The First Psychotherapist: Josef Breuer’s Invention of the Talking Cure
Introduction
Josef Breuer (1842-1925) has a unique and prominent place in the history of psychotherapy. While treating a patient known as Anna O., from 1880-82, Breuer, a distinguished Viennese physician, developed the cathartic method or talking cure for treating nervous disorders. As a result of that treatment, Breuer independently formulated many of the key ideas that laid the foundation for modern psychotherapy. Breuer is best known for his collaboration with Sigmund Freud, who was fourteen years younger and regarded Breuer as his mentor. In the course of their scientific discussions, Breuer introduced Freud to the case of Anna O. (whose real name was Bertha Pappenheim). The ideas emerging from that case so fascinated Freud that he devoted the rest of his career to developing them, in the form of psychoanalysis. The two men co-authored Studies on Hysteria, published in 1895, which is considered the founding text of psychoanalysis. However, the significance of Breuer’s contributions goes well beyond his role as Freud’s mentor and collaborator.
Breuer’s name is remembered today mostly as a footnote in the history of psychoanalysis. The conventional view, entrenched in psychoanalytic history, is that Breuer was too conservative to accept the implications of the ideas suggested by Anna O.’s treatment and to follow them to their logical conclusion, a task that only Freud had the intellectual depth, vision and boldness to accomplish. However, that picture misrepresents the true nature and significance of Breuer’s achievements. In many of the key respects that Freud’s views diverged from Breuer’s, such as the relative importance of sexuality versus trauma in the onset of psychopathology, and the role of intellectual understanding (i.e., analysis) versus emotional experience (i.e., catharsis) in clinical treatment, it is Breuer who has been vindicated by the passage of time. However, Breuer’s original views were so completely excluded from the mainstream of psychotherapy that few people are aware of his contributions or recognize their true value.
Breuer’s theory of hysteria provides a comprehensive framework for understanding the origin of psychopathology and its treatment, independent of Freud’s subsequent development of those ideas in the form of psychoanalysis. Breuer’s concepts of psychical trauma, intracerebral excitation, hysterical conversion, abreaction, associative correction, hypnoid states, unconscious ideas and splitting of the mind, and the cathartic method he developed as a treatment for nervous disorders are profound contributions in their own right. They are at the heart of many of the theoretical models and treatment approaches widely used in the field of psychotherapy today. Breuer’s ideas are just as relevant and compelling now, as they were when he formulated and published them, over a hundred years ago, and deserve to be more widely known. With the renewed emphasis in psychotherapy today, on the fundamental role of trauma and dissociation in the onset of mental illness, the field is returning to Breuer’s point of view, after a long detour.
In many ways, Breuer is the unacknowledged father of psychotherapy, a man of astonishing brilliance and vision, whose contributions to the conceptual framework and clinical techniques of psychotherapy continue to be of fundamental importance in the field today. Breuer’s achievements were neglected and unappreciated in his lifetime, and remain obscure to this day, because Freud downplayed and distorted Breuer’s role in their collaboration, while misappropriating his ideas to claim exclusive credit for their discoveries. Freud undermined and betrayed the man who was his intellectual mentor and had generously supported him professionally and financially for over ten years, in an act of opportunism and ingratitude that has received remarkably little attention.
Breuer was a brilliant physician and scientist and had made fundamental discoveries in physiology, even before he turned his attention to psychology. His work is remarkably prescient, anticipating many of the insights of modern neuroscience, and illuminating many other areas of human experience including the development of personality, relationships, love, creativity, and the nature of consciousness. It’s important to correct the historical record and give Breuer the credit he deserves, not just for accuracy and fairness, but because understanding and integrating his ideas, can enrich the field of psychotherapy and enhance the effectiveness of therapists everywhere, regardless of orientation.
Breuer was born in Vienna, where his father was a highly respected teacher of religion in the local Jewish community. Breuer’s mother died when he was very young, shortly after the birth of his brother, who was two years younger. Breuer had decided to become a physician at a young age, perhaps at least partly because it was one of the few respected careers open to a Jew at a time when anti-Semitism was still prevalent in academia and public service. Breuer enrolled at the University of Vienna in 1858, and received his medical degree in 1864. He then spent the next ten years combining experimental research with the practice of medicine, forging a brilliant scientific career, marked by two notable discoveries.
In 1868, working under Ewald Hering at the military medical school in Vienna, Breuer was the first to demonstrate the role of the vagus nerve in the reflex nature of respiration. This phenomenon, known as the Ewald-Breuer reflex, was a departure from previous physiological understanding, and changed the way scientists viewed the relationship of the lungs to the nervous system. Then, in 1873, Breuer, independently discovered, along with the eminent physicist and mathematician, Ernst Mach, how the sense of balance is managed by information the brain receives from the movement of a fluid in the semicircular canals of the inner ear. These findings are a testament to the power of Breuer’s intellect and his talent for generating bold hypotheses and then confirming them through rigorous experimental research. In spite of his remarkable achievements, Breuer decided against pursuing an academic career, perhaps because of his aversion to the political environment, and resigned his position from the university to establish a private practice.
Breuer went on to become one of the most sought-after physicians in Vienna, with a distinguished reputation as a diagnostician. His patients included many of the elite of Vienna and he had a wide circle of friends, including prominent artists, writers, musicians and philosophers, in addition to scientists and physicians. It was in these circumstances that Breuer came into contact with Sigmund Freud. The first meeting between the two men is thought to have occurred around 1877, while Freud was still a medical student at the University of Vienna. They were most likely introduced by Ernst Brucke, the eminent physiologist in whose laboratory, Freud was a research assistant from 1876-82. The two men developed a close friendship and Freud became a frequent visitor at Breuer’s household. Freud was on such cordial terms with Breuer’s wife, Mathilde, that when his first child was born in 1887, a daughter, he named her after Mathilde.
Breuer was already established as a successful physician, with a distinguished reputation, while Freud was still struggling to establish his practice and make a name for himself. Breuer was generous in lending Freud money and referring patients to him to help him set up his medical practice. They also spent endless hours discussing scientific matters. Freud was intensely interested in Breuer’s treatment of Anna O., and pressed Breuer for details of the case. The two men recognized the historic importance of the case and the issues raised by it, and worked closely together to understand its implications. Their collaboration culminated in two groundbreaking publications: a paper on hysteria in 1893, followed by Studies on Hysteria in 1895.
Theory of Hysteria
Science advances by the discovery and understanding of phenomena that can't be explained by existing concepts and theories, and require the revision or extension or replacement of existing conceptual categories. At the beginning of the 19th century, hysteria was one such phenomenon, considered by many leading physicians, as the major unsolved problem of neurology. It could not be explained by the concepts of physiology and anatomy known at the time, and became the intense focus of research by neurologists and psychiatrists. Building on previous work by researchers such as Jean-Martin Charcot, Hippolyte Bernheim, and Pierre Janet, Breuer and Freud had to invent a new set of concepts and principles to explain it, thereby transforming and revolutionizing our understanding of the human mind.
The disorder that became known as hysteria has a long history going back to the ancient Greeks. Although the condition is complex to describe, manifesting in a wide range of symptoms, affecting virtually every system of the body, its essential feature is simply described - a nervous disorder characterized by a loss of functioning that cannot be explained on any organic basis. Its symptoms include paralysis, amnesia, contractures, impairment of hearing, vision, digestion, respiration, and alternations in mood and personality. Different patients develop a different set of symptoms and even with the same patient, the type of symptoms and their severity can change over time. To understand the ideas Breuer introduced and appreciate the true nature of his achievement, it’s useful to first review the findings reported by him and Freud in their Preliminary Communication on hysteria, published in 1893. In that paper, titled On the Psychical Mechanism of Hysterical Phenomena Breuer and Freud outline the following view of hysteria, based on their clinical observations.
The key causative factor of hysteria is psychical trauma, which they define as any event that provokes intense, distressing affects, such as fear, anxiety, shame or physical pain. They distinguish between two types of hysteria: traumatic hysteria, caused by a single major trauma, such as an accident and common hysteria, caused by a series of partial traumas that “exercise a traumatic effect by summation.” In both cases, the memories of the psychical traumas persist, with their affect undiminished, long after the event was first experienced. However, these memories are not directly accessible to the patient, and their existence can only be deduced indirectly, through their effects, in the form of hysterical symptoms. This is the basis of the famous line from the paper: “Hysterics suffer mainly from reminiscences.” The patient has complete or partial amnesia of the traumatic events in his normal waking state, and the associated memories can only be recalled under hypnosis.
To explain how traumatic memories, charged with affect, can persist for long periods without the patient being aware of them, Breuer and Freud proposed the following mechanism. The memories are inaccessible because they exist in abnormal states of consciousness that are isolated from the normal consciousness of the patient. They assert that the fading of a memory and its associated affect requires an energetic reaction to the traumatic event, such as running away, or fighting back when attacked. “If the reaction is suppressed, the affect remains attached to the memory.”
