Sigmund Freud (1856–1939). A General Introduction to Psychoanalysis. 1920.
Part Three: General Theory of the NeurosesXVII. The Meaning of the Symptoms
I
The neurotic symptoms then have their meaning just like errors and the dream, and like these they are related to the lives of the persons in whom they appear. The importance of this insight into the nature of the symptom can best be brought home to you by way of examples. That it is borne out always and in all cases, I can only assert, not prove. He who gathers his own experience will be convinced of it. For certain reasons, however, I shall draw my instances not from hysteria, but from another fundamentally related and very curious neurosis concerning which I wish to say a few introductory words to you. This so-called compulsion neurosis is not so popular as the widely known hysteria; it is, if I may use the expression, not so noisily ostentatious, behaves more as a private concern of the patient, renounces bodily manifestations almost entirely and creates all its symptoms psychologically. Compulsion neurosis and hysteria are those forms of neurotic disease by the study of which psychoanalysis has been built up, and in whose treatment as well the therapy celebrates its triumphs. Of these the compulsion neurosis, which does not take that mysterious leap from the psychic to the physical, has through psychoanalytic research become more intimately comprehensible and transparent to us than hysteria, and we have come to understand that it reveals far more vividly certain extreme characteristics of the neuroses.
The chief manifestations of compulsion neurosis are these: the patient is occupied by thoughts that in reality do not interest him, is moved by impulses that appear alien to him, and is impelled to actions which, to be sure, afford him no pleasure, but the performance of which he cannot possibly resist. The thoughts may be absurd in themselves or thoroughly indifferent to the individual, often they are absolutely childish and in all cases they are the result of strained thinking, which exhausts the patient, who surrenders himself to them most unwillingly. Against his will he is forced to brood and speculate as though it were a matter of life or death to him. The impulses, which the patient feels within himself, may also give a childish or ridiculous impression, but for the most part they bear the terrifying aspect of temptations to fearful crimes, so that the patient not only denies them, but flees from them in horror and protects himself from actual execution of his desires through inhibitory renunciations and restrictions upon his personal liberty. As a matter of fact he never, not a single time, carries any of these impulses into effect; the result is always that his evasion and precaution triumph. The patient really carries out only very harmless trivial acts, so-called compulsive acts, for the most part repetitions and ceremonious additions to the occupations of every-day life, through which its necessary performances—going to bed, washing, dressing, walking—become long-winded problems of almost insuperable difficulty. The abnormal ideas, impulses and actions are in nowise equally potent in individual forms and cases of compulsion neurosis; it is the rule, rather, that one or the other of these manifestations is the dominating factor and gives the name to the disease; that all these forms, however, have a great deal in common is quite undeniable.
Surely this means violent suffering. I believe that the wildest psychiatric phantasy could not have succeeded in deriving anything comparable, and if one did not actually see it every day, one could hardly bring oneself to believe it. Do not think, however, that you give the patient any help when you coax him to divert himself, to put aside these stupid ideas and to set himself to something useful in the place of his whimsical occupations. This is just what he would like of his own accord, for he possesses all his senses, shares your opinion of his compulsion symptoms, in fact volunteers it quite readily. But he cannot do otherwise; whatever activities actually are released under compulsion neurosis are carried along by a driving energy, such as is probably never met with in normal psychic life. He has only one remedy—to transfer and change. In place of one stupid idea he can think of a somewhat milder absurdity, he can proceed from one precaution and prohibition to another, or carry through another ceremonial. He may shift, but he cannot annul the compulsion. One of the chief characteristics of the sickness is the instability of the symptoms; they can be shifted very far from their original form. It is moreover striking that the contrasts present in all psychological experience are so very sharply drawn in this condition. In addition to the compulsion of positive and negative content, an intellectual doubt makes itself felt that gradually attacks the most ordinary and assured certainties. All these things merge into steadily increasing uncertainty, lack of energy, curtailment of personal liberty, despite the fact that the patient suffering from compulsion neurosis is originally a most energetic character, often of extraordinary obstinacy, as a rule intellectually gifted above the average. For the most part he has attained a desirable stage of ethical development, is overconscientious and more than usually correct. You can imagine that it takes no inconsiderable piece of work to find one’s way through this maze of contradictory characteristics and symptoms. Indeed, for the present our only object is to understand and to interpret some symptoms of this disease.
