75

CHAPTER IV.

THE PSYCHOTHERAPY OF HYSTERIA.¹⁾

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 prac-
tical significance. “We found, at first to our very greatest sur-
prise, that the individual hysterical symptoms immediately disap-
peared without returning if we succeeded in thoroughly awakening
the memories of the causal process with its accompanying effect,
and if the patient circumstantially discussed the process giving
free play to the affect” (p. 4).

We furthermore attempted to explain how our psychothera-
peutic method acts. “It does away with the effects of the original
not ab-reacted to ideas by affording an outlet to the suppressed
affect through speech. It brings it into associative correction by
drawing it into normal consciousness (in mild hypnosis), or it is
done away with through the physician’s suggestions just as hap-
pens in somnambulism with amnesia” (p. 13).

Although the essential features of this method have been enu-
merated 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 adhere to the “Preliminary
Communication,” but I must confess that after continuous occu-
pation for years with the problems therein touched, I was con-
fronted with new views, 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. I therefore
take the weight of responsibility upon myself.

In attempting to use Breuer’s method of treating hysterical
symptoms in a great number of patients by investigation and

¹⁾Breuer u. Freud, Studien ueber Hysterie, 1895.

76

ab-
reaction in hypnosis, I encountered two obstacles, the pursuit
of which led me to change the technique as well as the concep-
tion. (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 question
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 diffi-
cult 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 remaining for 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 diag-
nosis of hysteria the therapeutic results were very poor, and even
the analysis revealed nothing of importance. At other times I
attempted to treat cases which no one took for hysteria by
Breuer’s method, and I found that I could influence them, and
even cure them. Such, for example, was my experience with
obsession, the real obsessions of Westphal’s type, cases which
did not show a single feature of hysteria. Thus the psychic
mechanism revealed in the “Preliminary Communication” could
not be pathognomonic of hysteria. Nor could I for the sake of
this mechanism throw so many neuroses into the same pot with
hysteria. From all the investigated 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 diagnosis of hysteria to be dependent upon the
result of this investigation.

It thus happened that, proceeding from Breuer’s methods, I
occupied myself mostly with the etiology and the mechanism of
the neuroses. After a relatively brief period I was fortunate in
obtaining useful results. I then became cognizant of the fact
that if we may speak of a reason for the acquirement of neuroses

77

the etiology must be sought for in the sexual moments. This
agrees with the fact that, generally speaking, various sexual
moments may also produce various pictures of neurotic disease.
Similarly we now venture to employ the etiology for the char-
acteristics of the neuroses, and build up a sharp line of demar-
cation between the morbid pictures of the neuroses. If the
etiological characters constantly agreed with the clinical ones, this
was justified.

In this way it was found that neurasthenia really corresponds
to a monotonous morbid picture in which, as shown by the anal-
ysis, “psychic mechanisms” play no part. From neurasthenia
we sharply distinguished the compulsion neurosis (Zwangsneu-
rose) [obsessions, doubts, impulses], the neurosis of the genuine
obsessions, in which we can recognize a complicated psychic
mechanism, an etiology resembling the one of hysteria, and a
far reaching possibility of an involution by psychotherapy. On
the other hand it seemed to me undoubtedly imperative to sepa-
rate from neurasthenia a neurotic symptom complex which de-
pends on a totally divergent, strictly speaking, on a contrary
etiology. The partial symptoms of this complex have been recog-
nized by E. Hecker¹⁾ as having a common character. They are
either symptoms, or equivalents, or rudiments of anxiety mani-
festations, and it is for that reason that this complex, so dif-
ferent from neurasthenia, was called by me anxiety neurosis. I
maintain that it originates from an accumulation of physical ten-
sion which is in turn of a sexual origin. This neurosis, too, has
no psychic mechanism, but regularly influences the psychic life,
so that among its regular manifestations we have anxious ex-
pectations, phobias, hyperesthesias to pain, and other symptoms.
This anxiety neurosis, as I take it, certainly corresponds in part
to the neurosis called hypochondria, which in same features re-
sembles hysteria and neurasthenia. Yet in none of the earlier
works can I consider the demarcation of this neurosis as correct,
and moreover, I find that the usefulness of the name hypo-
chondria 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 at-

¹⁾E. Hecker, Centralblatt für Nervenheilkunde, Dec., 1893.

78

tention to the commonly occurring cases of neuroses which enter
into the diagnosis of hysteria. I now said to myself that it would
not do to mark a neurosis as hysterical on the whole, merely
because its symptom complex evinced some hysterical signs. I
could readily explain this practice by the fact that hysteria is
the oldest, the most familiar, and the most striking neurosis
under consideration, but still it was an abuse which allowed the
placing of many features of perversion and degeneration under
the caption of hysteria. Whenever a 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 diagnosis was incorrect, it is also certain that
our classification must be made from the neurotic standpoint,
and as we know neurasthenia, anxiety neurosis, and similar con-
ditions in the pure state, there is 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
“Zwangsneurose” (obsessions, doubts, impulses) are rare, they
are usually combined with an anxiety neurosis. This frequent
occurrence of mixed neuroses is due to the fact that their etio-
logical moments are frequently mixed, now only accidentally, and
now in consequence of a causal relation between the processes
which give rise to the etiological moments of the neuroses. This
can be sustained and proven in the individual cases without any
difficulty. But it follows from this that it is hardly possible to
take hysteria out of connection with the sexual neuroses, that
hysteria as a rule presents only one side, one aspect of the com-
plicated 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 conception of the clinical dependence of

79

hysteria. Breuer’s patient, Anna O.,²⁾ seems to contradict this
and exemplifies a pure hysterical disease. Yet this case, which
became so fruitful for the knowledge of hysteria, was never con-
sidered 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 a 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 today 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, which was due to sexual abstinence
and was combined with hysteria.

