Part 24

Anyone of you who makes the necessary effort to look up this question will certainly be strongly impressed by the wealth of evidential material. But he will also meet with a difficulty. The meaning of a symptom lies, as we have seen, in its connection with the life of the patient. The more individually the symptom has been formed, the more clearly may we expect to establish this connection. Then the task resolves itself specifically into a discovery, for every nonsensical idea and every useless action, of the past situation in which the idea was justified and the action served a useful purpose. The obsessive act of the patient who ran to the table and rang for the maid is a perfect model of this kind of symptom. But symptoms of quite a different type are very frequently seen. They are what we call _typical_ symptoms of a disease, in each case they are practically identical, the individual differences in them vanish or at least fade away, so that it is difficult to connect them with the patient’s life or to relate them to special situations in his past. Let us consider the obsessional neurosis again. The second patient’s ceremonies preparatory to sleep are in many ways quite typical, although showing enough individual features as well to make an “historical” interpretation, so to speak, possible. But all obsessional patients are given to repetitions, to isolating certain of their actions and to rhythmic performances. Most of them wash too much. Those patients who suffer from agoraphobia (topophobia, fear of space), no longer reckoned as an obsessional neurosis but now classified as anxiety-hysteria, reproduce the same features of the pathological picture often with fatiguing monotony. They fear enclosed spaces, wide, open squares, long stretches of road, and avenues; they feel protected if accompanied, or if a vehicle drives behind them, and so on. Nevertheless, on this groundwork of similarity the various patients construct individual conditions of their own, moods, one might call them, which directly contrast with other cases. One fears narrow streets only, another wide streets only, one can walk only when few people are about, others only when surrounded with people. Similarly in hysteria, beside the wealth of individual features there are always plenty of common typical symptoms which appear to resist an easy interpretation on historical lines. Do not let us forget that it is these typical symptoms which enable us to take our bearings in forming a diagnosis. Supposing we do trace back a typical symptom in a case of hysteria to an experience or to a chain of similar experiences (for instance, an hysterical vomiting to a series of impressions of a disgusting nature), it will be confusing to discover in another case of vomiting an entirely dissimilar series of apparently causative experiences. It almost looks as though hysterical patients must vomit, for some unknown reason, and as though the historical factors revealed by analysis were but pretexts, seized upon by an inner necessity, when opportunity offered, to serve its purpose.

This brings us to the discouraging conclusion that although individual forms of neurotic symptoms can certainly be satisfactorily explained by their relation to the patient’s experiences, yet our science fails us for the far more frequent typical symptoms in the same cases. In addition to this, I have not nearly explained to you all the difficulties that arise during a resolute pursuit of the historical meaning of a symptom. Nor shall I do so; for although my intention is to conceal nothing from you and to gloss over nothing, I do not need to confuse you and stupefy you at the outset of our studies together. It is true that our understanding of symptom-interpretation has only just begun, but we will hold fast to the knowledge gained and proceed to overcome step by step the difficulties of the unknown. I will try to cheer you with the thought that it is hardly possible to presume a fundamental difference between the one kind of symptom and the other. If the individual form of symptom is so unmistakably connected with the patient’s experiences, it is possible that the typical symptom relates to an experience which is itself typical and common to all humanity. Other regularly recurring features of a neurosis, such as the repetition and doubt of the obsessional neurosis, may be universal reactions which the patient is compelled to exaggerate by the nature of the morbid change. In short, there is no reason to give up hastily in despair; let us see what more we can find out.

There is a very similar difficulty met with in the theory of dreams, one which I could not deal with in the course of our previous discussions of dreams. The manifest content of dreams is multifarious and highly differentiated individually, and we have shown exhaustively what can be obtained by analysis from this content. But there are also dreams which may in the same way be called _typical_ and occur in everybody, dreams with an identical content, which present the same difficulties to analysis. These are the dreams of falling, flying, floating, swimming, of being hindered, of being naked, and certain other anxiety-dreams; which yield first this, then that, interpretation, according to the person concerned, without any explanation of their monotonous and typical recurrence. But we notice that in these dreams also the common groundwork is embroidered with additions of an individually varying character. Most probably they too will prove to fit in with other knowledge about the dream-life, gained from a study of other kinds of dreams—not by any forcible twist, but by a gradual widening of our comprehension of these things.

