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CHAPTER IV

THE PSYCHOTHERAPY OF HYSTERIA

By DR. SIGMUND FREUD

In our “Preliminary Communication” we have stated that
while investigating the etiology of hysterical symptoms, we have
also discovered a therapeutic method which we consider of practical
significance. “We found, at first to our greatest surprise, that the
individual hysterical symptoms immediately disappeared without
returning if we succeeded in thoroughly awakening the memories of
the causal process with its accompanying affect, and if the patient
circumstantially discussed the process in the most detailed manner
and gave verbal expression to the affect” (p. 3).

We furthermore attempted to explain how our psychotherapeutic
method acts: “It abrogates the efficacy of the original non-abreacted
ideas by affording an outlet to their strangled affects through
speech. It brings them to associative correction by drawing them into
normal consciousness (in mild hypnosis) or by eliminating them
through medical suggestion in the same way as in somnambulism with
amnesia” (p. 12).

Although the essential features of this method have been
enumerated in the preceding pages, a repetition is unavoidable, and
I shall now attempt to show connectedly how far-reaching this method
is, its superiority over others, its technique, and its difficulties.

I

I, for my part, may state that I can firmly adhere to the “Pre-
liminary Communication,” but I must confess that in the years that
have elapsed since then, and after continuous occupation with the
problems touched on there, new viewpoints obtruded themselves on
me, as a result of which the former material underwent at least a
partial change in grouping and conception. It would be unjust to
impute too much of the responsibility for this development to my
honored friend, J. Breuer. The responsibility for the following
elucidations, therefore, rests preponderately upon me.

In attempting to use Breuer’s method for treating hysterical

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symptoms in a great number of patients by investigation and abre-
action in hypnosis, I encountered two obstacles, the pursuit of which
led me to change the technique, as well as the conception. (1) Not
all persons were hypnotizable who undoubtedly showed hysterical
symptoms, and in whom there most probably existed the same psychic
mechanism. (2) I had to take an attitude towards the question of
what essentially characterizes hysteria, and in what it differs from
other neuroses.

How I overcame the first difficulty, and what it taught me, I will
show later. I will first state what position I have taken in my daily
practice towards the second problem. It is very difficult to examine
a case of neurosis before it has been subjected to a thorough analysis,
such as would result only through the application of Breuer’s
method. But before we have such a thorough knowledge we are
obliged to decide upon the diagnosis and kind of treatment. Hence
the only thing left to me was to select such cases for the cathartic
method which could, for the time being, be diagnosed as hysteria, and
which showed some or many stigmata, or the characteristic symptoms
of hysteria. Yet, it sometimes happened that in spite of the diagnosis
of hysteria, the therapeutic results were very poor, and even the
analysis revealed nothing of importance. At other times I attempted
to treat cases by Breuer’s method, which no one took for hysteria, and
I found that I could influence them, and even cure them. Such, for
example, was my experience with obsessions, the real obsessions of
Westphal’s type, in cases which did not show a single feature of
hysteria. Thus, the psychic mechanism revealed in the “Preliminary
Communication” could not, therefore, be pathognomonic of hysteria.
Nor could I, for the sake of this mechanism, throw so many neuroses
into the same pot with hysteria. Out of all the instigated doubts I
finally seized upon a plan to treat all the other neuroses in question
just like hysteria, to investigate the etiology and the form of psychic
mechanisms, and to leave the decision for the justification of the
diagnosis of hysteria to the outcome of this investigation.

It thus happened, that proceeding from Breuer’s methods I occu-
pied myself mostly with the etiology and the mechanism of the
neuroses. After a relatively brief period I was fortunate in obtaining
useful results. First, I became impressed with the cognition that if
one may speak of a causation through which neuroses would be
acquired, that the etiology must be sought in sexual factors. This
agrees with the findings that, generally speaking, various sexual

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factors may also produce various pictures of neurotic diseases. And
depending on the amount of confirmation of the latter relation, one
could now also venture to utilize the etiology for the characteristics
of the neuroses, and build up a sharp line of demarcation between
the morbid pictures of the neuroses. If the etiological characters
constantly agreed with the clinical, then this was really justified.

In this way it was found that neurasthenia really corresponds to
a monotonous morbid picture in which, as shown by analysis,
“psychic mechanisms” play no part. From neurasthenia we sharply
distinguished the compulsion neurosis (obsessions, doubts, impulses),
the neurosis of genuine obsessions, in which we can recognize a
complicated psychic mechanism, an etiology resembling the one of
hysteria, and a far-reaching possibility of its reduction by psycho-
therapy. On the other hand, it seemed to me absolutely imperative
to separate from neurasthenia a neurotic symptom complex which
depends on a totally divergent, indeed, strictly speaking, on a contrary
etiology, the partial symptoms of this complex have already been
recognized by E. Hecker ¹⁾ as having a common character. They are
either symptoms, or equivalents, or rudiments of anxiety manifesta-
tions, and it is for that reason that in order to distinguish this com-
plex from neurasthenia, that I have called it anxiety neurosis. I
maintained that it originates from an accumulation of physical tension,
which is in turn of sexual origin. This neurosis, too, has no psychic
mechanism, but regularly influences the psychic life, so that among its
regular manifestations we have “anxious expectation,” phobias,
hyperesthesias to pain, and other symptoms. This anxiety neurosis,
as I take it, certainly corresponds in part to the neurosis called “hypo-
chondria,” which in some features resembles hysteria and neuras-
thenia. Yet, I cannot consider the demarcation of this neurosis in
the existing works as correct, and moreover, I find that the useful-
ness of the name hypochondria is impaired by its close relation to
the symptom of “nosophobia.”

After I had thus constructed for myself the simple picture of
neurasthenia, anxiety neuroses, and obsessions, I turned my attention
to the commonly occurring cases of neuroses which enter into con-
sideration in the diagnosis of hysteria. I now had to say to myself
that it would not do to mark a neurosis as a whole hysterical, merely
because its symptom complex evinced some hysterical features. I
could readily explain this practice by the fact that hysteria is the

¹⁾E. Hecker: Centralblatt für Nervenheilkunde, December, 1893.

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oldest, the most familiar, and the most striking neurosis under con-
sideration, but it was an abuse none-the-less to put so many char-
acteristics of perversion and degeneration under the caption of
hysteria. Whenever an hysterical symptom, such as anesthesia or a
characteristic attack, could be discovered in a complicated case of
psychic degeneration, the whole thing was called “hysteria,” and
hence, one could naturally find united under this same trade mark
the worst and most contradictory features. As certain as this diag-
nosis was incorrect, it is also certain that our classification must be
made on neurotic lines, and as we knew neurasthenia, anxiety
neurosis, and similar conditions in the pure state, there was no need
of overlooking them in combination.

It seemed, therefore, that the following conception was more
warrantable: The neuroses usually occurring, are generally to be
designated as “mixed.” Neurasthenia and anxiety neurosis can be
found without effort in pure forms, and most frequently in young
persons. Pure cases of hysteria and compulsion neurosis are rare,
they are usually combined with an anxiety neurosis. This frequent
occurrence of mixed neuroses is due to the fact that their etiological
factors are frequently mixed, now only accidentally, and now in
consequence of a causal relation between the processes which give
rise to the etiological factors of the neuroses. This can be sustained
and proven in the individual cases without any difficulty. But it
follows from this that for the purpose of examination it is hardly
possible to take hysteria out of its association with the sexual
neuroses, that hysteria, as a rule, presents only one side, one aspect
of the complicated neurotic case, and that only, as it were, in the
borderline case can it be found and treated as an isolated neurosis.
In a series of cases we can perhaps say a potiori fit denominatio.

I shall now examine the cases reported to see whether they speak
in favor of my view of the clinical dependence of hysteria. Breuer’s
patient, Anna O., seems to contradict this and exemplifies a pure
hysterical disease. Yet, this case, which became so fruitful for the
knowledge of hysteria, was never considered by its observer under
the guise of a sexual neurosis and hence, cannot at present be utilized
as such. When I began to analyze the second patient, Mrs. Emmy
v. N., the idea of a sexual neurosis on an hysterical basis was far
from my mind. I had just returned from the Charcot school, and
considered the connection of hysteria with the sexual theme as a sort
of insult—just as my patients were wont to do. But when I now

194

review my notes on this case, there is absolutely no doubt that I have
to consider it as a severe case of anxiety neurosis with anxious
expectations and phobias, due to sexual abstinence, which was com-
bined with hysteria.

The third case, Miss Lucy R., could perhaps more than any other
be called a borderline case of pure hysteria. It is a short episodic
hysteria based on an unmistakably sexual etiology, which would
correspond to an anxiety neurosis in an over-ripe, amorous girl,
whose love was too rapidly awakened through a misunderstanding.
Yet, the anxiety neurosis could either not be demonstrated or had
escaped me. Case IV, Katharina, is really a model of what I have
called virginal anxiety; it is a combination of an anxiety neurosis
and hysteria, the former creates the symptoms, while the latter repeats
them and works with them. At all events, it is a typical case of many
juvenile neuroses called “hysteria.” Case V, Miss Elisabeth v. R.,
was again not investigated as a sexual neurosis. I could only suspect
that there was a spinal neurasthenia at its basis, but I could not
confirm it. I must, however, add that since then pure hysterias have
become still rarer in my experience. That in grouping together
these four cases of hysteria I could disregard in the discussion the
decisive factors of sexual neuroses, was due to the fact that they were
older cases in which I had not as yet carried out the intentional and
urgent investigation for the neurotic sexual subsoil. Moreover, the
reason for my reporting four instead of twelve cases of hysteria, the
analyses of which would confirm our claims of the psychic mecha-
nism of hysterical phenomena, is due to one circumstance, namely,
that the analysis reveals these cases simultaneously as sexual neu-
roses, though there is no doubt that any diagnostician would have
denied them the name “hysteria.” However, the discussion of such
sexual neuroses would have overstepped the limits of our joint
publication.

I do not wish to be misunderstood and give the impression that
I refuse to accept hysteria as an independent neurotic affection, that
I conceive it only as a psychic manifestation of the anxiety neurosis,
that I ascribe it to only “ideogenous” symptoms, and that I
attribute the somatic symptoms, like hysterogenic points and
anesthesias to the anxiety neurosis. None of these statements are
true. I believe that hysteria, purified of all admixtures, can be
treated independently in every respect except in therapy. For in the
treatment we deal with a practical purpose, namely, we have to do

195

away with the whole diseased state, and if hysteria occurs in most
cases as a component of a mixed neurosis, the case merely resembles
a mixed infection, where the task is to preserve life and not merely
to combat the effect of one inciting cause of the disease.