Perhaps in reference to our previous discussions, you would like to know the position of present-day psychiatry to the problems of the compulsion neurosis. This is covered in a very slim chapter. Psychiatry gives names to the various forms of compulsion, but says nothing further concerning them. Instead it emphasizes the fact that those who show these symptoms are degenerates. That yields slight satisfaction, it is an ethical judgment, a condemnation rather than an explanation. We are led to suppose that it is in the unsound that all these peculiarities may be found. Now we do believe that persons who develop such symptoms must differ fundamentally from other people. But we would like to ask, are they more “degenerate” than other nervous patients, those suffering, for instance, from hysteria or other diseases of the mind? The characterization is obviously too general. One may even doubt whether it is at all justified, when one learns that such symptoms occur in excellent men and women of especially great and universally recognized ability. In general we glean very little intimate knowledge of the great men who serve us as models. This is due both to their own discretion and to the lying propensities of their biographers. Sometimes, however, a man is a fanatic disciple of truth, such as Emile Zola, and then we hear from him the strange compulsion habits from which he suffered all his life.
Psychiatry has resorted to the expedient of speaking of “superior degenerates.” Very well—but through psychoanalysis we have learned that these peculiar compulsion symptoms may be permanently removed just like any other disease of normal persons. I myself have frequently succeeded in doing this.
I will give you two examples only of the analysis of compulsion symptoms, one, an old observation, which cannot be replaced by anything more complete, and one a recent study. I am limiting myself to such a small number because in an account of this nature it is necessary to be very explicit and to enter into every detail.
A lady about thirty years old suffered from the most severe compulsions. I might indeed have helped her if caprice of fortune had not destroyed my work—perhaps I will yet have occasion to tell you about it. In the course of each day the patient often executed, among others, the following strange compulsive act. She ran from her room into an adjoining one, placed herself in a definite spot beside a table which stood in the middle of the room, rang for her maid, gave her a trivial errand to do, or dismissed her without more ado, and then ran back again. This was certainly not a severe symptom of disease, but it still deserved to arouse curiosity. Its explanation was found, absolutely without any assistance on the part of the physician, in the very simplest way, a way to which no one can take exception. I hardly know how I alone could have guessed the meaning of this compulsive act, or have found any suggestion toward its interpretation. As often as I had asked the patient: “Why do you do this? Of what use is it?” she had answered, “I don’t know.” But one day after I had succeeded in surmounting a grave ethical doubt of hers she suddenly saw the light and related the history of the compulsive act. More than ten years prior she had married a man far older than herself, who had proved impotent on the bridal night. Countless times during the night he had run from his room to hers to repeat the attempt, but each time without success. In the morning he said angrily: “It is enough to make one ashamed before the maid who does the beds,” and took a bottle of red ink that happened to be in the room, and poured its contents on the sheet, but not on the place where such a stain would have been justifiable. At first I did not understand the connection between this reminiscence and the compulsive act in question, for the only agreement I could find between them was in the running from one room into another,—possibly also in the appearance of the maid. Then the patient led me to the table in the second room and let me discover a large spot on the cover. She explained also that she placed herself at the table in such a way that the maid could not miss seeing the stain. Now it was no longer possible to doubt the intimate relation of the scene after her bridal night and her present compulsive act, but there were still a number of things to be learned about it.
In the first place, it is obvious that the patient identifies herself with her husband, she is acting his part in her imitation of his running from one room into the other. We must then admit—if she holds to this role—that she replaces the bed and sheet by table and cover. This may seem arbitrary, but we have not studied dream symbolism in vain. In dreams also a table which must be interpreted as a bed, is frequently seen. “Bed and board” together represent married life, one may therefore easily be used to represent the other.
