Churchill's Black Dog and Other Phenomena of the Human Mind

by Anthony Storr

  Freud was not only a medical man, but had also been trained in the laboratories of Ernst Brücke, a scientist who, according to his collaborator Emil du Bois-Reymond, had “pledged a solemn oath to put into power this truth: no other forces than the common physico-chemical ones are active within the organism.”1 This hardheaded, uncompromisingly deterministic point of view, which has proved so rewarding in the exact sciences of chemistry and physics, was, at that date, a departure from the vitalistic form of biology taught to Brücke and his fellows when they were students. For fifteen years, Freud conducted research, first into the nervous systems of fish, and then into the human central nervous system. Even when he had begun to formulate psychoanalytical ideas, he looked back with regret to his neuroanatomical days. As late as 1891, he published a monograph on aphasia, and a major work on childhood cerebral palsy appeared in 1897. Because Brücke’s two assistants were relatively young, Freud had little prospect of advancement within that laboratory. On this account, Brücke advised him to practice medicine. Freud’s decision to do so was reinforced by his having fallen in love with Martha Bernays, whom he could not marry without increasing his earnings. Freud reluctantly took his medical degree in 1881, and was then appointed a demonstrator in Brücke’s Physiological Institute.

  With so much “hard” science behind him, it was natural enough that Freud’s approach to the study of neurotic symptoms should derive from his medical and scientific training. That is, he approached neurotic symptoms as if they were phenomena of the same order as the physical symptoms of organic disease, and at first treated them with the physical methods of treatment then available: hydrotherapy, electrotherapy, and massage. But, in the summer of 1885, Freud applied for, and won, a traveling fellowship, which enabled him to spend the winter of 1885–1886 studying in Paris with the famous neurologist Charcot.

  Charcot had, for some years, been investigating hypnotism, with the object of finding a way of distinguishing between organic and hysterical paralyses. Charcot demonstrated to Freud that ideas, although intangible, could nevertheless be causal agents in neurosis. For when a patient developed an hysterical paralysis, the form which the paralysis took was not determined by the facts of anatomy, but by the patient’s faulty idea of anatomy. Instead of developing a paralysis which could be explained by a lesion of a particular peripheral nerve, he exhibited a paralysis of a limb which corresponded to his idea of where his leg began and ended. Moreover, Charcot demonstrated that hysterical paralyses could be artificially produced by means of hypnosis.

  If ideas could cause hysterical symptoms, then ideas might also bring about cures. By means of hypnosis, ideas of health could be forcibly implanted; and Freud found that hypnosis could indeed relieve a number of hysterical symptoms. Freud therefore began to employ hypnosis as his main method of treatment for neurotic disorders, and continued to do so until 1896.

  Hypnosis came to have two aspects. The first was the implantation of ideas of health into the mind of the patient; positive suggestions designed to counteract the negative ideas which were causing the symptoms. The second and more important aspect derived from the work of Freud’s friend and collaborator Josef Breuer. When treating his famous case, Anna O. (Bertha Pappenheim), with hypnosis, Breuer discovered that if she could be persuaded to recall the very first moment of the appearance of each hysterical symptom, the symptom disappeared. Breuer named this method of treatment “catharsis.” Hypnosis, therefore, came to be used as a method of getting the patient to recall forgotten origins. Instead of being used as a positive, direct attack upon neurotic symptoms, it became a method of investigation.

  Freud and Breuer came to hope that all neurotic symptoms could be abolished in this laborious, although essentially simple, way. In their first paper in Studies on Hysteria, they wrote:

  For we found, to our great surprise at first, that each individual hysterical symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing the accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affect into words.2

  Later, the same technique was applied to obsessional symptoms. In another paper, we read of a girl

  who had become almost completely isolated on account of an obsessional fear of incontinence of urine. She could no longer leave her room or receive visitors without having urinated a number of times. Reinstatement: it was an obsession based on temptation or mistrust. She did not mistrust her bladder, but her resistance to erotic impulses. The origin of this obsession shows this clearly. Once, at the theatre, on seeing a man who attracted her, she had felt an erotic desire, accompanied (as spontaneous pollutions in women always are) by a desire to urinate. She was obliged to leave the theatre, and from that moment on she was a prey to the fear of having the same sensation, but the desire to urinate had replaced the erotic one. She was completely cured.3

  We can see from this account that, although neurotic symptoms differed from those of physical disease in originating from unpleasant memories or unwelcome or unadmitted emotions, it was nevertheless possible to regard them in much the same light. Just as pneumococci might be regarded as the “cause” of pneumonia and abolished by suitable medication, so neuroses were “caused” by repressed emotions or traumas, and could be abolished by recall and abreaction.

  Moreover, while hypnosis remained the technical method for enabling the patient to recover the repressed memories and the unpleasant emotions which had accompanied them, it was possible to teach it in the same way that one could teach the technique of removing an appendix. The psychotherapist could therefore assume the traditional medical role of a skilled professional; a benign authority, giving the patient the benefit of his superior knowledge; benevolent, considerate, but essentially detached.

