Bleuler was a dedicated doctor who rose to new ideas, but was conscientiously cautious in their execution. At Rheinau, he had lived for ten years amidst the inmates; his personal rule, based on intimacy with the patients, meant that the mad had rallied in what many would have considered unthinkable circumstances. They had helped with the sick during a typhoid outbreak, for instance. Even the most dangerous had safely yielded axes when wood had to be fetched. These challenging tasks had helped alleviate and sometimes ‘cure’. Unexpected discharges had ensued. At the Burghölzli, Bleuler ran a tight ship. Some, like the fiery young Jung, chafed under his stewardship. But Bleuler brought a fine team of doctors to the hospital and introduced a regime of new psychological medicine which would make the Burghölzli recognized as far afield as America as a model teaching institution.
As in most nineteenth-century hospitals and clinics, doctors and their wives at the Burghölzli lived amidst their patients. What was new with Bleuler was that patients had to be seen regularly and individually twice a day. This was not a matter of surveillance, since Bleuler was aware that surveillance itself ‘awakes, increases and maintains the suicidal drive’ that schizophrenics so profoundly suffer. It was a question of talking therapy, of accommodation to the patient’s way of seeing the world, of attentiveness. Doctors were instructed to write down everything a patient said, whether it sounded like nonsense or not. The entire medical staff did rounds together three times a week and discussed patient cases and care. All this reinvention of the Burghölzli took time, and although Bleuler knew that Kraepelin’s diagnosis did not match his own experience of patients, he didn’t publish his findings on schizophrenia until 1911, though his students were led into his thinking far sooner, as were those who came to his important 1908 lecture.
Disputing that there was such a thing as premature dementia, Bleuler suggested renaming the condition ‘schizophrenia’, from the Greek ‘splitting’ and ‘soul’ or ‘mind’. It was intended as a dynamic concept. He didn’t mean that the patient was inhabited by ‘personalities’ who lived side by side within her, but that she seemed prone to splitting affective states, was inwardly ‘ambivalent’–a term he coined–as well as intellectually caught in the oppositional value of words and associations. Love and hate, wanting and not wanting, in the Bleulerian or indeed Freudian sense, coexist. They occupy the same moment. Bleuler’s schizophrenia is difficult to diagnose since its most visible characteristics, when they are not at a peak of intensity, fall within the spectrum of health. Amongst these characteristics he cites ‘indifference, lack of energy, unsociability, stubbornness, moodiness’. He combines this with symptoms like ‘blocking, confusion of symbols with reality’, creating neologisms. Fundamental to the condition as a whole is not today’s popular attribute of ‘hearing voices’ but a lack of affect and a loosening of associations, so that ideas don’t cohere in a usual way, and facts which do not suit affects are split off and take on a symbolic life.
As Bleuler describes it in his long book on the condition, the schizophrenic can manifest a complete lack of interest in external events, yet register them in detail. It is the persistent indifference to vital interests that is indicative of the disease; this is not the negativity of depression but a profoundly flat affect, an absence–what Freud, partly in response to Bleuler’s work with this general category of psychosis, described as a ‘turning away of the libido from the external world’. At times, Bleuler points out, schizophrenia can look like hysteria or paranoia in its ravings, and only time will help the doctor arrive at a diagnosis. In his generalizations, which sometimes seem to grapple irresolutely with the ineffability of conditions–and which lack the clinical acuity of description that Kraepelin provides–there is an underlying sense that he is trying to contend with a person rather than a patient described in a hospital record. Bleuler’s subject inhabits a changing reality both internal and external, not the fixity of a medical diagnosis which can only lead to deterioration.
Assiduous in his care of patients, generous to them and even to his renegade staff, Bleuler was perhaps a better doctor than theoretician. Yet he remained open to the new. Unlike his great student Jung, he also remained a lifelong friend of Freud’s and the two kept up a lively correspondence. Bleuler corroborated Freud’s insights about sexual disturbance in his own work with patients. Indeed, Bleuler applied the psychoanalytic method to the psychoses only to find that–despite Freud’s caution in this area–it helped treatment. He and Freud shared a sense of the mind as a dynamic space, an area of conflict in which, as Freud noted, ‘even the apparently most obscure and arbitrary mental phenomena invariably have a meaning and a causation’. Much of this was, of course, also common to Carl Gustav Jung, who eventually fell out with both of the older men.