I, therefore, find it important to separate the hysterical part in
the pictures of the mixed neuroses from neurasthenia, anxiety neu-
rosis, etc., for after this separation I can express concisely the thera-
peutic value of the cathartic method. Similarly I would venture to
assert that–principally–it can readily dispose of any hysterical
symptom, whereas, as can be easily understood, it is perfectly power-
less in the presence of neurasthenic phenomena, and can only seldom
and only through detours, influence the psychic results of the anxiety
neurosis. Its therapeutic efficacy in the individual case will depend
on whether or not the hysterical components of the morbid picture
can claim a practical and significant position in comparison to the
other neurotic components.

Still another limitation is placed on the efficacy of the cathartic
method, which we have already mentioned in our “Preliminary
Communication.” It does not influence the causal determinations of
hysteria, and hence, it cannot prevent the origin of new symptoms in
the place of those removed. Hence, on the whole, I must claim a
prominent place for our therapeutic method in the realm of a therapy
of neuroses, but I would caution against attaching any importance
to it, or putting it into practice outside of this connection. As I am
unable to give here a “Therapy of Neuroses” as would be required
by the practicing physician, the proceeding statements are put on a
level with a deferred reference to some later communication; still,
for purposes of discussion and elucidation, I can add the following
remarks:

1. I do not claim that I have actually removed all the hysterical
symptoms which I have undertaken to influence by the cathartic
method, but I believe that the obstacles were due to the personal
circumstances of the cases, and not to the general principles. In
passing sentence, these cases of failure may be left out of considera-
tion, just as the surgeon puts aside all cases who die as a result of
narcosis, hemorrhage, accidental sepsis, etc., when deciding upon a
new technique. Later when I will again consider the difficulties and
drawbacks of this method, I will again discuss the failures of such
origin.

2. The cathartic method does not become valueless simply because

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it is a symptomatic and not a causal therapy. For a causal therapy is
really in most cases only prophylactic; it stops the further progress
of the injury, but it does not necessarily remove the products which
have already resulted from it. It requires, as a rule, a second agent
to solve the latter task, and in cases of hysteria the cathartic method
is really unsurpassable for this purpose.

3. Where a period of hysterical production, or an acute hysterical
paroxysm, has been overcome, and the only remnant manifestations
left are hysterical symptoms, the cathartic method fulfills all indi-
cations, and achieves a full and lasting success. Such a favorable
constellation for the therapy rarely results in the realm of the sexual
life, in consequence of the marked fluctuations in the intensity of the
sexual need and the complications of the required determination for
a sexual trauma. Here the cathartic method accomplishes all that
is required of it, for the physician cannot possibly change an hysteri-
cal constitution. He must rest content if he can remove the disease
for which such a constitution shows a tendency, and which can arise
through the assistance of external determinants. He must be satis-
fied if the patient will again be able to function. Moreover, he needs
not despair of the future, even if he considers the possibility of a
relapse, for he knows the main character of the etiology of the
neuroses, namely that their origin is mostly overdetermined, and that
many factors must coöperate to produce this result. He can hope
that this coöperation will not take place very soon, even if some of
the etiological factors remained in force.

It may be argued that in such subsided cases of hysteria the
remaining symptoms would spontaneously disappear without any-
thing else, but this can be answered by stating that such spontaneous
cures very often terminate neither rapidly nor fully, and that the
cure will be extraordinarily advanced by the treatment. Whether
the cathartic treatment cures only that which is capable of spon-
taneous recovery, or incidentally also, that which would not cease
spontaneously, that question may surely be left open for the present.

4. Wherever we encounter an acute hysteria during the most
acute production of hysterical symptoms, and the consecutive over-
whelming of the ego by the morbid products (hysterical psychosis),
even the cathartic method will change little in the expression and
course of the disease. One finds himself in the same position to the
neurosis as the doctor to an acute infectious disease. The etiological
factors have exerted a sufficient amount of affect for some time past,

197

which is now beyond the reach of influence, and now that it has over-
come the interval of incubation, it comes to the surface. The affec-
tion cannot be warded off, it has to run its course, but meanwhile one
must bring about the most favorable conditions for the patient. If
during such an acute period one can remove the morbid products,
the newly formed hysterical symptoms, it may be expected that their
places will be taken by new ones. The physician will not be spared
the depressing impression of fruitless effort, the enormous expendi-
ture of exertion, and the disappointment of the relatives to whom
the idea of the necessary duration of time of an acute neurosis is
hardly as familiar as in the analogous case of an acute infectious
disease; these, and many other things, will probably largely impede
the consequent application of the cathartic method in the assumed
case. Nevertheless, it still remains to be considered whether, even in
an acute hysteria, the frequent removal of the morbid products does
not exercise a curative influence by supporting the normal ego, which
is occupied with the defense, and thus preventing it from merging into
a psychosis or into ultimate confusion.

That the cathartic method can accomplish something, even in an
acute hysteria, and that it can even reduce the new productions of
the morbid symptoms quite practically and noticeably, is undoubtedly
evident from the case of Anna O., in which Breuer first learned to
use this psychotherapeutic method.

5. Where we deal with chronic, progressive hysterias with
moderate or continued productions of hysterical symptoms, we feel
most the lack of a causally effective therapy, but we also learn to
value the importance of the cathartic method as a symptomatic
remedy. We then have to deal with an injury produced by a
chronically acting etiology. We have to strengthen the capacity of
resistance of the nervous system of our patient, and we must bear in
mind that the existence of an hysterical symptom signifies a weaken-
ing of resistance of the nervous system, and represents a predisposing
factor. From the mechanism of monosymptomatic hysteria we know
that a new hysterical symptom generally originates as an addition
to, and as an analogy of, one already in existence. The location once
penetrated² represents the weak spot which can be penetrated again.
The already split-off psychic group plays the part of the provoking
crystal from which a formerly omitted crystallization emanates with
great facility. To remove the already existing symptoms, to do away

²Cf. p. 148.

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with the psychic alterations lying at their bases, is to return to the
patients the full measure of their resistance capacity, with which they
are successfully able to resist the noxious influences. One can do a
great deal for the patient by such long continued watchfulness and
occasional “chimney-
sweeping.”³

6. I still have to mention the apparent contradiction between the
admission that not all hysterical symptoms are psychogenic, and the
assertion that they can all be removed by psychotherapeutic pro-
cedures. The solution lies in the fact that some of these non-
psychogenic symptoms, though they represent morbid symptoms, as
for instance, the stigmata, need, nevertheless, not be designated as
affections. It is, therefore, practically unimportant if they outlast
the successful treatment. Other symptoms of a similar nature seem
to be pulled along indirectly by some psychogenic symptoms, for
indirectly they really depend on some psychic causation.

I shall now speak of those difficulties and inconveniences of our
therapeutic method which are not evident from the preceding case
histories, or from the following remarks concerning the technique of
the method.—I will rather enumerate and indicate them than go into
details. The process is toilsome and wearisome for the physician, it
presupposes in him a profound interest for psychological occurrences,
and yet also a personal sympathy for the patient. I could not imagine
myself entering deeply into the psychic mechanism of an hysteria in
a person who would impress me as common and disagreeable, and
who would not, on closer acquaintanceship, be able to awaken in me
human sympathy; whereas I can treat a tabetic or a rheumatic
patient regardless of such personal interest. No less demanding are
the requisites on the patient’s side. The method is especially inap-
plicable in a person below a certain level of intelligence, and it
becomes extremely difficult wherever there is any tinge of mental
deficiency. It requires the full consent, the full attention of the
patients, but, above all, their confidence, for the analysis regularly
leads to the inmost and most secretly guarded psychic processes. A
large proportion of the patients suitable for such treatment withdraw
from the physician as soon as they get an inkling whither this investi-
gation tends. The physician remains a stranger to them. In others
who have determined to give themselves up to the physician and

³ See p. 20.

199

bestow their confidence upon him, something only voluntarily given,
but never demanded; in all those I say it is hardly avoidable that the
personal relation to the physician should not become unduly promi-
nent, at least for some time. Indeed, it seems as if such an influence
exerted by the physician is a condition under which alone a solution
of the problem is possible. I do not believe that it makes any essen-
tial difference in this state of affairs whether one resorts to hypnosis
or has to avoid or substitute it. Yet, fairness demands that we
emphasize the fact that although these inconveniences are inseparable
from our method, they, nevertheless, cannot be charged to it. On
the contrary, it is very obvious that they are conditioned in the
presuppositions of the neuroses destined to be cured, and that they
are interwoven in every medical activity which intensively concerns
itself with the patient, and produce in him a psychic change. I
could see no harm or danger in the application of hypnosis, even in
these cases where it was used excessively. The causes for the harm
produced lay elsewhere and deeper. When I review the therapeutic
efforts of those years since the communications of my honored
teacher and friend, J. Breuer, gave me the cathartic method, I believe
that I have more often produced good than harm, and brought about
some things which could not have been produced by any other thera-
peutic means. On the whole it was, as expressed in the “Prelimi-
nary Communication,” a “distinct therapeutic gain.”
I must mention still another advantage from the application of
this method. No severe case of complicated neurosis, with either an
excessive or slight tinge of hysteria, can better be explained than by
subjecting it to an analysis by Breuer’s method. In making this
analysis, I find that whatever shows the hysterical mechanism, disap-
pears first, while the rest of the manifestations I, meanwhile, learn to
interpret and trace back to their etiology. I thus gain the essential
factors indicated by the instrument of the therapy of the neurosis in
question. When I think of the ordinary differences between my
opinion of a case of neurosis before and after such an analysis, I am
almost tempted to maintain that the analysis is indispensable for the
knowledge of a neurotic disease. Moreover, I have made it a prac-
tice of applying the cathartic psychotherapy in acute cases in con-
junction with a Weir-Mitchell rest cure. This advantage lies in the
fact that, on the one side I avoid the very disturbing intrusion of new
psychic impressions which may be produced during psychotherapy;
on the other hand, I exclude the monotony of the Weir-Mitchell

200

treatment, during which the patient frequently merges into harmful
reveries.

II

I will now add to my former observations that in attempting to
use Breuer’s method in greater latitude I encountered the difficulty,
that although I made the diagnosis of hysteria, and the probabilities
spoke in favor of the prevalence of the psychic mechanism described
by us, yet a number of the patients could not be hypnotized. But as
hypnosis was necessary to broaden consciousness in order to find the
pathogenic reminiscences which do not exist in the ordinary con-
sciousness, I was, therefore, forced to either give up such patients
or bring about this broadening by other means.