EIGHTEENTH LECTURE FIXATION UPON TRAUMATA: THE UNCONSCIOUS

I said last time that we would take, as a starting-point for further work, the knowledge we have gained already, and not the doubts which it has roused in us. We have not yet even begun to discuss two of the most interesting conclusions arising from the analysis of the two examples.

First: both the patients give the impression that they are “_fixed_” to a particular point in their past, that they do not know how to release themselves from it, and are consequently alienated from both present and future. They are marooned in their illness, as it were; just as in former times people used to withdraw to the cloister to live out their unhappy fate there. In the case of the first patient, it was the marriage to the husband, which in reality had long ago come to an end, that had settled this doom upon her. Her symptoms enabled her to continue her relationship with him; we could perceive in them the voices which pleaded for him, excused him, exalted him, lamented his loss. Although she is young and could attract other men, she has seized upon every possible real and imaginary (magical) precaution that will preserve her fidelity to him. She will not meet strangers, she neglects her appearance; moreover, she cannot readily rise from any chair which she sits upon, and she refuses to sign her name and can give no presents, because no one must have anything which is hers.

With the second patient, the young girl, it is the erotic attachment to the father established in the years before puberty that plays this part in her life. She also has herself perceived that she cannot marry as long as she is so ill. We may suspect that she became so ill in order to be unable to marry and so to remain with her father.

We cannot avoid asking the question how, by what means, and impelled by what motives, anyone can take up such an extraordinary and unprofitable attitude towards life. Provided, that is, that this attitude is a universal character of neurosis and is not a special peculiarity of these two patients. As a matter of fact, this is so; it is a universal trait common to every neurosis, and one of great practical significance. Breuer’s first hysterical patient was _fixated_, in the same way, to the time when her father was seriously ill and she nursed him. In spite of her recovery, she has remained to some extent cut off from life since that time; for although she has remained healthy and active, she did not take up the normal career of a woman. In every one of our patients we learn through analysis that the symptoms and their effects have set the sufferer back into some past period of his life. In the majority of cases it is actually a very early phase of the life-history which has been thus selected, a period in childhood, even, absurd as it may sound, the period of existence as a suckling infant.

The closest analogy to this behaviour in our nervous patients is provided by the forms of illness recently made so common by the war—the so-called _traumatic neuroses_. Of course similar cases had occurred before the war, after railway accidents and other terrifying experiences involving danger to life. The traumatic neuroses are not fundamentally the same as those which occur spontaneously, which we investigate analytically and are accustomed to treat; neither have we been successful so far in correlating them with our views on other subjects; later on I hope to show you where this limitation lies. Yet there is a complete agreement between them on one point which may be emphasized. The traumatic neuroses demonstrate very clearly that a fixation to the moment of the traumatic occurrence lies at their root. These patients regularly reproduce the traumatic situation in their dreams; in cases showing attacks of an hysterical type in which analysis is possible, it appears that the attack constitutes a complete reproduction of this situation. It is as though these persons had not yet been able to deal adequately with the situation, as if this task were still actually before them unaccomplished. We take this attitude of theirs in all seriousness; it points the way to what we may call an _economic_ conception of the mental processes. The term ‘_traumatic_’ has actually no other meaning but this _economic_ one. An experience which we call traumatic is one which within a very short space of time subjects the mind to such a very high increase of stimulation that assimilation or elaboration of it can no longer be effected by normal means, so that lasting disturbances must result in the distribution of the available energy in the mind.

This analogy tempts us also to classify as traumatic those experiences to which our nervous patients seem to be fixated. In this way we should be provided with a simple condition for a neurotic illness; it would be comparable to a traumatic illness and would result from an incapacity to deal with an overpowering affective experience. Indeed, the first formula in which Breuer and I, in 1893–95, reduced our new observations to a theory was expressed very similarly. A case like that of the first patient described, the young woman separated from her husband, fits very well into this description; she had not been able to “get over” the impracticability of her marriage and was still attached to her trauma. But the second case of the young girl who was tied to her father shows us at once that the formula is not comprehensive enough. On the one hand, an infantile adoration of her father by a little girl is such a common experience and so frequently grown out of that the term ‘traumatic’ would lose all its meaning if applied to it; on the other hand, the history of the case shows that this first erotic fixation was gone through by the patient quite harmlessly at the time, to all appearances, and only several years later came to expression in the obsessional neurosis. So we see that there are complications ahead, a considerable variety and number of determining factors in neurosis; but we divine that the traumatic view will not necessarily be abandoned as false, and that it will fit in and have to be co-ordinated properly elsewhere.