The third case, Miss Lucy R., could perhaps be called the first
borderline case of pure hysteria. It is a short episodic hysteria
based on an unmistakably sexual etiology. It corresponds 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,³⁾ is really a model of what I have called
virginal anxiety; it is a combination of an anxiety neurosis and
hysteria, the former produces 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 neuras-
thenia at its base 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
was due to the fact that they were older
cases in which I had not as yet carried out the purposed and
urgent investigation for the neurotic sexual subsoil. Moreover
the reason for my reporting four instead of twelve cases of

²⁾See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 15.

³⁾See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 106.

80

hysteria, the analysis of which would have confirmed our claims
of psychic mechanism for hysterical phenomena, is due to one
circumstance, namely, that the analysis of these cases would have
simultaneously revealed them as sexual neuroses, though surely
no 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 to it “ideogenous” symptoms only, and
that I attribute the somatic symptoms, like hysterogenic points
and anesthesias to the anxiety neurosis. None of these state
ments are true. I believe that hysteria, purified of all admix-
tures, 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 away with the whole diseased state, and
even if the 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 picture of the mixed neuroses from neurasthenia, anxiety
neurosis, etc., for after this separation I can express concisely the
therapeutic value of the cathartic method. I would venture to
assert that—principally—it can readily dispose of any hysterical
symptom, whereas, as can be easily understood, it is perfectly
powerless in the presence of neurasthenic phenomena, and can
only seldom, and 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.

Another limitation placed on the efficacy of the cathartic method
we have already mentioned in our “Preliminary Communication.”
It does not influence the causal determinations of hysteria, and
hence it can not prevent the origin of new symptoms in the place
of those removed. Hence, on the whole, I must claim a promi-
nent place for our therapeutic method in the realm of the therapy

81

THE PSYCHOTHERAPY OF HYSTERIA.

of neuroses, but I would caution against attaching any impor-
tance 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 preceding statements
are put on a level with the deferred reference to a later com-
munication; 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 con-
sideration, just as the surgeon puts aside all cases who die as a
result of narcosis, hemorrhage, accidental sepsis, etc., when decid-
ing upon a new technique. I will again consider the failures of
such origin in my later discussions on the difficulties and draw-
backs of this method.

2. The cathartic method does not become valueless simply
because it is symptomatic and not causal. 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. To do this it
requires, as a rule, a second agent, and in cases of hysteria the
cathartic method is really unsurpassable for such purposes.

3. Where the period of hysterical production, or the acute
hysterical paroxysm, has subsided, and the only remnant mani-
festations left are hysterical symptoms, the cathartic method ful-
fills all indications, and achieves a full and lasting success. Such
a favorable constellation for the therapy does not seldom result
on the basis of the sexual life, in consequence of the marked
fluctuations in the intensity of the sexual desire and the com-
plications of the required determination for a sexual trauma.
Here the cathartic method accomplishes all that is required of it,
for the physician can not resolve to change a hysterical con-
stitution. 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
satisfied if the patient will again become capacitated. Moreover,
he can have some hopes for the future, if the possibility of a

82

relapse be considered, for he knows the main character of the
etiology of the neuroses, namely, that their origin is mostly over-
determined, and that many moments must unite to produce this
result. He can hope that this union will not take place very soon,
if individual etiological moments remain 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 the fact that such spon-
taneous 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 spontaneous recovery, or incidentally also, that which would
not cease spontaneously, that question may surely be left open for
the present.
4. Where we encounter an acute hysteria during the most
acute production of hysterical symptoms, and the consecutive
overwhelming of the ego by the morbid products (hysterical
psychosis), even the cathartic method will change little the ex-
pression and course of the disease. One finds himself in the
same position to the neurosis as the doctor to an acute infectious
disease. For some time past, now beyond the reach of influence,
the etiological moments exerted a sufficient amount of effect,
which becomes manifest after overcoming the interval of incu-
bation. The affection can not 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 im-
pression of fruitless effort, the enormous expenditure 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 famil-
iar as in the analogous case of an acute infectious disease; these,
and many other things, will probably make almost impossible
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
product does not exercise a curative influence by supporting the

83

normal ego which is occupied with the defense, and thus prevent
ing 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 un
doubtedly evident from the case of Anna O., in which Breuer
first learned to exercise this process.⁴⁾

5. Where we deal with chronic progressive hysterias with
moderate or continued productions of hysterical symptoms, we
learn to regret the lack of a causally effective therapy, but we
also learn to value the indications of the cathartic method as a
symtomatic remedy. We then deal with an injury produced by
an etiology which continue to act chronically. We have to
strengthen the capacity for resistance of the nervous system of
our patient, and we must bear in mind that the existence of an
hysterical symptom signifies a weakening of resistance of the
nervous system, and represents a predisposing moment. 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
penetrated represents the weak spot which can be penetrated
again. The split off psychic group plays the part of the pro
voking crystal from which a formerly omitted crystallization
emerges with great facility. To remove the already existing
symptoms, to do away with the psychic alterations lying at their
basis, is to return to the patients the full measure of their resist
ance 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.”

6. I still have to mention the apparent contradiction arising
between the admission that not all hysterical symptoms are psy
chogenic, and the assertion that they can all be removed by
psychotherapeutic procedures. The solution lies in the fact that
some of these non-psychogenic symptoms, though they represent
morbid symptoms, as, for instance, the stigmata, should never-
theless not be designated as affections, and hence it can not be

⁴⁾See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 15.

84

practically noticed even if they remain after the treatment is
finished. Other symptoms of a similar nature seem to be taken
along indirectly by the psychogenic symptoms, for indirectly they
really depend on some psychic causation.

