Vol. 2\1883-1895\Studies on Hysteria\Preliminary communic\Anna O.\ Frau Emmy Von N.\Miss Lucy R.\Kathrina\Frauline Elisabeth v\Breuer\ Affects\conversion\hypnoid states\Splitting of ego\Suggestion\ Cathretic method\Resistances\Transference\hypnosis\defense\
Preface to the Second Edition (p. xxi).
I) Pp. 4-8: Symptoms are described as ostensibly spontaneously idiopathic products and are strictly related to the precipating trauma. In other cases, however, the connection of experience to the relating trauma is not so clear and simple, but consists in a `symbolic` relationship between the original cause and the pathological idea. Thus, the authors find a connection between common hysteria and traumatic neuroses and, therefore, justify an extension of the above in the concept of `traumatic hysteria.` That is, the trauma caused by physical injury results with an affect of fright. In contrast, common hysteria develops from several partial traumas which form a group of provoking causes but in traumatic hysteria the physical trauma merely provokes the affect, releases the symptom and then lives on independent of it. Therefore, when each symptom is explained via the `cathartic` method it goes away.
II) Pp. 8-11: The fading of a memory or the loss of an affect is dependent upon:
`It may therefore be said that the ideas which have become pathological have persisted with such freshness and affective strength because they have been denied the normal wearing -away processes by means of abreaction and reproduction an states of uninhibited association.`
III) Pp. 11-13: `Splitting` is present in a rudimentary degree in every case of hysteria, and to the dissociation is attributed the basic phenomenon of this type of neurosis.
IV) Pp. 13-17: The four phases of hysteria are enumerated:
The proffered explanation begins at the third stage (hallucination of memory) and the treatment begins from this point (often artificially through hypnosis).
V) Pp. 17-21: The psychotherapeutic technique works via bringing to an end the operative force of the idea, which was not `abreacted` in the first place, by allowing the strangulated affect to find its way out via speech. The technique then subjects the affect to associative correction by introducing it into normal consciousness or by removing it through the physician's suggestion.
I) Case 1: Anna O. (Breuer) p. 22.
II) Case 2: Frau Emmy von N. (Freud) p. 48.
III) Case 3: Miss Lucy R. (Freud) p. 106. Here Freud exposes his frustration with hypnosis, i.e., he was incapable of causing several patients to enter the hypnotic state. Thus he began what was later be become the psychoanalytic technique, the `talking cure.` He instilled what he was later to refer to as the `fundamental rule` of psycho-analysis, that is, he insisted upon both complete honesty and utter compliance in telling the therapist anything that came to the patients` minds no matter how absurd or unlikely. He also indicates the necessity, on the part of the physician, of insistence that there is something to be brought out -- thus Freud alludes to the possibility of resistance's to therapeutic work.(108-111)
Theoretically, Freud notes that the essential condition for hysteria is the 1) intentional repression of an idea from the consciousness and that it be excluded from associative modification. 2) That repression is also the basis of the conversion of the sum of excitation, which can easily find its way along a `wrong` path to a somatic innervation. And, 3) the basis of repression can only be a feeling of unpleasure, the incompatibility of the singular idea repressed and the dominant mass of ideas that make up the ego, but repression is said to `take revenge` by becoming pathological.(116)
Case 4: Kathrina (Freud) p. 125ff:
Case 5: Fraüline Elisabeth von R. (Freud) p. 135ff: In terms of repression, Freud writes:
"The incompatible idea, which, together with its concomitants, are later excluded and forms a separate psychical group must originally have been in communication with the mainstream of thought. Otherwise the conflict which led to their exclusion could not have taken place. It is these moments, then, that are to be described as `traumatic`; it is at the moments that conversion takes place, of which the results are the splitting of consciousness and the hysterical symptom."(167)
1) ARE ALL HYSTERICAL PHENOMENA IDEOGENIC? Breuer is of the opinion that only part of hysteric phenomena are ideogenic. For instance, in terms of hysteric pain as being hallucinatory, Breuer indicates that ideas without any excitations of the perceptual apparatus, never, even at their greatest vividness and intensity, attain the character of objective existence which is the mark of hallucinations. it is precisely because only some of the phenomena of hysteria are ideogenic, the discovery of their psychical origin constitutes the most important step in the theory of the discovery.(186-9)
2) INTRACEREBRAL TONIC EXCITATIONS -- AFFECTS
3) HYSTERICAL CONVERSION (203) Failure to convert energy depends on:
Excessively strong excitations may by-pass\break through the usual coordinated centres and flow off in primitive movements (without one's control over it) and this is said to be characteristic of hysteria and is distinguishable because it receives the initial affect. The completion of hysterical conversion is dependent upon the abnormal reflex becoming facilitated by frequent repetition, draining away the operative force of the affect and thus emerges as a minimum force or not at all.(205) This process is completed when the "original intracerebral excitation belonging to the affect has been transferred into the excitatory process in the peripheral paths." I.e., what was originally an affective idea no longer provokes the affect but only the abnormal reflex(207) as determined by the "principle of least resistance" and is sometimes determined by symbolism.(208-9)
A normal response to such excitations is considered to be speech, i.e., "telling things is a relief; it discharges tension..."(211) and if denied release by speech it is sometimes converted into somatic phenomena.