The reason why one person is hypnotizable and another not, I
could no more explain than others, and hence, I could not start on
a causal way towards the removal of the difficulties. I also observed
that in some patients the obstacle was still more marked, they even
refused to submit to hypnosis. The idea then occurred to me that
both cases might be identical, and that in both it might merely
signify an unwillingness. Those who entertain psychic doubts against
hypnotism are not hypnotizable, it makes no difference whether they
express their unwillingness or not. It is not fully clear to me whether
I can firmly adhere to this view or not.

I was, therefore, forced to dispense with hypnotism and yet
obtain the pathogenic reminiscences. I attained this in the following
manner:

On asking my patients during our first interview whether they
remembered the first motive for the symptom in question, some said
that they knew nothing, while others thought of something which
they designated as an indistinct recollection, yet were unable to
pursue it. I then followed Bernheim’s example of forcibly awakening
apparently forgotten impressions from somnambulism.⁴ I assured
them that they did know it, and that they would recall it, etc., and
in this way some thought of something, while in others the recollec-
tions went even further. I urged still more, I ordered the patient
to lie down and voluntarily shut his eyes so as to “concen-
trate” his mind, and I then discovered that without any hypnosis
there emerged new and retrospective reminiscences which probably
belonged to our theme. Through such experiences I gained the

⁴Cf. p. 78, the case of Miss Lucy.

201

impression that through urging alone it would really be possible to
bring to light the definitely existing pathogenic series of ideas; and
as this urging necessitated much exertion on my part, and showed me
that I had to overcome a resistance, I, therefore, formulated this
whole state of affairs into the following theory: Through my psychic
work I had to overcome a psychic force in the patient which opposed
the pathogenic idea from becoming conscious (remembered). A new
insight seemed to have revealed itself to me when it occurred to me,
that this must really be the same psychic force which assisted in the
origin of the hysterical symptom, and which at that time prevented
the pathogenic idea from becoming conscious. What kind of force
could here be assumed as effective; and what motive could have
brought it into activity? I could easily formulate an opinion, for I
already had some complete analyses at my disposal, in which I found
examples of pathogenic, forgotten, and repressed ideas. From these
I could judge the general character of such ideas. They were alto-
gether of a painful nature adapted to provoke the affects of shame,
of reproach, of psychic pain, or the feeling of injury; they were
altogether of that kind which one would not have liked to experience
and preferred to forget. From all these there resulted the thought of
defense, as if spontaneously. Indeed, it is generally admitted by all
psychologists that the acceptance of a new idea (acceptance in the
sense of belief, admission of reality) depends on the mode and drift
of the ideas already united in the ego, and for the process of censor-
ship, to which the newly arrived idea is subjected, special technical
names have been created. An idea entered into the patient’s ego,
which proved to be unbearable and evoked a force of repulsion on the
part of the ego, the object of which was a defense against this unbear-
able idea. This defense actually succeeded, and the idea concerned
was crowded out of consciousness and out of memory, so that its
psychic trace could not apparently be found; yet, this trace must have
existed. When I made the effort to direct the attention to it, I felt
the same force as a resistance which showed itself as a repulsion in
the genesis of the symptom. If I could now make it probable that
the idea became pathogenic in consequence of the exclusion and
repression, the chain would seem complete. In many epicrises of
our histories, and in a small work concerning the defense neuro-
psychoses (1894), I have attempted to indicate the psychological
hypotheses with the help of which this connection, as well as the fact
of conversion, could be made clear.

202

Hence, a psychic force, the repugnance of the ego, has originally
crowded the pathogenic idea from the association, and now opposed
its return into the memory. The not know-
nig of the hysterics was
really a—more or less conscious—not willing to know, and the task
of the therapist was to overpower this association resistance by
psychic labor. Such accomplishment is, above all, brought about
by “urging”; that is, by applying a psychic force in order to direct
the patient’s attention to the ideas that one wishes to trace. It does
not, however, stop here, but as I will show, it assumes new forms in
the course of the analysis, and calls to aid more psychic forces.

I shall above all still linger at “the urging.” One cannot go very
far with such simple assurances as, “You do know it, just say it,”
or, “It will soon come to your mind.” After a few sentences the
thread breaks, even in the patient who is in a state of concentration.
We must not, however, forget that we deal everywhere here with a
quantitative comparison, with the struggle between motives of
diverse force and intensity. The urging by a strange and inexperi-
enced physician does not suffice to overcome “association resistance”
in a grave hysteria. One must think of more forceful means.

Here, I utilize in the first place a small technical artifice. I
inform the patient that in the next moment I will exert pressure on
his forehead, I assure him that during this pressure he will see some
reminiscence in the form of a picture, or some thought will occur
to him, and I obligate him to communicate to me this picture or this
thought, no matter what it may be. He must not keep it to himself
because he may think that it is not the desired or the right thing, or
because it is too disagreeable to say. There should be neither
criticism nor reservation because of affect or underestimation. Only
thus could we find the things desired, and only thus have we unfail-
ingly found them. I then exerted pressure for a few seconds on the
forehead of the patient lying in front of me, and after ceasing it, I
asked in a calm tone, as if any disappointment was out of the question,
“What have you seen?” or “What occurred to your mind?”

This method ⁵ taught me a great deal and led me to the goal every
time. Of course, I know that I can substitute this pressure on the
forehead by any other sign, or any other physical influence, but as
the patient lies before me, the pressure on the forehead, or the grasp-
ing of his head between my two hands, is the most suggestive and

⁵As mentioned in the preface, the author has long since discarded this
pressure procedure. [Translator’s note.]

203

most convenient thing that I could undertake for this end. To
explain the efficacy of this artifice I may perhaps say that it cor-
responds to a “momentary reënforced hypnosis”; but the mechanism
of hypnosis is so enigmatical to me that I would not like to refer to
it as an explanation.⁶⁾ I rather think that the advantage of the
process lies in the fact that through it I dissociated the attention of
the patient from his conscious quest and reflection, in brief, from
everything upon which his will could manifest itself. The fact that
under the pressure of my hand there always appeared that which I
was looking for taught me that the supposedly forgotten pathogenic
ideas always lie ready, “close by,” and are attainable through easily
approachable associations, all that is necessary is to clear away some
obstacle. This obstacle again seems to be the person’s will, and
different persons learn in different ways how to discard their wilful-
ness and to assume a perfectly objective attitude towards the psychic
processes within them.

It is not always a “forgotten” reminiscence which comes to the
surface under the pressure of the hand; in the rarest cases the real
pathogenic reminiscences can be superficially discovered. More fre-
quently an idea comes to the surface which is a link between the first
idea and the desired pathogenic idea of the association chain, or it is
an idea forming the starting point of a new series of thoughts and
reminiscences, at the end of which is the pathogenic idea. The
pressure, therefore, has really not revealed the pathogenic idea, which,
if torn from its connection without any preparation, would be incom-
prehensible; but it has shown the way to it, and indicated the direc-
tion towards which the investigation must proceed. The idea which
is at first awakened through the pressure may correspond to a familiar
reminiscence which was never repressed. If the connection becomes
torn on the road to the pathogenic idea, all that is necessary for the
reproduction of a new orientation and connection is a repetition of
the procedure, that is of the pressure.

In still other cases the pressure of the hand awakens a reminis-
cence well known to the patient, which appearance, however, causes
him surprise because he has forgotten its relation to the original
idea. In the further course of the analysis this relation becomes
clear. From all these results of the pressure one receives a delusive

⁶⁾The solution of this problem was later found by the author and his pupils.
Cf. here “Group Psychology and the Analysis of the Ego,” p. 98, Int. Psycho.
Press, and Ferenczi’s “Contributions to Psychoanalysis,” Chapter II, Badger,
Boston, 1916. [Translator’s note.]

204

impression of a superior intelligence outside of the patient’s con-
sciousness, which systematically holds a large psychic material for
definite purposes, and has provided an ingenious arrangement for its
return into consciousness. I presume, however, that this unconscious
second intelligence is really only apparent.
In every complicated analysis one works repeatedly, nay continu-
ously, with the help of this procedure (pressure on the forehead),
which leads us from the place where the patient’s wakeful recon-
ductions became interrupted, it shows us the way to reminiscences
which remained known, and calls our attention to connections which
have sunk into forgetfulness. It also evokes and connects memories
which have for years been withdrawn from association, though they
can still be recognized as memories; and finally, as the highest per-
formance of reproduction, it causes the appearance of thoughts which
the patient never wishes to recognize as his own, which he does not
remember, although he admits that they are inexorably required by
the connection, and is convinced that precisely these ideas will cause
the termination of the analysis and the cessation of the symptoms.
I will now attempt to give a series of examples which will show
the excellent achievements of this procedure. I treated a young lady
who suffered for six years from an intolerable and protracted nervous
cough, which apparently was nurtured by every common catarrh,
but must have had its strong psychic motives. Every other remedy
had long since shown itself powerless, and I, therefore, attempted to
remove the symptom by psychic analysis. All that she could remem-
ber was that the nervous cough began at the age of fourteen while
she boarded with her aunt. She remembered absolutely no psychic
excitement during that time, and did not believe that there was a
motive for her suffering. Under the pressure of my hand, she at first
recalled a large dog. She then recognized the memory picture; it
was her aunt’s dog which was attached to her, and used to accom-
pany her everywhere, and without any further aid it occurred to her
that this dog died and that the children buried it solemnly; and on
the return from this funeral her cough appeared. I asked her why
she began to cough, and the following thought occurred to her:
“Now I am all alone in this world; no one loves me here; this
animal was my only friend, and now I have lost it.” She then con-
tinued her story. “The cough disappeared when I left my aunt,
but reappeared a year and a half later.”—“What was the reason
for it?”—“I do not know.”—I again exerted some pressure on the

205

forehead and she recalled the news of her uncle’s death during which
the cough again manifested itself, and also recalled a train of thought
similar to the former. The uncle was apparently the only one in the
family who sympathized with her and loved her. That was, there-
fore, the pathogenic idea: People do not love her, everybody else is
preferred; she really does not deserve to be loved, etc. To the idea
of love there clung something which caused a marked resistance to
the communication. The analysis was interrupted before this
explanation was obtained.