Here again we must leave the path we have been following. At the moment it will take us no further, and we have much more to learn before we can find a satisfactory continuation of it. But before leaving the subject of fixation to traumata it should be noted that it is a phenomenon manifested extensively outside the neuroses; every neurosis contains such a fixation, but not every fixation leads to a neurosis, or is necessarily combined with a neurosis, or arises in the course of a neurosis. Grief is a prototype and perfect example of an affective fixation upon something that is past, and, like the neuroses, it also involves a state of complete alienation from the present and the future. But even the lay public distinguishes clearly between grief and neurosis. On the other hand, there are neuroses which may be described as morbid forms of grief.

It does also happen that persons may be brought to a complete standstill in life by a traumatic experience which has shaken the whole structure of their lives to the foundations, so that they give up all interest in the present and the future, and live permanently absorbed in their retrospections; but these unhappy persons do not necessarily become neurotic. Therefore this single feature must not be overestimated as a characteristic of neurosis, however invariable and significant it may be otherwise.

Now let us turn to the second conclusion to be drawn from our analyses; it is one upon which we shall not need to impose any subsequent limitation. With the first patient we have heard of the senseless obsessive act she performed and of the intimate memories she recalled in connection with it; we also considered the relation between the two, and deduced the purpose of the obsessive act from its connection with the memory. But there is one factor which we have entirely neglected, and yet it is one which deserves our fullest attention. As long as the patient continued this performance she did not know that it was in any way connected with the previous experience; the connection between the two things was hidden; she could quite truly answer that she did not know what impulse led her to do it. Then it happened suddenly that, under the influence of the treatment, she found this connection and was able to tell it. But even then she knew nothing of the purpose she had in performing the action, the purpose that was to correct a painful event of the past and to raise the husband she loved in her own estimation. It took a long time and much effort for her to grasp, and admit to me, that such a motive as this alone could have been the driving force behind the obsessive act.

The connection with the scene on the morning after the unhappy bridal-night, and the patient’s own tender feeling for her husband, together, make up what we have called the “meaning” of the obsessive act. But both sides of this meaning were hidden from her, she understood neither the _whence_ nor the _whither_ of her act, as long as she carried it on. Mental processes had been at work in her, therefore, of which the obsessive act was the effect; she was aware in a normal manner of their effect; but nothing of the mental antecedents of this effect had come to the knowledge of her consciousness. She was behaving exactly like a subject under hypnotism whom Bernheim had ordered to open an umbrella in the ward five minutes after he awoke, but who had no idea why he was doing it. This is the kind of occurrence we have in mind when we speak of the existence of _unconscious mental processes_; we may challenge anyone in the world to give a more correctly scientific explanation of this matter, and will then gladly withdraw our inference that unconscious mental processes exist. Until they do, however, we will adhere to this inference and, when anyone objects that in a scientific sense the Unconscious has no reality, that it is a mere makeshift, _une façon de parler_, we must resign ourselves with a shrug to rejecting his statement as incomprehensible. Something unreal, which can nevertheless produce something so real and palpable as an obsessive action!

In the second patient fundamentally the same thing is found. She has instituted a rule that the bolster must not touch the back of the bedstead, and she had to carry out this rule, but she does not know whence it comes, what it means, or to what it owes its strength. Whether she regards it indifferently, or struggles against it, or rages against it, or determines to overcome it, matters not; it will be followed. It must be followed; in vain she asks herself why. It is undeniable that these symptoms of the obsessional neurosis, these ideas and these impulses which arise no man knows where and which oppose such a powerful resistance against all the influences to which an otherwise normal mental life is susceptible, give the impression, even to the patients themselves, of being all-powerful visitants from another world, immortal beings mingling in the whirlpool of mortal things. In these symptoms lies the clearest indication of a special sphere of mental activity cut off from all the rest. They show the way unmistakably to conviction on the question of the unconscious in the mind; and for that very reason clinical psychiatry, which only recognizes a psychology of consciousness, can do nothing with these symptoms except to stigmatize them as signs of a special kind of degeneration. Naturally, the obsessive ideas and impulses are not themselves unconscious, any more than is the performance of the obsessive acts. They would not have become symptoms if they had not penetrated into consciousness. But the mental antecedents of them disclosed by analysis, the connections into which they fit after interpretation, are unconscious, at least until the time when we make the patient conscious of them by the work of the analysis.