Jung joined the Burghölzli Hospital staff in the spring of 1901 just when Bleuler was primed to launch a ‘laboratory’ and a new set of experiments in psychology. These were modelled on tests that Emil Kraepelin, trained by the psychologist Wilhelm Wundt, had set up in Munich under the aegis of Gustav Ashaffenburg as a way of further studying the minds of the mad. The experiment consisted of a timed series of word associations: the doctor or experimenter would hold up a card bearing a word to which the patient would reply. Response was timed and everything carefully noted. In Munich, the tests were repeated with normal subjects, and then intoxicated normal subjects. These latter results were compared with sufferers from dementia praecox and found to have a kinship, in that both associated predominantly to the sound of the word, rather than to its sense.
Jung, well read in a wide array of psychiatric literature and familiar with Freud’s early work, was an attribute for the Burghölzli. An ambitious young medic, he finished his dissertation under Bleuler. The older man also sent him to France, where he attended Janet’s lectures. On his return Jung thought of applying the word-association tests to patients to investigate how internal distractions and competing ideas might affect the associative process. Intense emotional associations, it turned out, interfered with ordinary responses. This pointed to possible sites of repression, most of which were found to have a sexual basis, as Jung’s paper, co-authored with another young researcher, Franz Ricklin, ‘The Associations of Normal Subjects’, spelled out. This was indeed a find. A psychological test had been devised which gave evidence of the existence of unconscious, ‘feeling-toned ideas’ and also provided a tool for uncovering buried ‘emotional complexes’. Jung barely bothered to acknowledge that all this corroborated Freud’s theoretical findings. Nor did he reveal the identity of his subjects. In time-honoured scientific fashion, one of his first had been himself. The other was a young Russian woman he was later to label a ‘schizophrenic hysteric’, Sabina Spielrein. Her story is intricately enmeshed with the battle between the Titans of psychoanalysis, Freud and Jung.
Sabina Spielrein (1885–1942) and C.G. Jung (1875–1961)
Much has been written about Sabina Spielrein’s relationship with the two men and particularly with Jung. Yet the importance of Sabina’s own story as a patient early diagnosed with Bleuler’s ‘schizophrenia’ and so permitted the possibility of getting better rather than languishing under what could well have been, given her extreme early symptoms, a Kraepelinian sentence of dementia praecox, has largely been neglected.
Spielrein began as Jung’s patient, then latterly and secretly became his lover. Jung, in an attempt to rid himself of what he feared might be the scandal of her, ‘gave’ her up and handed her over to Freud, having used her interesting case to help establish his relationship with the founding father of psychoanalysis. In the partisan battles that afflict the history of psychoanalysis and what became Jung’s ‘analytic psychology’, blame has been cast in different ways, depending in part on the source materials to hand. Jung has been targeted for allowing the ‘transference’ to go a tad too far, let alone for committing adultery with a patient and passing off–perhaps inadvertently–some of her ideas as his own. On the other side, Freud has been blamed f
or initially taking Jung’s side and treating Sabina as a pawn in a relationship between two dominant, doctoring males, without ever taking her own contribution to psychoanalysis seriously enough. Finally Spielrein herself has been blamed as a seductive and plotting ‘Jewess’, who led the married hero Jung astray, indeed fantasized a passionate affinity and affair, then threatened to expose him after he had cured her of a serious illness.
Conventional morality aside, blame in this case may be rather more a matter of affiliation than of a cool view of the inevitably muddled progress of any psychological treatment or love affair, complex enough even when the key players at one time or another don’t both rue and revel in their actions.