I shall now mention those difficulties and inconveniences of
our therapeutic method which are not evident from the preceding
histories, or from the following remarks concerning the tech-
nique of the method.–I will rather enumerate and indicate than
carry them out. The process is toilsome and wearisome for the
physician, it presupposes a profound interest for psychological
incidents, as well as a personal sympathy for the patient. I could
not conceive myself entering deeply into the psychic mechanism
of a hysteria in a person who appeared to me common and dis-
agreeable, and who would not, on closer acquaintanceship, be able
to awaken in me human sympathy; whereas I can well treat a
tabetic or a rheumatic patient regardless of such personal liking.
Not less are the requisites on the patient’s side. The process is
especially inapplicable below a certain niveau of intelligence. It
is rendered extremely difficult whenever there is any tinge of
weakmindedness. It requires the full consent and the 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 become
cognizant whither his investigations tend; to them the physician
remains a stranger. In others who have determined to give
themselves up to the physician and bestow their confidence upon
him, something usually 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 prominent, 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 made possible. I do not believe that it makes any
essential difference in this condition whether we make use of
hypnosis or have 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. It is much more evident that they are formed

85

in the preliminary states of the neuroses to be cured, and that
they then attach themselves to every medical activity which in-
tensively concerns itself with the patient, and produce in him a
psychic change. I could see no harm or danger in the applica-
tion of hypnosis even in those cases where it was used excess-
ively. The causes for the harm produced lay elsewhere and
deeper. When a 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 therapeutic
means. On the whole it was, as expressed in the “Preliminary
Communication,” “a distinct therapeutic gain.”

I must mention still another gain in the application of this
method. No severe case of complicated neurosis, with either an
excessive or slight tinge of hysteria can be 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
disappears first, while the rest of the manifestations I meanwhile
learn to interpret and refer to their etiology. I thereby gained
the essential factors indicated by the instrument of the therapy of
the neurosis in question. When I think of the usual 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. I have
furthermore made it a practice of applying the cathartic psycho-
therapy in conjunction with a rest cure, which when required is
changed to a full Weir–Mitchell treatment. This advantage lies
in the fact that, on the one side I avoid the very disturbing in-
trusion of new psychic impressions produced during psycho-
therapy; on the other hand, I exclude the monotony of the Weir–
Mitchell treatment, during which the patient not seldom merges
into harmful reveries. One might expect that the very consider-
able psychic labor often imposed upon the patient during the
cathartic cure, and the excitement resulting from the reproduc-
tion of traumatic events, would run counter to the sense of the
Weir–Mitchell rest cure, and would prevent the successes which
one is wont to obtain from it. But the contrary happens; through
the combination of the Breuer and the Weir–Mitchell therapy, we

86

obtain all the physical improvements which we expect from the
latter, and such marked psychic improvement as never occurs in
the rest cure without psychotherapy.

II.

I will now add to my former observations that in attempting
to use Breuer’s method in greater latitude I met this difficulty—
although the diagnosis was hysteria, and the probabilities spoke
in favor of the prevalence of the psychic mechanism described by
us, yet a number of patients could not be put into the hypnotic
state. The hypnosis was necessary to broaden consciousness so
as to find the pathogenic reminiscences which do not exist in the
ordinary consciousness. I, therefore, was forced to either give
up such patients, or to 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,
as they even refused to submit to hypnosis. The idea then oc-
curred to me that both cases might be identical, and that in both
it might merely be an unwillingness. Those who entertain a psy-
chic inhibition against hypnotism are not hypnotizable, it makes
no difference whether they utter their unwillingness or not. It is
not fully clear to me whether I can firmly adhere to this concep-
tion or not.

It was, therefore, important to avoid hypnotism and yet to
obtain the pathogenic reminiscences. This I attained in the fol-
lowing 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
awakening the apparently forgotten impressions obtained during
somnambulism (see the case of Miss Lucy). I urged them by
assuring them that they did know it, and that they will recall it,
etc., and thus some thought of something, while in others the
recollections were further. I became still more pressing, I

87

ordered the patient to lie down and voluntarily shut his eyes so
as to “concentrate” his mind, causing thereby at least a certain
similarity to hypnosis, and I then discovered that without any
hypnosis there emerged new and retrospective reminiscences
which probably belonged to our theme. Through such experi-
ences I gained the impression that through urging alone it would
really be possible to bring to light the definitely existing patho-
genic series of ideas; and as this urging necessitated much exer-
tion on my part, and showed me that I had to overcome a resist-
ance, 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). It then became clear
to me that this must really be the same psychic force which
assisted in the origin of the hysterical symptom, and at that time
prevented the pathogenic idea from becoming conscious. What
kind of effective force could here be assumed, 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 re-
pressed ideas. From these I could judge the general character
of such ideas. They were altogether of a painful nature adapted
to provoke the affects of shame, reproach, of psychic pain, and
the feeling of injury; they were altogether of that kind which one
would not like to experience and prefers to forget.

From all these the thought of defense resulted as if simul-
taneously. Indeed, it is generally admitted by all psychologists
that the assumption of a new idea (assumption in the sense of
belief, judgment of reality), depends on the mode and drift of
the ideas already united in the ego. For the process of the
censor, to which the newly formed ideas are subjected, special
technical names have been created. An idea entered into the ego
of the patient which proved to be unbearable and evoked a power
of repulsion on the part of the ego, the purpose of which was a
defense against this unbearable idea. This defense actually suc-
ceeded, and the idea concerned was crowded out of conscious-
ness and out of the 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 perceived as a

88

resistance the same force which showed itself as 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 also–the fact
of conversion–can be made clear.

Hence, a psychic force, the repugnance of the ego, has origi-
nally crowded the pathogenic idea from the association, and now
opposes its return into the memory. The not knowing of the
hysterics was really a–more or less conscious–not willing to
know, and the task of the therapeutist was to overpower this
resistance of association by psychic labor. Such accomplishment
is, above all, brought about by “urging,” that is, by applying a
psychic force in order to direct the attention of the patient on the
desired traces of ideas. It does not, however, stop here, but as I
will show, it assumes new form 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 sen-
tences 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 strug-
gle between motives of diverse force and intensity. The urging
of the strange and inexperienced physician does not suffice for
the “association resistance” in a grave hysteria. One must re-
sort to more forceful means.

