Civilized sexual morality, the lack of libidinal satisfaction, its delay or distortion through the patterns of late-nineteenth-and early-twentieth-century life and marriage, prohibitions against contraception and sheer ignorance about sex, produced, Freud underlined, anxiety and illness. He combined this early insight with a treatment which, by the century’s turn, put not only the clinical gaze but both suggestion and hypnosis into the background, and substituted for them a talking cure which was also a careful listening to patients as they followed the rule of free association–of saying everything that came into their minds. In that twosome which was the listening analyst and the speaking patient, the fantasies and phobias that prevented the free flow of life outside the consulting room were re-enacted and re-imagined, resistances overcome, so that the blocks and fixations that had accrued from childhood could, both hoped, be released.
Freud’s genius perhaps lay, above all, in the way he showed how the conflicts of sexuality in childhood not only shaped the person who might find her way into a clinic or to a mind doctor, but shaped us all. In one way or another, the adult human is a product of a family structure where the babe struggles to become a sexed human along the lines that differentiate the masculine from the feminine and can lead to that reproduction which Darwin had noted as the aim of life. Sex, for Freud, is not only pleasure and its attendant fantasies, or the fault-line along which illness or malaise can come, but the necessary animal goal. Our very humaneness, that extra which man and woman is, that plus which is civilization, may be what prevents us from fulfilling it.
Early in his career, Freud set himself apart from other neurologists and medical practitioners by declaring that neurasthenia–that condition which was contemporary to modernity–might have, but did not require, a direct basis in heredity. He pointed to a sexual aetiology not only for hysteria, but for the anxiety and obsessional neuroses as well. ‘This, to tell the truth, is no new, unheard-of proposition,’ he noted in 1896.
Sexual disorders have always been admitted among the causes of nervous illness, but they have been subordinated to heredity…What gives its distinctive character to my line of approach is that I elevate these sexual influences to the rank of specific causes, that I recognize their action in every case of neurosis, and finally that I trace a regular parallelism, a proof of a special aetiological relation, between the nature of the sexual influence and the pathological species of the neurosis.
The question of Freud’s originality, the early rejection or acceptance of his insights, has been contested for almost a century now. Clearly, while some hailed his ideas, arbiters of psychiatric knowledge in his own time were often hostile, as Freud himself noted with a sensitivity all writers will recognize. In 1899 Emil Kraepelin mocked, ‘If…our much-plagued soul can lose its equilibrium for all time as a result of long-forgotten unpleasant sexual experiences, that would be the beginning of the end for the human race; nature would have played a gruesome trick on us!’
If Freud, while working with his early hysterics, first presumed, like Janet, that a disturbing childhood sexual encounter or ‘trauma’ had set in train the conflicts which resulted in mental disorder, as his case base grew he modified his thinking. The omnipresence of what he called childhood ‘seduction’, and we now call ‘abuse’, made him suspicious. Could it be that the instigating event did not have to have taken place in the external world but needed only to be imagined?–just as Celia Brandon had told her husband of a ‘real’ punishment, when she needed only an imagined simulated one as a thought key for pleasure? Freud determined that a fantasized sexual memory, re-evoked as real at a later date, could set neuroses in process as well as a real one. Intense childhood desires, one of the hazards of everyday life in a family understood as a hothouse of secret cravings and suppressions, could trigger illness by coming into covert conflict with an ideal or even acceptable image of the self and then going underground. These early battles between libidinal impulse and disgust, shame, censorship, these travails of ‘civilized morality’ as lived by the child, could form a base for later neurosis, just as could an actual seduction by a parent, uncle or sibling or, rather more rarely, a stranger. The movement between infancy and maturity is fraught, for Freud, with sexual compromises and conflicts, charged and changed by the process of reminiscence itself. Indeed, one of Freud’s primary findings is that the child herself is already a sexual being who develops through desire and its forgetting or repression in a family where mothers, fathers and siblings all play their part in an Oedipal drama.