4) HYPNOID STATES (214FF): This frame of mind is said to be necessary for hysteria in that it corresponds to a vacancy of consciousness so that there is no resistance and amnesia and its power to affect `splitting` is most important and is a fundamental sign for `major hysteria`.(216) Hypnoid states include:
"Hysterics suffer mainly from reminiscences" -- if this is so then the memory of psychical trauma must be regarded as operating as a contemporary agent and, if, nevertheless, the patient has no consciousness of such memories or their emergence "then we must admit that unconscious ideas exist and are operative." We must also recognize that large complexes of ideas and involved psychical processes with important consequences remain completely unconscious in a number of patients and co-exist with conscious life. Therefore we must recognize splitting of mental activity and this is of fundamental value for understanding hysterics.(221)
5) UNCONSCIOUS IDEAS AND IDEAS INADMISIBLE TO CONSCIOUSNESS-- SPLITTING OF MIND (222FF): As a rule, the intensity of an unconscious idea increases as it enters consciousness, ipso facto.(223) Breuer suggests that the existence of pathological ideas indicates something pathological: "In normal people all ideas that can become current at all enter consciousness as well if they are sufficiently intense....the field of ideational psychical activity does not coincide with potential consciousness. The latter is more restricted than the former."(225)
Thus, splitting of consciousness occurs via a splitting of the mind, i.e., there is consciousness and unconsciousness and there are ideas that are admissible and inadmissible to the conscious.(225)
The central aspect of hysteria is a splitting off of a part of psychical activity (consciousness). The split-off part of the mind is said to be "thrust into darkness"; the phenomenon of `double consciousness` occurs when the two halves alternate and when they do not differ in their functional capability. Thus Breuer and Freud`s view point is in contradistinction to that of Janet (splitting as a result of `weak-mindedness`) because the patient's mental activity is seen as divided and that only a part of its capacity is at the disposal of their conscious thought.(227-31)
Comparable to the case of `normal` people, splitting can be characterized as being similar to a `preoccupation of the mind.` Thus splitting is considered to be a normal mental activity, but what makes it pathological is the amnesia that accompanies it (see: Anna O.). (232-4)
The discovery of the phenomena of splitting in hysteria has taught that:
In terms of suggestibility and splitting, we have learned the following:
6) INNATE DISPOSITION - DEVELOPMENT OF HYSTERIA:
I) Hysterics are characterized as being intellectual, hyper- active, hate boredom, and crave sensations -- i.e., their body, says Breuer, produces excessive excitations that may cause the splitting via amnesia that begins the hysteria.(240-42) Breuer continues to suggest that a the onset of puberty, excessive hormonal activities add to the already high level of excitement and can send previously normal children into hysterics. (243)
II) Breuer states that the sexual needs of hysterical patients are probably just as variable in degree from individual to individual and are no stronger in them than in normal people; but hysterics fall ill from them precisely owing to the struggle against them -- that is, because of their defense against sexuality.(247)
III) The third constitute of the hysterical disposition is the hypnoid state. (249)
Here Freud reviews the methods, techniques and the problems of other than his own. Freud reminds the reader that hysterical symptoms disappear when the events to which they are related are brought into conscious memory; thus, he continues, the talking cure works brings into operation the force of the idea which had not been abreacted in the first case, by allowing it to find its way out through speech and subjecting it to associative correction through its introduction to normal consciousness or by removing the symptom via suggestion.
1:(256FF)------------- The Problems in Breuer`s method are reviewed:
Soon, however, Freud learned that it was inappropriate to call all neuroses that contained some or several hysterical symptoms "hysteria." The reason for this change of mind was that it became obvious that aetiological factors are so often intertwined -- either by chance or by causal reasons.(258) After this change of heart, Freud learned that the occurrence of `pure hysteria` was more and more rare.(260)
Freud makes some statements upon the cathartic method (262-7):
Difficulties and disadvantages of the cathartic method:
2) (267-282)----------Freud begins this section by referring to the problems of hypnosis and then follows with several comments of the through which he by- passed these problems. Because of the need to overcome the patient's unconscious resistances of pathological material becoming conscious, Freud turned to non stopping questioning as a method. During the work, he came upon the notion that such pathological ideas must be related to or play a part in the generation of the hysterical symptom. Thus Freud realized several of what he calls `universal characteristics` of pathological ideas. These characteristics are as follows:(269)
From these notions Freud came across the conception of DEFENSE, i.e., censorship, related to the associative ideas already in the ego. Thus, when Freud directs his patients to approach pathological ideas, he became aware of the resistance as being some kind of a force that caused the initial repulsion when the symptom was originally generated. Therefore he came to the conclusion that an idea becomes pathogenic as a result of the expulsion and repression of said idea. Thus he noted there is an aversion on the part of the ego which drives such ideas from consciousness and opposes its return and (270) it became a question of hysterics "not wanting to know" opposed to "not knowing."
