¹
The possibility of a therapeutic procedure
of this kind has been clearly recognized by Delboeuf and Binet, as
is shown by the following quotations: 'On s’expliquerait
dès lors comment le magnétiseur aide à la
guérison. Il remet le sujet dans l’état
où le mal s’est manifesté et combat par la
parole le même mal, mais renaissant.’ [‘We can
now explain how the hypnotist promotes cure. He puts the subject
back into the state in which his trouble first appeared and uses
words to combat that trouble, as it now makes a fresh
emergence.’] (Delboeuf 1889.) -
‘. . . peut-être verra-t-on qu’en
reportant le malade par un artifice mental au moment même
où le symptôme a apparu pour la première fois,
on rend ce malade plus docile à une suggestion
curative.’ [‘. . . we shall perhaps find
that by taking the patient back by mean of a mental artifice to the
very moment at which the symptom first appeared, we may make him
more susceptible to a therapeutic suggestion.’] (Binet, 1892,
243.) - In Janet’s interesting study on mental automatism
(1889), there is an account of the cure of a hysterical girl by a
method analogous to ours.
Studies On Hysteria
10
It is plausible to suppose that
it is a question here of unconscious suggestion: the patient
expects to be relieved of his sufferings by this procedure, and it
is this expectation, and not the verbal utterance, which is the
operative factor. This, however, is not so. The first case of this
kind that came under observation dates back to the year 1881, that
is to say to the ‘pre-suggestion’ era. A highly
complicated case of hysteria was analysed in this way, and the
symptoms, which sprang from separate causes, were separately
removed. This observation was made possible by spontaneous
auto-hypnoses on the part of the patient, and came as a great
surprise to the observer.
We may reverse the dictum
‘
cessante causa cessat effectus
s’ [‘when
the cause ceases the effect ceases’] and conclude from these
observations that the determining process continues to operate in
some way or other for years - not indirectly, through a chain of
intermediate causal links, but as a
directly
releasing cause
just as a psychical pain that is remembered in waking consciousness
still provokes a lachrymal secretion long after the
event.
Hysterics suffer mainly from reminiscences.
¹
¹
In this preliminary communication it is not
possible for us to distinguish what is new in it from what has been
said by other authors such as Moebius and Strümpell who have
held similar views on hysteria to ours. We have found the nearest
approach to what we have to say on the theoretical and therapeutic
sides of the question in some remarks, published from time to time,
by Benedikt. These we shall deal with elsewhere.
Studies On Hysteria
11
II
At first sight it seems
extraordinary that events experienced so long ago should continue
to operate so intensely - that their recollection should not be
liable to the wearing away process to which, after all, we see all
our memories succumb. The following considerations may perhaps make
this a little more intelligible.
The fading of a memory or the
losing of its affect depends on various factors. The most important
of these is
whether there has been an energetic reaction to the
event that provokes the affect
. By ‘reaction’ we
here understand the whole class of voluntary and involuntary
reflexes - from tears to acts of revenge - in which, as experience
shows us, the affects are discharged. If this reaction takes place
to a sufficient amount a large part of the affect disappears as a
result. Linguistic usage bears witness to this fact of daily
observation by such phrases as ‘to cry oneself out’
[‘
sich ausweinen
’], and to ‘blow off
steam’ [‘
sich austoben
’, literally
‘to rage oneself out’]. If the reaction is suppressed,
the affect remains attached to the memory. An injury that has been
repaid, even if only in words, is recollected quite differently
from one that has had to be accepted. Language recognizes this
distinction, too, in its mental and physical consequences; it very
characteristically describes an injury that has been suffered in
silence as ‘a mortification’
[‘
Kränkung
’, literally ‘making
ill’]. - The injured person’s reaction to the trauma
only exercises a completely ‘cathartic’ effect if it is
an
adequate
reaction - as, for instance, revenge. But
language serves as a substitute for action; by its help, an affect
can be ‘abreacted’ almost as effectively. In other
cases speaking is itself the adequate reflex, when, for instance,
it is a lamentation or giving utterance to a tormenting secret,
e.g. a confession. If there is no such reaction, whether in deeds
or words, or in the mildest cases in tears, any recollection of the
event retains its affective tone to begin with.
Studies On Hysteria
12
'Abreaction’, however,
is not the only method of dealing with the situation that is open
to a normal person who has experienced a psychical trauma. A memory
of such a trauma, even if it has not been abreacted, enters the
great complex of associations, it comes alongside other
experiences, which may contradict it, and is subjected to
rectification by other ideas. After an accident, for instance, the
memory of the danger and the (mitigated) repetition of the fright
becomes associated with the memory of what happened afterwards -
rescue and the consciousness of present safety. Again, a
person’s memory of a humiliation is corrected by his putting
the facts right, by considering his own worth, etc. In this way a
normal person is able to bring about the disappearance of the
accompanying affect through the process of association.
To this we must add the general
effacement of impressions, the fading of memories which we name
‘forgetting’ and which wears away those ideas in
particular that are no longer affectively operative.
Our observations have shown, on
the other hand, that the memories which have become the
determinants of hysterical phenomena persist for a long time with
astonishing freshness and with the whole of their affective
colouring. We must, however, mention another remarkable fact, which
we shall later be able to turn to account, namely, that these
memories, unlike other memories of their past lives, are not at the
patients’ disposal. On the contrary,
these experiences are
completely absent from the patient’s memory when they are in
a normal psychical state, or are only present in highly summary
form
. Not until they have been questioned under hypnosis do
these memories emerge with the undiminished vividness of a recent
event.
