Part 22

In the analysis of this little symptomatic act you find nothing that is not already known to you; namely, the conclusion that it is no accident but has in it motive, meaning, and intention; that it belongs to a mental context which can be specified; and that it provides a small indication of a more important mental process. But above all it implies that the process thus indicated is not known to the consciousness of the person who carries it out; for not one of the patients who left the two doors open would have admitted that he wished to show any depreciation of me by his neglect. Many of them could probably recall a sense of disappointment on entering the empty waiting-room, but the connection between this impression and the succeeding symptomatic act certainly remained outside their consciousness.

Now let us place this little analysis of a symptomatic act by the side of an observation made on a patient. I will choose one which is fresh in my memory, and also because it can be described in comparatively few words. A certain amount of detail is indispensable for any such account.

A young officer, home on short leave of absence, asked me to treat his mother-in-law, who was living in the happiest surroundings and yet was embittering her own and her family’s lives by a nonsensical idea. I found her a well-preserved lady, fifty-three years of age, of a friendly, simple disposition, who gave without hesitation the following account of herself. She is most happily married, and lives in the country with her husband who manages a large factory. She cannot say enough of her husband’s kindness and consideration; theirs had been a love-marriage thirty years ago, since when they had never had a cloud, a quarrel, or a moment’s jealousy. Her two children have both married well, but her husband’s sense of duty keeps him still at work. A year before, an incredible and, to her, incomprehensible thing happened. She received an anonymous letter telling her that her excellent husband was carrying on an intrigue with a young girl, and believed it on the spot—since then her happiness has been destroyed. The details were more or less as follows: she had a housemaid with whom she discussed confidential matters, perhaps rather too freely. This young woman cherished a positively venomous hatred for another girl who had succeeded better in life than herself, although of no better origin. Instead of going into service, the other young woman had had a commercial training, been taken into the factory and, owing to vacancies caused by the absence of staff on service in the field, had been promoted to a good position. She lived in the factory, knew all the gentlemen, and was even addressed as “Miss.” The other one who had been left behind in life was only too ready to accuse her former schoolmate of all possible evil. One day our patient and her housemaid were discussing an elderly gentleman who had visited the house and of whom it was said that he did not live with his wife but kept a mistress. Why, she did not know, but she suddenly said: “I cannot imagine anything more awful than to hear that my husband had a mistress.” The next day she received by post an anonymous letter in disguised handwriting which informed her of the very thing she had just imagined. She concluded—probably correctly—that the letter was the handiwork of her malicious housemaid, for the woman who was named as the mistress of her husband was the very girl who was the object of this housemaid’s hatred. Although she at once saw through the plot and had seen enough of such cowardly accusations in her own surroundings to place little credence in them, our patient was nevertheless prostrated by this letter. She became terribly excited and at once sent for her husband to overwhelm him with reproaches. The husband laughingly denied the accusation and did the best thing he could. He sent for the family physician (who also attended the factory), and he did his best to calm the unhappy lady. The next thing they did was also most reasonable. The housemaid was dismissed, but not the supposed mistress. From that time on the patient claims to have repeatedly brought herself to a calm view of the matter, so that she no longer believes the contents of the letter; but it has never gone very deep nor lasted very long. It was enough to hear the young woman’s name mentioned, or to meet her in the street, for a new attack of suspicion, agony, and reproaches to break out.

This is the clinical picture of this excellent woman’s case. It did not require much experience of psychiatry to perceive that, in contrast to other neurotics, she described her symptoms too mildly—as we say, dissimulated them—and that she had never really overcome her belief in the anonymous letter.

Now what attitude does a psychiatrist take up to such a case? We know already what he would say to the symptomatic act of a patient who does not close the waiting-room doors. He explains it as an accident, without interest psychologically, and no concern of his. But he cannot continue to take up this attitude in regard to the case of the jealous lady. The symptomatic action appears to be unimportant; the symptom calls for notice as a grave matter. Subjectively it involves intense suffering, and objectively it threatens to break up a family; its claim to psychiatric interest is therefore indisputable. First the psychiatrist tries to characterize the symptom by some essential attribute. The idea with which this lady torments herself cannot be called nonsensical in itself; it does happen that elderly husbands contract relationships with young women. But there is something else about it that is nonsensical and incomprehensible. The patient has absolutely no grounds, except the anonymous letter, for supposing that her loving and faithful husband belongs to this category of men, otherwise not so uncommon. She knows that this communication carries no proof, she can explain its origin satisfactorily; she ought therefore to be able to say to herself that she has no grounds for her jealousy and she does even say so, but she suffers just as much as if she regarded her jealousy as well-founded. Ideas of this kind that are inaccessible to logic and the arguments of reality are unanimously described as _delusions_. The good lady suffers therefore, from a _delusion of jealousy_. That is evidently the essential characteristic of the case.

