Knowing me to be a neurologist, he asked my advice. I inquired about the patient's former life, but discovered that my traveling companion was little inclined to be communicative in this direction, in fact he was strikingly reticent. To my inquiry about the immediate origin of the insomnia, he told me it was immediately connected with a miserable dream which he had dreamt a month past, and from which he had awakened in terrible anxiety. I asked him to tell me this dream and gave him hope that perhaps the analysis of this might succeed in laying bare the cause of the insomnia. The substance of the dream was as follows:
"I was in a narrow gorge, formed by almost perpendicular walls of rock. This made me think of a similar narrow gorge which, during my journey, I had passed through at peril of my life. Upon a jutting rock a hundred yards high above the abyss, I saw a man and woman standing, shoulder to shoulder, both covering their eyes with their hands. They step forward and I see them plunge downwards together, and hear their bodies falling to destruction. Screaming wildly I awoke. Since that time I dare not let myself sleep for fear of the repetition of this dream.
The patient, accustomed to deadly peril on his long expedition, could not explain to himself the anxiety caused by this dream. I called Mr. X's attention to the fact that in my opinion an erotic conflict was concealed in the dream, and asked him point blank whether he had taken part in a love story. At this the patient grew deadly pale, struck the table with his fist and said "That you should have guessed it!" Now the confession followed, how he had had a love affair in which he had not cut a good figure and which ruined a woman's life, and that afterwards he had been violently remorseful and had lived with the idea of suicide. Then he had seized upon the opportunity offered him to lead a dangerous expedition. He wanted to die and here he would not find death ingloriously.
It is clear that the two people upon the rocks above symbolized the two, who went to meet destruction.
Soon afterwards the travelers parted. A year later the newspapers contained the report of the marriage of the famous explorer. The surmise is allowable that the analysis of this dream was the cause of this fortunate solution.
As I have already pointed out, the original cathartic method of Breuer and Freud, explained to some extent, is still followed by some investigators, by Muthman, Bezzola, Frank and many others. I had the opportunity in June and July, 1912, of observing for some time the treatment of patients by Dr. Frank in Zurich at his private clinic, and of gaining for myself a satisfactory idea of his technique. Frank by no means rejects the Freudian psychoanalysis with all its helps, but uses it only when he does not succeed in hypnotizing his patient. Preferably, and in a great number of cases, he uses, in a state of hypnotism, a cathartic method he originated.
Where Breuer and Freud profited from the spontaneous or the provoked somnabulistic state of the patient, and by questioning dug up the hidden depths, Frank decided to be satisfied with a light hypnose, a state of hypotaxie, which might be termed analogous to the half-conscious state of the person who after taking a mid-day nap frequently denies having been asleep. In this condition we can give an account on waking of what happened around us. One sleeps and one does not sleep; the upper-consciousness then can control what the sub-consciousness brings up.
Frank says that, except in the peculiarity that he is satisfied with a lighter degree of hypnose, his method differs from that of Breuer and Freud in that generally he does not question the patient when under hypnotism, neither suggests. Experience has taught him, he says, that the ideas loaded with affect, spontaneously discharge. They are the very ones which would do so in a dream, but are differentiated from the occurrences in the dream in the sense that these last enter phantastically dressed, while the first express themselves with the mental affects belonging to them, precisely as they were lived through.
Precisely as in the primitive-cathartic method, the affects pushing in here are disemburdened here, but at the same time, the connection between the existent sick-phenomena and the causes having a place here were automatically conscious to the patient. In some cases suggestion is called upon for help in order to free an affect or to direct the attention to the expected scene.
In most cases the process goes on itself, after the introduction of hypnosis. If the sleep is too deep, then the ideas are transferred into real dreams, which the patient immediately recognizes as such, or the production of scenes discontinues; the superconsciousness no longer works.
The scenes described are usually recalled by the patients, just as they were experienced by them, even when taken from the earliest youth. The reality of the events which happened in childhood, lived over again in hypnose, are substantiated as much as possible by the patient's parents or associates. He succeeds best in inducing this semi-sleep by exhorting the patient as he closes his eyes not to bother about whether he sleeps or not, but to fasten his attention upon the scenes which are about to present themselves; that is, to think himself, so to speak, into the state of someone at a moving picture show.