Some time ago I attempted to relieve an elderly lady of her
anxiety attacks, which, considering their characteristic qualities,
were hardly suitable for such treatment. Since her menopause she
had become extremely religious, and always received me as if I were
the Devil, she was always armed with a small ivory crucifix which
she hid in her hand. Her attacks of anxiety, which bore a hysterical
character, could be traced to her early girlhood, and were supposed
to have originated from the application of an iodine preparation to
reduce a moderate swelling of the thyroid. I naturally repudiated
this origin, and sought to substitute it by another which was in better
harmony with my views concerning the etiology of neurotic symp-
toms. To the first question for an impression of her youth, which
would stand in causal connection to the attacks of anxiety, there
appeared the reminiscences of reading a so-called devotional book
wherein piously enough there was some mention of the sexual proc-
esses. The passage in question made an impression on this girl,
which was contrary to the intention of the author. She burst into
tears and flung the book away. That was before the first attack of
anxiety. The next reminiscence referred to her brother’s teacher,
who showed her great respect and for whom she entertained a
warmer feeling. This reminiscence culminated in the reproduction
of an evening in her parents’ home during which they all sat around
the table with the young man, and delightfully enjoyed themselves
in a lively conversation. During the night following this evening,
she was awakened by the first attack of anxiety which surely had
more to do with some resistance against a sensual feeling than
perhaps with the coincidental use of iodine. In what other way
could I have succeeded in revealing in this obstinate patient, preju-
diced against me and every worldly remedy, such a connection
contrary to her own opinion and assertion?

206

On another occasion I had to deal with a young happily married
woman, who as early as in the first years of her girlhood, was found
every morning for some time in a state of lethargy, with rigid limbs,
opened mouth, and protruding tongue. Similar attacks, though not
so marked, recurred at the present time on awakening. A deep
hypnosis could not be produced, so that I began my investigation in
a state of concentration, and assured her during the first pressure
that she would see something that would be directly connected with
the cause of her condition during her childhood. She acted calmly
and willingly, she again saw the residence in which she had passed
her early girlhood, her room, the position of the bed, the grand-
mother who lived with them at the time, and one of her governesses
whom she dearly loved. Then there was a succession of small scenes
in these rooms and among these quite indifferent persons, the
conclusion of which was the leavetaking of the governess who mar-
ried from the home. I did not know what to start with these
reminiscences; I could not bring about any connection between them
and the etiology of the attacks. To be sure, the various circum-
stances were recognized as having occurred at the same time as the
attacks first appeared.

Before I could continue the analysis, I had occasion to talk to a
colleague, who, in former years, was my patient’s family physician.
From him I obtained the following explanation: At the time that
he treated the mature and physically well developed girl for these
first attacks, he was struck by the excessive affection in the relations
between her and the governess. He became suspicious and caused
the grandmother to watch these relations. After a short while the
old lady informed him that the governess was wont to pay nightly
visits to the child’s bed, and that quite regularly after such visits the
child was found in the morning in an attack. She did not hesitate
to bring about the quiet removal of this corruptress of youth. The
children, as well as the mother, were made to believe that the gover-
ness left the house in order to get married.
The treatment, which was above all successful, consisted in
informing the young woman of the explanations given to me.

Occasionally the explanations, which one obtains by the pressure
procedure, follow in very remarkable form, and under circumstances
which make the assumption of an unconscious intelligence appear
even more alluring. Thus, I recall a lady who suffered for years

207

from obsessions and phobias, and who referred the origin of her
trouble to her childhood, but could mention nothing to which it
could have been attributed. She was frank and intelligent, and
evinced only a very slight conscious resistance. I will add here that
the psychic mechanism of obsessions is very closely related to that
of hysterical symptoms, and that the technique of the analysis in
both is the same.

On asking the lady whether she had seen or recalled anything
under the pressure of my hand, she answered, “Neither, but a word
suddenly occurred to me.”—“A single word?”—“Yes, but it is too
foolish.”—“Just tell it.”—“Teacher.”—“Nothing more?”—“No.”

I exerted pressure a second time, and again a single word flashed
through her mind: “Shirt.”—I now observed that we dealt with a
new mode of replying, and by repeated pressure I evoked the fol-
lowing apparently senseless series of words: Teacher—shirt—bed-
city—wagon. I asked, “What does all that mean?” She reflected
for a moment, and it then occurred to her that “it can only refer to
this one incident which now comes to my mind. When I was ten
years old, my older sister of twelve had a violent emotional attack
one night and had to be bound, put in a wagon and taken to the
city. I remember distinctly that it was the teacher who overpowered
her and accompanied her to the asylum.”—We then continued this
manner of investigation, and received from our oracle another series
of words which, though we could not altogether interpret them, could
nevertheless be used as a continuation of the story, and as an appen-
dix to a second. The significance of this reminiscence was soon clear.

The reason why her sister’s illness made such an impression on her
was because they both shared a common secret. They slept in the
same room, and one night they both submitted to a sexual assault
by a certain man. In discovering this sexual trauma of early youth,
we revealed not only the origin of the first obsession, but also the
trauma which later acted pathogenically.—The peculiarity of this
case lies only in the appearance of single catch-words, which we had
to elaborate into sentences, for the seeming irrelevance and incoher-
ence in these oracle-like words generally occur in all ideas and scenes
as a result of pressure. On further investigation it is regularly found
that the seemingly disconnected reminiscences are connected by
intimate streams of thought, and that they lead quite directly to the
desired pathogenic factor.

I, therefore, recall with pleasure a case of analysis in which my
 

208

confidence in the results of this method was very splendidly justified.
A very intelligent, and apparently very happy, young woman con-
sulted me for persistent pain in her abdomen, which yielded to no
treatment. I found that the pain was located in the abdominal wall
and was due to palpable muscular hardening, and I, therefore, ordered
local treatment.

After months I again saw the patient who said that “the pain
had disappeared after taking the treatment and remained away a long
time, but it has now reappeared as a nervous pain. I recognize it
by the fact that I do not perceive it now on motion as before, but
only during certain hours, as for example, in the morning on awaken-
ing, and during certain excitements.” The patient’s diagnosis was
quite correct. It was now important to discover the cause of this
pain, but in this she could not assist me in her uninfluenced state.
When I asked her in a state of concentration and under the pressure
of my hand whether anything occurred to her, or whether she saw
anything, she began to describe her visual pictures. She saw some-
thing like a sun with rays, which I naturally had to assume to be a
phosphene produced by pressure on the eyes. I expected that the
needful pictures would follow, but she continued to see stars of a
peculiar pale blue light, like moonlight, etc., and I believed that she
merely saw glittering, shining, and twinkling spots before the eyes.
I was already prepared to add this attempt to the failures, and I was
thinking how I could quietly withdraw from this affair, when my
attention was called to one of the manifestations which she described.
She saw a big, black, inclined cross, the edges of which were sur-
rounded with a subdued moon-like light, in which all the pictures
thus far seen were shining, and upon the cross beam there flickered
a little flame that was apparently no longer a phosphene. I continued
to listen. She saw numerous pictures in the same light, peculiar
signs resembling somewhat Sanskrit. She also saw figures like
triangles, among which there was one big triangle, and again the
cross. I now thought of an allegorical interpretation, and asked,
“What does this cross mean?”–“It is probably meant to interpret
pain,” she answered. I argued, saying that, “By cross one usually
understands a moral burden,” and asked her what was hidden behind
that pain. She could not explain that and continued looking. She
saw a sun with golden rays which she interpreted as God, the primi-
tive force; she then saw a gigantic lizard which she examined
quizzically, but without fear; then a heap of snakes, then another

209

sun, but with mild silvery rays, and in front of it, between her own
person and this source of light, there was a barrier which concealed
from her the center of the sun.

I knew for some time that we dealt here with allegories, and I
immediately asked for an explanation of the last picture. Without
reflecting she answered: “The sun is perfection, the ideal, and the
barrier represents my weakness and failings which stand between me
and the ideal.” – “Indeed, do you reproach yourself?” Are you
dissatisfied with yourself?” – “Yes.” – “Since when?” – “Since I
became a member of the Theosophical Society and read the writings
edited by it. I have always had a poor opinion of myself.” – “What
was it that made the last strongest impression upon you?” – “A
translation from the Sanscrit, which now appears in serial numbers.”
A minute later I was initiated into her mental conflicts, and into her
self-
reproaches. She related a slight incident which gave occasion
for a reproach, and in which, as a result of an inciting conversion,
the former organic pain at first appeared. The pictures, which I had
at first taken for phosphenes, were symbols of occultistic streams of
thought, perhaps plain emblems from the title pages of occultistic
books.

Thus far, I have warmly praised the achievements of the pressure
procedure, and have entirely neglected the aspect of the defense or
the resistance, so that I certainly must have given the impression
that by means of this small artifice one is placed in a position to
become master of the psychic resistances to the cathartic method. But
to believe this would be a gross mistake. Such advantages do not
exist in the treatment so far as I can see; here, as everywhere else,
a great change requires much effort. The pressure procedure is
nothing but a trick serving to surprise for awhile the defensive ego;
in all graver cases it soon recalls its intentions and continues its
resistance.

I need only recall the various forms in which this resistance
manifested itself. At first, the pressure experiment usually fails the
first or second time. The patient then expresses himself disappointedly,
saying, “I believed that some idea would occur to me, but I only
thought how anxious I was for it, but nothing came.” Such attitudes
assumed by the patient are not yet to be counted as a resistance; we
usually answer to that, “You were really too anxious, the second
time things will come.” And they really come. It is remarkable

210

how completely the patients–even the most tractable and the most
intelligent–can forget the agreement into which they have previously
entered. They have promised to tell everything that occurs to
them, be it intimately related to them or not, be it agreeable to say
or not; that is, they are to tell everything without any choice, or
influence of criticism or affect. Yet, they do not keep their promise,
it is apparently beyond their powers. The work repeatedly stops,
they continue to assert that this time nothing came to their mind.
One need not believe them, and one must always assume, and also
say, that they hold back something because they believe it to be
unimportant, or perceive it as painful. One must insist, and assume
an assured attitude until one really hears something. The patient
then usually adds, “I could have told you that the first time.”–
“Why did you not say it?”––“I could not believe that that could
be it. Only after it returned repeatedly have I decided to tell it,”
or, “I had hoped that it would not be just that, that I could save
myself saying it, but only after it could not be repressed have I
noticed that I could not avoid it.”–Thus, the patient subsequently
betrays the motives of a resistance which he did not at first wish to
admit. He apparently could do nothing but offer resistances.

It is remarkable under what subterfuges these resistances are
frequently hidden. “I am distracted today; the clock or the piano
playing in the next room disturbs me,” they say. I become accus-
tomed to answer to that, “Not at all, you simply struck something
that you are not willing to say. That does not help you at all. Just
stick to it.”–The longer the pause between the pressure of my hand
and the utterance of the patient, the more suspicious I become, and
the more it is to be feared that the patient arranges what comes to
his mind, and distorts it in the reproduction. The most important
explanations are frequently ushered in as superfluous accessories,
just as the princes of the opera who are dressed as beggars. “Some-
thing now occurred to me, but it has nothing to do with it. I only
tell it to you because you wish to know everything.” With this
introduction we usually obtain the long desired solution. I always
listen when I hear a patient talk so lightly of an idea. That the
pathogenic idea should appear of so little importance on its reappear-
ance is a sign of the successful defense. One can infer from this, of
what the process of defense consisted. Its object was to make a
weak out of a strong idea, that is, to rob it of its affect.