The evidence that the compulsive act carries meaning would thus be plain; it appears as a representation, a repetition of the original significant scene. However, we are not forced to stop at this semblance of a solution; when we examine more closely the relation between these two people, we shall probably be enlightened concerning something of wider importance, namely, the purpose of the compulsive act. The nucleus of this purpose is evidently the summoning of the maid; to her she wishes to show the stain and refute her husband’s remark: “It is enough to shame one before the maid.” He—whose part she is playing—therefore feels no shame before the maid, hence the stain must be in the right place. So we see that she has not merely repeated the scene, rather she has amplified it, corrected it and “turned it to the good.” Thereby, however, she also corrects something else,—the thing which was so embarrassing that night and necessitated the use of the red ink—impotence. The compulsive act then says: “No, it is not true, he did not have to be ashamed before the maid, he was not impotent.” After the manner of a dream she represents the fulfillment of this wish in an overt action, she is ruled by the desire to help her husband over that unfortunate incident.
Everything else that I could tell you about this case supports this clue more specifically; all that we otherwise know about her tends to strengthen this interpretation of a compulsive act incomprehensible in itself. For years the woman has lived separated from her husband and is struggling with the intention to obtain a legal divorce. But she is by no means free from him; she forces herself to remain faithful to him, she retires from the world to avoid temptation; in her imagination she excuses and idealizes him. The deepest secret of her malady is that by means of it she shields her husband from malicious gossip, justifies her separation from him, and renders possible for him a comfortable separate life. Thus the analysis of a harmless compulsive act leads to the very heart of this case and at the same time reveals no inconsiderable portion of the secret of the compulsion neurosis in general. I shall be glad to have you dwell upon this instance, as it combines conditions that one can scarcely demand in other cases. The interpretation of the symptoms was discovered by the patient herself in one flash, without the suggestion or interference of the analyst. It came about by the reference to an experience, which did not, as is usually the case, belong to the half-forgotten period of childhood, but to the mature life of the patient, in whose memory it had remained unobliterated. All the objections which critics ordinarily offer to our interpretation of symptoms fail in this case. Of course, we are not always so fortunate.
And one thing more! Have you not observed how this insignificant compulsive act initiated us into the intimate life of the invalid? A woman can scarcely relate anything more intimate than the story of her bridal night, and is it without further significance that we just happened to come on the intimacies of her sexual life? It might of course be the result of the selection I have made in this instance. Let us not judge too quickly and turn our attention to the second instance, one of an entirely different kind, a sample of a frequently occurring variety, namely, the sleep ritual.
A nineteen-year old, well-developed, gifted girl, an only child, who was superior to her parents in education and intellectual activity, had been wild and mischievous in her childhood, but has become very nervous during the last years without any apparent outward cause. She is especially irritable with her mother, always discontented, depressed, has a tendency toward indecision and doubt, and is finally forced to confess that she can no longer walk alone on public squares or wide thoroughfares. We shall not consider at length her complicated condition, which requires at least two diagnoses—agoraphobia and compulsion neurosis. We will dwell only upon the fact that this girl has also developed a sleep ritual, under which she allows her parents to suffer much discomfort. In a certain sense, we may say that every normal person has a sleep ritual, in other words that he insists on certain conditions, the absence of which hinders him from falling asleep; he has created certain observances by which he bridges the transition from waking to sleeping and these he repeats every evening in the same manner. But everything that the healthy person demands in order to obtain sleep is easily understandable and, above all, when external conditions necessitate a change, he adapts himself easily and without loss of time. But the pathological ritual is rigid, it persists by virtue of the greatest sacrifices, it also masks itself with a reasonable justification and seems, in the light of superficial observation, to differ from the normal only by exaggerated pedantry. But under closer observation we notice that the mask is transparent, for the ritual covers intentions that go far beyond this reasonable justification, and other intentions as well that are indirect contradiction to this reasonable justification. Our patient cites as the motive of her nightly precautions that she must have quiet in order to sleep; therefore she excludes all sources of noise. To accomplish this, she does two things: the large clock in her room is stopped, all other clocks are removed; not even the wrist watch on her night-table is suffered to remain. Flowerpots and vases are placed on her desk so that they cannot fall down during the night, and in breaking disturb her sleep. She knows that these precautions are scarcely justifiable for the sake of quiet; the ticking of the small watch could not be heard even if it should remain on the night-table, and moreover we all know that the regular ticking of a clock is conducive to sleep rather than disturbing. She does admit that there is not the least probability that flowerpots and vases left in place might of their own accord fall and break during the night. She drops the pretense of quiet for the other practice of this sleep ritual. She seems on the contrary to release a source of disturbing noises by the demand that the door between her own room and that of her parents remain half open, and she insures this condition by placing various objects in front of the open door. The most important observances concern the bed itself. The large pillow at the head of the bed may not touch the wooden back of the bed. The small pillow for her head must lie on the large pillow to form a rhomb; she then places her head exactly upon the diagonal of the rhomb. Before covering herself, the featherbed must be shaken so that its foot end becomes quite flat, but she never omits to press this down and redistribute the thickness.