Sabina Spielrein was admitted to the Burghölzli on 17 August 1904, accompanied by policemen and an uncle. She had exhausted one private doctor, been refused by another and been violent at her hotel. Eighteen years old, she was the first of four surviving children of wealthy Russian Jews from Rostov on Dom, her mother already a university graduate, her father a merchant. Herself well educated, adept at a number of languages including Latin and Greek, and intensely intelligent, Sabina was in all ways a singular patient for the public facility that the Burghölzli was. A gymnasium graduate, despite her illness she had been admitted to the Zurich Medical School–which took only foreign women, and then only a small number. Withdrawn and difficult ever since puberty and the death of her younger sister, she had suffered a severe breakdown that summer. The private doctor her parents had taken her to could not manage the wildness of the young woman’s deliria. The Burghölzli was a final resort.
Jung depicted Sabina anonymously in a lecture he delivered three years later, in 1907. He elaborated on her anal obsessions and her sadomasochistic relationship to her father, which it seemed lay at the root of her disorder.
Puberty started when she was thirteen. From then on fantasies developed of a thoroughly perverse nature which pursued her obsessively. These fantasies had a compulsive character: she could never sit at a table without thinking of defecation while she was eating, nor could she watch anyone else eating without thinking of the same thing, and especially not her father. In particular, she could not see her father’s hands without feeling sexual excitement; for the same reason she could no longer bear to touch his right hand…If she was reproached or even corrected in any way, she answered by sticking out her tongue, or even with convulsive laughter, cries of disgust, and gestures of horror, because each time she had before her the vivid image of her father’s chastising hand, coupled with sexual excitements, which immediately passed over into ill-concealed masturbation…
It was perhaps Sabina’s involuntary fits of laughter alternating with deep depression, erotic activity and seemingly psychotic flights that earned her the occasional label ‘schizophrenic’. There is a fluidity of attributions in cases such as this, which only underscores the difficulty of diagnosis. Sabina’s condition on admission ‘had got so bad that she really did nothing else than alternate between deep depressions and fits of laughing, crying, and screaming. She could no longer look anyone in the face, kept her head bowed, and when anybody touched her stuck her tongue out with every sign of loathing.’
Jung described Sabina again as a case history of ‘psychotic hysteria’ in The Psychology of Dementia Praecox (1907). The masochistic aspects are reminiscent of Celia Brandon.
A certain young lady could not bear to see the dust beaten out of her cloak. This peculiar reaction could be traced back to her masochistic disposition. As a child her father frequently chastised her on the buttocks, thus causing sexual excitation. Consequently she reacted to anything remotely resembling chastisement with marked rage, which rapidly passed over into sexual excitement and masturbation. Once, when I said to her casually, ‘Well, you have to obey,’ she got into a state of marked sexual excitement.
Despite the horror of Sabina’s symptoms–which no one considered as a malingering hysterical performance–and her evident pain, her cure took less than a year. Whether this was due to time away from a manipulative and competing mother who insisted on keeping her daughter as sexually pure and ignorant as the ‘clean play’ of her name, from an authoritarian father and a loveless household, or to treatment by the new psychoanalytic method and ‘word association’, or to love for her handsome young doctor and the growing ability to play dirty, or a combination of all three, is not altogether an answerable question.
In Sabina Spielrein’s hospital chart, recently made available, there is a letter describing her addressed to Freud from Jung. Access to these records has clarified the mountain of speculation about Sabina’s case and her relations with Jung. Written some four months after her discharge on 1 June 1904, this ‘referral’ was never actually delivered–as evidently at one moment Jung feared it would be necessary–by Sabina’s mother to Freud. The letter is at once a deft case history and a recognition by Jung that matters with this young patient had moved beyond his control: he needs Freud to cope with this very Freudian case.
25.9.1905
Report about Ms. Spielrein to Professor Freud in Vienna, delivered to Mrs. Spielrein for possible use.
Dear Professor Freud:
The daughter of Mrs. Spielrein, Miss Sabina Spielrein, a medical student, suffers from hysteria. The patient has a heavy hereditary taint, father and mother are hysterics, especially the mother. A brother of the patient is a severe hysteric since his earliest youth. The patient is now 20 years old, clearly clinically ill for about the last 3 years. However, the pathogenic events and experiences, of course, reach back to her early age. I have analysed the clinical condition almost completely with the help of your method and with a favourable result from early on.