Having established this first point, our psychiatric interest increases. When a delusion cannot be dissipated by the facts of reality, it probably does not spring from reality. Where else then does it spring from? Delusions can have the most various contents; why is the content of it in this case jealousy? What kind of people have delusions, and particularly delusions of jealousy? Now we should like to listen to the psychiatrist, but he leaves us in the lurch here. He considers only one of our questions. He will examine the family history of this woman and will _perhaps_ bring us the answer that the kind of people who suffer from delusions are those in whose families similar or different disorders have occurred repeatedly. In other words, this lady has developed a delusion because she had an hereditary predisposition to do so. That is certainly something; but is it all that we want to know? Is it the sole cause of her disease? Does it satisfy us to assume that it is unimportant, arbitrary, or inexplicable that one kind of delusion should have been developed instead of another? And are we to understand the proposition—that the hereditary predisposition is decisive—also in a negative sense; that is, that no matter what experiences and emotions life had brought her she was destined some time or other to produce a delusion? You will want to know why scientific psychiatry gives no further explanation. And I reply: “Only a rogue gives more than he has.” The psychiatrist knows of no path leading to any further explanation in such a case. He has to content himself with a diagnosis and, in spite of wide experience, with a very uncertain prognosis of its future course.

Now can psycho-analysis do better than this? Yes, certainly I hope to show you that even in such an obscure case as this it is possible to discover something which makes closer comprehension possible. First, I shall ask you to notice this incomprehensible detail; that the anonymous letter on which her delusion is founded was positively provoked by the patient herself, by her saying to the scheming housemaid the day before that nothing could be more awful than to hear that her husband had an intrigue with a young woman. She first put the idea of sending the letter into the servant’s mind by this. So the delusion acquires a certain independence of the letter; it existed beforehand as a fear—or, as a wish?—in her mind. Besides this, the further small indications revealed in the bare two hours of analysis are noteworthy. The patient responded very coldly, it is true, to the request to tell me her further thoughts, ideas, and recollections, after she had finished her story. She declared that nothing came to her mind, she had told me everything; and after two hours the attempt had to be given up, because she announced that she felt quite well already and was certain that the morbid idea would not return. Her saying this was naturally due to resistance and to the fear of further analysis, In these two hours she had let fall some remarks, nevertheless, which made a certain interpretation not only possible but inevitable, and this interpretation threw a sharp light on the origin of the delusion of jealousy. There actually existed in her an infatuation for a young man, for the very son-in-law who had urged her to seek my assistance. Of this infatuation she herself knew nothing or only perhaps very little; in the circumstances of their relationship it was easily possible for it to disguise itself as harmless tenderness on her part. After what we have already learnt it is not difficult to see into the mind of this good woman and excellent mother. Such an infatuation, such a monstrous, impossible thing, could not come into her conscious mind; it persisted, nevertheless, and unconsciously exerted a heavy pressure. Something had to happen, some sort of relief had to be found; and the simplest alleviation lay in that mechanism of displacement which so regularly plays its part in the formation of delusional jealousy. If not merely she, old woman that she was, were in love with a young man, but if only her old husband too were in love with a young mistress, then her torturing conscience would be absolved from the infidelity. The phantasy of her husband’s infidelity was thus a cooling balm on her burning wound. Of her own love she never became conscious; but its reflection in the delusion, which brought such advantages, thus became compulsive, delusional and conscious. All arguments against it could naturally avail nothing; for they were directed only against the reflection, and not against the original to which its strength was due and which lay buried out of reach in the Unconscious.

Let us now piece together the results of this short, obstructed psycho-analytic attempt to understand this case. It is assumed of course that the information acquired was correct, a point which I cannot submit to your judgement here. First of all, the delusion is no longer senseless and incomprehensible; it is sensible, logically motivated, and has its place in connection with an affective experience of the patient’s. Secondly, it has arisen as a necessary reaction to another mental process which has itself been revealed by other indications; and it owes its delusional character, its quality of resisting real and logical objections, to this relation with this other mental process. It is something desired in itself, a kind of consolation. Thirdly, the fact that the delusion is one of jealousy and no other is unmistakably determined by the experience underlying the disease. You will also recognize the two important analogies with the symptomatic act we analysed; namely, the discovery of the sense or intention behind the symptom and the relation of it to something in the given situation which is unconscious.