As an example I give a fragment of a Frankian analysis of a case of
FEAR NEUROSIS (ANGST-NEUROSE)
Y. B., born 1883, a law clerk. Patient comes on the third of December, 1908, to Frank's consultation hour; he complains of periods of short breath; during these he feels as if his heart were ceasing to beat, especially when he is just going to bed. He feels then as if something heavy were striking him on the chest, great restlessness, and a feeling of faintness comes over him. After taking a glass of wine the condition is aggravated and becomes insupportable. These attacks come once or twice a day, mostly in the evenings. At times they keep off for eight or ten days. He lives continually in an excited state, he suffers from palpitations of the heart, from pain in the left thigh, pain in the left side, and at night cannot get to sleep.
Patient attributes this condition to an automobile accident which happened to him on June 2, 1908. Even before this accident he had been a trifle nervous on account of overwork. In the automobile accident he had been thrown out, and had been thrown a distance of ten or fifteen yards. The automobile, which was at high speed, had also plunged down the decline, but luckily the patient was not caught directly under the machine. He did not lose consciousness, and escaped with some scratches and a bad fright; it was a marvel that he and the chauffeur escaped with their lives. He plainly recalls thinking, during the fall, that his last hour had come, and even yet is amazed how extremely untroubled he had been by that thought. The days following the accident he felt as if his face were burning, and he was inwardly agitated whenever he thought of an automobile. On June 30, 1908, he was obliged to take a business journey. While seated in the station restaurant it suddenly grew dark before his eyes. He could breathe only with difficulty, his heartbeats were irregular and he had a strange sensation of fear. This condition lasted the whole day. On the return journey his train ran into an automobile truck. The patient was thrown to the floor of the coupe by the shock. This incident made a great impression upon him; nevertheless, for eight days he was free from the uneasiness already described. After that an attack of fear again set in, continuing at intervals, with periods of greater or lesser violence, until the present.
December 7, 1908. A first attempt to induce hypnosis was successful.
December 8, 1908. Patient goes to sleep immediately, becomes frightened and gives frequent signs of terror. When awakened, he mentioned that he had had a feeling as if he were falling into a hole, that had given him a very strange sensation. The patient speaks while he sleeps; his super-consciousness therefore remains awake and is able to take notice directly of the scene taking place. After some minutes he sees in the hypnosis a locomotive approaching. He cries out, "There it comes out of the tunnel." He is afraid of being run over, and is terrified. Two years previously he had been through this scene. He was standing on the track when a train approached, and he was afraid of being run over. In his sleep, the patient communicates the details and sees everything clearly. After a short interval of complete rest, he begins to breathe heavily, his pulse quickens, then he cries out in fright and excitement and dread, "Now it's coming, now the auto's coming, it's turning over, we're under it, there it's riding over us!" Gradually he quiets down again, and after a quarter of an hour, awakes. He says he now feels something lifted from his chest, that he has slept well, and feels better. He recalls everything. The train came out of the tunnel with gleaming lights; this scene took place in the evening. The automobile scene was reproduced precisely as he had taken part in it, no detail escaped him; his breathing is unobstructed now, and he has no more heart palpitations.
On the day appointed for the seance I was unexpectedly obliged to go away. When I wished to resume the treatment, January 9, the patient wrote me that his condition was strikingly improved, the heart palpitations and feelings of anxiety had not reappeared. His pleasure in life and work had returned once more, his night's rest left nothing to be desired, his appetite was excellent, therefore he thought that further treatment was not necessary for the present. To a later inquiry, February 12, 1910, a year afterwards, I obtained this answer: "Without exaggeration I am able to write you that in my whole life I have never felt so well as now. There has been no question of any nervous attacks or feelings of dread. My weight, which had gone down to fifty-eight kilos during my nervous sickness, has gone up to seventy kilos."
When Frank shuts himself up with his patients in a room, from which all outer noises are excluded as much as possible, by means of double windows and doors, although he-by means of electric light signals visible to him alone-keeps in touch with the servant outside, he has the patient recline as comfortably as possible upon a low sofa. He kneels on a cushion at the head, bends down over the patient and has the latter look upwards directly into his eyes. Meanwhile he lets his left hand rest upon the patient's forehead and gently presses the latter's eyelids with his thumb and forefinger. As soon as the patient shows signs of weariness, he carefully gets up, takes a seat next to the patient and continues carefully observant of the latter's behavior and expression of countenance. He makes note of everything that shows itself and rouses the patient after about a quarter of an hour, unless the latter awakes spontaneously. Now he talks over with him the material which has been procured and then has the patient go into a renewed hypnosis, until the end of an hour. Sometimes the seances are protracted when important scenes come up, and in the interest of the treatment it might be lengthened to two or even three hours.
Bezzola makes use of a small, light, black silk mask, which he puts on the eyes of the patient. He induces hypnosis, and for the rest follows Frank's technique already described.
While analysts who avail themselves of hypnosis as a means of help have all their patients take a reclining position, those who have given up hypnotism in their treatment, have also given up this reclining position. Freud continues to prefer having the patient assume a reclining position, and takes his position with his back to the patient, behind the head of the sofa. He considers that this manner of treatment induces the greatest calmness in the patient and makes it easier for him to express himself and to confess. He keeps as quiet as possible, listens with undivided attention, does not take any notes during the seance, not wishing to give rise to the suspicion that all the confession will be written down and perhaps seen by other eyes.
Jung receives the patient in his study just as he would receive any ordinary visitor. He thinks that in this way the patient is put most at his ease and that it makes him feel he is not considered as a patient, but rather as some one who, being in difficulties, comes to ask advice and needs to tell his troubles to a trusted friend. Even less than Freud does he take notes in the presence of the patient.
Stekel does as Jung, the only difference being that he remains seated at his writing-table and makes notes of the most important points.
The most satisfactory way for the uninitiated to make himself familiar with the technique of psychoanalysis is to submit himself to psychoanalysis. For that purpose one turns to an experienced analyst, and takes to him one's ideas and dreams. Consequently I submitted myself for two months to analysis from Dr. Jung, who in that way initiated me into the practice of psychological investigation. The interpretation of one's own dreams, reading and studying of the principal literature about analytical psychology or deep psychology, as Bleuler calls it; and the application of what is thus learned, at the start to simple, later to more difficult cases, must do the rest in making an independent investigator in this branch of psycho-therapy.
As has already been said, psychoanalysis aims at bringing into consciousness all the forgotten things. When all the gaps in the memory are filled in, when all the puzzling operations of the psychological life are explained, then the continuance and the return of the suffering has become impossible. The attainment of this ideal state is truly the attainment of Utopia. Most certainly a treatment does not need to be carried so far. One may be satisfied with the practical cure of the patient, with the restoration of his power for work, and with the abolition of the most difficult functional disturbances.
It is applicable in cases of chronic psychoneurosis which exhibit no difficult or dangerous phenomena. Among these are counted all sorts of compulsive neuroses, compulsive thoughts, compulsive behavior and cases of hysteria, where phobias and obsessions play a chief role, also somatic phenomena of hysteria which do not need to be acted upon quickly, such as, for example, anorexia. In acute cases of hysteria it is better to wait for a calmer period before applying psychoanalysis. In cases of nervous prostration this manner of treatment, which demands the serious co-operation and attention of the patient, which lasts a long time and at first takes no notice of the continuance of the phenomena, is difficult. This form of psychotherapy places great demands on the physician's patience and understanding. Psychoanalyses which last more than a year, are no rarity. It cannot be applied to the seriously degenerated; to people who have passed far beyond middle life, because among the last named the accumulated material compasses too much; to those who are entangled in a state of great fear and who live in deep depression. Analysis can be applied to the neuroses of children. It is desirable in those cases for the physician to be supported by a trusted person, as for example a woman assistant, but preferably by parents enlightened sufficiently to observe the spontaneous remarks of the child, to make notes of them, and communicate them to the physician. According to the experiments undertaken by the Zurich school, the expectation is justified within certain limits, that psychoanalysis will be therapeutically useful in certain forms of paranoia and dementia praecox.
I think that it will soon be said of psychoanalysis, as of so many other systems which like it were decried and yet later were highly valued, that the enemies of to-day are the friends of to-morrow.
Whoever wishes to judge Freud must take the trouble to initiate himself seriously into his doctrines, and use his methods for a long time in practice, according to his instructions.
Most of the condemnations are brought forward by investigators who judge a priori, without acquaintance with the facts, upon uncertain theoretical grounds and with prepossession against his sexual theory.
Whoever initiates himself seriously into the practice of psychoanalysis, will arrive at the conclusion that this new form of psychical curing deserves, to a great degree, the attention of the physician and that it may be considered as an enrichment of the armory of the psychotherapy, not yet sufficiently valued.
Does it render other forms of psychotherapy superfluous? There can be no thought of that.
Taking the pros and cons given here, we see that each of the forms of psychical therapy deserves in its turn preference, and that all support and complement each other.
Jung, as well as Freud, both of whom have made their life's aim the perfection of psychoanalysis, and who for that reason now concern themselves exclusively with it, appreciate all forms of verbal treatment, as well with hypnotism as without it. Hypnotic suggestion and suggestion given when awake was used at an earlier period by both of them with good results, and they still are not averse to using this method where quick comprehension and the immediate subdual of a troublesome symptom is desired.
The psychoanalyst follows the longer road, and assails rather the root of the sickness; it works more radically; hypnotic treatment takes hold quicker and is directed at the symptoms.
Freud explains it in this manner: when one treats the patient by hypnotic suggestion, one introduces a new idea from outside in exchange for the morbid idea; if psychoanalysis is applied, then one simply eliminates the morbid idea. Within certain limits the modus agendi of the two methods is in absolute opposition.
The suggestion method, substituting one idea for another, puts in something; the analytical, expelling an idea, takes out something. Both aim at and obtain the same end, a more or less lasting cure. Suggestion neutralizes, stops the poison; analysis expels the harmful matter. The latter manner of treatment is positive and the most decisive.
"Don't we all analyze?" Bernheim inquires, and once more I agree that all forms of psychotherapeutics do, but there is a difference in analysis.
Superficial analysis can bring us a long way toward the goal. In many cases it may suffice. But the profound, the Freudian analysis, is what we need if we wish to attain the radical cure of psychoneurosis, as far as we can ever speak of a radical cure. Many cases of illness do not lend themselves to deep analysis.
When, because of the nature of the illness, or the lifetime, or the feeble intelligence of the patient, or because of temporary circumstances of a moral or material nature, its adaptation is excluded or impossible, it is advisable, especially in chronic cases- to take refuge in the more palliative forms of the psychic methods of cure.
Thus the psychotherapeutic as moral leader fills the role of guide (directeur-d'ames), one who helps along the doubter, encourages the toilers, calms the frightened, arouses courage, keeps up hope and comforts where comfort is needed.
Pierre Janet, in his instructive book ("Obsessions et Idees Fixes"), observes that one of his chronic patients gave him the pet name of "le remonteur de pendules," an expression which luminously describes the role of the physician of souls, who, tirelessly, day in, day out, lifts the burdens, and for a time breathes new life into the depressed.
Hypnotic suggestion, which induces sleep, stills pain, silences fear, abolishes functional disturbances, works chiefly palliatively. The place for its application is where quick comprehension is desired. In its simplest form it resembles the treatment of a mother, who soothes her child with pacifying words and loving touch, and rocks him to sleep, and also it resembles the behavior of the father, who asserts his authority by force and breaks down the childish opposition. We find hypnotic suggestion, perfected and clothed in its scientific garment, in Liebeault's assertion: "It is a cure of authority, of faith, of confidence, a cure which frequently performs semi-miracles. Respect on one side, sympathy on the other, is what gives the hypnotiser results."
However highly we may value this last mentioned form of therapy, however numerous the cures due to it may be, however indispensable it may be in the practice of medicine, yet its splendor pales before the light which shines forth from the cures which aim at reeducation and which are directed toward the understanding. Those are the cures which make use of analysis.
One method, which we will call the superficial analytical method, is directed exclusively toward the upper consciousness and cures principally through exhorting, convincing, exercising and hardening. Its sponsors are Bernheim, Rosenbach, P. E. Levy, Dubois. At least it is true to its birth, it has suggestion blood in its veins.
The other method is the deeper: the Freudian analysis. This does not allow itself to be satisfied with seeing only one side of the medal, it does not limit its field of activity to the superliminal consciousness, in searching for the causes of psychogenic illnesses, but it penetrates into the strata which lie hidden under the threshold of the consciousness.
Where the moral and the suggestive methods of cure are limited exclusively to symptomatic treatment, the first form of educative therapy, limited merely to a superficial analysis, is only partly symptomatic, but the second form of educative therapy penetrates with its deep-going analysis to the root of the trouble, and has as its aim a fundamental cure.
Only too frequently the physician must be satisfied with the cure of the symptoms, with lightening the load. He always strives to remove the cause. Freud's great service is that he has opened before the physician a path which leads to the cause.
These lines of Vondel's seem as if composed for him:
"The physician must not only know How high the pulse has mounted, And where the sickness lies, which makes him groan with pain, But he must see the cause, from where The great weakness of this sickness came."
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