  So long as this view of neurosis could be maintained, it also followed that the patient could be treated as an isolated individual, without reference to his present circumstances or current interpersonal relationships. For, if the cause of neurosis lay in the past, the task of the therapist was merely to facilitate remembrance of things past. Psychoanalysts have often been criticized for only attempting to understand their patients when the latter have been put into an isolated, artificial situation which is remote from ordinary life, and which precludes access to those who know them best, their relatives and friends. But, if it is assumed that neurosis is caused by repressed emotions originating in the past, more particularly in the earliest years of the patient’s childhood, it is not unreasonable to disregard current relationships and to create a situation in which the recall of the past is facilitated. If a patient’s illness is due to an inflamed appendix, the surgeon’s task is to locate the appendix and remove it. Relatives’ descriptions of the patient’s reactions to pain and illness are unlikely to be relevant.

  The case history of the girl with the obsessional fear of incontinence of urine is not given in any detail. There are many questions about her to which any psychiatrist practicing today would like to have answers. But, as Freud presents the case, we are told that she was completely cured; and this was probably good enough for her as it must be good enough for us. Freud’s attitude toward his patient, at this period of history, is similar to that advocated by behavior therapists today. Although behavior therapists think of neurotic symptoms as learned, maladaptive habits rather than as being caused by repressed emotions, their attitude toward the patient resembles that adopted by a physician toward a patient suffering from a physical illness; and this was also Freud’s attitude when he began treating such patients. The physician has as his aim the understanding of the underlying cause of whatever symptoms the patient presents, and the abolition of those symptoms by appropriate techniques of treatment. This is entirely proper. There is no need for the physician to get to know his patient as a person, and still less for him to examine his own personality and motives. The physician’s ideal is to discover ways of treat
ing disease by methods which can be learned and applied by any other doctor; methods to which the personality of the doctor is irrelevant. In similar fashion, Eysenck has been heard to say that behavior therapists should be like dentists: considerate and kind, no doubt; but essentially skilled technicians who apply techniques of treatment which can be learned by any intelligent person, and which can be evaluated by the ordinary methods of science.

  This objective, scientific approach is perfectly all right as far as it goes, both in physical disorders and in certain defined types of neurotic disorder. If I consult a physician for asthma, what I want is that he shall be an expert in respiratory disease, and that he shall be able to prescribe what drugs are necessary. If he happens to be skilled in interpersonal relationships and comes to understand me as a person, this an unsought bonus for which I may be grateful, but which is a secondary gain rather than a prime objective.

  Behavior therapists score their greatest successes with specific phobias, especially with those which take origin from defined traumatic incidents, and I am the last person to question their achievements. Indeed, I have considerable sympathy with their point of view. It would be admirable if all forms of neurosis could be treated by objective, scientific techniques which anyone could learn. This was certainly Freud’s hope in the early days, and one which he never completely abandoned. However, subjective factors began to interfere with this aspiration, even before the close of the nineteenth century. In his paper “The Aetiology of Hysteria,” published in 1896, Freud states that, having treated eighteen cases, “whatever case and whatever symptom we take as our point of departure, in the end we infallibly come to the field of sexual experience. So here for the first time we seem to have discovered an aetiological precondition for hysterical symptoms.”4

  Freud goes on to point out that, in cases in which the onset of hysterical symptoms seems to have been triggered by something trivial, psychoanalytic investigation reveals that “at the bottom of every case of hysteria there are one or more occurrences of premature sexual experience, occurrences which belong to the earliest years of childhood but which can be reproduced through the work of psycho-analysis in spite of the intervening decades.”5

  Roger Brown has drawn attention to the fact that this was Freud’s last attempt to give figures concerning etiology, and that, even in this instance, there were no controls. Brown suggests that there were two reasons for Freud’s change of attitude. First, he came to believe that some of his patients were telling him fantasies, not facts, about their pasts. Second, Freud had embarked upon his own self-analysis. Freud knew that, in his own case, the case of the nineteenth patient, the Oedipus complex had bulked large in childhood. But he also knew that he had not experienced actual sexual seduction. Accordingly, Freud transferred his interest from so-called traumatic incidents, of which sexual seduction had seemed to be the most important variety, to an examination of the patient’s inner world of fantasy. Psychoanalysis changed from what might be called a scientific attempt to disclose a causal series of events culminating in the outbreak of a neurosis, to an exploration of the patient’s imaginative world which could not be categorized as scientific.6

  These were not the only reasons for supposing that Freud’s ideal of establishing psychoanalysis as a true science of the mind was doomed to failure. Freud’s original hypothesis concerning precocious sexual arousal was based on dramatic cases of “conversion hysteria” which are hardly ever seen today. Why this is so is uncertain; but it has been suggested, rather convincingly, that it may be connected with the fact that women, however incomplete their freedom, are at least more emancipated than they were in the days of Freud. In the nineteenth century, life had very little to offer an intelligent woman who did not get married, or who was unhappily married. Condemned to social, as well as to sexual, frustration, and either despised for not achieving the status of marriage or locked into a situation from which there was no escape, such women expressed their dissatisfaction in dramatic fashion, developing symptoms which, if they did not get them what they wanted, at least ensured that they were paid attention.

