Chapter One
A tale of two theories
Phyllis L. Sloate
The field of analytic psychosomatics arose out of the dualistic Cartesian preoccupations of the late nineteenth century, but its development after that was shaped less by philosophy than by the cultural and interpersonal styles of its founders. The history of the mindâbody question in psychoanalysis is a complicated and often tumultuous journey through psychoanalysis itself.
It begins with Sigmund Freudâs and Pierre Janetâs seminal investigations into the perplexing bodily expressions of hysteria. At first, Freud and Janet were not too far apart in their theories, but their thinking and methods of inquiry diverged, and with them their relationship. The legacy of their estrangement was an enduring bitterness and mutual disrespect that sadly retarded the theoretical and clinical development of psychosomatic studies. It has taken many years for their theoretical heirsâFreudâs in America, Janetâs in Franceâto begin to bridge the divide and reclaim a complicated but very rich double inheritance.
Freud and Janet were both fascinated by the splitting of consciousness in hysteria, with which Janet indelibly associated the earlier term dissociation (van der Hart & Horst, 1989). Their interest led them to Paris, to study with Jean-Martin Charcot at the SalpĂȘtriĂšre Hospital there. Charcot refused to attribute hysterical symptoms to demonic possession, conscious manipulation, or disordered wombs. He thought that hysteria was a disease of the nervous system caused by an inherited predisposition of the brain, and, therefore, worthy of scientific study. Although he came to acknowledge that some hysterias were precipitated by psychic factors such as trauma, in his view, innate somatic factors were primary (Goetz et al., 1995, pp. 201, 207). Charcot also importantly demonstrated that, in some patients at least, hypnosis could both elicit and banish hysterical symptoms (Goetz et al., 1995, p. 198; Jones, 1953, pp. 248â249); in other words, he showed that hysterical symptoms were ideational, that they were accessible through the psyche, and that they could be treated.
Freud, intrigued by Charcotâs treatment of hysteria with hypnosis, went to Paris in 1885 to learn more. Janet, too, was a student of Char cotâs, held in such high esteem by him that his mentor appointed him overseer of his Psychological Laboratory. But from that common beginning, their interests developed in different directions, and so did their assumptions about etiology. Janet elaborated Charcotâs view that hysterical dissociation and symptoms are the effects of traumatic over-stimulation on the context of structural weakness, and, as such, are devoid of symbolic meaning. Freud, however, was evolving a new dynamic conflict model; he explained hysterical symptoms as sym bolic substitutes for forbidden unconscious wishes, and dissociation as a defense against them.
Nadelman (1990) discovered Freudâs first explicit foray into psychosomatics in a long-forgotten paper of uncertain date entitled âPsychical (or mental) treatmentâ (Freud, 1890a, p. 283), which originally appeared in Die Gesundheit: Ihre Erhaltung, ihre Störungen, ihre Wiederherstellung (Health: Its Preservation, Disturbances, and Restoration), a work described by Fichtner (2008, p. 827) as âa family reference book for educated lay persons.â1
This brief early paper is remarkable for Freudâs lucid commentary on, and critique of, the prevailing ideas of his time, as well as for the contemporary feel of some of his intuitions. In it, Freud defined psychical treatment as the treatment of mental or physical disorders âby measures which operate in the first instance and immediately upon the human mindâ (Freud, 1890a, p. 283). He speculated that all thoughts have an affective component, and that they impact physically upon the body as affectâs physiological excitations are discharged into the smooth or striated musculature. Thus, emotional factors such as excitement, fear, anger, or sorrow may contribute to the creation of physical symptoms, and Freud asserted that in some patients, symptoms are generated by âa change in the action of their minds on their bodiesâ (p. 286).2 (It is worth noting that Freudâs interest in mindâbody issues antedates the publication of the Die Gesund heit paper, which appears to have been written after his time in Paris with Charcot. Freud had been intrigued with Breuerâs treatment of his hysterical patient Anna O. by the âcathartic methodââwhich she called âthe talking cureââas far back as 1882.)