Among other signs, the pathogenic memories can also be recog-
 

211

nized by the fact that they are designated by the pa-
tial, despite the fact that they are uttered with resistance. There are
also cases where the patient seeks to disavow the recollections, even
while they are being reproduced, with such remarks as these: “Now
something occurred to me, but apparently you talked it into me”;
or “I know what you expect to this question, you surely think that
I thought of this and that.” An especially clever way of shifting
responsibility is found in the following expression: “Now something
really occurred to me, but it seems to me as if I added it, and that it
is not a reproduced thought.”–In all these cases I remain inflexibly
firm, I admit none of these distinctions, but I explain to the patient
that these are only forms and subterfuges of the resistance against
the reproduction of a recollection, which in spite of all we are forced
to recognize.

One generally experiences less trouble in the reproduction of
pictures than thoughts. Hysterical patients who are usually visual
are easier to manage than patients suffering from obsessions. Once
the picture emerges from the memory we can hear the patient state
that as he proceeds to describe it, it proportionately fades away and
becomes indistinct; the patient wears it out, so to speak, by trans-
forming it into words. We then orient ourselves through the
memory picture itself, in order to find the direction towards which
the work should be continued. We say to the patient, “Just look
again at the picture, has it disappeared?”–“As a whole, yes, but I
still see this detail.”–“Then this must have some meaning, you will
either see something new, or this remnant will remind you of some-
thing.” When the work is finished, the visual field becomes free
again, and a new picture can be called forth; but at other times such
a picture, in spite of its having been described, remains persistently
before the inner eye of the patient, and I take this as a sign that he
still has something important to tell me concerning its theme. As
soon as this has been accomplished, the picture disappears like a
wandering spirit returning to rest.

It is naturally of great value for the progress of the analysis to
carry our point with the patient, otherwise we have to depend on
what he thinks it proper to impart. It, therefore, will be pleasant
to hear that the pressure procedure never failed except in a single
case which I shall discuss later, but which I can now characterize by
the fact that there was a special motive for the resistance. To be
sure, it may happen under certain conditions that the procedure may

212

be applied without bringing anything to light; as, for example, we
may ask for the further etiology of a symptom when the same has
already been exhausted; or we may investigate for the psychic
genealogy of a symptom, perhaps a pain, which really is of somatic
origin. In these cases the patient equally insists that nothing occurred
to him, and he is right. We should strive to avoid doing an injus-
tice to the patient by making it a general rule not to lose sight of
his features while he calmly lies before us during the analysis. One
can then learn to distinguish, without any difficulty, the psychic
calm in the real non-appearance of a reminiscence from the tension
and emotional signs under which the patient labors in trying to
disavow the emerging reminiscences with the object of defense. The
differential diagnostic application of the pressure procedure is really
based on such experiences.

We can thus see that even with the help of pressure procedure
the task is not an easy one. The only advantage gained is the fact
that we have learned from the results of this method in which direc-
tion to investigate, and what things we have to force upon the patient.
For some cases this suffices, for it is essentially a question of finding
the secret, and telling it to the patient, so that he is then usually
forced to relinquish his resistance. In other cases more is necessary;
here the surviving resistance of the patient manifests itself by the
fact that the connections become torn, the solutions do not appear,
and the recalled pictures come indistinctly and incompletely. On
reviewing, at a later period, the earlier results of an analysis, we
are often surprised at the distorted aspects of all the occurrences and
scenes which we have snatched from the patient. It usually lacks the
essential part, the relations to the person or to the theme, and for
that reason the picture remained incomprehensible. I will now give
one or two examples showing the effects of such a censoring during
the first appearance of the pathogenic memories. The patient sees
the upper part of a female body on which a loose covering fits care-
lessly, only much later he adds to this torso the head, and thereby
betrays a person and a relationship. Or, he relates a reminiscence
of his childhood about two boys whose forms are very indistinct,
and to whom a certain mischievousness was attributed. It required
many months and considerable progress in the course of the analysis
before he again saw this reminiscence and recognized one of the
children as himself and the other as his brother. What means have
we now at our disposal to overcome this continued resistance?

213

We have but few, yet we have almost all those by which one other
wise exerts a psychic influence on the other. In the first place, we
must remember that psychic resistance, especially of long continu-
ance, can only be broken slowly, gradually, and with much patience.
We can also count on the intellectual interest which manifests itself
in the patient after a brief period of the analysis. On explaining
and imparting to him the knowledge of the marvelous world of
psychic processes, which we have gained only through such analysis,
we obtain his collaboration and cause him to view himself with the
objective interest of the investigator, and we thus drive back the
resistance which rests on an affective basis. But finally—and this
remains the strongest motive force—after the motives for the defense
have been discovered, we must make the attempt to reduce them or
even substitute them by stronger ones. Here, the possibility of
expressing the therapeutic activity in formulæ ceases. One does as
well as he can as an explainer where ignorance has produced shyness,
as a teacher, as a representative of a freer and more superior philos-
ophy of life, and as a confessor, who through the continuance of his
sympathy and his respect imparts, so to say, absolution after the
confession. One endeavors to do something humane for the patient
as far as the range of one’s own personality and the measure of
sympathy which one can set apart for the case allows. It is an
indispensable prerequisite for such psychic activities to have approxi-
mately discovered the nature of the case and the motives of the
defense that are here effective. Fortunately the technique of urging
and the pressure procedure take us just so far. The more we have
solved such enigmas the easier will we discover new ones, and the
earlier will we be able to manage the actual curative psychic work.
For it is well to bear in mind that although the patient can rid him-
self of an hysterical symptom only after reproducing and uttering
under emotion its causal pathogenic impressions, yet the therapeutic
task merely consists in inducing him to do it, and once the task has
been accomplished, there remains nothing for the doctor to correct
or abolish. All the contrary suggestions necessary have already
been employed during the struggle carried on against the resistance.
The case may be compared to the unlocking of a closed door, where
as soon as the door knob has been pressed downward, no other diffi-
culties are encountered in opening the door.

Among the intellectual motives employed for the overcoming of
the resistance one can hardly dispense with one affective factor, that

214

is, the personal equation of the doctor, and in a number of cases this
alone is enough to break the resistance. The conditions here do
not differ from those found in any other branch of medicine, and one
should not expect any therapeutic method to fully disclaim the coöp-
eration of this personal factor.

III

In view of the discussions in the preceding section concerning the
difficulty of my technique, which I have unreservedly exposed—I
have really collected them from my most difficult cases, though it
will often be easier work—in view then of this state of affairs, every
body will wish to ask whether it would not be more suitable, instead
of all these tortures, to apply one’s self more energetically to hypnosis,
or to limit the application of the cathartic method to only such cases
as can be put into deep hypnosis. To the latter proposition I should
have to answer that the number of patients available for my skill
would shrink considerably, but to the former advice I will advance
the supposition that even where hypnosis could be produced the
resistance would not be very much lessened. My experiences in this
respect are not particularly extensive, so that I am unable to go
beyond this supposition, but wherever I achieved a cathartic cure
in the hypnotic state, I found that the work devolved upon me was
not less than in the state of mere concentration. I have only recently
finished such a treatment during which course I caused the disap-
pearance of an hysterical paralysis of the legs. The patient merged
into a state, psychically very different from the conscious, and
somatically distinguished by the fact that she was unable to open her
eyes or rise without my ordering her to do so; and still I never had
a case showing greater resistance than this one. I placed no value
on these physical signs, and towards the end of the ten months’ treat-
ment, they really became imperceptible. The state of the patient on
which we worked has, therefore, lost nothing of its psychic peculiari-
ties, such as the ability to recall the unconscious, and its very peculiar
relation to the person of the physician. To be sure, in the history
of Mrs. Emmy v. N. I have described an example of a cathartic cure
accomplished in a profound somnambulism in which the resistance
played almost no part. But nothing that I obtained from this woman
would have required any special effort; I obtained nothing that she
could not have told me in her waking state after a longer acquaint-
anceship and some personal regard. The real causes of her disease,

215

which were surely identical with the causes of her relapses after my
treatment, I have never found-
it was my first attempt in this
therapy-
and when I once asked her accidentally for a reminiscence
which contained a fragment of the erotic, I found her just as resistive
and unreliable in her statements as any one of my later non-
som
nambulic patients. This patient’s resistance, even in the somnam-
bulic state, against other requirements and exactions I have already
discussed in her history. Since I have witnessed cases which, even
in deep somnambulism were absolutely refractory therapeutically
despite their obedience in everything else, I really have become
skeptical as to the value of hypnosis for the facilitation of the
cathartic treatment. A case of this kind I have in brief reported
(p. 72) and could still add others. Besides, I admit that even
this experience fell badly short of my need for a quantitative relation
between cause and effect in the psychic spheres.

In our discussion thus far the idea of resistance has thrust itself
to the foreground. I have shown how, in the therapeutic work, one
is led to the conception that hysteria originates through the repres-
sion of an unbearable idea as a motive of defense, that the repressed
idea remains as a weak (mildly intensive) reminiscence and that the
affect snatched from it is used for a somatic innervation, that is, for
conversion of the excitement. By virtue of its repression the idea
becomes the cause of morbid symptoms, that is, pathogenic. A
hysteria showing this psychic mechanism may be designated by the
name of “defense hysteria,” but both Breuer and myself have
repeatedly spoken of two other kinds of hysterias which we have
named “hypnoid-
and retention-
hysteria.” The first to reveal itself
to us was really the hypnoid-
hysteria, for which I can mention no
better example than Breuer’s case of Miss Anna O. For this form
of hysteria Breuer gives an essentially different psychic mechanism
than for the form which is characterized by conversion. Here the
idea becomes pathogenic through the fact that it is conceived in a
peculiar psychic state, having remained from the very beginning
external to the ego. It, therefore, needs no psychic force to keep it
away from the ego, and it need not awaken any resistance when,
with the help of the somnambulic psychic authority, it is initiated into
the ego. The history of Anna O. really shows nothing of such a
resistance.