Consider now, in addition, that the facts established in these two cases are confirmed in every symptom of every neurotic disease; that always and everywhere the meaning of the symptoms is unknown to the sufferer; that analysis invariably shows that these symptoms are derived from unconscious mental processes which can, however, under various favourable conditions, become conscious. You will then understand that we cannot dispense with the unconscious part of the mind in psycho-analysis, and that we are accustomed to deal with it as with something actual and tangible. Perhaps you will also be able to realize how unfitted all those who only know the Unconscious as a phrase, who have never analysed, never interpreted dreams, or translated neurotic symptoms into their meaning and intention, are to form an opinion on this matter. I will repeat the substance of it again in order to impress it upon you: The fact that it is possible to find meaning in neurotic symptoms by means of analytic interpretation is an irrefutable proof of the existence—or, if you prefer it, of the necessity for assuming the existence—of unconscious mental processes.

But that is not all. Thanks to a second discovery of Breuer’s, for which he alone deserves credit and which seems to me even more far-reaching in its significance than the first, more still has been learnt about the relation between the Unconscious and the symptoms of neurotics. Not merely is the meaning of the symptom invariably unconscious; there exists also a connection of a substitutive nature between the two; the existence of the symptom is only possible by reason of this unconscious activity. You will soon understand what I mean. With Breuer, I maintain the following: Every time we meet with a symptom we may conclude that definite unconscious activities which contain the meaning of the symptom are present in the patient’s mind. Conversely, this meaning must be unconscious before a symptom can arise from it. Symptoms are not produced by conscious processes; as soon as the unconscious processes involved are made conscious the symptom must vanish. You will perceive at once that here is an opening for therapy, a way by which symptoms can be made to disappear. It was by this means that Breuer actually achieved the recovery of his patient, that is, freed her from her symptoms; he found a method of bringing into her consciousness the unconscious processes which contained the meaning of her symptoms and the symptoms vanished.

This discovery of Breuer’s was not the result of any speculation but of a fortunate observation made possible by the co-operation of the patient. Now you must not rack your brains to try and understand this by seeking to compare it with something similar that is already familiar to you; but you must recognize in it a fundamentally new fact, by means of which much else becomes explicable. Allow me therefore to express it again to you in other words.

The symptom is formed as a substitute for something else which remains submerged. Certain mental processes would, under normal conditions, develop until the person became aware of them consciously. This has not happened; and, instead, the symptom has arisen out of these processes which have been interrupted and interfered with in some way and have had to remain unconscious. Thus something in the nature of an exchange has occurred; if we can succeed in reversing this process by our therapy we shall have performed our task of dispersing the symptom.

Breuer’s discovery still remains the foundation of psycho-analytic therapy. The proposition that symptoms vanish when their unconscious antecedents have been made conscious has been borne out by all subsequent research; although the most extraordinary and unexpected complications are met with in attempting to carry this proposition out in practice. Our therapy does its work by transforming something unconscious into something conscious, and only succeeds in its work in so far as it is able to effect this transformation.

Now for a rapid digression, lest you should run the risk of imagining that this therapeutic effect is achieved too easily. According to the conclusions we have reached so far, neurosis would be the result of a kind of ignorance, a not-knowing of mental processes which should be known. This would approach very closely to the well-known Socratic doctrine according to which even vice is the result of ignorance. Now it happens in analysis that an experienced practitioner can usually surmise very easily what those feelings are which have remained unconscious in each individual patient. It should not therefore be a matter of great difficulty to cure the patient by imparting this knowledge to him and so relieving his ignorance. At least, one side of the unconscious meaning of the symptom would be easily dealt with in this way, although it is true that the other side of it, the connection between the symptom and the previous experiences in the patient’s life, can hardly be divined thus; for the analyst does not know what the experiences have been, he has to wait till the patient remembers them and tells him. But one might find a substitute even for this in many cases. One might ask for information about his past life from the friends and relations; they are often in a position to know what events have been of a traumatic nature, perhaps they can even relate some of which the patient is ignorant because they took place at some very early period of childhood. By a combination of these two means it would seem that the pathogenic ignorance of the patients might be overcome in a short time without much trouble.