Janet followed Charcot in his attention to the role of external trauma (that is, unmanageable overstimulation) in the genesis of hysteria. But he was more specific than Charcot in his ideas about etiology, and although he was not the originator of the concept, he focused on the role of dissociation in the formation of hysterical dis orders. In Janetâs model, the mind is bypassed in the initiation of hysterical symptoms, which therefore remain unconnected with any symbolic meaning; his work was an attempt to elucidate the psychic weakness that gives rise to this result (van der Hart & Horst, 1989).
Specifically, Janet thought that in individuals who are predisposed to hysteria, emotionally charged or traumatic experiences are not well processed or integrated, so that upsetting ideas, feelings, and/or mental imagery end up being excluded from consciousness (van der Hart & Friedman, 1989). The resulting mental fragmentation, which Janet called la dĂ©sagrĂ©gation psychologique, leaves the new hystericâs consciousness âsplitâ into multiple states that do not communicate with each other.
Thus sequestered in dissociated personality fragments, traumatic memories evolve into what Janet called primary idĂ©es fixes. They remain distinct from ordinary conscious experience, and when the dissociated memories recur, they create the âdouble consciousnessâ of hysteria that so interested both Janet and Freud. Unintegrated, they are often felt as intrusive thoughts or flashbacks, but they may also appear as involuntary muscle movements, paralysis, or other characteristic somatic forms. For Janet, these idĂ©es fixes were both the direct result of an innate weakness in the brainâs capacity for mental integration and synthesis and the direct cause of the symptomatic manifestation of that weakness. As such, he saw them as the core of hysteria.
Early divergences
In their first chapter of Studies on Hysteria (Breuer & Freud, 1895d), and in an earlier version published as a separate paper two years previously under the title âOn the psychical mechanism of hysterical phenomena: Preliminary communicationâ (Breuer & Freud, 1893a), Freud and Breuer affirmed Charcotâs notion that ideas could cause hysterical symptoms, and they acknowledged the influence of Janet and the other French investigators who viewed hysteria as a splitting of consciousness. They also accepted the possibility that some intolerable ideas had to be banished from awareness (Breuer & Freud, 1895d, p. 10). In one of his following theoretical chapters, however, Breuer (pp. 215â221) diverged from the position of Charcot and Janet. He proposed that the necessary precondition for the formation of hysterical symptoms is not an innate factor, but a hypnoid state. By this, he meant the altered state of consciousness that might occur when a person is falling asleep, or in a trance. According to Breuer, during hypnoid states ideas are cut off from associative connection with the rest of consciousnessâthat is, consciousness is âsplit.â He also thought that some people are more vulnerable than others to over-stimulation while in hypnoid states and, therefore, more prone to develop hysterical symptoms.