In the first place I make use of a small technical artifice. I
informed the patient that I will in the next moment 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 oblige him to communicate to me this picture
or this thought, no matter what it may be. He is not supposed
to hold it back because he may perhaps 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 reserve on account of affect
or disregard. Only thus could we find the things desired, and

89

only thus have we unfailingly found them. I then exert pressure
for a few seconds on the forehead of the patient lying in front
of me, and after stopping the pressure, I ask in a calm tone, as
if any disappointment is out of the question, “What have you
seen?” or, “What occurred to your mind?”

This method⁵ 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 grasping of his head between my two hands, is the most
suggestive and most convenient thing that I could undertake for
this end. To explain the efficacy of this artifice, I may perhaps
say that it corresponds to a “momentary reenforced hypnosis”;
but the mechanism of hypnosis is so enigmatical to me that I
would not like to refer to it as an explanation. I rather think
that the advantage of the process lies in the fact that through it
I dissociate the attention of the patient from his conscious quest
and reflection, in brief, from everything upon which his will can
manifest itself. This resembles the process of staring at a crys-
tal globe, etc. The fact, that under the pressure of my hand
there always appears that which I am looking for teaches that the
supposedly forgotten pathogenic ideas always lie ready, “close
by,” being attainable through easily approachable associations, and
all that is necessary is to clear away some obstacle. This obstacle
again seems to be the person’s will, and different persons learn
to discard their premeditations and to assume a perfectly objec-
tive attitude toward 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 frequently an idea comes to the surface which is a link be-
tween the starting idea and the desired pathogenic one 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 the
pathogenic idea exists. The pressure, therefore, has really not
revealed the pathogenic idea, which, if torn from its connections
without any preparation, would be incomprehensible; but it has

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

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shown the way to it, and indicated the direction 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 be-
comes torn on the road to the pathogenic idea, all that is neces-
sary 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 remi-
niscence well known to the patient, which appearance, however,
causes him surprise because he had forgotten its relation to the
starting idea. In the further course of the analysis this relation
becomes clear. From all these results of the pressure one re-
ceives a delusive impression of a superior intelligence external
to the patient’s consciousness, which systematically holds a large
psychic material for definite purposes, and has provided an in-
genious arrangement for its return into consciousness. I pre-
sume, however, that this unconscious second intelligence is really
only apparent.

In every complicated analysis one works repeatedly, nay, con-
tinuously, with the help of this procedure (pressure on the fore-
head), which leads us from the place where the patient’s con-
scious reconductions become interrupted, showing us the way
over reminiscences which remained known, and calling our atten-
tion to connections which have merged into forgetfulness. It
also evokes and connects memories which have for years been
withdrawn from the association, but can still be recognized as
memories; and finally, as the highest performance of reproduc-
tion, 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 demanded by the
connection, and is convinced that just these ideas cause the termi-
nation of the analysis and the cessation of the symptoms.

I will now attempt to give a series of examples showing the
excellent achievements of this procedure. I treated a young
lady who suffered for six years from an intolerable and pro-
tracted 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 to be powerless,
and I therefore attempted to remove the symptom by psycho-

91

analysis. All that she could remember 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 after helping her with the
pressure, 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 continued her
story. “The cough disappeared when I left my aunt, but reap-
peared a year and half later.”–“What was the reason for it?”
–“I do not know.”–I again exerted some pressure on the fore-
head, 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 and loved her.
That was, therefore, 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.

Some time ago I attempted to relieve an elderly lady of her
anxiety attacks, which considering their characteristic qualities,
were hardly adapted to such influence. 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 cru-
cifix which she hid in her hand. Her attacks of anxiety, which
bore the hysterical character, could be traced to her early girl-
hood, and were supposed to have originated from the application
of an iodine preparation used to reduce a moderate swelling of
the thyroid. I naturally repudiated this origin and sought to sub-
stitute it by another which was in better harmony with my views
concerning the etiology of neurotic symptoms. To the first

92

question for an impression of her youth which would stand in
causal connection to the attacks of anxiety, there appeared under
the pressure of my hand the reminiscence of reading a so called
devotional book wherein piously enough there was some mention
of the sexual processes. The passage in question made an im-
pression 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. A second pressure on the
forehead of the patient evoked the next reminiscence, it referred
to her brother’s teacher who showed her great respect, and for
whom she entertained a warmer feeling. This reminiscence cul-
minated 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 coin-
cidently used iodine. In what other way could I have succeeded
in revealing in this obstinate patient, prejudiced against me and
every worldly remedy, such a connection contrary to her own
opinion and assertion?

On another occasion I had to deal with a young happily mar-
ried 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 members, opened mouth, and protruding tongue. Sim-
ilar 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 dur-
ing 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 her bed, the grandmother who lived with
them at the time, and one of her governesses whom she dearly
loved. There was then a succession of small, quite indifferent
scenes, in these rooms, and among these persons, the conclusion
of which was the leave taking of the governess who married from
the home. I did not know what to start with these reminis-

93

cences; I could not bring about any connection between them and
the etiology of the attacks. To be sure the various circumstances
were recognized as having occurred at the same time at which
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 phy-
sician. From him I obtained the following explanation: At the
time that he treated the mature and physically very well devel-
oped girl for these first attacks, he was struck by the excessive
affection in the relations between her and her 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 governess 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 pres-
sure procedure, follow in very remarkable form, and under cir-
cumstances which make the assumption of an unconscious intel-
ligence appear even more alluring. Thus I recall a lady who
suffered for years 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 resist-
ance. 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 have dealt with a new mode of replying, and by repeated pres-

94

sure I evoked the following 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 an attack of frenzy 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, could nevertheless be
used as a continuation of the story, and as an appendix to a sec-
ond. 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 pecu-
liarity of this case lies only in the appearance of single catch
words which we had to elaborate into sentences, for the irrele-
vance and incoherence found in these oracle like uttered words
adhere to all ideas and scenes which generally occur as a result
of pressure. On further investigation it is regularly found that
the seemingly disconnected reminiscences are connected by close
streams of thought, and that they lead quite directly to the
desired pathogenic moment.