Allow me to pass over the other trivial incidents of this ritual; they would teach us nothing new and cause too great digression from our purpose. Do not overlook, however, the fact that all this does not run its course quite smoothly. Everything is pervaded by the anxiety that things have not been done properly; they must be examined, repeated. Her doubts seize first on one, then on another precaution, and the result is that one or two hours elapse during which the girl cannot and the intimidated parents dare not sleep.
These torments were not so easily analyzed as the compulsive act of our former patient. In the working out of the interpretations I had to hint and suggest to the girl, and was met on her part either by positive denial or mocking doubt. This first reaction of denial, however, was followed by a time when she occupied herself of her own accord with the possibilities that had been suggested, noted the associations they called out, produced reminiscences, and established connections, until through her own efforts she had reached and accepted all interpretations. In so far as she did this, she desisted as well from the performance of her compulsive rules, and even before the treatment had ended she had given up the entire ritual. You must also know that the nature of present-day analysis by no means enables us to follow out each individual symptom until its meaning becomes clear. Rather it is necessary to abandon a given theme again and again, yet with the certainty that we will be led back to it in some other connection. The interpretation of the symptoms in this case, which I am about to give you, is a synthesis of results, which, with the interruptions of other work, needed weeks and months for their compilation.
Our patient gradually learns to understand that she has banished clocks and watches from her room during the night because the clock is the symbol of the female genital. The clock, which we have learned to interpret as a symbol for other things also, receives this role of the genital organ through its relation to periodic occurrences at equal intervals. A woman may for instance be found to boast that her menstruation is as regular as clockwork. The special fear of our patient, however, was that the ticking of the clock would disturb her in her sleep. The ticking of the clock may be compared to the throbbing of the clitoris during sexual excitement. Frequently she had actually been awakened by this painful sensation and now this fear of an erection of the clitoris caused her to remove all ticking clocks during the night. Flowerpots and vases are, as are all vessels, also female symbols. The precaution, therefore, that they should not fall and break at night, was not without meaning. We know the widespread custom of breaking a plate or dish when an engagement is celebrated. The fragment of which each guest possesses himself symbolizes his renunciation of his claim to the bride, a renunciation which we may assume as based on the monogamous marriage law. Furthermore, to this part of her ceremonial our patient adds a reminiscence and several associations. As a child she had slipped once and fallen with a bowl of glass or clay, had cut her finger, and bled violently. As she grew up and learned the facts of sexual intercourse, she developed the fear that she might not bleed during her bridal night and so not prove to be a virgin. Her precaution against the breaking of vases was a rejection of the entire virginity complex, including the bleeding connected with the first co-habitation. She rejected both the fear to bleed and the contradictory fear not to bleed. Indeed her precautions had very little to do with a prevention of noise.