The theoretical ideas of Breuer and Freud were still in flux at that time; Breuerâs description of the alternating states of consciousness in his patient Anna O. (Breuer & Freud, 1895d, p. 24) evokes Janetâs views, and Breuer and Freud appear to be in accord with him when they write:
As Berman (1981) notes, similar comments apparently agreeing with the French model are scattered throughout the Studies. But, in 1894, in âThe neuro-psychoses of defence,â Freud explicitly disagrees with Janetâs formulation about the cause of hysteria. The more patients he treated, the more convinced he became that hysteria was not the result of innate structural weakness, but of a dynamic process (Gottlieb, 2003, p. 867). He challenged Janet directly in 1889 when he wrote in the case of Frau Emmy von N.,
Freud was getting ready to discard Breuerâs notions about hyp noid states, too. He was rapidly coming to believe that hysterical symptoms have symbolic meaning for the patient; by 1894, defence hysteria would emerge as central in his theorizing (Freud, 1894a). He began to distinguish between actual neuroses, which manifest themselves somatically and whose symptoms are not caused by under lying fantasy, and psychoneuroses, the symptoms of which are symbolically meaningful and rooted in intrapsychic conflict. In the actual neuroses, he thought, there was a failure of psychic elaboration, which he explained with the concept of binding (1895a, p. 368), the capacity of primary process energy to attach to ideas and the linkages between them, and so support a stable ego state. When âexcitationâ never reached the psychic apparatus that could âbindâ it into symbolic representations that are capable of being experienced and understood as âanxiety,â it could be experienced only physically. Freud argued at first that in that case, the physical symptoms developed independent of any psychic mechanism, and so lacked mental content (Freud, 1895b, p. 93). But once he accepted that psychoneurosis and actual neurosis could coexist in the same person, he softened this position, and so prepared himself for the hypothesis that unprocessed excitation could be converted into physical symptomatology:4
In favor of his emerging conflict model, Freud increasingly rejected both Charcotâs ideas: that inherited predisposition is a necessary if not always sufficient condition of hysteria, and that hysteria âis based on an innate weakness of the capacity for psychical synthesisâ (1894a, p. 46). By then he was focusing on the egoâs need to defend against unacceptable ideas. Once conceived, he pointed out, a distressing idea cannot be simply unthought. It can sometimes be separated from the affect that accompanies it, and its danger thereby reduced. But in that case, what happens to the now-orphaned emotional charge? The answer, he asserted, is displacement: âIn hysteria, the incompatible idea is rendered innocuous by its sum of excitation [that is, its load of affect] being transformed into something somaticâ (1894a, pp. 46â49; my italics). Freud called this process conversion, and attributed to it two kinds of meaning: first, it rendered innocuous an unacceptable idea; second, however, and simultaneously, it maintained a disguised con nection between that idea and particular distressing or anxiety-pro voking memories. These memories are defensively sequestered and form a âsecond psychical groupâ (p. 49) separate from the personâs primary consciousness.
While he repudiated with increasing conviction the idea that inherited weakness was the basis of hysteria, Freud was also abandoning hypnosis. Between 1887 and 1896, according to Strachey, he acknowledged not only that hypnosis was not the strongest tool in his skill set, but also that he increasingly found it unnecessary (Freud, 1895d, âMiss Lucy R.,â p. 108). He was learning from his patients to trust instead to what would ultimately become his treatment of choiceâanalytic listening to free association. Gay notes that in 1918 Freud told one of Emmy von N.âs daughters that her mother had taught him that âtreatment by means of hypnosis is a senseless and worthless proceedingâ (Gay, 1988, p. 71). The more invested he became in his conflict model, the less hypnotism interested him; it did not sufficiently engage what he thought to be the cause of hysterical symptomsâthat is, unconscious conflicts over forbidden wishes.
In 1895, in what might have been his first direct foray into the interpretation of psychosomatic symptoms, Freud suggested a connection between them and psychic conflict (1895a, pp. 95, 98). He proposed further that in anxiety neurosis, physical tension may be present in the body without a psychical component and wrote of âa psychical insufficiency, as a consequence of which abnormal somatic processes ariseâ (1895a, p. 115). This sounds like the way he would later talk about the actual neuroses, but he did not pursue this early insight. And (as we see in the quote above) he subsequently rejected the psychical insufficiency concept. While he was elaborating the conversion theory as an explanation for the somatic presentation of hysteria, he wrote a letter to Fliess (Letter 55) speculating on other interplays between mind and body (1897, p. 240). But these speculations too (about mourning, guilt, and physical identification with a dead loved one) would not come to fruition until much later, in âMourning and melancholiaâ (1917e).
Interactive or parallel?
In 1909, Freud distinguished obsessional symptoms from hysterical ones, asserting that obsessional symptoms âdo not involve the leap from a mental process to a somatic innervationâhysterical conversionâwhich can never be fully comprehensible to usâ (1909b, p. 157). His preoccupation with the psychogenesis of physical s...