If an adequate reaction did not occur at the time of the event, the affect can be discharged at a later time, in one of two ways: by expressing it in words, a process they call abreaction, or by the gradual wearing-away effect of integration with the patient’s existing store of memories and impressions. This process, which they call associative correction, is the mechanism by which normal memories fade over time. However, if neither of the two processes, abreaction or associative correction, occurs, the traumatic memory continues to exist with its affect undiminished.
The paper describes two reasons a patient might not have an appropriate reaction to a traumatic event, either at the time it is experienced or afterwards. Either the event is of a distressing or shameful nature, so the patient does not want to remember it (a phenomenon Freud named repression), or the event occurs in an abnormal state of consciousness, so the patient cannot remember it (dissociation). Often, both conditions exist together, because the distressing event can induce the abnormal state of consciousness in which the memory becomes inaccessible. This corresponds to the common phenomenon whereby victims of accidents, explosions or other injuries, end up having amnesia for the circumstances around the traumatic event.
Breuer coined the term hypnoid states to refer to these abnormal states of consciousness, because of their similarity to the state of consciousness experienced by patients under hypnosis. The key characteristic of hypnoid states is that "the ideas which emerge in them are very intense but are cut off from associative communication with the rest of the content of consciousness.” Hypnoid states are similar to dreams, but unlike most dreams, their affective charge is so intense as to "intrude into waking life in the form of hysterical symptoms.”
Using the above concepts, Breuer and Freud explain the typical course of hysteria as follows - memories formed as a result of traumatic experience are isolated in abnormal states of consciousness (hypnoid states) where they can persist with undiminished intensity for long periods of time. The affect associated with the traumatic memories depends on the severity of the trauma, and if it becomes sufficiently intense, can intrude into the patient’s awareness in the form of symptoms and attacks. In extreme cases, the ideational content present in the hypnoid states can be sufficiently complex to organize itself into an alternate personality. A state of equilibrium is established between the two psychic states, so that hysterical attacks and normal life co-exist. However, the equilibrium is unstable, so that hysterical symptoms and attacks can appear spontaneously, if the patient’s personality is weakened by exhaustion or illness. It is also possible to provoke an attack, in the same way that normal memories can be evoked in accordance with the laws of association, that is if the patient has an experience similar to the original traumatic event.
Breuer and Freud conclude that the essence of hysteria is "the splitting of consciousness” or dissociation, a phenomenon first described by the French psychologist, Pierre Janet. They go on to write that “a tendency to such a dissociation, and with it the emergence of abnormal states of consciousness (which we shall bring together under the term ‘hypnoid’) is the basic phenomenon of this neurosis…the basis and sine qua non of hysteria is the existence of hypnoid states.”
The treatment method that follows from this view of hysteria is to help the patient recall the traumatic memories and discharge the affects they contain. This requires the patient to describe the traumatic event in detail and express the associated affect. “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 its accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affect into words. Recollection without affect almost invariably produces no result." This procedure has a curative effect because it subjects the memories to the processes of abreaction and associative correction, thereby releasing their undischarged affect. However, since the memories are not readily accessible to the normal consciousness of the patient, the patient must be guided to recall them by the use of hypnosis.
In their Preliminary Communication, Breuer and Freud, assert that psychic traumas are the cause of hysteria, and describe the broad outlines of the process involved, that is, the formation of abnormal states of consciousness, in which traumatic memories and affects persist for long periods of time. However, they don’t provide any details about this process. Why do traumatic memories lead to hysterical symptoms, and why are the symptoms relieved by recalling the memories and discharging the affects? These are the momentous questions Breuer takes up in his theoretical essay in Studies on Hysteria.
Intracerebral Excitation
Breuer’s theoretical essay repays close reading, by any psychotherapist today, as many of the observations and insights in it are remarkably prescient. The essay is over sixty pages in length and provides a comprehensive account of the nature, cause and treatment of hysteria, that is astonishing in its clarity, rigor, boldness and depth of insight. In keeping with Breuer’s training as a careful researcher, his reasoning is rigorously scientific. Although some of his hypotheses are speculative, they are grounded in careful clinical observation, and informed and constrained by the facts of physiology and anatomy. Breuer’s arguments are detailed and persuasive and his chain of logic so carefully constructed, that it is hard to deny the validity of his conclusions. The entire paper is a tour de force of scientific reasoning and exposition, leading to insights that are as compelling as they are radical. James Strachey, the English translator of Studies on Hysteria, wrote about Breuer’s paper “It is very far from being out of date; on the contrary, it conceals thoughts and suggestions which have even now not been turned to sufficient account. Anyone immersing himself in this speculative essay will form a true impression of the mental build of this man.”
Breuer introduces the concept of intracerebral excitation, which corresponds roughly to the activation of neural pathways, revealed by functional imaging in MRI and CAT scans, a standard tool of modern neuroscientists. Breuer asserts that intracerebral excitation varies along a continuum, with an alert, wakeful state and dreamless sleep at opposite ends, and all intermediate points realized during the transition from wakefulness to sleep. He then describes a few characteristics of intracerebral excitation. It spontaneously changes in response to external events that elicit strong emotions, increasing during agitation or excitement, and decreasing in circumstances of safety and comfort. A certain amount of intracerebral excitation exists in the conductive paths of the brain when awake, even if the organism is at rest; that's why merely being awake without performing any work causes fatigue. It is also increased in a state of alertness, prepared for action, which is why such a state is fatiguing.
An excess of intracerebral excitation is uncomfortable and must be discharged, either by sensory experience, thinking or bodily activity. This in in keeping with the principle of constancy proposed by Breuer and Freud, according to which the body has a natural tendency to keep the level of intracerebral excitation constant, in analogy with homeostasis of other body functions such as temperature, blood pressure and so on. According to Breuer, the reason for this is that there is an optimum level of excitation for being prepared to work in which the brain is receptive to external stimuli, reflexes are facilitated, and association of ideas is possible corresponding to "a clear and reasonable state of mind.” This is borne out by the fact that a “surplus of intracerebral excitation is a burden and nuisance, and an urge to use it up arises in consequence. If it cannot be used in sensory or ideational activity, the surplus flows away in purposeless motor action.” Breuer provides various examples in support of this hypothesis, for example, the phenomenon of individuals pacing when they are agitated.
The dynamic equilibrium of the nervous system is constantly at risk of being disturbed by external events, especially those that produce strong affects. This is because strong affects restrict the “train of ideas” or association. The ideas that provoked the affect become so intense that they dominate the individual’s consciousness, at the expense of all other ideas. As a result, the increased excitation cannot be discharged through associative activity. This paves the way for Breuer’s explanation of the mechanism of hysterical symptoms.
Hysterical Conversion
To explain his view of hysteria, Breuer draws an analogy between the human nervous system and an electrical network. In an electrical network, current flows along specific paths, because its flow into other areas is restricted by means of insulation. However, a sudden increase in voltage can lead to a breakdown of the insulation separating different areas, creating alternate paths of conduction through which current can enter areas from which it was previously excluded. Similarly, although the nervous system as a whole forms an interconnected network, there is a high degree of resistance to the transmission of nerve impulses between the areas involved in different functions. Under normal circumstances, the pathways in the brain involved in ideas or emotions are insulated from the nerves involved in sensory perception, digestion, respiration, movement, and so on.
However, an abrupt increase in intracerebral excitation that is not discharged through the usual means, emotional expression, physical movement or associative correction, can lead to a breakdown of this resistance, stimulating nervous activity in areas that were previously isolated from each other. For example, if the excitation due to an idea or emotion is discharged into the digestive system, it may cause queasiness in the stomach or diarrhea, or if discharged into the respiratory system, may lead to alterations in the rate of breathing. Further, if the excitation is discharged into the sensory nerves, the individual may perceive an image or sound even though there is no external object corresponding to it, that is, a hallucination. This process, whereby an idea can be expressed somatically, resulting in an “abnormal expression of the emotions” is called hysterical conversion because the affect associated with the trauma has been “converted” into a hysterical symptom. Each hysterical symptom is a pathological manifestation of the experiences that produced the original affect, that is the psychical traumas.
Vulnerability to such a breakdown depends on the innate disposition of the individual, with some people naturally having a nervous system more excitable than others. A breakdown in resistance also occurs from the weakening of the nervous system due to exhaustion, illness or injury. The level of intracerebral excitation is inversely proportion to the conversion; therefore the greater the excitation that needs to be discharged, the stronger the hysterical symptom. If the conversion is repeated, it becomes reinforced and occurs more easily, so that over time the idea no longer provokes the affect but only the abnormal reflex. The individual directly converts the idea into a somatic symptom, without experiencing the corresponding emotion. In other words, the emotion is expressed through the body without the patient being aware of its cause. Abnormal affective reactions are indicative of a nervous disorder (if the affect has an objective basis) or of hysteria (if they occur spontaneously with no apparent basis).
Strong affects cause a disturbance of "the dynamic equilibrium of the nervous system...intracerebral excitation is powerfully increased, but is employed neither in associative nor in motor activity" leading to an abnormal expression of the emotions. The original trauma and the part of the body in which the abnormal expression of the emotions occurs is connected by a chain of ideas, either directly or symbolically. For example, disgust can be expressed through vomiting. Breuer points out that “in a large number of cases the path taken by the train of determination remains unintelligible to us, because we often have a very incomplete insight into the patient’s mental state and an imperfect knowledge of the ideas which were active at the time of the origin of the hysterical phenomena. But we may assume that the process is not entirely unlike what we can observe in more favorable cases.”
Multiple causes must converge for a hysterical symptom to be formed, that is, symptoms are overdetermined. This can happen with repeated experiences of a traumatic nature but even the memory of a single experience repeated many times before its affect has been weakened can have the same effect. This is the case with traumatic hysteria, which corresponds to the modern diagnosis of PTSD. In general, the excitation due to an affective idea gradually reduces with time due to the wearing-away by interaction with other ideas. However, this process of associative correction doesn’t happen if the idea is withdrawn from associative contact. Ideas that are not accessible to consciousness retain their affect undiminished; each time the idea is renewed, all of the original affect is released, causing the abnormal reflex (i.e., conversion) to be reinforced and stabilized. As a result, the hysterical symptom becomes self-sustaining and continues even after the original provoking cause is no longer present.
Although hysterical symptoms were ideogenic to begin with, by repetition they can become imprinted into the body, causing modifications of the nervous system, thus becoming self-sustaining somatic symptoms. However the fact that the symptoms can disappear when the associated affect is accessed and discharge under hypnosis indicates that the changes in the nervous system are reversible. If in the stream of consciousness, an idea appears that has a strong affect attached to it, the affect is revived with a high degree of intensity, making the idea more vivid. The strength of the affect depends on the extent to which it has been subjected to associative correction or abreaction. If the original affect was discharged in an abnormal way, the excitation from the affective idea is converted into a somatic phenomenon. This is plausible because the reverse is clearly true, e.g., trying to suppress a somatic phenomenon such as sneezing, leads to an increase in excitation or tension. Breuer points out that the normal reaction to excitation caused by strong, irreconcilable ideas, is to communicate them by speech. He asserts that this is the basis of the religious practice of confession, and why expressing concerns and preoccupations in words is a relief.
Hypnoid States
According to Breuer, the conditions that make individuals prone to hysterical conversion are either innate disposition or the existence of a special state of mind, similar to a state of hypnosis, in which ideas are not opposed, i.e., hypnoid states. Such states can be brought about by hypnotism as well as by strong emotions, such as fear or anger, or conditions of exhaustion, hunger, sleeplessness (a plausible reason for the visions of mystics, induced by fasting). There are two conditions for formation of hypnoid states: defense (voluntary) and dissociation (involuntary).
Experiences in hypnoid states are subject to amnesia in waking life but can be remembered in artificial hypnosis. Because the ideas formed in these states are not subject to associative correction by normal consciousness, they can persist undiminished for long periods and develop into the wildest delusions. It is mostly in these states that there is an irrational, symbolic connection between the precipitating cause (traumatic experience) and the pathological phenomenon (i.e., the hysterical symptom).
Hysterical conversion takes place more easily in hypnoid states than in the waking state for the same reason that suggested ideas (movements, hallucinations etc.) are realized more easily in hypnosis, that is, the relaxation of critical faculties and absence of conflict with competing ideas. The repeated experience of auto-hypnosis, as in habitual reverie, can pave the way for hypnoid states by making the person more susceptible to them. Such states of absent-mindedness (vacancy of consciousness) occur naturally in daydreaming or creative imagination. However, those states don’t become pathogenic because there is a lack of strong affect (as in daydreaming) or energetic work is carried out to discharge the affect that arises (as in creative production). However reveries filled with emotion and imaginative states accompanied by fatigue, so no work can be performed, are pathogenic. This includes the common experiences of brooding with anxiety, nursing a sick person, or being in love. They all have in common the occurrence of strong affect with absence of competing ideas (due to intense focus on a single object), so the large quantity of excitation is undischarged, satisfying both the conditions for hysterical conversion.
Unconscious Ideas and the Splitting of the Mind
Breuer opens the section on unconscious ideas with a provocative passage about the nature of consciousness. “There exists in human beings the strange fact of self-consciousness. We are able to view and observe, as though they were objects, ideas that emerge in us and succeed one another…We describe as conscious those ideas which we observe as active in us, or which we should so observe if we attended to them. At any given moment of time there are very few of them, and if others, apart from those, should be current at the time, we should have to call them unconscious ideas.”
He asserts that it is a matter of everyday experience that a large number of ideas are unconscious, in that they operate and have effects, without us being aware of them. For example, a person might be uneasy at having forgotten to do something without knowing what it is, and only remember much later the task he had forgotten. Clearly, the idea of that task was operative in his mind without his being aware of it; in other words, it was unconscious. “A great deal of what we describe as ‘mood’ comes from sources of this kind, from ideas that exist and are operative beneath the threshold of consciousness. Indeed, the whole conduct of our life is constantly influenced by subconscious ideas.”
Breuer describes a hysterical symptom as the somatic expression of an unconscious idea; the duration and severity of the symptom is a measure of the persistence and strength of the affect associated with the idea. Since hysterical symptoms can exist for a long time (many years), their cause (memories of psychical trauma) must also continue to exist even though the patient is not aware of them. This leads to the inescapable conclusion that “unconscious ideas exist and are operative” in hysterical patients. Further, if such a patient continues to suffer repeated, traumatic experiences that are not resolved by the usual means, over time, the store of unconscious ideas grows in size, leading to the formation of large complexes of related ideas, which can become organized into elaborate patterns, while remaining unconscious. These ideas co-exist with the conscious mental life of the patient, and have important consequences even though the patient is not aware of their existence. Breuer describes this division of psychical activity as “the splitting of mind” and asserts that it is “of fundamental value for our understanding of hysteria.” According to him the “splitting of psychical activity which is so striking in the well-known cases in the form of “double conscience” is present to a rudimentary degree in every major hysteria’, and that ‘the liability and tendency to such a dissociation is the basic phenomenon of this neurosis.”
Breuer’s concept of “splitting of the mind” is equivalent to the concept of dissociation, introduced by Pierre Janet, the great French psychologist. However, there is an important difference between their positions. Janet believed hysterical patients had an innate weakness of mind that made them constitutionally incapable of the synthesis of ideas required for normal functioning. Breuer’s view was that Janet had reversed cause and effect. “It is not the case that the splitting of consciousness occurs because the patients are weak-minded; they appear to be weak-minded because their mental activity is divided and only a part of its capacity is at the disposal of their conscious thought.”
According to Breuer, the splitting of mind explains not just the physical symptoms of hysteria, but also many of its other characteristic features. This is because unconscious ideas can influence a person’s waking thoughts while remaining below awareness, in two ways. First, through their direct effects - for example, by creating hallucinations which appear meaningless and bizarre, but whose meaning becomes clear under hypnosis. Secondly, by influencing the course of association, thereby reinforcing some ideas and making them more vivid than they would have been otherwise. Hence, certain ideas can force themselves into the patient’s awareness compulsively, so that he is forced to think of them. As a result, unconscious ideas can influence the patient’s emotional tone or state of feeling.
This accounts for the fluctuations of mood in hysterical patients, which seem to occur for no apparent reason. Breuer writes that “the ‘split-off mind’ acts as a sounding board to the note of a tuning fork.” Hence, any event that provokes unconscious memories liberates all of the affect associated with those memories, leading to an affective response out of proportion to what would have risen in the conscious mind alone. This is the reason for hysterical patient’s intense emotionality, and their abrupt, and intense reaction to events that on the surface appear lacking in importance. The narrowing of attention or absent-mindedness of hysterics is because “every idea takes possession of the whole of their limited mental activity” due to restriction of field of consciousness. The patient’s suggestibility is due to the lack of associative correction in the conscious mind due to “poverty and incompleteness of its ideational content.” Finally, their aversion to boredom, craving for excitement and hyperactivity can be explained as a consequence of the fact that a surplus of excitation is generated in their nervous system even in a state of rest.
Breuer’s theory, with its emphasis on dissociation due to trauma, thus provides a compelling explanation of the major features of hysteria. At this point, it’s useful to examine the key differences between Breuer’s and Freud’s views.
The Rift Between Freud and Breuer
The appearance of Studies on Hysteria, marked both the culmination of the Breuer-Freud collaboration as well as its end. After the book’s publication, Freud sought to develop his theoretical views in a different direction and gradually distanced himself from Breuer. Both men came to have serious disagreements in matters of both theory and clinical technique. Their main point of difference was the relative importance of hypnoid states versus sexuality in causing hysteria. Freud increasingly came to believe that conflicts related to sexuality played an essential role in all cases of hysteria. Breuer fully acknowledged the importance of sexuality but considered it as only one of many factors, and asserted that the phenomenon of dissociation, which was implicit in his theory of hypnoid states, was more fundamental.
In a letter to the Swiss psychiatrist Auguste Forel in 1907, Breuer wrote, “this immersion in the sexual in theory and practice is not to my taste.” He went on to write, “Freud is a man given to absolute and exclusive formulations: this is a psychical need, which in my opinion, leads to excessive generalization.” Freud for his part was skeptical of the whole concept of hypnoid states. In Five Lectures on Psychoanalysis (1905), Freud wrote that “Breuer's theory of 'hypnoid states' turned out to be impeding and unnecessary, and it has been dropped by psycho-analysis today.” Freud went on to refer dismissively to “the screen of hypnoid states erected by Breuer.”
Freud also promoted the idea that Breuer was too cautious and conservative to recognize the true importance of sexuality. To support this view, Freud claimed that Breuer had to abruptly terminate his work with Anna O. because she developed strong sexual feelings towards him, and he therefore resolved never to work with hysterical patients again. This view was asserted as fact by Freud’s biographer, Ernest Jones, and came to define the conventional view of the matter. However, there is considerable evidence that the entire incident was fabricated. Louis Breger, a psychoanalyst and Freud biographer, writes “This account of the conclusion of Bertha’s treatment has passed into psychoanalytic lore and been endlessly recycled by a number of the faithful. Freud’s version of what happened is simply not true. It is an example of the “resistance” argument that he later used to dismiss everyone who raised questions about his theory of sexuality: They could not accept it because it was too personally threatening.” Freud would later use a similar argument with many of his followers who disagreed with him, including Carl Jung, Alfred Adler, Sandor Ferenczi and Otto Rank. Breger goes on to assert that “The truth is that Breuer did not flee from Bertha but remained involved with her treatment for several years.”
Freud’s statements about the value of Breuer’s contributions gradually evolved as Freud became more famous. In his Five Lectures on Psychoanalysis (1909), Freud was gracious in acknowledging Breuer’s role: “If it is a merit to have brought psychoanalysis into being, that merit is not mine. I was a student and working for my final examinations at the time when another Viennese physician, Dr. Josef Breuer, first (in 1880-2) made use of this procedure on a girl who was suffering from hysteria…Never before had anyone removed a hysterical symptom by such a method or had thus gained so deep an insight into its causation.” However, in an essay he contributed to the book On the History of the Psychoanalytic Movement (1914), Freud categorically stated “I have come to the conclusion that I must be the true originator of all that is particularly characteristic in psychoanalysis.”
An important factor in the souring of the Breuer-Freud relationship was Freud’s intense desire for fame (well-documented in his own writings), and his pattern of engaging in questionable conduct to claim exclusive credit for discoveries. Freud also had a history of strong relationships with older men, who he first idolized and then rejected. This was evident, for example, in Freud’s friendship with Wilhelm Fliess, a surgeon from Berlin, who replaced Breuer as Freud’s mentor and confidant. The two men had an intense friendship lasting from 1887-1900 which started in mutual respect and ended in acrimony and bitterness. Freud’s biographer, Peter Gay reports that at Freud’s last meeting with Fliess, in 1900, “the two men quarreled violently” each attacking the other about “the value, the very validity, of his work.”
In The Interpretation of Dreams (1900), Freud wrote: “An intimate friend and a hated enemy have always been necessary requirements of my emotional life. I always knew how to provide myself with both over and over…sometimes the two were united within the same person.” This statement is at least partly descriptive of Freud’s attitude towards Breuer. It is also notable that Breuer had been more than a collaborator to Freud, consistently treating him with generosity and affection, lending him money, referring patients to his practice, and welcoming him into his home. Peter Gay writes about Freud that, “His disagreeable grumbling about Breuer in the 1890s is a classic case of ingratitude, the resentment of a proud debtor against his benefactor.”
In this connection it is interesting to note that in their dispute, Breuer took the high road and never publicly challenged Freud or responded to his criticisms, choosing instead to withdraw from the field of psychology to focus on his medical practice. Given that Freud had the field all to himself, and continued to publish extensively in the field, steadily building his reputation, it was easy for him to caricature and disparage Breuer’s cautious attitude, which represented appropriate scientific restraint, as timidity, and to exalt his own need for exaggeration beyond the facts as boldness and vision. Polemics aside, the key question is whose position was more valid and in that regard history is squarely on the side of Breuer. Freud’s emphasis on sexuality as the dominant factor shaping human development and contributing to psychopathology is no longer taken seriously today. Instead, the role of dissociation due to childhood trauma is increasingly recognized as more fundamental in many mental disorders.
The psychoanalytic literature provides considerable evidence for Freud’s penchant for exaggeration and overstatement, especially when describing the importance of his discoveries. That tarnishes but does not negate his achievements. Freud was a brilliant writer and gifted thinker in his own right, and a passionate and highly effective advocate for the value of psychotherapy. He contributed enormously to building on the foundation laid by Breuer, developing and applying the fundamental concepts of repression, resistance, transference, the value of dreams and fantasies as a highway to the unconscious, and developing an important body of work that was to exercise an enduring influence. Through the clarity and eloquence of his writings, the field developed enormously, attracting many talented people to extend his ideas and increasing the stature of psychotherapy, while broadening its audience. Freud almost single-handedly made psychotherapy a subject of universal interest and importance, provoking an important conversation that we are still having, and whose absence would have impoverished our discourse. However, it is important to assign credit proportionate to the facts and arrive at a just appreciation of Breuer, who was unfairly maligned during his lifetime.
The Legacy of Josef Breuer
Breuer’s theoretical description of the cause, mechanism and treatment of hysteria is strikingly consistent with modern approaches to psychotherapy. If we compare Breuer’s model of psychopathology, as outlined in his theory of hysteria, with Freud’s views, as expressed in his formulation of psychoanalysis, there are three clear differences: psychic trauma vs. sexual conflict as the fundamental cause of psychopathology, hypnoid states (dissociation) vs. repression (defense) as the mechanism, and catharsis/associative correction vs. interpretation/analysis, as the means of recovery. In every point that Breuer’s theory differs from Freud, the modern view of psychotherapy has increasingly come to favor Breuer.
Translated into contemporary language, Breuer’s theory of hysteria can be expressed as follows. The inability to feel and express the feelings appropriate to a traumatic situation (defined as any situation where the individual is exposed to the threat of physical or emotional injury) leads to dissociation, which is the root cause of psychopathology. The dissociated feelings are isolated in a separate state of consciousness, and lead to the creation and development of an alternate psychic organization (personality structure), i.e., the false self, which exists in parallel with the normal personality (primary ego or real self). The more severe and numerous the incidents of trauma the individual is exposed to, the greater the number and intensity of feelings that have to be repressed, and the greater the degree of repression and dissociation. Recovery and healing requires the ability to selectively access those dissociated experiences, in a calibrated way, and integrate them with the individual’s normal state of consciousness. That requires experiencing and expressing the affects contained in the dissociated (hypnoid) states through catharsis, so that the energy bound up in them is available to waking consciousness (i.e., the normal self).
Consider the following statement by the eminent psychiatrist and author, Irvin Yalom, in his book The Gift of Therapy: “Psychotherapy may be thought of as an alternating sequence of affect expression and affect analysis. In other words, you encourage acts of emotional expression but you always follow with reflection upon the emotions expressed.” If you replace affect expression by catharsis and affect analysis by associative correction, Yalom’s statement is effectively indistinguishable from Breuer’s views on the treatment of hysteria.
When Breuer developed the cathartic method to treat Anna O., he initiated several radical changes. First, he shifted the focus of therapy from suggestion by the therapist to self-discovery by the patient. Second, he enhanced the autonomy of the patient by reducing the emphasis on the authority of the therapist. He also expanded the scope of therapy from a narrow focus on treating symptoms to considering all aspects of the personality of the patient, thereby founding psychotherapy as a distinct discipline in its own right, separate from neurology. While conventional wisdom assigns Freud credit for all these factors, the fact is all of them were present in Breuer’s treatment of Anna O., long before his collaboration with Freud began. Breuer not only completed the first effective treatment in the history of psychotherapy, in the process he developed the foundations for its theoretical framework and clinical techniques. This is not just an academic matter—the entire profession of psychotherapy, along with every psychotherapist practicing today and every client who has ever benefitted from psychotherapy owes an unacknowledged debt to Breuer.
Breuer had the combination of analytical rigor and artistic intuition that is fundamental to every major scientific revolution. The value of grounding speculations in neuroscience/physiology when theorizing about psychotherapy, as Breuer did, in contrast to Freud’s unbridled speculation, is that it defines constraints any theory must satisfy. This helps the investigator to eliminate a whole class of theories, increasing the probability that any conjectures and hypotheses generated will be consistent with reality and therefore valid and useful in explaining the essential features of the phenomena in question. Freud went directly from anatomy to philosophy without ever developing a deep understanding of physiology. That's why he never gained an intuitive understanding of psychology, viewing the various disciplines in isolation, making his theorizing overly speculative and ultimately sterile. Breuer had an integrated view of all disciplines and therefore profound insight about their point of convergence. This is reflected in the fact that Breuer had several distinguished achievements as a scientist long before his collaboration with Freud began, while Freud had been struggling to establish his scientific credibility and had a relatively undistinguished career both as a scientist and as a physician prior to meeting Breuer.
Breuer’s key achievements, and the reasons he deserves to be considered the father of psychotherapy can be summarized as follows. He was the first person to treat mental illness using long-term depth psychotherapy, and in the process, invented the talking cure, i.e., the treatment approach that is the foundation of all psychotherapy. He was the first to discover and work out the physiological basis of the principle of constancy (in terms of intracerebral excitation), which is the basis of dynamic psychotherapy. He was the first person to identify and assert the fundamental role of trauma in the origin of mental illness. He was the first person to develop the concept of hypnoid states, which provides a rigorous, cohesive and compelling model for the unconscious, grounded in physiology, and is the unifying link between hypnosis, free association, mindfulness and focusing, as well as modern techniques such as neurofeedback and EMDR. He was the first person to develop a cohesive theoretical framework explaining psychopathology, in terms of trauma, dissociation and hypnoid states. Finally, he was the first person to realize the critical importance of emotional expression and talking about symptoms for treatment and to articulate the reasons, abreaction and associative correction, respectively for their effectiveness
For all these reasons, it is appropriate to consider Breuer as the first psychotherapist. This view is endorsed by Yalom, whose historical novel, When Nietzsche Wept, features Breuer as the fictional psychotherapist who treats the philosopher Friedrich Nietzsche. Yalom explains his choice of Breuer as follows: “my task was to find a contemporary therapist for Nietzsche. I combed historical documents to learn that in 1882 there was no such thing as a psychotherapist; the field of psychotherapy did not yet exist. Freud was only twenty-seven, a medical intern, and had yet to enter the field of psychiatry.” Yalom eventually concluded that “there was indeed one therapist in 1882 Europe—history’s first dynamic psychotherapist—and that was Josef Breuer. Though Studies on Hysteria, containing Breuer’s description of Anna O., the first dynamic psychotherapy patient, was published in 1895 (and a preliminary communication two years earlier), Breuer had actually treated Anna O. in 1882.”
The greatness of Breuer is he had the curiosity and openness of mind to recognize that his patient had a lot to teach him and the humility and intelligence to be willing to learn from her, to place his expertise and authority in a subordinate position to the client's self-knowledge. Breuer noted as much in his 1907 letter to Forel, “The main contribution that can be credited to me is that I recognized what an enormously instructive, scientifically important case chance had assigned to me for treatment, and that I persevered in attentive and faithful observation and did not disturb the simple apprehension of the important facts with preconceived notions. In this way I learned many things, things valuable from a scientific view.”
Introduction
Josef Breuer (1842-1925) has a unique and prominent place in the history of psychotherapy. While treating a patient known as Anna O., from 1880-82, Breuer, a distinguished Viennese physician, developed the cathartic method or talking cure for treating nervous disorders. As a result of that treatment, Breuer independently formulated many of the key ideas that laid the foundation for modern psychotherapy. Breuer is best known for his collaboration with Sigmund Freud, who was fourteen years younger and regarded Breuer as his mentor. In the course of their scientific discussions, Breuer introduced Freud to the case of Anna O. (whose real name was Bertha Pappenheim). The ideas emerging from that case so fascinated Freud that he devoted the rest of his career to developing them, in the form of psychoanalysis. The two men co-authored Studies on Hysteria, published in 1895, which is considered the founding text of psychoanalysis. However, the significance of Breuer’s contributions goes well beyond his role as Freud’s mentor and collaborator.
Breuer’s name is remembered today mostly as a footnote in the history of psychoanalysis. The conventional view, entrenched in psychoanalytic history, is that Breuer was too conservative to accept the implications of the ideas suggested by Anna O.’s treatment and to follow them to their logical conclusion, a task that only Freud had the intellectual depth, vision and boldness to accomplish. However, that picture misrepresents the true nature and significance of Breuer’s achievements. In many of the key respects that Freud’s views diverged from Breuer’s, such as the relative importance of sexuality versus trauma in the onset of psychopathology, and the role of intellectual understanding (i.e., analysis) versus emotional experience (i.e., catharsis) in clinical treatment, it is Breuer who has been vindicated by the passage of time. However, Breuer’s original views were so completely excluded from the mainstream of psychotherapy that few people are aware of his contributions or recognize their true value.
Breuer’s theory of hysteria provides a comprehensive framework for understanding the origin of psychopathology and its treatment, independent of Freud’s subsequent development of those ideas in the form of psychoanalysis. Breuer’s concepts of psychical trauma, intracerebral excitation, hysterical conversion, abreaction, associative correction, hypnoid states, unconscious ideas and splitting of the mind, and the cathartic method he developed as a treatment for nervous disorders are profound contributions in their own right. They are at the heart of many of the theoretical models and treatment approaches widely used in the field of psychotherapy today. Breuer’s ideas are just as relevant and compelling now, as they were when he formulated and published them, over a hundred years ago, and deserve to be more widely known. With the renewed emphasis in psychotherapy today, on the fundamental role of trauma and dissociation in the onset of mental illness, the field is returning to Breuer’s point of view, after a long detour.
In many ways, Breuer is the unacknowledged father of psychotherapy, a man of astonishing brilliance and vision, whose contributions to the conceptual framework and clinical techniques of psychotherapy continue to be of fundamental importance in the field today. Breuer’s achievements were neglected and unappreciated in his lifetime, and remain obscure to this day, because Freud downplayed and distorted Breuer’s role in their collaboration, while misappropriating his ideas to claim exclusive credit for their discoveries. Freud undermined and betrayed the man who was his intellectual mentor and had generously supported him professionally and financially for over ten years, in an act of opportunism and ingratitude that has received remarkably little attention.
Breuer was a brilliant physician and scientist and had made fundamental discoveries in physiology, even before he turned his attention to psychology. His work is remarkably prescient, anticipating many of the insights of modern neuroscience, and illuminating many other areas of human experience including the development of personality, relationships, love, creativity, and the nature of consciousness. It’s important to correct the historical record and give Breuer the credit he deserves, not just for accuracy and fairness, but because understanding and integrating his ideas, can enrich the field of psychotherapy and enhance the effectiveness of therapists everywhere, regardless of orientation.
Breuer was born in Vienna, where his father was a highly respected teacher of religion in the local Jewish community. Breuer’s mother died when he was very young, shortly after the birth of his brother, who was two years younger. Breuer had decided to become a physician at a young age, perhaps at least partly because it was one of the few respected careers open to a Jew at a time when anti-Semitism was still prevalent in academia and public service. Breuer enrolled at the University of Vienna in 1858, and received his medical degree in 1864. He then spent the next ten years combining experimental research with the practice of medicine, forging a brilliant scientific career, marked by two notable discoveries.
In 1868, working under Ewald Hering at the military medical school in Vienna, Breuer was the first to demonstrate the role of the vagus nerve in the reflex nature of respiration. This phenomenon, known as the Ewald-Breuer reflex, was a departure from previous physiological understanding, and changed the way scientists viewed the relationship of the lungs to the nervous system. Then, in 1873, Breuer, independently discovered, along with the eminent physicist and mathematician, Ernst Mach, how the sense of balance is managed by information the brain receives from the movement of a fluid in the semicircular canals of the inner ear. These findings are a testament to the power of Breuer’s intellect and his talent for generating bold hypotheses and then confirming them through rigorous experimental research. In spite of his remarkable achievements, Breuer decided against pursuing an academic career, perhaps because of his aversion to the political environment, and resigned his position from the university to establish a private practice.
Breuer went on to become one of the most sought-after physicians in Vienna, with a distinguished reputation as a diagnostician. His patients included many of the elite of Vienna and he had a wide circle of friends, including prominent artists, writers, musicians and philosophers, in addition to scientists and physicians. It was in these circumstances that Breuer came into contact with Sigmund Freud. The first meeting between the two men is thought to have occurred around 1877, while Freud was still a medical student at the University of Vienna. They were most likely introduced by Ernst Brucke, the eminent physiologist in whose laboratory, Freud was a research assistant from 1876-82. The two men developed a close friendship and Freud became a frequent visitor at Breuer’s household. Freud was on such cordial terms with Breuer’s wife, Mathilde, that when his first child was born in 1887, a daughter, he named her after Mathilde.
Breuer was already established as a successful physician, with a distinguished reputation, while Freud was still struggling to establish his practice and make a name for himself. Breuer was generous in lending Freud money and referring patients to him to help him set up his medical practice. They also spent endless hours discussing scientific matters. Freud was intensely interested in Breuer’s treatment of Anna O., and pressed Breuer for details of the case. The two men recognized the historic importance of the case and the issues raised by it, and worked closely together to understand its implications. Their collaboration culminated in two groundbreaking publications: a paper on hysteria in 1893, followed by Studies on Hysteria in 1895.
Theory of Hysteria
Science advances by the discovery and understanding of phenomena that can't be explained by existing concepts and theories, and require the revision or extension or replacement of existing conceptual categories. At the beginning of the 19th century, hysteria was one such phenomenon, considered by many leading physicians, as the major unsolved problem of neurology. It could not be explained by the concepts of physiology and anatomy known at the time, and became the intense focus of research by neurologists and psychiatrists. Building on previous work by researchers such as Jean-Martin Charcot, Hippolyte Bernheim, and Pierre Janet, Breuer and Freud had to invent a new set of concepts and principles to explain it, thereby transforming and revolutionizing our understanding of the human mind.
The disorder that became known as hysteria has a long history going back to the ancient Greeks. Although the condition is complex to describe, manifesting in a wide range of symptoms, affecting virtually every system of the body, its essential feature is simply described - a nervous disorder characterized by a loss of functioning that cannot be explained on any organic basis. Its symptoms include paralysis, amnesia, contractures, impairment of hearing, vision, digestion, respiration, and alternations in mood and personality. Different patients develop a different set of symptoms and even with the same patient, the type of symptoms and their severity can change over time. To understand the ideas Breuer introduced and appreciate the true nature of his achievement, it’s useful to first review the findings reported by him and Freud in their Preliminary Communication on hysteria, published in 1893. In that paper, titled On the Psychical Mechanism of Hysterical Phenomena Breuer and Freud outline the following view of hysteria, based on their clinical observations.
The key causative factor of hysteria is psychical trauma, which they define as any event that provokes intense, distressing affects, such as fear, anxiety, shame or physical pain. They distinguish between two types of hysteria: traumatic hysteria, caused by a single major trauma, such as an accident and common hysteria, caused by a series of partial traumas that “exercise a traumatic effect by summation.” In both cases, the memories of the psychical traumas persist, with their affect undiminished, long after the event was first experienced. However, these memories are not directly accessible to the patient, and their existence can only be deduced indirectly, through their effects, in the form of hysterical symptoms. This is the basis of the famous line from the paper: “Hysterics suffer mainly from reminiscences.” The patient has complete or partial amnesia of the traumatic events in his normal waking state, and the associated memories can only be recalled under hypnosis.
To explain how traumatic memories, charged with affect, can persist for long periods without the patient being aware of them, Breuer and Freud proposed the following mechanism. The memories are inaccessible because they exist in abnormal states of consciousness that are isolated from the normal consciousness of the patient. They assert that the fading of a memory and its associated affect requires an energetic reaction to the traumatic event, such as running away, or fighting back when attacked. “If the reaction is suppressed, the affect remains attached to the memory.”
If an adequate reaction did not occur at the time of the event, the affect can be discharged at a later time, in one of two ways: by expressing it in words, a process they call abreaction, or by the gradual wearing-away effect of integration with the patient’s existing store of memories and impressions. This process, which they call associative correction, is the mechanism by which normal memories fade over time. However, if neither of the two processes, abreaction or associative correction, occurs, the traumatic memory continues to exist with its affect undiminished.
The paper describes two reasons a patient might not have an appropriate reaction to a traumatic event, either at the time it is experienced or afterwards. Either the event is of a distressing or shameful nature, so the patient does not want to remember it (a phenomenon Freud named repression), or the event occurs in an abnormal state of consciousness, so the patient cannot remember it (dissociation). Often, both conditions exist together, because the distressing event can induce the abnormal state of consciousness in which the memory becomes inaccessible. This corresponds to the common phenomenon whereby victims of accidents, explosions or other injuries, end up having amnesia for the circumstances around the traumatic event.
Breuer coined the term hypnoid states to refer to these abnormal states of consciousness, because of their similarity to the state of consciousness experienced by patients under hypnosis. The key characteristic of hypnoid states is that "the ideas which emerge in them are very intense but are cut off from associative communication with the rest of the content of consciousness.” Hypnoid states are similar to dreams, but unlike most dreams, their affective charge is so intense as to "intrude into waking life in the form of hysterical symptoms.”
Using the above concepts, Breuer and Freud explain the typical course of hysteria as follows - memories formed as a result of traumatic experience are isolated in abnormal states of consciousness (hypnoid states) where they can persist with undiminished intensity for long periods of time. The affect associated with the traumatic memories depends on the severity of the trauma, and if it becomes sufficiently intense, can intrude into the patient’s awareness in the form of symptoms and attacks. In extreme cases, the ideational content present in the hypnoid states can be sufficiently complex to organize itself into an alternate personality. A state of equilibrium is established between the two psychic states, so that hysterical attacks and normal life co-exist. However, the equilibrium is unstable, so that hysterical symptoms and attacks can appear spontaneously, if the patient’s personality is weakened by exhaustion or illness. It is also possible to provoke an attack, in the same way that normal memories can be evoked in accordance with the laws of association, that is if the patient has an experience similar to the original traumatic event.
Breuer and Freud conclude that the essence of hysteria is "the splitting of consciousness” or dissociation, a phenomenon first described by the French psychologist, Pierre Janet. They go on to write that “a tendency to such a dissociation, and with it the emergence of abnormal states of consciousness (which we shall bring together under the term ‘hypnoid’) is the basic phenomenon of this neurosis…the basis and sine qua non of hysteria is the existence of hypnoid states.”
The treatment method that follows from this view of hysteria is to help the patient recall the traumatic memories and discharge the affects they contain. This requires the patient to describe the traumatic event in detail and express the associated affect. “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 its accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affect into words. Recollection without affect almost invariably produces no result." This procedure has a curative effect because it subjects the memories to the processes of abreaction and associative correction, thereby releasing their undischarged affect. However, since the memories are not readily accessible to the normal consciousness of the patient, the patient must be guided to recall them by the use of hypnosis.
In their Preliminary Communication, Breuer and Freud, assert that psychic traumas are the cause of hysteria, and describe the broad outlines of the process involved, that is, the formation of abnormal states of consciousness, in which traumatic memories and affects persist for long periods of time. However, they don’t provide any details about this process. Why do traumatic memories lead to hysterical symptoms, and why are the symptoms relieved by recalling the memories and discharging the affects? These are the momentous questions Breuer takes up in his theoretical essay in Studies on Hysteria.
Intracerebral Excitation
Breuer’s theoretical essay repays close reading, by any psychotherapist today, as many of the observations and insights in it are remarkably prescient. The essay is over sixty pages in length and provides a comprehensive account of the nature, cause and treatment of hysteria, that is astonishing in its clarity, rigor, boldness and depth of insight. In keeping with Breuer’s training as a careful researcher, his reasoning is rigorously scientific. Although some of his hypotheses are speculative, they are grounded in careful clinical observation, and informed and constrained by the facts of physiology and anatomy. Breuer’s arguments are detailed and persuasive and his chain of logic so carefully constructed, that it is hard to deny the validity of his conclusions. The entire paper is a tour de force of scientific reasoning and exposition, leading to insights that are as compelling as they are radical. James Strachey, the English translator of Studies on Hysteria, wrote about Breuer’s paper “It is very far from being out of date; on the contrary, it conceals thoughts and suggestions which have even now not been turned to sufficient account. Anyone immersing himself in this speculative essay will form a true impression of the mental build of this man.”