Freud goes on to speak further about resistances. For instance, he comments that resistances always are dependent upon a question of quantity. He also comments on his original means of trying to deal with resistances in the therapeutic situation. Initially, he placed his hand on the head of the patient when it was clear that his insistence that the patient knew the answer was not sufficient.(271)
This operated by causing the patient to concentrate on something other than the issue at hand. That is, it dissociated the patient's attention from conscious searching and reflection. This technique worked for the reason that pathogenic ideas which have been repressed always lie `close at hand` and can be reached by associations which are easily accessible. Thus, in most cases the ideas that resulted from this technique are ones that are a link in a chain which are closer to the pathological idea being investigated. Examples are illustrated on page 273.
However, Freud notes that the pressure technique is not much else but a temporary means of tricking the ego and therefore is ultimately unsatisfactory in serious cases.(278) There are several forms of resistance to this method which include the following: 1) if the pressure technique fails on the first or second attempt, the result is that the patient feels disappointed as he had expected too much; and, 2) the patient, as often is the case, finds all kinds of excuses to maintain his defenses.(279)
When the pathological idea is recognized by the patient, as well as others, the recollection is often described as unimportant and nevertheless only utters it under resistance. In the overcoming of resistances one must remember that: (282)
Memories as visual images: on this topic Freud writes: "When memories return in the form of pictures our task is in general easier than when they return as thoughts. Hysterical patients, who are as a rule of a `visual` type, do not make such difficulties for the analyst as those with obsessions." Freud also notes that the patient often attempts to get rid of the image by turning it into words, i.e., that it becomes fragmented and obscure in proportion.(280)
3) (283-end)-------(283-85) Freud once more gives voice to his skepticism of hypnotherapy.
Hysterics is said to originate through the repression of incompatible idea by a motive of defense, i.e., the repressed idea persists as a weak memory trace, while the affect that was attached to it is torn away and would be used fro a somatic innervation. (see: `conversion` 108-111, 183ff.)
Freudout lines several of his impressions of pathogenic psychical material.
Freud then notes, not unimportantly, that this picture of pathogenic organization is a useless starting point for therapy because it is meaningless to the patient and in fact resolves nothing.(292) Also a direct approach to the nucleus serves less purpose, thus it is necessary to start from the outside and to work ones way into the nucleus. Freud describe this activity as chiseling away at the resistances and that often as they begin to break away, they begin to work with the therapist and not against.
There are two problem that the therapist must account for in the patient at this time as follows:
Thus, one must grab hold of the logical thread and follow it into the interior of the nucleus. If one examines the ides of the patient with a critical eye, he/she may soon notice the gaps and void present (especially in terms of `stuff` gotten into with out much resistance). Thus the doctor would be correct in looking behind such weak spots to find where the logical thread has twisted or broken off. If it seems that the thread goes no further, one must pay attention to the patient's reactions (body language -- facial) or start with another thread. After doing this several times and once the strata has been penetrated far enough, one clean thrust into the nucleus should what is necessary to complete the therapy.(293-95)
"We are not in a position to force anything on the patient about the things of which he is ostensibly ignorant or to influence the products of the analysis by arousing an expectation."(295)
Every spontaneous reaction in analysis has a significance: "An intrusion of irrelevant mnemic images (which happens in some way or other to be associated with the important ones) in fact never happens."
(296) Thoughts or pictures which do not go away must be further explored.
A recollection never reoccurs once its been properly "talked away" and if it does we can assume it is accompanied with a second set of associated ideas with new implications that have not been completely dealt with.
Symptoms take on form during analysis as one approaches the "region of pathogenic organization which contains the symptom's aetiology" and they become stronger the closer the patient comes to uttering the memory -- i.e., the resistance is also a symptom.
Once the patient is gripped by the therapy his general condition becomes more and more dependent upon the state of the work, i.e., each milestone passed is a relief to the patient.
Problems are caused when the patient's relationship with the doctor are disturbed -- i.e., the pressure technique fails consistently. There are three instances of this happening, which are as follows: