The Development of the Symptoms IN the layman's eyes the symptom shows the nature of the disease, and cure means removal of symptoms. The physician, however, finds it important to distinguish the symptoms from the disease and recognizes that doing away with the symptoms is not necessarily curing the disease. Of course, the only tangible thing left over after the removal of the symptoms is the capacity to build new symptoms. Accordingly, for the time being, let us accept the layman's viewpoint and consider the understanding of the symptoms as equivalent to the understanding of the sickness. The symptoms,—of course, we are dealing here with psychic (or psychogenic) symptoms, and psychic illness—are acts which are detrimental to life as a whole, or which are at least useless; frequently they are obnoxious to the individual who performs them and are accompanied by distaste and suffering. The principal injury lies in the psychic exertion which they cost, and in the further exertion needed to combat them. The price these efforts exact may, when there is an extensive development of the symptoms, bring about an extraordinary impoverishment of the personality of the patient with respect to his available psychic energy, and consequently cripple him in all the important tasks of life. Since such an outcome is dependent on the amount of energy so utilized, you will readily understand that "being sick" is essentially a practical concept. But if you take a theoretical standpoint and disregard these quantitative relations, you can readily say that we are all sick, or rather neurotic, since the conditions favorable to the development of symptoms are demonstrable also among normal persons. As to the neurotic symptoms, we already know that they are the result of a conflict aroused by a new form of gratifying the libido. The two forces that have contended against each other meet once more in the symptom; they become reconciled through Here the development toward perversion branches off sharply from that of the neuroses. If the regressions do not awaken the resistance of the ego, then a neurosis does not follow and the libido arrives at some actual, even if abnormal, satisfaction. The ego, however, controls not alone consciousness, but also the approaches to motor innervation, and hence the realization of psychic impulses. If the ego then does not approve this regression, the conflict takes place. The libido is locked out, as it were, and must seek refuge in some place where it can find an outlet for its fund of energy, in accordance with the controlling demands for pleasurable gratification. It must withdraw from the ego. Such an evasion is offered by the fixations established in the course of its evolution and now traversed regressively, against which the ego had, at the time, protected itself by suppressions. The libido, streaming back, occupies these suppressed positions and thus withdraws from before the ego and its laws. At the same time, however, it throws off all the influences acquired under its tutelage. The libido could be guided so long as there was a possibility of its being satisfied; under the double pressure of external and internal denial it becomes unruly and harks back to former and more happy times. Such is its character, fundamentally unchangeable. The ideas which the libido now takes over in order to hold its energy belong to the system of the unconscious, and are therefore subject to its peculiar processes, especially elaboration and displacement. Conditions are set up here which are entirely comparable to those of dream formation. Just as the latent dream, the fulfillment of a You see, this evasion which the libido finds under the conditions of the conflict is possible only by virtue of the existing fixations. When these fixations are taken in hand by the regression, the suppression is side-tracked and the libido, which must maintain itself under the conditions of the compromise, is led off or gratified. By means of such a detour by way of the unconscious and the old fixations, the libido has at last succeeded in breaking its way through to some sort of gratification, however extraordinarily limited this may seem and however unrecognizable any longer as a genuine satisfaction. Now allow me to add two further remarks concerning this final result. In the first place, I should like you to take note of the intimate connection between the libido and the unconscious on the one hand, and on the other of the ego, consciousness, and reality. The connection that is evidenced here, however, does not indicate that originally they in any way belong together. I should like you to bear continually in mind that everything I have said here, and all that will follow, pertains only to the symptom development of hysterical neurosis. Where, now, can the libido find the fixations which it must have in order to force its way through the suppressions? In the The libido fixation of adults, which we have referred to as representative of the constitutional factor in the etiological comparison of the neuroses, can be thought of, so far as we are concerned, as divisible into two separate factors, the inherited disposition and the tendency acquired in early childhood. We know that a schematic representation is most acceptable to the student. Let us combine these relations as follows:
The hereditary sexual constitution provides us with manifold tendencies, varying with the special emphasis given one or the other component of the instinct, either individually or in combination. With the factor of infantile experience, there is again built up a complementary series within the sexual constitution which is perfectly comparable with our first series, namely, the gradations between disposition and the chance experiences of the adult. Here again we find the same extreme cases and similar relations in the matter of substitution. At this point the question becomes pertinent as to whether the most striking regressions of the libido, those which hark back to very early stages in sexual organization, are not essentially conditioned by the hereditary constitutional factor. The answer to this question, however, may best be put off until we are in a position to consider a wider range in the forms of neurotic disease. Let us devote a little time to the consideration of the fact that analytic investigation of neurotics shows the libido to be bound up with the infantile sexual experiences of these persons. In this light they seem of enormous importance for both the life and health of mankind. With respect to therapeutic work their importance remains undiminished. But when we do not take this into account we can herein readily recognize the danger of being misled by the situation as it exists in neurotics into adopting a mistaken and one-sided orientation toward life. In figuring the importance of the infantile experiences we must also subtract the influences arising from the fact that the libido has returned to them by regression, after having been forced out of its later positions. Thus we approach the opposite conclusion, that experiences of the libido had no importance whatever in their own time, but rather acquired it at the time of regression. You will remember that we were led to a similar alternative in the discussion of the Oedipus-complex. A decision on this matter will hardly be difficult for us. The statement is undoubtedly correct that the hold which the infantile experiences have on the libido—with the pathogenic influences this involves—is greatly augmented by the regression; still, to allow them to become definitive would nevertheless be misleading. Other considerations must be taken into account as well. In the first place, observation shows, in a way that leaves no room for doubt, that infantile experiences have their particular significance which is evidenced already during childhood. There are, furthermore, neuroses in children in which the factor of displacement in time is necessarily greatly minimized or is entirely lacking, since the illness follows as an immediate consequence of the traumatic experience. The study of these infantile neuroses keeps us from many dangerous misunderstandings of adult neuroses, just as the dreams of children similarly serve as the key to the understanding of the dreams of adults. As a matter of fact, the neuroses of children are very frequent, far more frequent than is generally believed. They are often overlooked, dismissed as signs of badness or naughtiness, and often suppressed by the authority of the nursery; in retrospect, however, they may be easily recognized later. They occur most frequently in the form of anxiety hysteria. What this implies we shall learn upon another occasion. When a neurosis breaks out in later life, analysis regularly shows that it is a direct continuation of that infantile malady which had perhaps developed only obscurely and incipiently. However, there are cases, as already stated, in which this childish nervousness continues, without any interruption, as a lifelong affliction. We have been able to analyze a very few examples of such neuroses during childhood, while they were actually going on; much more often we had to be satisfied with obtaining our insight into the childhood neurosis subsequently, when the patient is already well along in life, under conditions in which we are forced to work with certain corrections and under definite precautions. Secondly, we must admit that the universal regression of the libido to the period of childhood would be inexplicable if there were nothing there which could exert an attraction for it. The fixation which we assume to exist towards specific developmental phases, conveys a meaning only if we think of it as stabilizing These relations have a certain interest for that pedagogy which assumes as its object the prevention of neuroses by an early interference in the sexual development of the child. So long as we keep our attention fixed essentially on the infantile sexual experiences, we readily come to believe we have done everything for the prophylaxis of nervous afflictions when we have seen to it that this development is retarded, and that the child is spared this type of experience. Yet we already know that the conditions for the causation of neuroses are more complicated and cannot in general be influenced through one single factor. The strict protection in childhood loses its value because it is powerless against the constitutional factor; furthermore, it is more difficult to carry out than the educators imagine, and it brings with it two new dangers that cannot be lightly dismissed. It accomplishes too much, for it favors a degree of sexual suppression which is harmful for later years, and it sends the child into life without the power to resist the violent onset of sexual demands that must be expected during puberty. The profit, therefore, which childhood prophylaxis can yield is most dubious; it seems, indeed, that better success in the prevention of neuroses can be gained by attacking the problem through a changed attitude toward facts. Let us return to the consideration of the symptoms. They serve as substitutes for the gratification which has been forborne, by a regression of the libido to earlier days, with a return to There is something else that makes the symptoms appear remarkable and inexplicable as a means of libidinous satisfaction. They in no way recall anything from which we normally are in the habit of expecting satisfaction. They usually require no object, and thereby give up all connection with external reality. We understand this to be a result of turning away from fact and of returning to the predominance of pleasurable gratification. But it is also a return to a sort of amplified autoeroticism, such as was yielded the sex impulse in its earliest satisfactions. In the place of a modification in the outside world, we have a physical change, in other words, an internal I have indicated that we must still become familiar with a new factor. It is something really surprising and confusing. You know that by analysis of the symptoms we arrive at a knowledge of the infantile experiences upon which the libido is fixated and out of which the symptoms are formed. Well, the surprising thing is this, that these infantile scenes are not always true. Indeed, in the majority of cases they are untrue, and in some instances they are directly contrary to historical truth. You see that this discovery, as no other, serves either to discredit the analysis which has led to such a result, or to discredit the patients upon whose testimony the analysis, as well as the whole understanding of neuroses, is built up. In addition there is something else utterly confusing about it. If the infantile experiences, revealed by analysis, were in every case real, we should have the feeling of walking on sure ground; if they were regularly falsified, disclosed themselves as inventions or phantasies of the patients, we should have to leave this uncertain ground and find a surer footing elsewhere. But it is neither the one nor the other, for when we look into the matter we find that the childhood experiences which are recalled or reconstructed in the course of the analysis may in some in some instances be false, in others undeniably true, and in the majority of cases a mixture of truth and fiction. The symptoms then are either the representation of actual experiences to which we may ascribe After reflecting a bit we can easily understand what is so confusing in this matter. It is the slight regard for reality, the neglect to keep fact distinct from phantasy. We are apt to feel insulted that the patient has wasted our time with invented tales. There is an enormous gap in our thinking between reality and invention and we accord an entirely different valuation to reality. The patient, too, takes this same viewpoint in his normal thinking. When he offers the material which, by way of the symptom, leads back to the wish situations which are modeled upon the childhood experiences, we are at first, to be sure, in doubt whether we are dealing with reality or with phantasy. Later certain traits determine this decision; we are confronted with the task of acquainting the patient with them. This can never be accomplished without difficulty. If at the outset we tell him that he is going to reveal phantasies with which he has veiled his childhood history, just as every people weaves myths around its antiquity, we notice (to our comfort) that his interest in the further pursuit of the subject suddenly diminishes. He, too, wants to discover realities, and despises all "notions." But if until this is accomplished we allow him to believe that we are investigating the actual occurrences of his childhood, we run the risk of later being charged with error and with our apparent gullibility. For a long time he is unable to reconcile himself to the idea of considering phantasy and reality on equal terms and he tends, with reference to the childish experiences to be explained, to neglect for the time being the difference between the real and the imaginary. And yet this is obviously the only correct attitude toward these psychological products because they are, in a sense, real. It is Among the experiences which recur continually in the early history of neurotics and, in fact, are never lacking, some are of particular significance and accordingly I consider them worthy of special treatment. I shall enumerate a few examples of this species: observation of the parental intercourse, seduction by an adult, and the threat of castration. It would be a grievous error to assume that physical reality can never be accorded them; this may often be proved beyond doubt by the testimony of adult relatives. So, for example, it is not at all unusual if the little boy who begins to play with his penis, and does not yet know that one must conceal this, is threatened by his parents or nurse with the cutting off of the organ or the guilty hand. Parents often admit upon questioning that they thought they had done the right thing by this intimidation; many individuals retain a correct, conscious memory of these threats, especially if it has occurred in later childhood. When the mother or some other woman makes the threat she usually delegates the responsibility of executing it to the father or to the doctor. In the famous Struwelpeter by the pediatrist Hoffman, of Frankfort, rhymes which owe their popularity to his very fine understanding of the sexual and other complexes of childhood, you find a milder substitute for castration in the cutting off of the thumbs as a punishment for insistent sucking. But it is highly improbable that the threat of castration is actually made as often as it occurs in the analyses of neurotics. We are content to understand that the child imaginatively constructs this threat for himself from suggestions, from the knowledge that auto-erotic satisfaction is forbidden, and from the impression of castration he has received in discovering the female genital. It is, moreover, in no way impossible that the little child, so long as he is not credited with any understanding or memory, will, even in families outside the proletariat, become a witness to the sexual act between his parents or some other We cannot avoid the impression that such experiences of childhood are in some way necessary to the neurosis, that they are claimed by its iron rule. If they exist in reality, then well and good, but if reality has withheld them they are constructed from suggestions and supplemented by the imagination. The result is the same, and to this day we have been unable to trace any difference in the results, whether fancy or fact played the larger part in these childish occurrences. Here again we encounter one of the complementary relationships so frequently met with; it is, to be sure, the most estranging of all those we have become acquainted with. Whence comes the need for these What we have just discussed makes it necessary for us to enter further into the origin and significance of that mental activity that is called imagination. As you well know, it enjoys universal esteem, although we have never clearly understood its place in the psychic life. I have this much to say about it. As you know, the ego of man is slowly educated by the influence of external necessity to an appreciation of reality and a pursuit of the principle of reality, and must therefore renounce temporarily or permanently various objects and goals of its strivings for satisfaction, sexual and otherwise. But renunciation of gratification has always been difficult for man. He cannot accomplish it without something in the nature of compensation. Accordingly he has reserved for himself a psychological activity wherein all these abandoned sources of pleasures and means of pleasurable gratification are granted a further existence, a form of existence in which they are freed from the requirements of reality and what we like to call the test of reality. Every impulse is soon transformed into the form of its own fulfillment. There is no doubt that dwelling on the imagined fulfillment of a given wish affords some satisfaction, although the realization that it is unreal is unobscured. In the activity of the imagination, man enjoys that freedom from external compulsion that he has The best known productions of phantasy are the so-called "day dreams," which we already know, pictured satisfactions of ambitious, of covetous and erotic wishes, which flourish the more grandly the more reality admonishes them to modesty and patience. There is unmistakably shown in them the nature of imaginative happiness, the restoration of the independence of pleasurable gratification from the acquiescence of reality. We know such day dreams are nuclei and models for the dreams of night. The night dream is essentially nothing but a day dream, distorted by the nocturnal forms of psychological activity, and made available by the freedom which the night gives to instinctive impulses. We have already become acquainted with the idea that a day dream is not necessarily conscious, that there are also unconscious day dreams. Such unconscious day dreams are as much the source of night dreams as of neurotic symptoms. The significance of phantasy for the development of symptoms will become clear to you by the following: We have said that in a case of renunciation, the libido occupies regressively the positions once abandoned by it, to which, nevertheless, it has clung in certain ways. We shall neither retract this statement nor correct it, but we shall insert a missing link. How does the libido find its way to these points of fixation? Well, every object and tendency of the libido that has been abandoned, is not abandoned in every sense of the word. They, or their derivatives, are still held in presentations of the phantasy, with a The return of the libido to phantasy is an intermediate step on the road to symptom development and well deserves a special designation. C. G. Jung coined for it the very appropriate name of introversion, but inappropriately he also lets it stand for other things. Let us therefore retain the idea that introversion signifies the turning aside of the libido from the possibilities of actual satisfaction and the excessive accumulation of the phantasies hitherto tolerated as harmless. An introvert is not yet a neurotic, but he finds himself in a labile situation; he must develop symptoms at the next dislocation of forces, if he does not find other outlets for his pent-up libido. The intangible nature of neurotic satisfaction and the neglect of the difference between imagination and reality are already determined by arrest in the phase of introversion. You have certainly noticed that in the last discussions I have introduced a new factor into the structure of the etiological chain, namely, the quantity, the amount of energy that comes under consideration. We must always take this factor into account. Purely qualitative analysis of the etiological conditions is not sufficient. Or, to put it in another way, a dynamic conception alone of these psychic processes is not enough; there is need of an economic viewpoint. We must say to ourselves that the conflict between two impulses is not released before certain occupation-intensities have been reached, even though the qualitative So much I wanted to tell you about symptom development in the neuroses. Yes, but do not let me neglect to emphasize this especially: everything I have said here relates to the symptom development in hysteria. Even in compulsion neuroses, which retain the same fundamentals, much is found that is different. The counter-siege directed against the claims of the instincts, of which we have spoken in connection with hysteria, press to the fore in compulsion neuroses, and control the clinical picture by means of so-called "reaction-formations." The same kind and more far-reaching variations are discoverable among the other neuroses, where the investigations as to the mechanism of symptom development have in no way been completed. Before I leave you today I should like to have your attention for a while for an aspect of imaginative life which is worthy of the most general interest. For there is a way back from imagination to reality and that is—art. The artist is an incipient introvert who is not far from being a neurotic. He is impelled by too powerful instinctive needs. He wants to achieve honor, power, riches, fame and the love of women. But he lacks the means of achieving these satisfactions. So like any other unsatisfied person, he turns away from reality, and transfers all his interests, his libido, too, to the elaboration of his imaginary wishes, all of which might easily point the way to neurosis. A |