Breuer introduces the concept of intracerebral excitation, which corresponds roughly to the activation of neural pathways, revealed by functional imaging in MRI and CAT scans, a standard tool of modern neuroscientists. Breuer asserts that intracerebral excitation varies along a continuum, with an alert, wakeful state and dreamless sleep at opposite ends, and all intermediate points realized during the transition from wakefulness to sleep. He then describes a few characteristics of intracerebral excitation. It spontaneously changes in response to external events that elicit strong emotions, increasing during agitation or excitement, and decreasing in circumstances of safety and comfort. A certain amount of intracerebral excitation exists in the conductive paths of the brain when awake, even if the organism is at rest; that's why merely being awake without performing any work causes fatigue. It is also increased in a state of alertness, prepared for action, which is why such a state is fatiguing.
An excess of intracerebral excitation is uncomfortable and must be discharged, either by sensory experience, thinking or bodily activity. This in in keeping with the principle of constancy proposed by Breuer and Freud, according to which the body has a natural tendency to keep the level of intracerebral excitation constant, in analogy with homeostasis of other body functions such as temperature, blood pressure and so on. According to Breuer, the reason for this is that there is an optimum level of excitation for being prepared to work in which the brain is receptive to external stimuli, reflexes are facilitated, and association of ideas is possible corresponding to "a clear and reasonable state of mind.” This is borne out by the fact that a “surplus of intracerebral excitation is a burden and nuisance, and an urge to use it up arises in consequence. If it cannot be used in sensory or ideational activity, the surplus flows away in purposeless motor action.” Breuer provides various examples in support of this hypothesis, for example, the phenomenon of individuals pacing when they are agitated.
The dynamic equilibrium of the nervous system is constantly at risk of being disturbed by external events, especially those that produce strong affects. This is because strong affects restrict the “train of ideas” or association. The ideas that provoked the affect become so intense that they dominate the individual’s consciousness, at the expense of all other ideas. As a result, the increased excitation cannot be discharged through associative activity. This paves the way for Breuer’s explanation of the mechanism of hysterical symptoms.
Hysterical Conversion
To explain his view of hysteria, Breuer draws an analogy between the human nervous system and an electrical network. In an electrical network, current flows along specific paths, because its flow into other areas is restricted by means of insulation. However, a sudden increase in voltage can lead to a breakdown of the insulation separating different areas, creating alternate paths of conduction through which current can enter areas from which it was previously excluded. Similarly, although the nervous system as a whole forms an interconnected network, there is a high degree of resistance to the transmission of nerve impulses between the areas involved in different functions. Under normal circumstances, the pathways in the brain involved in ideas or emotions are insulated from the nerves involved in sensory perception, digestion, respiration, movement, and so on.
However, an abrupt increase in intracerebral excitation that is not discharged through the usual means, emotional expression, physical movement or associative correction, can lead to a breakdown of this resistance, stimulating nervous activity in areas that were previously isolated from each other. For example, if the excitation due to an idea or emotion is discharged into the digestive system, it may cause queasiness in the stomach or diarrhea, or if discharged into the respiratory system, may lead to alterations in the rate of breathing. Further, if the excitation is discharged into the sensory nerves, the individual may perceive an image or sound even though there is no external object corresponding to it, that is, a hallucination. This process, whereby an idea can be expressed somatically, resulting in an “abnormal expression of the emotions” is called hysterical conversion because the affect associated with the trauma has been “converted” into a hysterical symptom. Each hysterical symptom is a pathological manifestation of the experiences that produced the original affect, that is the psychical traumas.
Vulnerability to such a breakdown depends on the innate disposition of the individual, with some people naturally having a nervous system more excitable than others. A breakdown in resistance also occurs from the weakening of the nervous system due to exhaustion, illness or injury. The level of intracerebral excitation is inversely proportion to the conversion; therefore the greater the excitation that needs to be discharged, the stronger the hysterical symptom. If the conversion is repeated, it becomes reinforced and occurs more easily, so that over time the idea no longer provokes the affect but only the abnormal reflex. The individual directly converts the idea into a somatic symptom, without experiencing the corresponding emotion. In other words, the emotion is expressed through the body without the patient being aware of its cause. Abnormal affective reactions are indicative of a nervous disorder (if the affect has an objective basis) or of hysteria (if they occur spontaneously with no apparent basis).
Strong affects cause a disturbance of "the dynamic equilibrium of the nervous system...intracerebral excitation is powerfully increased, but is employed neither in associative nor in motor activity" leading to an abnormal expression of the emotions. The original trauma and the part of the body in which the abnormal expression of the emotions occurs is connected by a chain of ideas, either directly or symbolically. For example, disgust can be expressed through vomiting. Breuer points out that “in a large number of cases the path taken by the train of determination remains unintelligible to us, because we often have a very incomplete insight into the patient’s mental state and an imperfect knowledge of the ideas which were active at the time of the origin of the hysterical phenomena. But we may assume that the process is not entirely unlike what we can observe in more favorable cases.”
Multiple causes must converge for a hysterical symptom to be formed, that is, symptoms are overdetermined. This can happen with repeated experiences of a traumatic nature but even the memory of a single experience repeated many times before its affect has been weakened can have the same effect. This is the case with traumatic hysteria, which corresponds to the modern diagnosis of PTSD. In general, the excitation due to an affective idea gradually reduces with time due to the wearing-away by interaction with other ideas. However, this process of associative correction doesn’t happen if the idea is withdrawn from associative contact. Ideas that are not accessible to consciousness retain their affect undiminished; each time the idea is renewed, all of the original affect is released, causing the abnormal reflex (i.e., conversion) to be reinforced and stabilized. As a result, the hysterical symptom becomes self-sustaining and continues even after the original provoking cause is no longer present.
Although hysterical symptoms were ideogenic to begin with, by repetition they can become imprinted into the body, causing modifications of the nervous system, thus becoming self-sustaining somatic symptoms. However the fact that the symptoms can disappear when the associated affect is accessed and discharge under hypnosis indicates that the changes in the nervous system are reversible. If in the stream of consciousness, an idea appears that has a strong affect attached to it, the affect is revived with a high degree of intensity, making the idea more vivid. The strength of the affect depends on the extent to which it has been subjected to associative correction or abreaction. If the original affect was discharged in an abnormal way, the excitation from the affective idea is converted into a somatic phenomenon. This is plausible because the reverse is clearly true, e.g., trying to suppress a somatic phenomenon such as sneezing, leads to an increase in excitation or tension. Breuer points out that the normal reaction to excitation caused by strong, irreconcilable ideas, is to communicate them by speech. He asserts that this is the basis of the religious practice of confession, and why expressing concerns and preoccupations in words is a relief.
Hypnoid States
According to Breuer, the conditions that make individuals prone to hysterical conversion are either innate disposition or the existence of a special state of mind, similar to a state of hypnosis, in which ideas are not opposed, i.e., hypnoid states. Such states can be brought about by hypnotism as well as by strong emotions, such as fear or anger, or conditions of exhaustion, hunger, sleeplessness (a plausible reason for the visions of mystics, induced by fasting). There are two conditions for formation of hypnoid states: defense (voluntary) and dissociation (involuntary).
Experiences in hypnoid states are subject to amnesia in waking life but can be remembered in artificial hypnosis. Because the ideas formed in these states are not subject to associative correction by normal consciousness, they can persist undiminished for long periods and develop into the wildest delusions. It is mostly in these states that there is an irrational, symbolic connection between the precipitating cause (traumatic experience) and the pathological phenomenon (i.e., the hysterical symptom).
Hysterical conversion takes place more easily in hypnoid states than in the waking state for the same reason that suggested ideas (movements, hallucinations etc.) are realized more easily in hypnosis, that is, the relaxation of critical faculties and absence of conflict with competing ideas. The repeated experience of auto-hypnosis, as in habitual reverie, can pave the way for hypnoid states by making the person more susceptible to them. Such states of absent-mindedness (vacancy of consciousness) occur naturally in daydreaming or creative imagination. However, those states don’t become pathogenic because there is a lack of strong affect (as in daydreaming) or energetic work is carried out to discharge the affect that arises (as in creative production). However reveries filled with emotion and imaginative states accompanied by fatigue, so no work can be performed, are pathogenic. This includes the common experiences of brooding with anxiety, nursing a sick person, or being in love. They all have in common the occurrence of strong affect with absence of competing ideas (due to intense focus on a single object), so the large quantity of excitation is undischarged, satisfying both the conditions for hysterical conversion.
Unconscious Ideas and the Splitting of the Mind
Breuer opens the section on unconscious ideas with a provocative passage about the nature of consciousness. “There exists in human beings the strange fact of self-consciousness. We are able to view and observe, as though they were objects, ideas that emerge in us and succeed one another…We describe as conscious those ideas which we observe as active in us, or which we should so observe if we attended to them. At any given moment of time there are very few of them, and if others, apart from those, should be current at the time, we should have to call them unconscious ideas.”