One day she guessed the central idea of her ceremonial, when she suddenly understood her rule not to let the pillow come in contact with the bed. The pillows always had seemed a woman to her, the erect back of the bed a man. By means of magic, we may say, she wished to keep apart man and wife; it was her parents she wished to separate, so to prevent their marital intercourse. She had sought to attain the same end by more direct methods in earlier years, before the institution of her ceremonial. She had simulated fear or exploited a genuine timidity in order to keep open the door between the parents’ bedroom and the nursery. This demand had been retained in her present ceremonial. Thus she had gained the opportunity of overhearing her parents, a proceeding which at one time subjected her to months of sleeplessness. Not content with this disturbance to her parents, she was at that time occasionally able to gain her point and sleep between father and mother in their very bed. Then “pillow” and “wooden wall” could really not come in contact. Finally when she became so big that her presence between the parents could not longer be borne comfortably, she consciously simulated fear and actually succeeded in changing places with her mother and taking her place at her father’s side. This situation was undoubtedly the starting point for the phantasies, whose after-effects made themselves felt in her ritual.
If a pillow represented a woman, then the shaking of the featherbed till all the feathers were lumped at one end, rounding it into a prominence, must have its meaning also. It meant the impregnation of the wife; the ceremonial, however, never failed to provide for the annulment of this pregnancy by the flattening down of the feathers. Indeed, for years our patient had feared that the intercourse between her parents might result in another child which would be her rival. Now, where the large pillow represents a woman, the mother, then the small pillow could be nothing but the daughter. Why did this pillow have to be placed so as to form a rhomb; and why did the girl’s head have to rest exactly upon the diagonal? It was easy to remind the patient that the rhomb on all walls is the rune used to represent the open female genital. She herself then played the part of the man, the father, and her head took the place of the male organ. (Cf. the symbol of beheading to represent castration.)
Wild ideas, you will say, to run riot in the head of a virgin girl. I admit it, but do not forget that I have not created these ideas but merely interpreted them. A sleep ritual of this kind is itself very strange, and you cannot deny the correspondence between the ritual and the phantasies that yielded us the interpretation. For my part I am most anxious that you observe in this connection that no single phantasy was projected in the ceremonial, but a number of them had to be integrated,—they must have their nodal points somewhere in space. Observe also that the observance of the ritual reproduce the sexual desire now positively, now negatively, and serve in part as their rejection, again as their representation.
It would be possible to make a better analysis of this ritual by relating it to other symptoms of the patient. But we cannot digress in that direction. Let the suggestion suffice that the girl is subject to an erotic attachment to her father, the beginning of which goes back to her earliest childhood. That perhaps is the reason for her unfriendly attitude toward her mother. Also we cannot escape the fact that the analysis of this symptom again points to the sexual life of the patient. The more we penetrate to the meaning and purpose of neurotic symptoms, the less surprising will this seem to us.
By means of two selected illustrations I have demonstrated to you that neurotic symptoms carry just as much meaning as do errors and the dream, and that they are intimately connected with the experience of the patient. Can I expect you to believe this vitally significant statement on the strength of two examples? No. But can you expect me to cite further illustrations until you declare yourself convinced? That too is impossible, since considering the explicitness with which I treat each individual case, I would require a five-hour full semester course for the explanation of this one point in the theory of the neuroses. I must content myself then with having given you one proof for my assertion and refer you for the rest to the literature of the subject, above all to the classical interpretation of symptoms in Breuer’s first case (hysteria) as well as to the striking clarification of obscure symptoms in the so-called dementia praecox by C. G. Jung, dating from the time when this scholar was still content to be a mere psychoanalyst—and did not yet want to a prophet; and to all the articles that have subsequently appeared in our periodicals. It is precisely investigations of this sort which are plentiful. Psychoanalysts have felt themselves so much attracted by the analysis, interpretation and translation of neurotic symptoms, that by contrast they seem temporarily to have neglected other problems of neurosis.