Looking back on the findings of his new science in his ‘Short Account of Psychoanalysis’, written when he was sixty-eight, Freud retrospectively once more underlined the importance of sexuality both in understanding neurosis and in ordinary human development. He summarized his major findings: a theory ‘which gave a satisfactory account of the origin, meaning and purpose of neurotic symptoms’, and which gave ‘even the apparently most obscure and arbitrary mental phenomena…a meaning and a causation, the theory of psychical conflict and of the pathogenic nature of repression, the view that symptoms are substitutive satisfactions, the recognition of the aetiological importance of sexual life, and in particular of the beginnings of infantile sexuality’. To that he added the philosophical contention that the ‘mental does not coincide with the conscious’, and that children have ‘complicated emotional relations to their parents’. It became clear to him that in this Oedipal matter lay the nucleus of every case of neurosis; and in the ‘patient’s behaviour towards his analyst certain phenomena of his emotional transference emerged which came to be of great importance for theory and technique alike’.
As women analysts chipped away at and fed into his original theories, Freud came increasingly to see that for the girl the move from childhood to adulthood was even more fraught than for the boy. Becoming woman meant engaging in the complicated task of somehow learning to desire the male. Children of both sexes were first fixed on the mother or the maternal carer. For the girl, growing up entailed having to move her original Oedipal desires to the father, or the male who might give her a child. Along the way, the ‘phallic’ satisfactions of clitoral sexuality would need to be abandoned for the more ‘mature’ pleasures of vaginal sex and penetration. Freud locates the spur for this change in what he calls ‘penis-envy’–the girl’s discovery that she lacks the penis which is the organ of sexual pleasure. This discovery and its attendant disappointment can lead to sexual inhibition, neurosis, or to what Freud calls ‘normal femininity’. It can lead the girl to deny her lack and mimic maleness in her various pursuits or sexual choices. Or it can resign her to what Freud calls ‘femininity, that is, a settling into the “passive” role in which she expects to receive the penis in the form of a child from her father or sometimes her mother’.
If Freud at first seems to make things easier for the penis-bearing boy, it shouldn’t be forgotten that his path to maturity means measuring up to bigger Dad. The boy’s attendant fears of castration, his murderous fantasies, are not exactly a sunny alternative to femininity. Indeed, Freud’s view of the rocky path into adulthood makes Peter Pan a definite attraction, were it not that the whole trajectory is hardly the individual’s consciously to choose. Like civilization, sexual maturity has its palpable discontents. For the ordinary neurotic, analysis is simply there to make these more bearable.
A proud paterfamilias himself, a firm believer that the birth of a child would sort out many women’s hysterical or neurotic impulses, and that the ‘masculine’ pursuits of suffragette struggles or intellectual work might put a strain on a woman’s psyche, Freud nonetheless–and despite the opposition of some of the early male psychoanalysts–welcomed women into the profession and numbered some of their leading lights amongst his closest confidantes. Always a pessimist, he was uncertain whether the difficult psychic trajectory he and analysts like Ruth Mack Brunswick and Hélène Deutsch had elaborated for women could ever be altogether satisfactorily accomplished. Nor did he lay any emphatic
value on it. His daughter Anna, who in childhood had had beating fantasies not all that dissimilar to Celia Brandon’s, never married nor bore a child. Freud called her his ‘Antigone’ and valued not only her work as a psychoanalyst and for the movement, but her indomitable courage. Confronted by the Gestapo, Anna had effectively saved the family. There was not a little help, too, from Princess Marie Bonaparte, another ‘masculine’ woman and one-time analysand. ‘Women are the more capable,’ he wrote to Ernest Jones.
Indeed, for all his utterances about the ‘normal’ path of femininity, Freud seemed to prefer independent spirits who had a professional ardour rare for the times. H.D., the American poet Hilda Dolittle who memorialized her analysis with Freud ten years after the event, and who was not only an independent woman, but one whose sexual orientation wavered, returned the compliment, as had the writer and femme fatale Lou Andreas-Salomé and others before her, and evoked Freud as a ‘blameless physician’.
Whether blameless or not, it is clear that Freud, in charting sexuality and putting it centre stage both as in need of reform and as a seedbed of problems, had no moralizing project at the core of his work. Perversion, fetishism, a disorder in sexual aim or object, seem to him an all too common matter. But the psychoanalytic profession, particularly in America, would take his findings and transform them into norms with which women must comply. In the process, new neurotic conditions would flourish, stigmatizing women with psychological diagnoses that had their basis as much in the needs of medical and social conformity as in sexual difficulties. The frigid woman and the nymphomaniac would become popular icons of psychic imbalance in post-Second World War America, where psychoanalysis flourished as a far more normative profession than Freud had ever imagined. The ‘dark continent’ which he had called woman and which he had set out to explore, without ever charting its outposts more than tentatively, had been given a grid-like map whose strip lighting led only to the suburban mall. Unlike Freud, who had never been able satisfactorily to answer the question, ‘Was will das Weib?’, these later analysts also seemed emphatically to know what women wanted–and it was home, hubby, and certainly no intellectual aspirations.
Meanwhile, elsewhere, the psychoanalytic profession would take hold with what became known as a more ‘classically Freudian’ configuration. The ever resisted notion of infantile sexuality–which most recently has found our cultural abhorrence of its existence writ large in the scapegoating of ‘paedophiles’–has continued to be the manifold structure which analysts focus on within the analysis, precisely because it so often results in producing what is called the ‘negative’ transference. This elaborating within the relationship established with the analyst of the subject’s nastiest hates, contempt, fears, is what the analysis will contend with. The Freudian profession would set to work to uncover what dark matter drove Celia Brandon’s hallucinatory horror.
The easiest part of the Freudian project to describe is its radical educational aspect, together with the cultural importance of Freud’s writings. The most difficult is to do with what a psychoanalytic therapy actually contends with shifts or treats within the individual in that long and sometimes interminable process which is an analysis. Moving around the ghostly furniture of the unconscious, finding the trace of wish beneath the heap of hate, may remain a novelist’s or former analysand’s business, even though some brain imagers and biochemical explorers have now found ‘evidence’ of hysterical desire and post-talking-therapy changes in the neural activity of the brain.
8
SCHIZOPHRENIA
Celia Brandon heard vile, persecutory voices who took her over and ran her life. Nowhere did the hospital even begin to consider she was suffering from schizophrenia. Others heard voices, too. They were diagnosed as hysterics, or dissociated personalities or mediums. Schizophrenia had not yet been named as a separate entity and when it was, hearing voices was hardly its primary symptom. Indeed, confusion over what schizophrenia might be persisted, and persists into our own time. This confusion stretches across the condition’s–if it is a single condition–origins, causes and constituent parts, whatever the occasional casualness or certainty of a growing body of psychiatrists in attributing the diagnosis from the early years of the twentieth century on.
This has been due not only to a professional lack: the complexity of mental disorders, the wide range of their symptoms–a proportion of them overlapping with each other even for very different conditions–the changing spectrum of behaviours over time, make clarity a goal rather than a fact. DSM-IV, the most commonly used psychiatric diagnostic manual today, recommends that an individual be monitored over a six-month period before a diagnosis of schizophrenia is attributed. Of the characteristic symptoms that the DSM names–delusions, hallucinations, disorganized speech (frequent derailment or incoherence), grossly disorganized or catatonic behaviour, and negative symptoms such as ‘affective flattening’–two are needed for a diagnosis. However, only one is needed if ‘delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behaviour or thoughts, or two or more voices conversing with each other’. Whether Celia Brandon, diagnosed by her medics in 1914 as ‘peculiar’, would at the same time in Vienna have been diagnosed as suffering from a paranoid hysteria, in Munich as suffering from dementia praecox, and in Switzerland then or in London today as a schizophrenic, is an open question.