This does not, of course, answer all the questions arising out of this case. On the contrary, it bristles with further problems, some of which have not yet proved soluble at all, while others cannot be solved owing to the unfavourable circumstances met with in this case. For instance, why does this happily-married lady fall in love with her son-in-law, and why does relief come to her in the form of this kind of reflection, this projection of her own state of mind on to her husband, when other forms of relief were also possible? Do not think that it is idle and uncalled-for to propound these questions. We have already a good deal of material at hand to provide possible answers. The patient had come to that critical time of life which brings a sudden and unwelcome increase of sexual desire to a woman; that may have been sufficient in itself. Or there may have been an additional reason, in that the sexual capacity of her excellent and faithful husband may have been for some years insufficient for the still vigorous woman’s needs. Observation has taught us that it is just such men, whose fidelity is thus a matter of course, who treat their wives with particular tenderness and are unusually considerate of their nervous ailments. Neither is it unimportant, moreover, that the object of this abnormal infatuation should be her daughter’s young husband. A strong erotic attachment to the daughter, with its roots in the individual sexual constitution of the mother, often manages to maintain itself in such a transformation. I may perhaps remind you in this connection that the relation between mother-in-law and son-in-law has from time immemorial been regarded by mankind as a particularly sensitive one, which among primitive races has given rise to very powerful taboos and precautions.[44] On the positive as well as on the negative side it frequently exceeds the limits regarded as desirable in civilized society. Of these three possible factors, whether one of them has been at work in the case before us, or two of them, or whether all three together have taken part, I cannot tell you; though only because the analysis of the case could not be continued beyond the second hour.

I perceive now that I have been speaking entirely of things which you were not yet prepared to understand. I did so in order to carry out the comparison between psychiatry and psycho-analysis. But I may ask you one thing at this point: Have you observed anything in the nature of a contradiction between the two? Psychiatry does not employ the technical methods of psycho-analysis, neglects any consideration of the content of the delusion, and in pointing to heredity gives us but a general and remote ætiology instead of first disclosing the more specific and immediate one. But is any contradiction or opposition contained in this? Is not the one rather a supplement to the other? Is the hereditary factor inconsistent with the importance of experience and would they not both work together most effectively? You will admit that there is nothing essential in the work of psychiatry which could oppose psycho-analytic researches. It is therefore the psychiatrists who oppose it, and not psychiatry itself. Psycho-Analysis stands to psychiatry more or less as histology does to anatomy; in one, the outer forms of organs are studied, in the other, the construction of these out of the tissues and constituent elements. It is not easy to conceive of any contradiction between these two fields of study, in which the work of the one is continued in the other. You know that nowadays anatomy is the basis of the scientific study of medicine; but time was when dissecting human corpses in order to discover the internal structure of the body was as much a matter for severe prohibition as practising psycho-analysis in order to discover the internal workings of the human mind seems to-day to be a matter for condemnation. And, presumably at a not too distant date, we shall have perceived that there can be no psychiatry which is scientifically radical without a thorough knowledge of the deep-seated unconscious processes in mental life.

There may be some of you who perhaps are friendly enough towards psycho-analysis, often attacked as it is, to wish that it would justify itself in another direction also, that is, therapeutically. You know that psychiatric therapy has hitherto been unable to influence delusions. Can psycho-analysis do so perhaps, by reason of its insight into the mechanism of these symptoms? No, I have to tell you that it cannot; for the present, at any rate, it is just as powerless as any other therapy to heal these sufferers. It is true that we can understand what has happened to the patient; but we have no means by which we can make him understand it himself. You have heard that I could not continue the analysis of this delusion beyond the first preliminaries. Would you then maintain that analysis of such cases is undesirable because it remains fruitless? I do not think so. It is our right, yes, and our duty, to pursue our researches without respect to the immediate gain effected. The day will come, where and when we know not, when every little piece of knowledge will be converted into power, and into therapeutic power. Even if psycho-analysis showed itself as unsuccessful with all other forms of nervous and mental diseases as with delusions, it would still remain justified as an irreplaceable instrument of scientific research. It is true that we should not be in a position to practise it; the human material on which we learn lives, and has its own will, and must have its own motives in order to participate in the work; and it would then refuse to do so. I will therefore close my lecture for to-day by telling you that there are large groups of nervous disturbances for which this conversion of our own advance in knowledge into therapeutic power has actually been carried out; and that with these diseases, otherwise so refractory, our measures yield, under certain conditions, results which give place to none in the domain of medical therapy.