  The kind of hysterical symptoms produced by Anna O. and her sisters could, in many instances, be traced to a defined origin and abolished in much the same fashion as could symptoms of physical disorders. But the majority of neurotic symptoms are not like this. If a patient complains of headache, it is legitimate to think of this symptom as an alien intruder. The same is true of a limited range of neurotic symptoms, of which specific phobias are the best examples. But most neurotic symptoms are much more intimately connected with the patient’s personality as a whole, and cannot be understood unless the patient’s whole personality is taken into account.

  Consider, for example, the common symptom of agoraphobia. In some instances, agoraphobia may take origin from a frightening experience, a so-called traumatic incident. For instance, one may expect that a girl who has been sexually assaulted in the street will be reluctant to venture out alone for a while. But, in most cases, it will be found that agoraphobia originates from what Bowlby calls a disturbance in “attachment behavior.” That is, inquiry into the patient’s early emotional development will reveal that, during childhood, attachment figures were unreliable or absent, with the consequence that, instead of developing increasing confidence, the child came to regard the world as a frightening and unpredictable place into which it was not safe to venture alone without a supporting arm.

  Or consider recurrent depression. People who are prone to depression tend to feel both helpless and hopeless in the face of any form of adversity. If one is to understand the reasons why anyone habitually reacts with severe depression to disappointment, loss, or challenge, it is necessary to investigate the emotional climate in which the patient was reared. Although a specific attack of depression may be relieved by physical methods of treatment, the tendency to become severely depressed cannot be understood without taking the whole personality into account; nor can the person be expected to learn to deal better with this tendency because his symptom has been directly attacked with antidepressant drugs or electroconvulsive therapy.

  As time went on, patients seeking psychoanalysis presented symptoms which were even less defined than agoraphobia or recurrent depression. Today, many patients asking for psychotherapy are not suffering from any definable neurosis but from generalized unhappiness, from tensions at work, or from difficulties in interpersonal relationships. They bring to the psychoanalyst what Thomas Szasz has accurately called “problems in living,”7 and therefore demand to be understood as persons rather than treated for particular symptoms. Since its inception in the 1890s, psychoanalysis has moved farther and farther away from the medical model.

  Another important reason for psychoanalysis becoming more concerned with persons as a whole rather than with neurotic symptoms springs from Freud’s change in technique. I mentioned earlier that Freud continued to use hypnosis until 1896. I should rather have written that he finally abandoned its use in 1896. From 1892 onward, he was gradually modifying his technique. Freud’s substitution of free association for hypnosis was, I believe, his most momentous therapeutic innovation. The employment of free association compels the psychotherapist to assume a much more passive, less authoritarian role than that conventionally expected of the doctor, and makes the patient take the initiative. Hypnosis is a treatment which is principally dependent upon the doctor’s authority and the patient’s compliance. The hypnotized patient recovers because the hypnotist tells him that he will; or recalls the remote past because the hypnotist urges him to do so. The adoption of free association means that the patient retains his or her autonomy, instead of being automatically placed in a submissive or childish relation to the therapist. Instead of looking to the therapist for direct advice or specific instructions, the patient learns to use psychoanalysis as a means of understanding himself better and, through this, begins to learn to solve his own problems.

  This change toward greater autonomy for the patient is th
e most important consequence of adopting free association, but it is not the only one. If a person is encouraged to say everything which comes into his mind without censorship, he will talk not only about his symptoms but also about his hopes and fears, his aspirations and disappointments, his successes and failures, and everything else which preoccupies him and which constitutes him as a unique person. Once again, we observe that the emphasis in psychoanalytic treatment has shifted from a direct attack upon neurotic symptoms to the consideration of the whole person.

  A further reinforcement of this shift was Freud’s discovery of transference. As he proceeded with his psychoanalytic work, he found that he became emotionally important to his patients in a way he did not welcome but reluctantly came to realize was a vital part of psychoanalytic procedure. Freud at first thought of transference as an erotic attachment to the psychoanalyst, as indeed it can be. However deplorable this might be, it was, so Freud considered, a useful way of overcoming resistance. Later Freud came to think of transference as an artificially induced neurosis in which the patient repeated all the attitudes which he had held toward his parents. By means of interpretation, Freud strove to convert this repetition into recollection, thus reducing the intensity of the patient’s present emotions by affirming that they really belonged to the past. Freud wrote:

  The patient, that is to say, directs toward the physician a degree of affectionate feeling (mingled, often enough, with hostility) which is based on no real relationship between them and which—as is shown by every detail of its emergence—can only be traced back to old wishful phantasies of the patient’s which have become unconscious.8

  In other words, Freud was striving to discount any possibility that his patients might be experiencing genuine emotional feelings toward him in the here and now.