I hold this distinction as so essential that it has readily induced

216

me to adhere to the formation of the hypnoid-
hysteria. It is, however, remarkable that in my own experience I
encountered no genuine hypnoid-hysteria, whatever I treated changed
itself into a defense hysteria. Not that I have never dealt with
symptoms which manifestly originated in separated conscious states,
and, therefore, were excluded from being accepted into the ego. I
encountered this also in my own cases, but I could show that the
so-called hypnoid state owed its separation to the fact that a split-
off psychic group originated before through defense. In brief, I
cannot suppress the suspicion that hypnoid and defense hysteria meet
somewhere at their roots, and that the defense is the primary thing,
but I know nothing about it.

Equally uncertain is at present my opinion concerning the reten-
tion hysteria in which the therapeutic work is also supposed to follow
without any resistance. I had a case which I took for a typical
retention hysteria, and I was pleased with the anticipation of an
easy and certain success, but this success failed to come, easy as the
work really was. I, therefore, presume, and again with all caution
appropriate to ignorance, that in retention hysteria, too, we can find
at its basis a fragment of defense, which has thrust the whole process
into hysteria. Let us hope that new experiences will soon decide
whether I am running into the danger, of one-sidedness and error, in
my tendency to spread the conception of defense for the whole of
hysteria.

Thus far I have dealt with the difficulties and technique of the
cathartic method. I would now like to add a few indications to
show how one does an analysis with this technique. For me this is
a very interesting theme, but I do not expect that it will excite
similar interest in others who have not practiced such analyses.
Properly speaking, we shall again deal with technique, but this time
with those difficulties concerning which the patient cannot be held
responsible, and which must in part be the same in a hypnoid and a
retention hysteria as in the defense hysteria which I have in mind as
a model. I start with this last fragment of discussion with the hope,
that the psychic peculiarities to be revealed here might sometimes
attain a certain value as raw material for ideational dynamics.

The first and strongest impression which one gains from such
an analysis is surely the fact that the pathogenic psychic material,
apparently forgotten and not at the disposal of the ego, which plays

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no rôle in the association and in memory, still lies ready in some
manner and, what is more, in proper and good order. All that is
necessary is to remove the resistances blocking the way. Barring
that, everything is known as well as we know anything at all. The
proper connections of the individual ideas among themselves and
with the non-pathogenic, which are frequently remembered, are
present; they have been produced in their time and retained in
memory. The pathogenic psychic material appears as the property
of an intelligence which is not necessarily inferior to the normal ego.
The semblance of a second personality is often most delusively
produced.

Whether this impression is justified, whether the arrangement of
the psychic material resulting after the adjustment is not transferred
back into the period of the disease—these are questions, which I do
not like to consider in this place. One cannot certainly describe the
experiences gained from such analyses more easily and more clearly
than by placing one’s self in the position which one may take for a
survey after the whole thing has been completed.

The situation is usually not so simple as one represents it in
special cases, as, for example, in a single case in which a symptom
originates through a large trauma. We frequently deal not with a
single hysterical symptom, but with a number of such, which are
partially independent of one another and partially connected. We
must not expect a single traumatic reminiscence, and as its nucleus
one single pathogenic idea, but we must be ready to assume a series
of partial traumas and concatenations of pathogenic mental streams.
The monosymptomatic traumatic hysteria is, as it were, an ele-
mentary organism, a single being in comparison to the complicated
structure of a grave hysterical neurosis, as we generally encounter it.
The psychic material of such hysteria presents itself as a multi-
dimensional formation of at least triple stratification. I hope to be
able to justify soon this figurative expression. First of all there is
a nucleus of such reminiscences (either experiences or mental
streams) in which the traumatic moment culminated, or in which
the pathogenic idea has found its purest formation. Around this
nucleus we often find an incredibly rich mass of other memory
material which we have to elaborate in the analysis in the triple
arrangement mentioned before. In the first place, there is an unmis-
takable linear chronological arrangement, which takes place within
every individual theme. As an example of this, I can only cite the

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arrangement in Breuer’s analysis of Anna O. The theme is that of
becoming deaf, of not hearing,¹⁾ which then becomes differentiated
according to seven determinants, and under each heading there were
from ten to one hundred single reminiscences in chronological order.
It read like an abstract from an orderly kept archive. The analysis
of my patient Emmy v. N. contained similar memory fascicles though
not so fully described, but they formed part of every analysis. They
always appeared in chronological order which were as definitely
reliable as the serial sequences of the days of the week or the names
of the months in psychically normal individuals. They increased the
work of the analysis through the peculiarity of reversing the series
of their origin in the reproduction; the freshest and the most recent
occurrence of the accumulation occurred first, so to speak, as a
“wrapper,” and the one with which the series really began gave the
impression of the conclusion.

The grouping of similar reminiscences in a multiplicity of linear
stratifications, as represented in a bundle of documents, in a package,
etc., I have designated as the formation of a theme. These themes
now show a second form of arrangement. I cannot express it differ-
ently than by saying that they are concentrically stratified around the
pathogenic nucleus. It is not difficult to say what determines these
strata, and according to to what decreasing or increasing magnitude
this arrangement follows. They are layers of equal resistance tend-
ing towards the nucleus, accompanied by zones of similar alteration
of consciousness into which the individual themes extend. The most
peripheral layers contain those reminiscences (or fascicles) of the
different themes, which can readily be recalled and which were
always perfectly conscious. The deeper one penetrates the more
difficult it becomes to recognize the emerging reminiscences, until
one strikes those near the nucleus which the patient disavows, even
at the reproduction.

As we shall hear later, it is the peculiarity of the concentric
stratification of the pathogenic psychic material which gives to the
course of such an analysis its characteristic features. We must now
mention the third and most essential arrangement concerning which
a general statement can hardly be made. It is the arrangement
according to the content of thought, the connection which reaches the
nucleus through the logical threads, which might in each case cor-
respond to a special, irregular, and manifoldly devious road. This

¹⁾Cf. p. 24.

219

arrangement has a dynamic character in contradistinction to both
morphological stratifications mentioned before. Whereas, in a specially
formed scheme, the latter would be represented by rigid, arched, and
straight lines, the course of the logical concatenation would have to
be followed with a wand, over the most tortuous route, from the
superficial into the deep layers and back, generally, however, pro-
gressing from the peripheral to the central nucleus, and touching
thereby all stations; that is, its movement is similar to the zigzag
movement of the knight in the solution of a chess problem.

I shall still adhere for a moment to the last comparison in order
to call attention to a point in which it does not do justice to the
qualities of the thing compared. The logical connection corresponds
not only to a zigzag-like devious line, but rather to a ramifying and
especially to a converging system of lines. It has a junction in
which two or more threads meet, only to proceed thence united, and,
as a rule, many threads running independently, or here and there
connected by by-paths, open into the nucleus. To put it in different
words, it is very remarkable how frequently a symptom is manifoldly
determined, that is overdetermined.

I will introduce one more complication, and then my effort to
illustrate the organization of the pathogenic psychic material will be
achieved. It can happen that we may deal with more than one single
nucleus in the pathogenic material, as, for example, when we have
to analyze a second hysterical outbreak having its own etiology, but
which is still connected with the first outbreak of an acute hysteria,
which has been overcome years before. It can readily be imagined
what strata and streams of thought must be added in order to pro-
duce a connection between the two pathogenic nuclei.

I will still add a few observations to the given picture of the
organization of the pathogenic material. We have said of this
material that it behaves like a foreign body, and that the therapy also
acts like the removal of a foreign body from the living tissues. We
are now in position to consider the shortcomings of this comparison.
A foreign body does not enter into any connection with the layers
of tissue surrounding it, although it changes them and produces in
them a reactive inflammation. On the other hand, our pathogenic
psychic group does not allow itself to be cleanly shelled out from the
ego, its outer layers radiate in all directions into the parts of the
normal ego, and really belong to the latter as much as to the
pathogenic organization. The boundaries between both become

220

purely conventional in the analysis, being placed now here, now there,
and in certain locations no demarcation is possible. The inner layers
become more and more estranged from the ego without showing a
visible beginning of the pathogenic boundaries. The pathogenic
organization really does not behave like a foreign body, but rather
like an infiltration. The infiltrate must, in this comparison, be
assumed to be the resistance. Indeed, the therapy does not consist
in extirpating something-
psychotherapy cannot do that at present-
but it causes a melting of the resistance, and thus opens the way for
the circulation into a hitherto closed territory.

(I make use here of a series of comparisons all of which have only
a very limited resemblance to my theme, and do not even agree among
themselves. I am aware of that, and I am not in danger of over-
estimating their value; but, as it is my intention to illustrate the
many sides of a most complicated and not as yet depicted idea, I,
therefore, take the liberty of dealing also in the following pages with
comparisons which are not altogether free from objections.)

If, after a thorough adjustment, one could show to a third party
the pathogenic material in its present recognized, complicated and
multidimensional organization, he would justly propound the ques-
tion, “How could such a camel go through the needle’s eye?”
Indeed, one does not speak unjustly of a “narrowing of conscious-
ness.” The term gains in sense and freshness for the physician who
accomplishes such an analysis. Only one single reminiscence can
enter into the ego-
consciousness; the patient, occupied in working
his way through this one, sees nothing of that which follows, and
forgets everything that has already wedged its way through. If the
conquest of this one pathogenic reminiscence strikes against impedi-
ments, as, for example, if the patient does not let up the resistance
against it, but wishes to repress or distort it, the strait is, so to speak,
blocked; the work comes to a standstill, it cannot advance, and the
one reminiscence in the breach confronts the patient until he takes
it up into the breadth of his ego. The whole spatially extended mass
of the pathogenic material is thus drawn through a narrow fissure
and reaches consciousness as if disjointed into fragments or strips.
It is the task of the psychotherapist to put it together again into the
conjectured organization. He who desires still more comparisons
may think here of a Chinese puzzle.

If one is about to begin an analysis in which one may expect such
an organization of the pathogenic material, the following results of

221

experience may be useful: It is perfectly hopeless to attempt to make
any direct headway towards the nucleus of the pathogenic organiza-
tion. Even if it could be guessed, the patient would still not know
what to start with the explanation given to him, nor would it change
him psychically.

There is nothing left to do but follow up the periphery of the
pathogenic psychic formation. One begins by allowing the patient to
relate and recall what he knows, during which one can already direct
his attention, and may even overcome slight resistances. Whenever
a new way is opened, it can be expected that the patient will follow
it for some distance without any new resistance.

After having worked for a while in such manner, a coöperating
activity is usually manifested in the patient. A number of reminis-
cences now occur to him without any need of questioning or setting
him a task. A way has thus been opened into an inner stratum,
within which the patient now spontaneously disposes of the material
of equal resistance. It is well to allow him to reproduce for a while
without influencing him; of course, he is unable to reveal important
connections, but he may be allowed to clear things within the same
stratum. The things which he thus reproduces often seem discon-
nected, but they give up the material which is later revived by the
recognized connections.