Jung goes on to describe how after a childhood of being beaten by her father, threats or the sight of any aggression became enough to bring about sexual arousal, but after analysis there emerged ‘a most intelligent and gifted person endowed with the highest degree of sensibility’. That summer, however, when her studies resumed, an inadvertent side-effect had manifested itself–one that Jung is a little too quick to blame on Sabina: ‘In the course of her treatment the patient had the bad luck to fall in love with me. She continues to rave blatantly to her mother about this love and her secret spiteful glee in scaring her mother is not the least of her motives. Therefore the mother would like, if needed, to have her referred to another doctor, with which I naturally concur.’
For whatever mixture of reasons, contact with Freud didn’t take place for some time to come. Meanwhile the love, it emerged, was hardly only on Sabina’s side.
Sabina was in many respects a model patient. She was the first patient that Jung–with Bleuler’s constant support–treated with the new Freudian psychoanalytic method; and the one with whom he was so ably led to the emotional complexes behind word associations. Her treatment after the first three months, when her symptoms were at their most intense, became almost an exploratory collaboration in the ways of the new science.
The hospital notes speak of Jung’s analytically dissolving Sabina’s present symptoms, her tics and grimaces and defensive gestures, her masochistic dreams and daydreams, by tracing them back to her father’s erotically charged beatings. The sexual basis is important, but, in line with Freud’s own changing sense of the need for an original sexual trauma to provoke disorders, no single one is found here. Sabina suffers from fantasy. Jung ‘educates’ her in the reasons behind her symptoms and allows the aggression and rage embedded in them a discharge.
Towards the end of her hospital stay, when Jung deems her well enough to take up her medical studies and she registers at the university naming the Burghölzli as her address, Bleuler gives Sabina a medical statement certifying that she has undergone treatment for ‘nervousness with hysterical symptoms’, and recommends that she begin her studies at the medical school of Zurich University that autumn. Bleuler and Jung also write to Sabina’s father asking him to release his daughter from any duties towards family members, whether it is writi
ng letters or looking after one of her brothers who was to study in Zurich.
Sabina moved into an apartment in central Zurich and continued to see Jung as an outpatient at the Burghölzli. She saw him, it would appear, at irregular intervals and for a span probably ending in December of 1909. There is a correspondence about bills between her and Bleuler until then. It was probably during this period that the love affair–‘the poetry’, as Sabina called it–between her and Jung rose to its romantic and passionate heights and tumbled into destructive disarray. In her diary in 1910, she looked back at that time: ‘We came to know each other, we became fond of each other without noticing it was happening; it was too late for flight; several times we sat “in tender embrace”. Yes, it was a great deal!’
The great deal was not only sexual passion, which even without the naming of parts it is clear–given the tenor of letters and diary, the talk of contraception and birth–there was. Sabina also became the spur for Jung’s concept of the ‘anima’–that unconscious feminine component which is part of everyman and which, materialized in a loved other, becomes a key to the self. He showed her a section of his diary in which it became clear that he saw her, indeed had had a vision of her, as a new edition of his mediumistic cousin, Hélène Preiswerk. Then, too, Sabina was Jung’s stimulus to fresh ideas, a necessary party to his work, not only as a patient but as an intellectual interlocutor. Certainly she felt herself to have been Jung’s collaborator. From early on, he had given her psychiatric literature to read. They shared ideas and she helped him with his thesis. Later, when everything had gone wrong, she explained all this in a letter to Freud:
We had numerous discussions about it, and he said, ‘Minds such as yours help advance science. You must become a psychiatrist.’ I stress these things again and again so that you may see it was not just the usual doctor–patient relationship that brought us so close together. He was writing the paper while I was still in the mental hospital…I spoke of the equality or intellectual independence of woman, whereupon he replied that I was an exception, but his wife was an ordinary woman and accordingly only interested in what interested her husband.
Mad, Bad, and Sad: A History of Women and the Mind Doctors Page 25