With pleasure do I therefore recall a case of analysis in which
my confidence in the results of pressure was 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 situated in the abdominal
wall and was due to palpable muscular hardening, and I ordered
local treatment.

After months I again saw the patient, who said that “the
former pain disappeared after following the treatment and re-
mained away a long time, but now it has 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,

95

in the morning on awakening, 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, in a state of concentration
and under the pressure of my hand, I asked her whether any-
thing occurred to her, or whether she saw anything, she began to
describe her visual pictures. She saw something like a sun with
rays, which I naturally had to assume to be a phosphène pro-
duced by pressure on the eyes. I expected that the useful pic-
tures 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 cross which was inclined,
the edges of which were surrounded by a subdued moonlike light
in which all the pictures thus far seen were shining, and upon the
arm there flickered a little flame that was apparently no longer a
phosphène. 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, say-
ing, 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 primitive force; she then
saw a gigantic lizard which she examined quizzically but without
fear; then a heap of snakes, then another sun but with mild sil-
very 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

96

yourself? Are you dissatisfied with you-
self? “Since when?”— “Since I became a member of the Theosoph-
ical Society and read the writings edited by it. I have always
had a poor opinion of myself.”— “What was is that made the
last strongest impression upon you?”— “A translation from the
Sanskrit which now appears in serial numbers.” A minute later
I was initiated into her mental conflicts, and into her self re-
proaches. 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.

I have thus far so warmly praised the achievements of the pres-
sure procedure, and have so entirely neglected the aspect of the
defense or the resistance, that I certainly must have given the
impression that by means of this small artifice one is placed in
position to become master of the psychic resistance against the
cathartic cure. 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, great change requires much effort.
The pressure procedure is nothing but a trick serving to surprise
for awhile the defensive ego, which in all graver cases recalls
its intentions and continues its resistance.

I need only recall the various forms in which this resistance
manifested itself. In the first place, the pressure experiment
usually fails the first or second time. The patient then expresses
himself disappointed, saying, “I believed that some idea would
occur to me, but I only thought so; as attentive as I was 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 how completely the patients—even
the most tractable and the most intelligent—can forget the agree-
ment which they have previously entered into. They have prom-
ised to tell everything that occurs to them under the pressure of
the hand, be it closely related to them or not, and whether it is
agreeable to them to say it or not; that is, they are to tell every-
 

97

thing without any choice, or influence by critique 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 needs not believe
them, and one must always assume, and also say, that they hold
back something because they believe it to be unimportant, or per-
ceive it as painful. One must insist, repeat the pressure, and
assume an assured attitude until one really hears something.
The patient then 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 spare myself from 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 not help
offering 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 disturb me,” they say. I be-
came accustomed to answer to that, “Not at all, you simply
struck against something that you do not willingly wish 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 is it to be
feared that the patient arranges what comes to his mind, and dis-
torts 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. “Something
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 in-
troduction 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 reap-
pearance 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-
nized by the fact that they are designated by the patient as unes-

98

sential, and yet are only uttered with resis-
tance. There are also
cases where the patient seeks to disavow the recollections, even
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 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 explain to the patient that these are only forms and subter-
fuges 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 obses-
sions. Once the picture emerges from the memory we can hear
the patient state that as he proceeds to describe it, it proportion-
ately fades away and becomes indistinct; the patient wears it out,
so to speak, by transforming it into words. We then orient our
selves through the memory picture itself in order to find the di-
rection 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 something.” 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 some-
thing 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 is 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

99

resistance. To be sure, it may happen under certain conditions
that the procedure may 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 was of somatic origin. In these cases the pa-
tient equally insists that nothing occurred to him, and he is right.
We should strive to avoid doing an injustice 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 for the purpose of defense. The differ-
ential diagnostic application of the pressure procedure is really
based on such experiences.

We can see, therefore, that even with the help of the 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 what direction to investigate, and what things we
have to force upon the patient. For some cases that suffices,
for the question is really to find the secret, and tell it to the pa-
tient, so that he is usually then 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 pic-
tures came 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 by the pressure procedure. It
usually lacks the essential part, the relations to the person or to
the theme, and for that reason the picture remained incomprehen-
sible. 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 carelessly, only much later he adds to
this torso the head, and thereby betrays a person and a relation-
ship. Or, he relates a reminiscence of his childhood about two
boys whose forms are very indistinct, and to whom a certain mis-

100

chievousness was attributed. It required many months and con-
siderable progress in the course of the analysis before he again
saw this reminiscence and recognized one of the children as him-
self and the other as his brother. What means have we now at
our disposal to overcome this continued resistance?

We have but few, yet we have almost all those by which one
person exerts a psychic influence on the other. In the first place
that psychic resistance, especially of long con-
tinuance, 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, caus-
ing 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 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
timorousness, as a teacher, as a representative of a freer and
more superior world-conception, and as confessor, who through
the continuance of his sympathy and his respect, imparts, so to
say, absolution after the confession. One endeavors to do some-
thing humane for the patient in so 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 approximately discovered the nature
of the case and the motives of the defense here effective. For-
tunately the technique of the urging and the pressure procedure
take up 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 himself of an
hysterical symptom only after reproducing and uttering under
emotion its causal pathogenic impression, yet the therapeutic task
merely consists in inducing him to do it, and once the task has

101

been accomplished there remains nothing for the doctor to cor-
rect 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 difficulties are encountered in opening the
door.