SEVENTEENTH LECTURE THE MEANING OF SYMPTOMS

In the last lecture I explained to you that clinical psychiatry troubles itself little about the actual form of the individual symptom or the content of it; but that psycho-analysis has made this its starting-point, and has ascertained that the symptom itself has a meaning and is connected with experiences in the life of the patient. The meaning of neurotic symptoms was first discovered by J. Breuer in the study and successful cure of a case of hysteria (1880–82), which has since then become famous. It is true that P. Janet independently reached the same result; in fact, priority in publication must be granted to the French investigator, for Breuer did not publish his observations until more than a decade later (1893–95), during the period of our work together. Incidentally, it is of no great importance to us who made the discovery, for you know that every discovery is made more than once, and none is made all at once, nor is success meted out according to deserts. America is not called after Columbus. Before Breuer and Janet, the great psychiatrist Leuret expressed the opinion that even the delusions of the insane would prove to have some meaning, if only we knew how to translate them. I confess that for a long time I was willing to accord Janet very high recognition for his explanation of neurotic symptoms, because he regarded them as expressions of “_idées inconscientes_” possessing the patient’s mind. Since then, however, Janet has taken up an attitude of undue reserve, as if he meant to imply that the Unconscious had been nothing more to him than a manner of speaking, a makeshift, _une façon de parler_, and that he had nothing “real” in mind. Since then I have not understood Janet’s views, but I believe that he has gratuitously deprived himself of great credit.

Neurotic symptoms then, just like errors and dreams, have their meaning and, like these, are related to the life of the person in whom they appear. This is an important matter which I should like to demonstrate to you by some examples. I can merely assert, I cannot prove, that it is so in every case; anyone observing for himself will be convinced of it. For certain reasons though, I shall not take these examples from cases of hysteria, but from another very remarkable form of neurosis, closely allied in origin to the latter, about which I must say a few preliminary words. This, which we call _the obsessional neurosis_, is not so popular as the widely-known _hysteria_; it is, if I may so express myself, not so noisily ostentatious, behaves more as if it were a private affair of the patient’s, dispenses almost entirely with bodily manifestations and creates all its symptoms in the mental sphere. The obsessional neurosis and hysteria are the two forms of neurotic disease upon the study of which psycho-analysis was first built up, and in the treatment of which also our therapy celebrates its triumphs. In the obsessional neurosis, however, that mysterious leap from the mental to the physical is absent, and it has really become more intimately comprehensible and transparent to us through psycho-analytic research than hysteria; we have come to understand that it displays far more markedly certain extreme features of the neurotic constitution.

The obsessional neurosis[45] takes this form: the patient’s mind is occupied with thoughts that do not really interest him, he feels impulses which seem alien to him, and he is impelled to perform actions which not only afford him no pleasure but from which he is powerless to desist. The thoughts (obsessions) may be meaningless in themselves or only of no interest to the patient; they are often absolutely silly; in every case they are the starting-point of a strained concentration of thought which exhausts the patient and to which he yields most unwillingly. Against his will he has to worry and speculate as if it were a matter of life or death to him. The impulses which he perceives within him may seem to be of an equally childish and meaningless character; mostly, however, they consist of something terrifying, such as temptations to commit serious crimes, so that the patient not only repudiates them as alien, but flees from them in horror, and guards himself by prohibitions, precautions, and restrictions against the possibility of carrying them out. As a matter of fact he never, literally not even once, carries these impulses into effect; flight and precautions invariably win. What he does really commit are very harmless, certainly trivial acts—what are termed the obsessive actions—which are mostly repetitions and ceremonial elaborations of ordinary everyday performances, making these common necessary actions—going to bed, washing, dressing, going for walks, etc.—into highly laborious tasks of almost insuperable difficulty. The morbid ideas, impulses, and actions are not by any means combined in the same proportions in individual types and cases of the obsessional neurosis; on the contrary, the rule is that one or another of these manifestations dominates the picture and gives the disease its name; but what is common to all forms of it is unmistakable enough.