Thus, for six whole months, one
of our patients reproduced under hypnosis with hallucinatory
vividness everything that had excited her on the same day of the
previous year (during an attack of acute hysteria). A diary kept by
her mother with out her knowledge proved the completeness of the
reproduction. Another patient, partly under hypnosis and partly
during spontaneous attacks, re-lived with hallucinatory clarity all
the events of a hysterical psychosis which she had passed through
ten years earlier and which she had for the most part forgotten
till the moment at which it re-emerged. Moreover, certain memories
of aetiological importance which dated back from fifteen to
twenty-five years were found to be astonishingly intact and to
possess remarkable sensory force, and when they returned they acted
with all the affective strength of new experiences.
Studies On Hysteria
13
This can only be explained on the
view that these memories constitute an exception in their relation
to all the wearing-away processes which we have discussed above.
It appears, that is to say, that these memories correspond to
traumas that have not been sufficiently abreacted
; and if we
enter more closely into the reasons which have prevented this, we
find at least two sets of conditions under which the reaction to
the trauma fails to occur.
In the first group are those
cases in which the patients have not reacted to a psychical trauma
because the nature of the trauma excluded a reaction, as in the
case of the apparently irreparable loss of a loved person or
because social circumstance made a reaction impossible or because
it was a question of things which the patient wished to forget, and
therefore intentionally repressed from his conscious thought and
inhibited and suppressed. It is precisely distressing things of
this kind that, under hypnosis, we find are the basis of hysterical
phenomena (e.g. hysterical deliria in saints and nuns, continent
women and well-brought-up children).
The second group of conditions
are determined, not by the content of the memories but by the
psychical states in which the patient received the experiences in
question. For we find, under hypnosis, among the causes of
hysterical symptoms ideas which are not in themselves significant,
but whose persistence is due to the fact that they originated
during the prevalence of severely paralysing affects, such as
fright, or during positively abnormal psychical states, such as the
semi-hypnotic twilight state of day-dreaming, auto-hypnoses, and so
on. In such cases it is the nature of the states which makes a
reaction to the event impossible.
Both kinds of conditions may, of
course, be simultaneously present, and this, in fact, often occurs.
It is so when a trauma which is operative in itself takes place
while a severely paralysing affect prevails or during a modified
state of consciousness. But it also seems to be true that in many
people a psychical trauma
produces
one of these abnormal
states, which, in turn, makes reaction impossible.
Both of these groups of
conditions, however, have in common the fact that the psychical
traumas which have not been disposed of by reaction cannot be
disposed of either by being worked over by means of association. In
the first group the patient is determined to forget the distressing
experiences and accordingly excludes them so far as possible from
association; while in the second group the associative working-over
fails to occur because there is no extensive associative connection
between the normal state of consciousness and the pathological ones
in which the ideas made their appearance. We shall have occasion
immediately to enter further into this matter.
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 process by means of abreaction and reproduction
in states of uninhibited association
.
Studies On Hysteria
14
III
We have stated the conditions
which, as our experience shows, are responsible for the development
of hysterical phenomena from psychical traumas. In so doing, we
have already been obliged to speak of abnormal states of
consciousness in which these pathogenic ideas arise, and to
emphasize the fact that the recollection of the operative psychical
trauma is not to be found in the patient’s normal memory but
in his memory when he is hypnotized. The longer we have been
occupied with these phenomena the more we have become convinced
that
the splitting of consciousness which is so striking in the
well-known classical cases under the form of
‘double
conscience’
is present to a rudimentary degree in every
hysteria, and that a tendency to such dissociation, and with it the
emergence of abnormal states of consciousness (which we shall bring
together under the term ‘hypnoid’) is the basic
phenomenon of this neurosis
. In these views we concur with
Binet and the two Janets, though we have had no experience of the
remarkable findings they have made on anaesthetic patients.
We should like to balance the
familiar thesis that hypnosis is an artificial hysteria by another
- the basis and
sine qua non
of hysteria is the existence of
hypnoid states. These states share with one another and with
hypnosis, however much they may differ in other respects, one
common feature: the ideas which emerge in them are very intense but
are cut off from associative communication with the rest of the
content of consciousness. Associations may take place between these
hypnoid states, and their ideational content can in this way reach
a more or less high degree of psychical organization. Moreover, the
nature of these states and the extent to which they are cut off
from the remaining conscious processes must be supposed to vary
just as happens in hypnosis, which ranges from a light drowsiness
to somnambulism, from complete recollection to total amnesia.
If hypnoid states of this kind
are already present before the onset of the manifest illness, they
provide the soil in which the affect plants the pathogenic memory
with its consequent somatic phenomena. This corresponds to
dispositional
hysteria. We have found, however, that a
severe trauma (such as occurs in a traumatic neurosis) or a
laborious suppression (as of a sexual affect, for instance) can
bring about a splitting-off of groups of ideas even in people who
are in other respects unaffected; and this would be the mechanism
of
psychically acquired
hysteria. Between the extremes of
these two forms we must assume the existence of a series of cases
within which the liability to dissociation in the subject and the
affective magnitude of the trauma vary inversely.