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Christopher D. Green
York University, Toronto, Ontario
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Part 2 of 5
Ladies and Gentlemen: At about the same time that Breuer was using the "talking-cure" with his patient, M. Cbarcot began in Paris, with the hystericals of the Salpetrière, those researches which were to lead to a new understanding of the disease. These results were, however, not yet known in Vienna. But when about ten vears later Breuer and I published our preliminary communication on the psychic mechanism of hysterical phenomena, which grew out of the cathartic treatment of Breuer's first patient, we were both of us under the spell of Charcot's investigations. We made the pathogenic experiences of our patients, which acted as psychic traumata, equivalent to those physical traumata whose influence on hysterical paralyses Charcot had determined; and Breuer's hypothesis of hypnoidal states is itself only an echo of the fact that Charcot had artificially reproduced those traumatic paralyses in hypnosis.
The great French observer, whose student I was during the years 1885-86, had no natural bent for creating psychological theories. His student, P. Janet, was the first to attempt to penetrate more deeply into the psychic processes of hysteria, and we followed his example, when we made the mental splitting and the dissociation of personality the central points of our theory, Janet propounds a theory of hysteria which draws upon the principal theories of heredity and degeneration which are current in France. According to his view hysteria is a form of degenerative alteration of the nervous system, manifesting itself in a congenital " weakness " of the function of psychic synthesis. The hysterical patient is from the start incapable of correlating and unifying the manifold of his mental processes, and so there arises the tendency to mental dissociation. If you will permit me to use a banal but clear illustration, Janet's hysterical reminds one of a weak woman who has been shopping, and is now on her way home, laden with packages and bundles of every description. She cannot manage the whole lot with her two arms and her ten fingers, and soon she drops one. When she stoops to pick this up, another breaks loose, and so it goes on.
Now it does not agree very well, with this assumed mental weakness of hystericals, that there can be observed in hysterical cases, besides the phenomena of lessened functioning, examples of a partial increase of functional capacity, as a sort of compensation. At the time when Breuer's patient had forgotten her mother-tongue and all other languages save English, her control of English attained such a level that if a German book was put before her she could give a fluent, perfect translation of its contents at sight. When later I undertook to continue on my own account the investigations begun by Breuer, I soon came to another view of the origin of hysterical dissociation (or splitting of consciousness). It was inevitable that my views should diverge widely and radically, for my point of departure was not, like that of Janet, laboratory researches, but attempts at therapy. Above everything else, it was practical needs that urged me on. The cathartic treatment, as Breuer had made use of it, presupposed that the patient should be put in deep hypnosis, for only in hypnosis was available the knowledge of his pathogenic associations, which were unknown to him in his normal state. Now hypnosis, as a fanciful, and so to speak, mystical, aid, I soon came to dislike; and when I discovered that, in spite of all my efforts, I could not hypnotize by any means all of my patients, I resolved to give up hypnotism and to make the cathartic method independent of it.
Since I could not alter the psychic state of most of my patients at my wish, I directed my efforts to working with them in their normal state. This seems at first sight to be a particularly senseless and aimless undertaking. The problem was this: to find out something from the patient that the doctor did not know and the patient himself did not know. How could one hope to make such a method succeed? The memory of a very noteworthy and instructive proceeding came to my aid, which I had seen in Bernheim's clinic at Nancy. Bernheim showed us that persons put in a condition of hypnotic somnambulism, and subjected to all sorts of experiences, had only apparently lost the memory of those somnambulic experiences, and that their memory of them could be awakened even in the normal state. If he asked them about their experiences during somnambulism, they said at first that they did not remember, but if he persisted, urged, assured them that they did know, then every time the forgotten memory came back.
Accordingly I did this with my patients. When I had reached in my procedure with them a point at which they declared that they knew nothing more, I would assure them that they did know, that they must just tell it out, and I would venture the assertion that the memory which would emerge at the moment that I laid my hand on the patient's forehead would be the right one. In this way I succeeded, without hypnosis, in learning from the patient all that was necessary for a construction of the connection between the forgotten pathogenic scenes and the symptoms which they had left behind. This was a troublesome and in its length an exhausting proceeding, and did not lend itself to a finished technique. But I did not give it up without drawing definite conclusions from the data which I had gained. I had substantiated the fact that the forgotten memories were not lost. They were in the possession of the patient, ready to emerge and form associations with his other mental content, but hindered from becoming conscious, and forced to remain in the unconscious by some sort of a force. The existence of this force could be assumed with certainty, for in attempting to drag up the unconscious memories into the consciousness of the patient, in opposition to this force, one got the sensation of his own personal effort striving to overcome it. One could get an idea of this force, which maintained the pathological situation, from the resistance of the patient.