Among the intellectual motives employed for the overcoming of
the resistance one can hardly dispense with one affective moment,
that is, the personal equation of the doctor, and in a number of
cases this alone will be able to break the resistance. The condi-
tions 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 assistance of this personal moment.

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 everybody will wish to ask whether it would not be more
suitable, instead of all these tortures, to apply oneself more ener-
getically to hypnosis, or to limit the application of the cathartic
method to only such cases as can be placed in 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 ex-
tensive, 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 concentration. I have only recently finished such a treatment
during which course I caused the disappearance of a hysterical
paralysis of the legs. The patient merged in 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 phys-

102

ical signs, and toward the end of the ten months’ treatment they
really became imperceptible. The condition of the patient during
our work has therefore lost nothing of its psychic peculiarities,
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 re-
sistance 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 acquaintanceship and some esteem. The real causes of
her disease, 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 resistant and unreliable in her statements as
any one of my later non-somnambulic patients. This patient’s
resistance, even in the somnambulic state, against other require-
ments and exactions I have already discussed in his history.
Since I have witnessed cases who, even in deep somnambulism,
were absolutely refractory therapeutically despite their obedience
in everything else, I really became skeptical as to the value of
hypnosis for the facilitation of the cathartic treatment. A case
of this kind I have reported in brief,⁶ and could still add others.

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 repression of an unbearable idea from a motive of defense,
that the repressed idea remains as a weak, mildly intensive, remi-
niscence, and that the affect snatched from it is used for a
somatic innervation, that is, 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.

⁶See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 85.

103

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.¹⁾ 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 no such resistance.

I held this distinction as so essential that it has readily induced
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
found 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 pri-
mary thing; but I know nothing about it.

Equally uncertain is at present my opinion concerning the re-
tention 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 over the anticipa-
tion of an easy and certain success; but this success did not come
as easy as the work really was. I therefore presume, and again
with all caution appropriate to ignorance, that in retention hys-
teria, 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

¹⁾c., p. 15.

104

cathartic method, I would now like to add a few indications show-
ing how one makes an analysis with 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 the 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 well as in the defense
hysteria which I have in mind as a model. I start on this last
fragment of discussion with the expectation that the psychic
peculiarities revealed here might sometimes attain a certain value
as raw material for an intellectual dynamics.

The first and strongest impression which one gains through
such analysis is surely the fact that the pathogenic psychic
material, apparently forgotten and not at the disposal of the ego,
playing no rôle in the association and in memory, still lies ready
in some manner and in proper and good order. All that is nec-
essary is to remove the resistances blocking the way. Barring
that, everything is known as we know anything else, the proper
connections of the individual ideas among themselves and with
the non-pathogenic are frequently recalled and are present; they
have been produced in their time and retained in memory. The
pathogenic psychic material appears as the property of an intel-
ligence which is not necessarily inferior to the normal ego. The
semblance of a second personality is often most delusively pro-
duced. Whether this impression is justified, whether the arrange-
ments of the psychic material resulting after the adjustment is
not transferred back into the time of the disease, these are ques-
tions which I do not like to consider in this place. One cannot
easily and intuitively describe the experiences resulting from
these analyses as if he placed himself in the position, which one
can only take a survey of after their disappearance.

The condition 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 serious trauma. We frequently deal not
with a single hysterical symptom but with a number of the same
which are partially independent of one another and partially con-
nected. We must not expect a single traumatic reminiscence
whose nucleus is a single pathogenic idea, but we must be ready

105

to assume a series of partial traumas and a concatenation of
pathogenic streams of thought. The monosymptomatic trau-
matic hysteria is, as it were, an elementary organism, it is a
single being in comparison to the complicated structure of a grave
hysterical neurosis as is generally encountered.

The psychic material of such hysteria presents itself as a multi-
dimensional formation of at least triple stratification. I hope to
be able soon to justify this figurative expression. First of all
there is a nucleus of such reminiscences (either experiences or
streams of thought) 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 by the analysis
in the triple arrangement mentioned before. In the first place,
there is an unmistakable linear chronological arrangement which
takes place within every individual theme. As an example of
this I can only cite the arrangement in Breuer’s analysis of Anna
O. The theme is that of becoming deaf, of not hearing⁸⁾ which
then became differentiated according to seven determinants, and
under each heading there were from ten to one hundred single
reminiscences in chronological order. It was as if one should
take up an orderly kept record. In the analysis of my patient,
Emmy v. N., there were similar if not so many memory subdi-
visions; they formed quite a general event in every analysis.
They always occurred in a chronological order which was 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 as a “wrapper,” and that 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 can
not express it differently than by saying that they are concen-

⁸⁾See Breuer and Freud, Studien über Hysterie. Deuticke, Wien und
Leipzig, 1895, p. 28.

106

trically stratified around the pathogenic nucleus. It is not dif-
ficult to say what determines these strata, and according to what
decreasing or increasing magnitude this arrangement follows.
They are layers of equal resistance tending 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 were always perfectly con-
scious. 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 con-
cerning which a general statement can hardly be made. It is the
arrangement according to the content of thought, the connection
through the logical thread reaching to the nucleus which might
in each case correspond to a special, irregular, and manifoldly
devious road. This 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, progressing from the pe-
ripheral 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 will still adhere for a moment to the last comparison in order
to call attention to a point in which it does not justice to the
qualities of the thing compared. The logical connection corre-
sponds not only to a zigzag-like devious line, but rather to a rami-
fying 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, over-determined.

107

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 produce a connection between the two
pathogenic nuclei.

