the analytic psychotherapy has accomplished but little one can cheerfully assert that any other treatment would have certainly resulted in nothing.

(e) You will surely wish to ask me about the possibility of doing harm through the application of psychoanalysis. To this I will reply that if you will judge justly you will meet this procedure with the same critical good-feeling as you have met our other therapeutic methods, and doing this you will have to agree with me that a rationally executed analytic treatment entails no dangers for the patient. One who, like a layman, is accustomed to ascribe to the treatment everything occurring during the disease, will probably judge differently. It is really not so long since our hydrotherapeutic asylums met with similar opposition. Thus one who was advised to go to such an asylum became thoughtful because he had an acquaintance who entered the asylum as nervous and there become insane. As you surmise we deal with cases of initial general paresis who in the first stages could still be sent to hydrotherapeutic asylums, and who there merged into the irresistible course leading to manifest insanity. For the layman the water was the cause and author of this sad transformation. Where it is a question of unfamiliar influences, even doctors are not free from such mistaken judgment. I recall having once attempted to treat a woman by psychotherapy who passed a great part of her existence by alternating between mania and melancholia. I began to treat her at the end of a melancholia and everything seemed to go well for two weeks, but in the third week she was again merging into a mania. It was surely a spontaneous alteration of the morbid picture, for two weeks is no time in which anything can be accomplished by psychotherapy, but the prominent—now deceased—physician who saw the case with me could not refrain from remarking that this decline must have been due to the psychotherapy. I am quite convinced that he would have been more critical under different conditions.

(f) In conclusion, gentlemen, I must say to myself that it will not do to lay claim to your attention so long in favor of the analytic psychotherapy without telling you of what this treatment consists, and on what it is based. To be sure I can only indicate it as I have to be brief. This therapy is founded on the understanding that unconscious ideas—or rather the unconsciousness of certain psychic processes—are the main causes of a morbid symptom. We share this conviction with the French school (Janet) which moreover by gross schematization reduces the hysterical symptom to an unconscious idée fixe. Do not fear now that we will thus merge too far into the obscurest philosophy. Our unconscious is not quite the same as that of the philosophers and what is more, most philosophers wish to know nothing of the “psychical unconscious.” But if you will put yourselves in our position, you will understand that the interpretation of this unconscious, in patients’ psychic life, into the conscious, must result in a correction of their deviation from the normal, and in an abrogation of the compulsion controlling their psychic life. For the conscious will reaches as far as the conscious psychic processes and every psychic compulsion is substantiated by the unconscious. You need never fear that the patient will be harmed by the emotion produced in the entrance of his unconscious into consciousness, for you can theoretically readily understand that the somatic and affective activity of the emotion which became conscious can never become as great as those of the unconscious. For we only control all our emotions by directing upon them our highest psychic activities which are connected with consciousness.

We can still choose another point of view for the understanding of the psychoanalytic treatment. The revealing and interpreting of the unconscious takes place under constant resistance on the part of the patient. The emerging of the unconscious is connected with displeasure and owing to this displeasure it is continuously repulsed by the patient. It is upon this conflict in the patient’s psychic life that you encroach, and if you succeed in prevailing upon him to accept something, for motives of better insight, which he has thus far repulsed (repressed) on account of the automatic adjustment of displeasure, you have achieved in him a piece of educational work. For it is really an education if you can induce a person to leave his bed early in the morning despite his unwillingness to do so. As such an after training for the overcoming of inner resistances you can conceive the psychoanalytic treatment in quite a general manner. But in no sphere of the nervous patients is such an after training so essential as in the psychic elements of their sexual life. For nowhere have culture and education produced as much harm as here, and it is here, as experience will show you, that the controlling etiologies of the neuroses are found. The other etiological element, the constitutional contribution, is really given to us as something immutable. But this gives rise to an important demand on the doctor. Not only must he be of unblemished character—“morality is really a matter of course” as the principal person in Th. Vischer’s “Auch Einer” used to say—but he must have overcome in his own personality the mixture of lewdness and prudishness with which so many others are wont to meet the sexual problems.

This is perhaps the place for another observation. I know that the emphasis which I laid on the sexual rôle in the origin of the psychoneuroses has become widely known. But I also know that restriction and nearer determinations are of little use with the great public; the multitude has little room in its memory, and generally retains from a statement the bare nucleus, thus creating for itself an easily remembered extreme. The same might also have happened to some physicians when the faint notion that they have of my theory is that I trace back the neurosis in the last place to sexual privation. Of such there is surely no dearth under the vital conditions of our society. But if that supposition were true would it not seem obvious that in order to avoid the roundabout way of the psychic treatment and tend directly towards the cure, we should directly recommend sexual participation as the remedy? I really do not know what could induce me to suppress these conclusions if they were justified. But the state of affairs is different. The sexual need or privation is merely one of the factors playing a part in the mechanism of the neurosis, and if it alone existed the result would not be a disease but a dissipation. The other equally indispensable factor, which one is only too ready to forget, is the sexual repugnance of neurotics, their inability to love; it is that psychic feature which I have designated as “repression.” It is only from the conflict between the two strivings that the neurotic malady originates, and it is for this reason that the advice for sexual participation in the psychoneuroses can really only seldom be designated as good.

Allow me to conclude with this guarded remark. Let us hope that with an interest for psychotherapy, purified of all hostile prejudice, you will help us to do some good in the treatment of the severe cases of psychoneuroses.

CHAPTER IX.
My Views on the Rôle of Sexuality in the Etiology of the Neuroses.[^[54]]

I am of the opinion that my theory on the etiological significance of the sexual moment in the neuroses can be best appreciated by following its development. I will by no means make any effort to deny that it passed through an evolution during which it underwent a change. My colleagues can find the assurance in this admission that this theory is nothing other than the result of continued and painstaking experiences. In contradistinction to this whatever originates from speculation can certainly appear complete at one go and continue unchanged.