S. Freud (1856 – 1939), within the 1909 American conferences, declares the beginning ofpsychoanalysis happened with the treatment of the patient Anna O. by J. Breuer (1842-1925). Theclinical case is described in the “Studies on Hysteria”, published in 1895 by both clinicians.A major psychic trauma is considered as the basis of “traumatic hysteria” that originates thepathological phenomenon (hysteric symptoms), while a number of partial traumas are consideredthe cause of “common hysteria”1. Hysterical symptoms are not linked to traumas, but to the inabilityto discharge it. Through the “talking cure” and the cathartic method, Breuer hypnotizes the patientand arouses her memories of the original factor2 allowing its abreaction3 (emotional discharge), by use of language4 5.
After abandoning the traumatic hypothesis of hysteria, Freud develops the “Drive Theory” andconceptualizes a model of psychic apparatus comprising three physiologically conflictingintrapsychic instances (Es, Ego, and Super-ego). Psychoanalysis, through “free association”, aims atreducing such conflict by supporting the Ego, which is considered a “reconciling” agent between anunknowable unconscious (Es), filled with sex drives that require an immediate discharge, and anauthoritarian and censoring Super-ego. The final conceptualization, in 1920, of a psychic apparatuswhere the sexual drive (Eros, life drive) is mixed with a death drive (Thanatos), as natural tendencyto bring all living beings to an inorganic state, definitively establishes the impossibility ofovercoming with psychotherapy the repetition compulsion of patient.
Massimo Fagioli (1932-2017): psychiatry as psychotherapyFrustration (Versagung) is considered by Freud as one of the obstacles to satisfying libido, and as apossible mechanism that generates the neurosis6. Frustration is never considered as an activetherapeutic intervention to oppose and refuse the destructive dynamics expressed by patients withinthe relationship (negative transference). The idea of a healthy human mental reality at birth leadsFagioli to an active psychotherapeutic approach aimed at curing mental illness by interpreting andrefusing (frustration) psychopathological dynamics7 of patients.“The analyst is absent; The patient experiences frustration”8: frustration-interest andfrustration-aggressiveness, starting from the difference between needs and requirements.“The patient’s needs are the isolated and partial pulsions that demand immediate satisfaction. (…)In this context, non-frustration (…) would be an absence, aggressiveness”9. Requirements are instead developmental tendencies that, if not satisfied by the analyst, can be afrustration-aggressiveness and an absence toward the patient10.
Forcing the patient to accept one’s personal needs as a mere fact, without considering their impacton the conscious and unconscious dynamics, means to annul the patient: “an absence of theanalyst”, a therapist who is physically present but psychologically absent, who “suddenly becomessilent, does not answer, is not there; in the patient’s mind, (…), the analyst disappears, dies”11.“Contrary to how it may seem, this disinterest, this absence, is not the lack of something but, rather,it is actively directing a pulsion, the death instinct, against the external object” 12. Fagioli discoversand conceptualizes the annulment pulsion (death instinct) as a non-conscious psychopathologicaldynamic, causing mental illness, which should be actively opposed if we want to truly considerpsychiatry as psychotherapy.
Note
1Cf. Breuer, J., Freud, S. (2020). Studi sull’isteria e altri scritti: 1886-1895, in S. Freud, Opere di S Freud, 1 vol.,BollatiBoringhieri, Torino 1967, ristampa maggio 2020, pp.175-176.
2Ibid, page 176
3Ibid, page 180
4Ibid, page 180
5The “Preliminary communication” ends by stating: “It will now be understood how it is that the psychotherapeuticprocedure which we have described in these pages has a curative effect. It brings to an end the operative force of theidea which was not abreacted in the first instance, by allowing its strangulated affect to find a way out through speech; and it subjects it to associative correction by introducing it into normal consciousness (under light hypnosis) or byremoving it through the physician’s suggestion, as it is done in somnambulism accompanied by amnesia”, ibid, page178.However, in 1883, in an unpublished letter to his fiancée Martha Bernays, Freud writes that he knew from Breuer thatBertha Pappenheim (Anna O.) was completely shattered and that, after several relapses, she had been admitted to amental hospital. In 1887, Martha wrote to her mother (unpublished letters written January 2 and May 31) that Berthahad developed an addiction to morphine and still had nocturnal hallucinations. Ibid, pp.168-169.
6“L’individuo era sano fintantoché il suo bisogno d’amore veniva soddisfatto da un oggetto reale del mondo esterno;diventa nevrotico quando questo oggetto gli viene sottratto senza che se ne trovi un sostituto” . Freud, S. (1912). Überneurotische Erkrankungstypen. Zentralblatt für Psychoanalyse 2:297-302. Trad. https://www.treccani.it/enciclopedia/frustrazione-gratificazione_%28Dizionario-di-Medicina%29/ . “The subject was healthy so long at his need for love was satisfied by a real object in the external world; he becomes neurotic as soon asthis object is withdrawn from him without a substitute taking its place”.
7After discovering the annulment pulsion, Fagioli gives a new meaning to the word negation, as a psychopathologicalnon-conscious dynamic, that must be identified in the transference and in the dreams brought forward by the patient, tobe interpreted and frustrated within the therapeutic relationship.
8Cf. Fagioli, M. (2019). Death instinct and knowledge. I English edition. Rome: L’Asino d’oro edizioni. Page 15.
9Ibid, pp. 19-20.
10 See “interpretations of the patient’s communication, verbalization of the patient’s transferential relationchip with theanalyst”. Ibid, page 22
11 Ibid, page 16.
12 Ibid, pp. 23-24.
References
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- Breuer, J., Freud, S. (2020). Studi sull’isteria e altri scritti: 1886-1895, in S. Freud, Opere di S Freud, 1 vol. (1967). Torino: Bollati Boringhieri.
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- Fagioli, M. (2019). Death instinct and knowledge. I English edition. Rome: L’Asino d’oroedizioni.
- Fagioli, M. (2021). La psichiatria esiste?. Roma: L’Asino d’Oro Edizioni. Fagioli, M. (2021). La psichiatria come psicoterapia. Roma: L’Asino d’Oro Edizioni.
- Ferenczi, S. (2021). Diario clinico. Gennaio-Ottobre 1932. Milano: Raffaello Cortina Editore.
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