One has to guard here in general against two things. If the
patient is checked in the reproduction of the inflowing ideas, some-
thing is apt to be “buried” which must be uncovered later with great
effort. On the other hand, one must not overestimate his “uncon-
scious intelligence,” and one must not allow it to direct the whole
work. If I should wish to schematize the mode of labor, I could
perhaps say that one should himself undertake the opening of the
inner strata and the advancement in the radial direction, while the
patient should take care of the peripheral extension.

The advancement is brought about by the fact that the resistance
is overcome in the manner indicated above. As a rule, however, one
must at first solve another problem. One must obtain a piece of a
logical thread by which direction alone one can hope to penetrate into
the interior. One should not expect that the voluntary information of
the patient, the material which is mostly in the superficial strata,
will make it easy for the analyst to recognize its deep seated locations,
and to which points the desired connections of thought are attached.
On the contrary, just this is cautiously concealed, the patient’s

222

assertion sounds as if perfect and firm in itself. One is at first con-
fronted, as it were, by a wall which shuts off every view, and gives
no suggestion of anything hidden behind it.

If, however, one views with a critical eye the assertion obtained
from the patient without much effort and resistance, one will unmis-
takably discover in it gaps and damages. Here the connection is
visibly interrupted and scantily supplemented by the patient through
phrases which convey only insufficient information. There one
strikes against a motive which in a normal person would be desig-
nated as flimsy. The patient refuses to recognize these gaps when
his attention is called to them. The physician, however, does well to
seek under these weak points access to the material of the deeper
layers and hope to discover just here the threads of the connection,
which he traces by the pressure procedure. One, therefore, tells the
patient, “You are mistaken, what you assert can have nothing to do
with the thing in question; here we will have to strike against some-
thing which will occur to you under the pressure of my hand.”

The hysterical stream of thought, even if it reaches into the
unconscious, may be expected to show the same logical connections
and sufficient motivations as those that would be expected in a normal
individual. A looseness of these relationships does not lie within
the sphere of the neurosis. If the association of ideas of neurotics,
and especially of hysterics, makes a different impression, if the rela-
tion of the intensities of different ideas does not seem to be explain-
able here on psychological determinants alone, we know that such
manifestations are due to the existence of concealed unconscious
motives. Such secret motives may be expected, wherever such a
deviation in the connection, or a transgression from the normally
justified motivations can be demonstrated.

One must naturally free himself from the theoretical prejudice
that one has to deal with abnormal brains of dégénérés and
déséquilibrés, in whom the freedom of overthrowing the common
psychological laws of the association of ideas is a stigma, or in whom
a preferred idea without any motive may grow intensively excessive,
and another without psychological motives may remain indestruc-
tible. Experience shows the contrary in hysteria; as soon as the
hidden—often unconsciously remaining—motives have been revealed
and brought to account, there remains nothing in the hysterical
mental stream that is enigmatical and anomalous.

Thus, by tracing the breaches of the patient’s first statements,

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which are often hidden by “false connections,” one gets hold of a
part of the logical thread at the periphery, and thereafter continues
the route by the pressure procedure.

Very seldom do we succeed in working our way into the inner
strata by the same thread, usually it breaks on the way and yields
either no experience, or one which cannot be explained or be con-
tinued despite all efforts. In such a case we soon learn how to pro-
tect ourselves from the obvious confusion. The expression of the
patient must decide whether one really reached an end or encoun-
tered a case needing no psychic explanation, or whether it is the
enormous resistance that halts the work. If the latter cannot be
overcome soon, it may be assumed that the thread has been followed
into a stratum which is, as yet, impenetrable. One lets it fall in
order to grasp another thread, which may, perhaps, be followed up
just as far. If one had followed all the threads into this stratum, if
the nodes have been reached through which no single isolated thread
can be followed, it is well to think of seizing anew the resistances on
hand.

One can readily imagine how complicated such a work may
become. By constantly overcoming the resistance, one pushes his
way into the inner strata, gaining knowledge concerning the accumu-
lative themes and passing threads found in this layer; one examines
as far as he can advance with the means at hand, and thus gains
first information concerning the content of the next stratum, the
threads are dropped, taken upon again, and followed until they reach
the juncture; they are always retrieved, and by following a memory
fascicle one reaches some by-way which finally opens again. In this
manner it is finally possible to leave the stratifications, and advance
directly on the main road to the nucleus of the pathogenic organi-
zation. With this the fight is won, but not finished. One has to
follow up the other threads and exhaust the material; but now the
patient again helps energetically, for his resistance has mostly been
broken.

In these later stages of the work it is of advantage if one can
surmise the connection and tell it to the patient before it has been
revealed to him. If the conjecture is correct, the course of the
analysis is accelerated, but even an incorrect hypothesis helps, for it
urges the patient to participate and elicits from him energetic refu-
tation, thus revealing that he surely knows better.

One, thereby, becomes astonishingly convinced that it is not

224

possible to press upon the patient things which he apparently does not
know, or to influence the results of the analysis by exciting his expec-
tations. I have not succeeded a single time in altering or falsifying
the reproductions of memory or the connections of events by my pre-
dictions; had I succeeded it surely would have been revealed in the
end by a contradiction in the construction. If anything occurred as
I predicted, the correctness of my conjecture was always attested to
by numerous trustworthy reminiscences. Hence, one must not fear
to express his opinion to the patient concerning the connections
which are to follow; it does no harm.

Another observation which I had occasion to see again and again
refers to the patient’s independent reproductions. It can be asserted
that not a single reminiscence comes to the surface during such an
analysis which has no significance. An interposition of irrelevant
memory pictures which has no connection with the important asso-
ciations, does not really occur. An exception not contrary to the rule
may be postulated for those reminiscences which, though in them-
selves unimportant, are indispensable as intercalations, since the
associations between two closely related reminiscences pass over
them. As mentioned above, the period during which a reminiscence
abides in the narrow pass of the patient’s consciousness is directly
proportionate to its significance. A picture which does not disap-
pear requires further consideration; a thought which cannot be
abolished must be followed further. A reminiscence never recurs if
it has been adjusted, a picture spoken away cannot be seen again.
However, if that does happen, it can be definitely expected that the
second time the picture will be joined by a new content of thought,
that the idea will contain a new inference which will show that no
perfect adjustment has been place. On the other hand, a recurrence
of different intensities, at first vaguely, then quite plainly, often
occurs, but it does not, however, contradict the assertion just
advanced.

If one of the tasks of the analysis is to remove a symptom (pains,
symptoms like vomiting, sensations and contractures), which is
capable of aggravation or recurrence, the symptom shows during the
work the interesting and not undesirable phenomenon of “joining
in the discussion.” The symptom in question reappears, or appears
with greater intensity, as soon as one penetrates into the region of the
pathogenic organization containing the etiology of this symptom, and
it continues to accompany the work with characteristic and instruc-

225

tive fluctuations. The intensity of the same (let us say of a nausea)
increases the deeper one penetrates into its pathogenic reminis-
cences; it reaches its height shortly before the latter has been
expressed, and suddenly subsides or disappears completely for a
while after it has been fully expressed. If through resistance the
patient delays the expression, the tension of the sensation of nausea
becomes unbearable, and if the expression cannot be forced, vomiting
actually sets in. One, thus, gains a plastic impression of the fact
that the vomiting takes the place of a psychic action (here, that of
speaking) just as was asserted in the conversion theory of hysteria.

These fluctuations of intensity on the part of the hysterical symp-
tom recur as often as one of its new and pathogenic reminiscences is
attacked; the symptom remains, as it were, all the time on the order
of the day. If it is necessary to drop for a while the thread upon
which this symptom hangs, the symptom, too, merges into obscurity
in order to emerge again at a later period of the analysis. This play
continues until, through the completion of the pathogenic material,
there occurs a definite adjustment of this symptom.

Strictly speaking, the hysterical symptom does not behave here
differently than a memory picture or a reproduced thought which is
evoked by the pressure of the hand. Here, as there, the adjustment
necessitates the same obsessing obstinacy of recurrence in the memory
of the patient. The difference lies only in the apparent spontaneous
appearance of the hysterical symptom, whereas one readily recalls
having himself provoked the scenes and ideas. But in reality the
memory symbols run in an uninterrupted series from the unchanged
memory remnants of affectful experiences and thinking-acts to the
hysterical symptoms.

The phenomenon of “joining in the discussion” of the hysterical
symptom during the analysis carries with it a practical inconvenience
to which the patient should be reconciled. It is quite impossible to
undertake the analysis of a symptom in one stretch or to divide the
pauses in the work in such a manner as to precisely coincide with the
resting points in the adjustment. Furthermore, the interruption
which is categorically dictated by the accessory circumstances of the
treatment, like the late hour, etc., often occurs in the most awkward
locations, just when some critical point could be approached or when
a new theme comes to light. These are the same inconveniences
which every newspaper reader experiences in reading the daily frag-
ments of his newspaper romance, when, immediately after the

226

decisive speech of the heroine, or after the report of a shot, etc., he
reads, “To be continued.” In our case, the raked-
up, but unabolishe-
theme, the symptom at first strengthened but not yet explained,
remains in the patient’s psyche, and troubles him perhaps more than
before. But the patient must understand this, as it cannot be differ-
ently arranged. Indeed, there are patients who during such an
analysis are unable to get rid of the theme once touched; they are
obsessed by it even during the interval between two treatments,
and as they are unable to advance alone with the adjustment, they
suffer more than before. Such patients, too, finally learn to wait for
the doctor, postponing all interest which they have in the adjustment
of the pathogenic material for the hours of the treatment, and they
then begin to feel freer during the intervals.

The general condition of the patient during such an analysis seems
also worthy of consideration. For a while it remains uninfluenced
by the treatment, expressing the former effective factors, but then a
moment comes in which the patient is “seized,” and his interest
becomes chained, and from that time his general condition becomes
more and more dependent on the condition of the work. Whenever a
new explanation is gained and an important contribution in the chain
of the analysis is reached, the patient feels relieved and experiences
a presentiment of the approaching deliverance, but at each standstill
of the work, at each threatening entanglement, the psychic burden
which oppresses him, grows, and the unhappy sensation of his
incapacity increases. To be sure, both conditions are only tem-
porary, for the analysis continues, disdaining to boast of a moment
of well being, and continues regardlessly over the period of gloomi-
ness. One is generally pleased if it is possible to substitute the
spontaneous fluctuations in the patient’s condition by such as one
himself provokes and understands, just as one prefers to see in place
of the spontaneous discharge of the symptoms that order of the day
which corresponds to the state of the analysis.