Emil Kraepelin (1856–1926), Eugen Bleuler (1857–1939) and the Burghölzli
The history of the diagnosis of schizophrenia begins in psychiatric hospitals and with Freud’s contemporary, Emil Kraepelin, arguably the greatest classifier in psychiatric medicine. A brilliant clinician and compiler of illness profiles, developed out of the programme he initiated for the systematic accumulation of hospital files, Kraepelin made Munich a centre for psychiatric research. He also utterly rejected Freud’s psychodynamic technique. In his revised textbook of 1899, replete with those clinical observations which made him a model diagnostician and which are still pertinent today as descriptions of behaviour, Kraepelin elaborated and distinguished between the course and outcome of three separate diagnostic categories he had only mooted earlier: manic depression with its cyclical nature; paranoia; and a new entity, ‘dementia praecox’. This last made a whole host of peculiarities into an elaborate disease process.
Drawing on a vast hospital base of case records, influenced too by the work of the pioneering Prussian Karl Kahlbaum, who ran the Gorlitz Sanatorium, Kraepelin described sample life histories for sufferers of dementia praecox which turned their existence into the narrative of an illness. Beginning with a working life in which the patients ‘become negligent…pass no examinations, are turned away everywhere as useless, and easily fall into the condition of beggars and vagabonds’, he underscored the pattern of a worsening of symptoms and general deterioration as time passed. Throughout, the patients showed a remarkable lack of concern for what befell them:
Hopes and wishes, cares and anxieties are silent; the patient accepts without emotion dismissal from his post, being brought to the institution, sinking to the life of a vagrant, the management of his own affairs being taken from him; he remains without ado where he is put ’till he is dismissed; begs that he may be taken care of in an institution, feels no humiliation, no satisfaction; he lives one day at a time in a state of apathy. The background of his disposition is either a meaningless hilarity or a morose and shy irritability. One of the most characteristic features of the disease is a frequent, causeless, sudden outburst of laughter.
On top of the lack of affect, the flattened emotion which becomes a dominant part of the condition when it is recast as schizophrenia, Kraepelin also notes a lack of regard for surroundings, or what we might today call a lack of reality-testing; the loss of feelings of disgust and shame, so that ‘sphincters’ are loosened any and everywhere, bodies uncovered, sexual acts performed in public, obscene talk, improper advances and shameless masturbation indulged in. The patients may either grow mo
nosyllabic and lose all wish to express themselves, even to complain; or, in contrast, their talk can be a prodigious flow which has no link to need or situation and can simply be a torrent of abuse or cursing. Onset in males is with adolescence; with women a little later, often after the first child, and sexual activity in women is (inevitably) more marked.
Kraepelin understands all this as in some sense an early stage of senile dementia. It is a premature version of the same death-dealing syndrome and he maintains little hope, except through the vagaries of fate, of change or cure.
A hospital doctor who was more hospitable to Freud’s findings and had written an early positive review of the Studies on Hysteria emphatically disagreed with Kraepelin’s diagnosis. This was Eugen Bleuler, and his Burghölzli Hospital on the outskirts of Zurich became one of the premier hospitals of the early twentieth century. It was here that schizophrenia was diagnosed as a separate condition–not as Kraepelin would have had it, as an early manifestation of senile dementia, or dementia praecox. Unlike Kraepelin, Bleuler was convinced that schizophrenia was not irreversible, but was susceptible to improvement if patients were talked to and treated on a one-to-one basis, as well as given tasks in the real world.
Eugen Bleuler had been the first person in his peasant village of Zollikon, not far from Zurich, to go to medical school. Story would have it that as a former student at the Burghölzli, and then the chief of a secondary asylum in Rheinau, he was hardly in the front line for the senior post at the hospital, which was attached to a highly prestigious professorship at the University of Zurich. But Auguste Forel, the retiring head of the Burghölzli, wanted someone in place who would keep up his ban on alcohol–a potentially profitable trade for asylum chief and canton alike–and he knew Bleuler could be trusted in this. In 1898, a year before Kraepelin published his diagnosis of dementia praecox, Bleuler took over the Burghölzli.
Mad, Bad, and Sad: A History of Women and the Mind Doctors Page 24