It is on this idea of resistance that I based my theory of the psychic processes of hystericals. It had been found that in order to cure the patient it was necessary that this force should be overcome. Now with the mechanism of the cure as a starting point, quite a definite theory could be constructed. These same forces, which in the present situation as resistances opposed the emergence of the forgotten ideas into consciousness, must themselves have caused the forgetting, and repressed from consciousness the pathogenic experiences. I called this hypothetical process "repression" (Verdrängung), and considered that it was proved by the undeniable existence of resistance.
But now the question arose: what were those forces, and what were the conditions of this repression, in which we were now able to recognize the pathogenic mechanism of hysteria? A comparative study of the pathogenic situations, which the cathartic treatment has made possible, allows us to answer this question. In all those experiences, it had happened that a wish had been aroused, which was in sharp opposition to the other desires of the individual, and was not capable of being reconciled with the ethical, aesthetic and personal pretensions of the patient's personality. There had been a short conflict, and the end of this inner struggle was the repression of the idea which presented itself to consciousness as the bearer' of this irreconcilable wish. This was, then, repressed from consciousness and forgotten. The incompatibility of the idea in question with the "ego" of the patient was the motive of the repression, the ethical and other pretensions of the individual were the repressing forces. The presence of the incompatible wish, or the duration of the conflict, had given rise to a high degree of mental pain; this pain was avoided by the repression. This latter process is evidently in such a case a device for the protection of the personality.
I will not multiply examples, but will give you the history of a single one of my cases, in which the conditions and the utility of the repression process stand out clearly enough. Of course for my purpose I must abridge the history of the case and omit many valuable theoretical considerations. It is that of a young girl, who was deeply attached to her father, who had died a short time before, and in whose care she had shared -- a situation analogous to that of Breuer's patient. When her older sister married, the girl grew to feel a peculiar sympathy for her new brother-in-law, which easily passed with her for family tenderness. This sister soon fell ill and died, while the patient and her mother were away. The absent ones were hastily recalled, without being told fully of the painful situation. As the girl stood by the bedside of her dead sister, for one short moment there surged up in her mind an idea, which might be framed in these words: "Now he is free and can marry me." We may be sure that this idea, which betrayed to her consciousness her intense love for her brother-in-law, of which she had not been conscious, was the next moment consigned to repression by her revolted feelings. The girl fell ill with severe hysterical symptoms, and, when I came to treat the case, it appeared that she had entirely forgotten that scene at her sister's bedside and the unnatural, egoistic desire which had arisen in her. She remembered it during the treatment, reproduced the pathogenic moment with every sign of intense emotional excitement, and was cured by this treatment.
Perhaps I can make the process of repression and its necessary relation to the resistance of the patient, more concrete by a rough illustration, which I will derive from our present situation.
Suppose that here in this hall and in this audience, whose exemplary stillness and attention I cannot sufficiently commend, there is an individual who is creating a disturbance, and, by his ill-bred laughing, talking, by scraping his feet, distracts my attention from my task. I explain that I cannot go on with my lecture under these conditions, and thereupon several strong men among you get up, and, after a short struggle, eject the disturber of the peace from the hall. He is now "repressed," and I can continue my lecture. But in order that the disturbance may not be repeated, in case the man who has just been thrown out attempts to force his way back into the room, the gentlemen who have executed my suggestion take their chairs to the door and establish themselves there as a "resistance," to keep up the repression. Now, if you transfer both locations to the psyche, calling this "consciousness," and the outside the "unconscious," you have a tolerably good illustration of the process of repression.
We can see now the difference between our theory and that of Janet. We do not derive the psychic fission from a congenital lack of capacity on the part of the mental apparatus to synthesize its experiences, but we explain it dynamically by the conflict of opposing mental forces, we recognize in it the result of an active striving of each mental complex against the other.