Usually the deeper one penetrates into the above described layers
of the psychic structure, the more obscure and difficult the work will
at first become. But once the nucleus is reached, light ensues and
there is no more fear that a strong gloom will overcast the condition
of the patient. However, the reward of the labor, the cessation of
symptoms of the disease can be expected only when the full analysis

227

of every individual symptom has been accomplished; indeed, where
the individual symptoms are connected through many junctures, one
is not even encouraged by partial successes during the work. By
virtue of the great number of existing causal connections every
unadjusted pathogenic idea acts as a motive for the complete creation
of the neurosis, and only with the last word of the analysis does the
whole picture of the disease disappear, very similarly to the behavior
of the individually reproduced reminiscence.

If a pathogenic reminiscence or a pathogenic connection which was
previously withdrawn from the ego-consciousness is revealed by the
work of the analysis and inserted into the ego, one can observe in the
psychic personality which was thus enriched, the many ways in which
it gave utterance to its gain. Especially does it frequently happen
that after the patients have been painstakingly forced to a certain
knowledge, they say: “Why I have known that all the time, I could
have told you that before.” Those who have more insight recognize
this afterwards as a self-deception and accuse themselves of ingrati-
tude. In general the position that the ego takes towards the new
acquisition depends upon the stratum of the analysis from which the
latter originates. Whatever belongs to the outermost layers is recog-
nized without any difficulty, for it always remained in the possession
of the ego, and the only thing that was new to the ego was its con-
nection with the deeper layers of the pathogenic material. Whatever
is brought to light from these deeper layers also finds appreciation
and recognition, but frequently only after long hesitation and reflec-
tion. Of course, visual memory pictures are here more difficult to
deny than reminiscences of mere streams of thought. Not very
seldom the patient will at first say, “It is possible that I thought of
that, but I cannot recall it,” and only after a longer familiarity with
this assumption recognition will appear. He then recalls and even
verifies by side associations that he once really had this thought.
During the analysis I make it a point of considering the value of an
emerging reminiscence independently of the patient’s recognition.
I am not tired of repeating that we were obliged to accept everything
that we bring to light with our means. Should there be anything
unreal or incorrect in the material thus revealed, the connection will
later teach us to separate it. I may add that I rarely ever have
occasion to subsequently withdraw the recognition from a reminis-
cence which I had preliminarily admitted. In spite of the deceptive

228

appearance of an urgent contradiction, whatever came to the surface
finally proved itself correct.

Those ideas which originate in the deepest layer, and from the
nucleus of the pathogenic organization, are recognized by the patient
as reminiscences only with the greatest difficulty. Even after every-
thing is accomplished, when the patients are overcome by the logical
force and are convinced of the curative effect accompanying the
emergence of this idea—I say even if the patients themselves assume
that they have thought “so and so,” they often add, “but to recall,
that I have thought so, I cannot.” One readily comes to an under-
standing with them by saying that these were unconscious thoughts.
But how should we note this state of affairs in our own psychological
views? Should we pay no heed to the patient’s demurring recog-
nition, which has no motive after the work has been completed;
should we assume that it is really a question of thoughts which
never occurred, and for which there was only a possibility of exist-
ence, so that the therapy consisted in the consummation of a psychic
act, which at that time was omitted? It is obviously impossible to
state anything about it, that is, to state anything concerning the
condition of the pathogenic material previous to the analysis, before
one has thoroughly explained his psychological views, especially con-
cerning the essence of consciousness. It is, however, a fact worthy
of reflection that in such analyses one can follow a stream of thought
from the conscious into the unconscious (that is, absolutely not
recognized as a reminiscence), thence draw it for some distance
through consciousness, and again see it end in the unconscious;
and yet this alteration of the “psychic elucidation” would change
nothing in it, in its logic, and in the connection of its single parts.
Should I then have this stream of thought freely before me, I
could not conjecture what part was, and what part was not, recog-
nized by the patient as a reminiscence. In a measure I see only the
points of the stream of thought that merge into the unconscious, just
the reverse of that which has been claimed concerning our normal
psychic processes.

I have still another theme to treat which plays an undesirably
great part in the work of such a cathartic analysis. I have already
admitted the possibility that the pressure procedure may fail, and
despite all assurance and urging it may evoke no reminiscences. I

229

also stated that two possibilities are to be considered, there is really
nothing to evoke, in the place where we investigate,—that can be
recognized by the perfectly calm expression of the patient—or, we have
struck against a resistance to be overcome only at some future time.
We are confronted with a new layer into which we cannot as yet
penetrate, and this can again be read from the drawn and psychic
exertion of the patient’s expression. A third cause may be possible
which also indicates an obstacle, not from within, but externally.
This cause occurs when the relation of the patient to the physician
is disturbed, and signifies the worst obstacle that can be encountered.
One can expect this in every more serious analysis.

I have already alluded to the important rôle falling to the per-
sonality of the physician in the creation of motives which are to over-
come the psychic force of the resistance. In not a few cases, especially
in women and where we deal with explanations of erotic streams of
thoughts, the coöperation of the patients becomes a personal sacrifice
which must be recompensed by some kind of a substitute for love.
The great effort and the patient friendliness of the physician must
suffice for such substitutes. If this relation of the patient to the
physician is disturbed, the readiness of the patient’s collaboration
fails; if the physician desires information concerning the next patho-
genic idea, the patient is confronted by the consciousness of the
unpleasantness which has accumulated in her against the physician.
As far as I have discovered, this obstacle occurs in three principal
cases:

1. In personal estrangement, if the patient believes herself
slighted, disparaged and insulted, or if she hears unfavorable
accounts concerning the physician and his methods of treatment.
This is the least serious case. This obstacle can readily be overcome
by discussion and explanation, although the sensitiveness and the
suspicion of hysterics can occasionally manifest itself in unimag-
inable dimensions.

2. If the patient is seized with the fear that she is becoming too
dependent on her physician, that in his presence she loses her inde-
pendence and could even become sexually dependent upon him; this
case is more significant because it is less determined individually.
The occasion for this obstacle lies in the nature of the therapeutic
distress. The patient has now a new motive for resistance which
manifests itself not only in a certain reminiscence, but at each attempt
of the treatment. Whenever the pressure procedure is started, the

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patient usually complains of headache. Her new motive for the
resistance remains for the most part unconscious, and she manifests
it by a newly created hysterical symptom. The headache signifies
the aversion towards being influenced.

3. If the patient fears lest the painful ideas emerging from the
content of the analysis would be transferred to the physician. This
happens frequently, and, indeed, in many analyses it is a regular
occurrence. The transference to the physician occurs through false
connections. I must here give an example. The origin of a certain
hysterical symptom in one of my hysterical patients was the wish she
entertained years ago which was immediately banished into the
unconscious, that the man with whom she at that time conversed
would heartily grasp her and force a kiss on her. After the ending
of a session such a wish occurred to the patient in reference to me.
She was horrified and spent a sleepless night, and at the next session,
although she did not refuse the treatment she was totally unfit for
the work. After I had discovered the obstacle and removed it, the
work continued. The wish that so frightened the patient appeared
as the next pathogenic reminiscence, that is, as the one now required
by the logical connection. It came about in the following manner:
The content of the wish at first appeared in the patient’s conscious
ness which would have transferred this wish into the past. Through
the associative force prevailing in her consciousness the existing wish
became connected with my own person, with which the patient could
naturally occupy herself, and in this mesalliance-
connection–the same affect awakened which originally urged the
patient to banish this clandestine wish. Now that I have discovered
this, I can presuppose in every similar claim on my personality that
this is another transference and false connection. It is remarkable
how the patient falls a victim to deception on every new occasion.
No analysis can be brought to an end if one does not know how
to meet the resistances resulting from the causes mentioned. The
way can be found if one bears in mind that the new symptom pro-
duced after the old model should be treated like the old symptoms.
In the first place it is necessary to make the patient conscious of the
obstacle. In one of my patients, in whom I had cause to assume an
unconscious idea like the one mentioned above in 2, I met it for the
first time with an unexpected attack. I told her that there must
have originated some obstacle, and then pressed her head. She then

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said, surprisingly, “I see you sitting here on the
nonsense, what can that mean?”–But now I could explain it.

In another patient the obstacle did not usually show itself directly
on pressure, but I could always demonstrate it by taking the patient
back to the moment in which it originated. The pressure procedure
never failed to bring back this moment. By discovering and demon-
strating the obstacle, the first difficulty was removed, but a greater
one still remained. The difficulty lay in inducing the patient to give
information where there was an obvious personal relation and where
the third person coincided with the physician. At first I was very
much annoyed about the increase of this psychic work until I had
learned to see the lawful part of this whole process, and I then also
noticed that such a transference does not cause any considerable
increase in the work. The work of the patient remained the same,
she perhaps had to overcome the painful affect of having entertained
such a wish, and it seemed to be the same for the success whether
she took this psychic repulsion as a theme of the work in the historical
case or in the recent case with me. The patients also gradually
learned to see that in such transferences to the person of the physician
they generally dealt with a force or a deception which disappeared
when the analysis was accomplished. I believe, however, that if I
should have delayed in making clear to them the nature of the
obstacle, I would have given them a new, though a milder, hysterical
symptom for another spontaneously developed.

I now believe that I have sufficiently indicated how such analyses
should be executed, and the experiences gained from them. They
perhaps make some things appear more complicated than they are,
for many things really result by themselves during such work. I
have not enumerated the difficulties of the work in order to give the
impression that in view of such requirements it does not pay the
physician or patient to undertake a cathartic analysis except in the
rarest cases. However, in my medical activities I am influenced by
contrary suppositions.–To be sure, I am unable to formulate the
most definite indications for the application of the therapeutic method
discussed here without entering into the valuation of the more
significant and more comprehensive theme of the therapy of the
neuroses in general. I have often compared the cathartic psycho-
therapy to surgical measures, and designated my cures as psycho-

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therapeutic operations; the analogies follow the opening of a pus
pocket, the curetting of a carious location, etc. Such an analogy
finds its justification, not so much in the removal of the morbid
material as in the production of better curative conditions for the
issue of the process.

When I promised my patients help and relief through the
cathartic method, I was often obliged to hear the following objections,
“You say, yourself, that my suffering has probably much to do with
my own relation and destinies. You cannot change any of that. In
what manner, then, can you help me?” To this I could always
answer: “I do not doubt at all that it would be easier for fate than
for me to remove your sufferings, but you will be convinced that
much will be gained if we succeed in transforming your hysterical
misery into everyday unhappiness, against which you will be better
able to defend yourself with a restored nervous system.”