I will still add a few observations to the picture obtained 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 shortcom-
ings 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 purely conventional in the anal-
ysis, 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

108

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, compli-
cated and multidimensional organization, he would justly pro-
pound the question, “How could such a camel go through the
needle’s eye?” Indeed, one does not speak unjustly of a “nar-
rowing of consciousness.” The term gains in sense and fresh-
ness 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 impediments, as, for example, if the
patient does not yield 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 spacially extended mass of the
pathogenic material is thus drawn through a narrow fissure and
reaches consciousness as if disjointed into fragments or strips,
and it is the task of the psychotherapist to recompense it into
the conjectured organization. He who desires still more com-
parisons 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 experience may be useful: It is perfectly hopeless to
attempt to make any direct headway towards the nucleus of the
pathogenic organization. Even if it could be guessed the patient
would still not know what to start with 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 pa-
tient to relate and recall what he knows, during which one can
already direct his attention, and through the application of the
pressure procedure slight resistances may be overcome. When-
ever a new way is opened through pressure it can be expected
that the patient will continue it for some distance without any
new resistance.

109

After having worked for a while in such manner a coöperating
activity is usually manifested in the patient. A number of remi-
niscences 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 being influenced; 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 disconnected, but they give up the mate-
rial 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,
something is apt to be “buried” which must be uncovered later
with great effort. On the other hand one must not overestimate
his “unconscious 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 under-
take 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 resist-
ance is overcome in the manner indicated above. As a rule, how-
ever, 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 analyzer to
recognize the locations where it enters into the deep, and to which
points the desired connections of thought are attached. On the
contrary, just this is cautiously concealed, the assertion of the
patient sounds perfect and fixed 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 un-
mistakably discover in it gaps and injuries. Here the connection
is manifestly interrupted and is scantily completed by the patient
by an expression conveying quite insufficient information. Here

110

one strikes against a motive which in a normal person would be
designated 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 to 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 something 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 con-
nections and sufficient causations as those that would be formed
in a normal individual. A looseness of these relationships does
not lie within the sphere of influence of the neurosis. If the as-
sociation of ideas of neurotics, and especially of hysterics, makes
a different impression, if the relation of the intensities of dif-
ferent ideas does not seem to be explainable 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 con-
nection, or a transgression from the normally justified causations
can be demonstrated.

To be sure one must free himself form the theoretical preju-
dice that one has to deal with abnormal brains of dégénérés and
déséquilibrés, in whom the freedom of overthrowing the com-br> mon psychological laws of the association of ideas is a stigma,
or in whom a preferred idea without any motive may grow inten-
sively excessive, and another without psychological motives may
remain indestructible. Experience shows the contrary in hys-
teria; as soon as the hidden–often unconsciously remaining–
motives have been revealed and brought to account there remains
nothing in the hysterical thought connection that is enigmatical
and anomalous.

Thus by tracing the breaches in the first statements of the
patient, which are often hidden by “false connections,” one gets
hold of a part of the logical thread at the periphery, and there-
after continues the route by the pressure procedure.

Very seldom do we succeed in working our way into the inner

III

strata by the same thread, usually it breaks on the way when the
pressure fails, giving up either no experience, or one which can
not be explained or be continued despite all efforts. In such a
case we soon learn how to protect ourselves from the obvious con-
fusion. The expression of the patient must decide whether one
really reached an end or encountered a case needing no psychic
explanation, or whether it is the enormous resistance that halts
the work. If the latter cannot soon be overcome, 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
has followed all the threads into this stratum, if the knottings
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
accumulative themes and passing threads found in this layer; one
examines as far as he can advance with the means at hand, and
by means of the pressure procedure he gains first information
concerning the content of the next stratum.

The threads are dropped, taken up again, and followed until
they reach the juncture; they are always retrieved, and by fol-
lowing a memory fascicle one reaches some by-way which finally
opens again. In this manner it is possible to leave the work,
layer by layer, and advance directly on the main road to the
nucleus of the pathogenic organization. Thus the fight is won
but not finished. One has to follow up the other threads and
exhaust the material; but now the patient helps again energetic-
ally, 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. 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 refuta-
tion, thus revealing that he surely knows better.

One, thereby, becomes astonishingly convinced, that it is not
possible to press upon the patient things which he apparently does
not know, or to influence the results of the analysis by exciting

112

his expectations. I have not succeeded a-
single time in altering
or falsifying the reproductions of memory or the connections of
events by my predictions; 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 con-
jecture was always attested by numerous trustworthy reminis-
cences. Hence, one must not fear to express his opinion to the
patient concerning the connections which are to follow; it does
no harm.

Another manifestation which can be repeatedly observed 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 irrele-
vant memory pictures having no connection with the important
associations does not really occur. An exception not contrary to
the rule may be postulated for those reminiscences which, though
in themselves unimportant, are indispensable as intercalations,
since the associations between two related reminiscences passed
through them only.—As mentioned above, the period during
which a reminiscence abides in the pass of the patient’s conscious-
ness is directly proportionate to its significance. A picture which
does not disappear requires further consideration; a thought
which cannot be abolished must be followed further. A reminis-
cence 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 taken
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 the object 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

113

characteristic and instructive fluctuations. The intensity of the
same (let us say of a nausea) increases the deeper one penetrates
into its pathogenic reminiscence; 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 ex-
pressed. 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.

The fluctuations of intensity on the part of the hysterical
symptom recurs as often as one of its new and pathogenic remi-
niscences is attacked; the symptom remains, as it were, all the
time 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 comple-
tion of the pathogenic material, there occurs a definite adjust-
ment 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 ad-
justment 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 uninter-
rupted 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 hyster-
ical symptom during the analysis carries with it a practical incon-
venience 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 point 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

114

critical point could be approached or when a new theme comes
to light. These are the same inconveniences which every news-
paper reader experiences in reading the daily fragments of his
newspaper romance, when, immediately after the 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-
the at first strengthened but not yet explained symptom, re-
mains in the patient’s psyche, and troubles him perhaps more
than before.