Whoever among you takes the trouble to look into the matter will undoubtedly be deeply impressed by the wealth of evidential material. But he will also encounter difficulties. We have learned that the meaning of a symptom is found in its relation to the experience of the patient. The more highly individualized the symptom is, the sooner we may hope to establish these relations. Therefore the task resolves itself specifically into the discovery for every nonsensical idea and useless action of a past situation wherein the idea had been justified and the action purposeful. A perfect example for this kind of symptom is the compulsive act of our patient who ran to the table and rang for the maid. But there are symptoms of a very different nature which are by no means rare. They must be called typical symptoms of the disease, for they are approximately alike in all cases, in which the individual differences disappear or shrivel to such an extent that it is difficult to connect them with the specific experiences of the patient and to relate them to the particular situations of his past. Let us again direct our attention to the compulsion neurosis. The sleep ritual of our second patient is already quite typical, but bears enough individual features to render possible what may be called an historic interpretation. But all compulsive patients tend to repeat, to isolate their actions from others and to subject them to a rhythmic sequence. Most of them wash too much. Agoraphobia (topophobia, fear of spaces), a malady which is no longer grouped with the compulsion neurosis, but is now called anxiety hysteria, invariably shows the same pathological picture; it repeats with exhausting monotony the same feature, the patient’s fear of closed spaces, of large open squares, of long stretched streets and parkways, and their feeling of safety when acquaintances accompany them, when a carriage drives after them, etc. On this identical groundwork, however, the individual differences between the patients are superimposed—moods one might almost call them, which are sharply contrasted in the various cases. The one fears only narrow streets, the other only wide ones, the one can go out walking only when there are few people abroad, the other when there are many. Hysteria also, aside from its wealth of individual features, has a superfluity of common typical symptoms that appear to resist any facile historical methods of tracing them. But do not let us forget that it is by these typical symptoms that we get our bearings in reaching a diagnosis. When, in one case of hysteria we have finally traced back a typical symptom to an experience or a series of similar experiences, for instance followed back an hysterical vomiting to its origin in a succession of disgust impressions, another case of vomiting will confuse us by revealing an entirely different chain of experiences, seemingly just as effective. It seems almost as though hysterical patients must vomit for some reason as yet unknown, and that the historic factors, revealed by analysis, are chance pretexts, seized on as opportunity best offered to serve the purposes of a deeper need.
Thus we soon reach the discouraging conclusion that although we can satisfactorily explain the individual neurotic symptom by relating it to an experience, our science fails us when it comes to the typical symptoms that occur far more frequently. In addition, remember that I am not going into all the detailed difficulties which come up in the course of resolutely hunting down an historic interpretation of the symptom. I have no intention of doing this, for though I want to keep nothing from you, and so paint everything in its true colors, I still do not wish to confuse and discourage you at the very outset of our studies. It is true that we have only begun to understand the interpretation of symptoms, but we wish to hold fast to the results we have achieved, and struggle forward step by step toward the mastery of the still unintelligible data. I therefore try to cheer you with the thought that a fundamental difference between the two kinds of symptoms can scarcely be assumed. Since the individual symptoms are so obviously dependent upon the experience of the patient, there is a possibility that the typical symptoms revert to an experience that is in itself typical and common to all humanity. Other regularly recurring features of neurosis, such as the repetition and doubt of the compulsion neurosis, may be universal reactions which are forced upon the patient by the very nature of the abnormal change. In short, we have no reason to be prematurely discouraged; we shall see what our further results will yield.
We meet a very similar difficulty in the theory of dreams, which in our previous discussion of the dream I could not go into. The manifest content of dreams is most profuse and individually varied, and I have shown very explicitly what analysis may glean from this content. But side by side with these dreams there are others which may also be termed “typical” and which occur similarly in all people. These are dreams of identical content which offer the same difficulties for their interpretation as the typical symptom. They are the dreams of falling, flying, floating, swimming, of being hemmed in, of nakedness, and various other anxiety dreams that yield first one and then another interpretation for the different patients, without resulting in an explanation of their monotonous and typical recurrence. In the matter of these dreams also, we see a fundamental groundwork enriched by individual additions. Probably they as well can be fitted into the theory of dream life, built up on the basis of other dreams,—not however by straining the point, but by the gradual broadening of our views.