New questions at once arise in great number from our theory. The situation of psychic conflict is a very frequent one; an attempt of the ego to defend itself from painful memories can be observed everywhere, and yet the result is not a mental fission. We cannot avoid the assumption that still other conditions are necessary, if the conflict is to result in dissociation. I willingly concede that with the assumption of "repression" we stand, not at the end, but at the very beginning of a psychological theory. But we can advance only one step at a time, and the completion of our knowledge must await further and more thorough work.
Now do not attempt to bring the case of Breuer's patient under the point of view of repression. This history cannot be subjected to such an attempt, for it was gained with the help of hypnotic influence. Only when hypnosis is excluded can you see the resistances and repressions and get a correct idea of the pathogenic process. Hypnosis conceals the resistances and so makes a certain part of the mental field freely accessible. By this same process the resistances on the borders of this field are heaped up into a rampart, which makes all beyond inaccessible. '
The most valuable things that we have learned from Breuer's observations were his conclusions as to the connection of the symptoms with the pathogenic experiences or psychic traumata, and we must not neglect to evaluate this result properly from the standpoint of the repression-theory. It is not at first evident how we can get from the repression to the creation of the symptoms Instead of giving a complicated theoretical derivation, I will return at, this point to the illustration which I used to typify repression.
Remember that with the ejection of the rowdy and the establishment of the watchers before the door, the affair is not necessarily ended. It may very well happen that the ejected man, now embittered and quite careless of consequences, gives us more to do. He is no longer among us, we are free from his presence, his scornful laugh, his half-audible remarks, but in a certain sense the repression has miscarried, for he makes a terrible uproar outside, and by his outcries and by hammering on the door with his fists interferes with my lecture more than before. Under these circumstances it would be hailed with delight if possibly our honored president, Dr. Stanley Hall, should take upon himself the role of peacemaker and mediator. He would speak with the rowdy on the outside, and then turn to us with the recommendation that we let him in again, provided he would guarantee to behave himself better. On Dr. Hall's authority we decide to stop the repression, and now quiet and peace reign again. This is in fact a fairly good presentation of the task devolving upon the physician in the psychoanalytic therapy of neuroses To say the same thing more directly: we come to the conclusion, from working with hysterical patients and other neurotics, that they have not fully succeeded in repressing the idea to which the incompatible wish is attached. They have, indeed, driven it out of consciousness and out of memory, and apparently saved themselves a great amount of psychic pain, but in the unconscious the suppressed wish still exists, only waiting for its chance to become active, and finally succeeds in sending into consciousness, instead of the repressed idea, a disguised and unrecognizable surrogate-creation (Ersatzbildung), to which the same painful sensations associate themselves that the patient thought he was rid of through his repression. This surrogate of the suppressed idea -- the symptom -- is secure against further attacks from the defences of the ego, and instead of a short conflict there originates now a permanent suffering. We can observe in the symptom, besides the tokens of its disguise, a remnant of traceable similarity with the originally repressed idea; the way in which the surrogate is built up can be discovered during the psychoanalytic treatment of the patient, and for his cure the symptom must be traced back over the same route to the repressed idea. If this repressed material is once more made part of the conscious mental functions -- a process which supposes the overcoming of considerable resistance -- the psychic conflict which then arises, the same which the patient wished to avoid, is made capable of a happier termination, under the guidance of the physician, than is offered by repression. There are several possible suitable decisions which can bring conflict and neurosis to a happy end; in particular cases the attempt may be made to combine several of these. Either the personality of the patient may be convinced that he has been wrong in rejecting the pathogenic wish, and he may be made to accept it either wholly or in part; or this wish may itself be directed to a higher goal which is free from objection, by what is called sublimation (Sublimierung); or the rejection may be recognized as rightly motivated, and the automatic and therefore insufficient mechanism of repression be reinforced by the higher, more characteristically human mental faculties: one succeeds in mastering his wishes by conscious thought.
Forgive me if I have not been able to present more clearly these main points of the treatment which is to-day known as "psychoanalysis." The difficulties do not lie merely in the newness of the subject.
Regarding the nature of the unacceptable wishes, which succeed in making their influence felt out of the unconscious, in spite of repression; and regarding the question of what subjective and constitutional factors must be present for such a failure of repression and such a surrogate or symptom creation to take place, we will speak in later remarks.