But the patient must understand this as it cannot be differently
arranged. Indeed, there are patients who during such an anal-
ysis are unable to get rid of the theme once touched; they are
obsessed by it even during the interval between the two treat-
ments, and as they are unable to advance alone with the adjust-
ment, 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 un-
influenced by the treatment expressing the former effective
factors. But then a moment comes in which the patient is seized,
and his interest 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 contri-
bution in the chain of the analysis is reached, the patient feels
relieved and experiences a presentiment of the approaching deliv-
erance; 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 temporary, for the analysis con-
tinues disdaining to boast of a moment of wellbeing, and contin-
ues regardlessly over the period of gloominess. One is generally
pleased if it is possible to substitute the spontaneous fluctuations
in the condition of the patient by such as one himself provokes
and understands, just as one prefers to see in place of the spon-
taneous discharge of the symptoms that order of the day which
corresponds to the condition of the analysis.

115

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 marked gloom will be
cast over the condition of the patient. However, the reward of
the labor, the cessation of symptoms of the disease can only be
expected when the full analysis 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 patho-
genic 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, just as happens in the
behavior of the individual reproduced reminiscence.

If a pathogenic reminiscence or a pathogenic connection which
was previously withdrawn from the ego–consciousness is re-
vealed by the work of the analysis and inserted into the ego,
one can observe in the psychic personality which was thus en-
riched by 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 ungratefulness. In
general the position that the ego takes towards the new acquisi-
tion depends upon the strata of the analysis from which the
latter originates. Whatever belongs to the outermost layers is
recognized 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 connection 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 reflection. Of course, visual memory pic-
tures 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 supposition recog-
nition will appear. He then recalls and even verifies by sight

116

associations that he once really had this thought. During the
analysis I make it a point of holding the value of an emerging
reminiscence independent of the patient’s recognition. I am not
tired of repeating that we are 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 subsequently to withdraw the recognition from a
reminiscence which I had preliminarily admitted. In spite of
the deceptive 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 only with the greatest
difficulty recognized by the patient as reminiscences. Even after
everything is accomplished, when the patients are overcome by
the logical force and are convinced of the curative effect accom-
panying the emerging 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 understanding 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 recognition which has no motive
after the work has been completed; should we assume that it was
really a question of thoughts which never occurred, and for which
there is only a possibility of existence so that the therapy would
consist in the consummation of a psychic act which at that time
never took place? 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 thor-
oughly explained his psychological views especially concerning
the essence of consciousness. It is 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 recog-
nized as a reminiscence) thence draw it for some distance through
the consciousness, and again see it end in the unconscious; and
still this variation of the psychic elucidation would change noth-
ing in it, in its logicalness, and in a single part of its connection.
Should I then have this stream of thought freely before me, I

117

could not conjecture what part it was, and what part was not
recognized by the patient as a reminiscence. In a measure I see
only the points of the stream of thought merging into the uncon-
scious, just the reverse of that which has been claimed for our
normal psychic processes.

I still have 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 remi-
niscences. I also stated that two possibilities are to be con-
sidered, there is really nothing to evoke in the place where we
investigate–that can be recognized by the perfectly calm expres-
sion of the patient’s expression—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 pa-
tient’s expression. A third cause may be possible which also
indicates an obstacle, not as to the purport, but externally. This
cause occurs when the relation of the patient to the physician is
disturbed, and signifies the worst obstacle that can be encoun-
tered. One may consider that 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
overcome the psychic force of the resistance. In not a few cases,
especially in women and where we deal with the explanation of
erotic streams of thought, the coöperation of the patient becomes
a personal sacrifice which must be recompensed by some kind of
a substitute of love. The great effort and the patient friendli-
ness for the physician suffice as such substitutes. If this relation
of the patient to the physician is disturbed the readiness of the
patient fails; if the physician desires information concerning the
next pathogenic idea, the patient is confronted by the conscious-
ness 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.

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This is the least serious case. The obstacle can readily be over-
come by discussion and explanation, although the sensitiveness
and the suspicion of hysterics can occasionally manifest itself in
unsuspected dimensions.

2. If the patient is seized with the fear that she becomes too
accustomed to her physician, that in his presence she loses her
independence 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
to resist which manifests itself, not only in a certain reminis-
cence but at each attempt of the treatment. Whenever the pres-
sure procedure is started the patient usually complains of head-
ache. Her new motive for the resistance remains to her 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.⁹⁾ 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 im-
mediately 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 without the recollection of the accessory circumstances
which would have transferred this wish into the past. By the

⁹⁾See Breuer und Freud, Studien über Hysterie. Deuticke, Leipzig und
Wien, 1895, p. 55.

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associative force prevailing in consciousness the existing wish
became connected with my own person, with which the patient
could naturally occupy herself, and in this mesalliance—which I
call a false connection—the same affect became reawakened
which originally urged the patient to banish this clandestine wish.
As soon as I discovered this I could presuppose every similar
claim on my personality to be another transference and false
conception. 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 symp-
tom produced 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 the
pressure symptoms suddenly failed and I had cause to assume an
unconscious idea like the one mentioned in 2, I met it for the first
time with an unexpected attack. I told her that there must have
originated some obstacle against the continuation of the treat-
ment and that the pressure procedure has at least the power to
show her the obstacle, and then pressed her head. She then said,
surprisingly, “I see you sitting here on the chair, but that is non-
sense, 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 demonstrating 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

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case or in the recent case with me. The patient also gradually
learned to see that in such transference to the person of the phy-
sician they generally dealt with a force or a deception which
disappeared when the analysis was accomplished. I believe, how-
ever, 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 connected with
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 pays for the physician and patient to undertake a cathartic
analysis only in the rarest cases. I allow my medical activities
to be inflected by the contrary suppositions.–To be sure, I am
unable to formulate the most definite indications for the applica-
tion of the here discussed therapeutic method 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 psychotherapy to surgical measures, and
designated my cures as psychotherapeutic operations; the analo-
gies 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 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 ob-
jections: “You say, yourself, that my suffering has probably 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 destiny 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.”