He asserts that it is a matter of everyday experience that a large number of ideas are unconscious, in that they operate and have effects, without us being aware of them. For example, a person might be uneasy at having forgotten to do something without knowing what it is, and only remember much later the task he had forgotten. Clearly, the idea of that task was operative in his mind without his being aware of it; in other words, it was unconscious. “A great deal of what we describe as ‘mood’ comes from sources of this kind, from ideas that exist and are operative beneath the threshold of consciousness. Indeed, the whole conduct of our life is constantly influenced by subconscious ideas.”
Breuer describes a hysterical symptom as the somatic expression of an unconscious idea; the duration and severity of the symptom is a measure of the persistence and strength of the affect associated with the idea. Since hysterical symptoms can exist for a long time (many years), their cause (memories of psychical trauma) must also continue to exist even though the patient is not aware of them. This leads to the inescapable conclusion that “unconscious ideas exist and are operative” in hysterical patients. Further, if such a patient continues to suffer repeated, traumatic experiences that are not resolved by the usual means, over time, the store of unconscious ideas grows in size, leading to the formation of large complexes of related ideas, which can become organized into elaborate patterns, while remaining unconscious. These ideas co-exist with the conscious mental life of the patient, and have important consequences even though the patient is not aware of their existence. Breuer describes this division of psychical activity as “the splitting of mind” and asserts that it is “of fundamental value for our understanding of hysteria.” According to him the “splitting of psychical activity which is so striking in the well-known cases in the form of “double conscience” is present to a rudimentary degree in every major hysteria’, and that ‘the liability and tendency to such a dissociation is the basic phenomenon of this neurosis.”
Breuer’s concept of “splitting of the mind” is equivalent to the concept of dissociation, introduced by Pierre Janet, the great French psychologist. However, there is an important difference between their positions. Janet believed hysterical patients had an innate weakness of mind that made them constitutionally incapable of the synthesis of ideas required for normal functioning. Breuer’s view was that Janet had reversed cause and effect. “It is not the case that the splitting of consciousness occurs because the patients are weak-minded; they appear to be weak-minded because their mental activity is divided and only a part of its capacity is at the disposal of their conscious thought.”
According to Breuer, the splitting of mind explains not just the physical symptoms of hysteria, but also many of its other characteristic features. This is because unconscious ideas can influence a person’s waking thoughts while remaining below awareness, in two ways. First, through their direct effects - for example, by creating hallucinations which appear meaningless and bizarre, but whose meaning becomes clear under hypnosis. Secondly, by influencing the course of association, thereby reinforcing some ideas and making them more vivid than they would have been otherwise. Hence, certain ideas can force themselves into the patient’s awareness compulsively, so that he is forced to think of them. As a result, unconscious ideas can influence the patient’s emotional tone or state of feeling.
This accounts for the fluctuations of mood in hysterical patients, which seem to occur for no apparent reason. Breuer writes that “the ‘split-off mind’ acts as a sounding board to the note of a tuning fork.” Hence, any event that provokes unconscious memories liberates all of the affect associated with those memories, leading to an affective response out of proportion to what would have risen in the conscious mind alone. This is the reason for hysterical patient’s intense emotionality, and their abrupt, and intense reaction to events that on the surface appear lacking in importance. The narrowing of attention or absent-mindedness of hysterics is because “every idea takes possession of the whole of their limited mental activity” due to restriction of field of consciousness. The patient’s suggestibility is due to the lack of associative correction in the conscious mind due to “poverty and incompleteness of its ideational content.” Finally, their aversion to boredom, craving for excitement and hyperactivity can be explained as a consequence of the fact that a surplus of excitation is generated in their nervous system even in a state of rest.
Breuer’s theory, with its emphasis on dissociation due to trauma, thus provides a compelling explanation of the major features of hysteria. At this point, it’s useful to examine the key differences between Breuer’s and Freud’s views.
The Rift Between Freud and Breuer
The appearance of Studies on Hysteria, marked both the culmination of the Breuer-Freud collaboration as well as its end. After the book’s publication, Freud sought to develop his theoretical views in a different direction and gradually distanced himself from Breuer. Both men came to have serious disagreements in matters of both theory and clinical technique. Their main point of difference was the relative importance of hypnoid states versus sexuality in causing hysteria. Freud increasingly came to believe that conflicts related to sexuality played an essential role in all cases of hysteria. Breuer fully acknowledged the importance of sexuality but considered it as only one of many factors, and asserted that the phenomenon of dissociation, which was implicit in his theory of hypnoid states, was more fundamental.
In a letter to the Swiss psychiatrist Auguste Forel in 1907, Breuer wrote, “this immersion in the sexual in theory and practice is not to my taste.” He went on to write, “Freud is a man given to absolute and exclusive formulations: this is a psychical need, which in my opinion, leads to excessive generalization.” Freud for his part was skeptical of the whole concept of hypnoid states. In Five Lectures on Psychoanalysis (1905), Freud wrote that “Breuer's theory of 'hypnoid states' turned out to be impeding and unnecessary, and it has been dropped by psycho-analysis today.” Freud went on to refer dismissively to “the screen of hypnoid states erected by Breuer.”
Freud also promoted the idea that Breuer was too cautious and conservative to recognize the true importance of sexuality. To support this view, Freud claimed that Breuer had to abruptly terminate his work with Anna O. because she developed strong sexual feelings towards him, and he therefore resolved never to work with hysterical patients again. This view was asserted as fact by Freud’s biographer, Ernest Jones, and came to define the conventional view of the matter. However, there is considerable evidence that the entire incident was fabricated. Louis Breger, a psychoanalyst and Freud biographer, writes “This account of the conclusion of Bertha’s treatment has passed into psychoanalytic lore and been endlessly recycled by a number of the faithful. Freud’s version of what happened is simply not true. It is an example of the “resistance” argument that he later used to dismiss everyone who raised questions about his theory of sexuality: They could not accept it because it was too personally threatening.” Freud would later use a similar argument with many of his followers who disagreed with him, including Carl Jung, Alfred Adler, Sandor Ferenczi and Otto Rank. Breger goes on to assert that “The truth is that Breuer did not flee from Bertha but remained involved with her treatment for several years.”
Freud’s statements about the value of Breuer’s contributions gradually evolved as Freud became more famous. In his Five Lectures on Psychoanalysis (1909), Freud was gracious in acknowledging Breuer’s role: “If it is a merit to have brought psychoanalysis into being, that merit is not mine. I was a student and working for my final examinations at the time when another Viennese physician, Dr. Josef Breuer, first (in 1880-2) made use of this procedure on a girl who was suffering from hysteria…Never before had anyone removed a hysterical symptom by such a method or had thus gained so deep an insight into its causation.” However, in an essay he contributed to the book On the History of the Psychoanalytic Movement (1914), Freud categorically stated “I have come to the conclusion that I must be the true originator of all that is particularly characteristic in psychoanalysis.”
An important factor in the souring of the Breuer-Freud relationship was Freud’s intense desire for fame (well-documented in his own writings), and his pattern of engaging in questionable conduct to claim exclusive credit for discoveries. Freud also had a history of strong relationships with older men, who he first idolized and then rejected. This was evident, for example, in Freud’s friendship with Wilhelm Fliess, a surgeon from Berlin, who replaced Breuer as Freud’s mentor and confidant. The two men had an intense friendship lasting from 1887-1900 which started in mutual respect and ended in acrimony and bitterness. Freud’s biographer, Peter Gay reports that at Freud’s last meeting with Fliess, in 1900, “the two men quarreled violently” each attacking the other about “the value, the very validity, of his work.”
In The Interpretation of Dreams (1900), Freud wrote: “An intimate friend and a hated enemy have always been necessary requirements of my emotional life. I always knew how to provide myself with both over and over…sometimes the two were united within the same person.” This statement is at least partly descriptive of Freud’s attitude towards Breuer. It is also notable that Breuer had been more than a collaborator to Freud, consistently treating him with generosity and affection, lending him money, referring patients to his practice, and welcoming him into his home. Peter Gay writes about Freud that, “His disagreeable grumbling about Breuer in the 1890s is a classic case of ingratitude, the resentment of a proud debtor against his benefactor.”
In this connection it is interesting to note that in their dispute, Breuer took the high road and never publicly challenged Freud or responded to his criticisms, choosing instead to withdraw from the field of psychology to focus on his medical practice. Given that Freud had the field all to himself, and continued to publish extensively in the field, steadily building his reputation, it was easy for him to caricature and disparage Breuer’s cautious attitude, which represented appropriate scientific restraint, as timidity, and to exalt his own need for exaggeration beyond the facts as boldness and vision. Polemics aside, the key question is whose position was more valid and in that regard history is squarely on the side of Breuer. Freud’s emphasis on sexuality as the dominant factor shaping human development and contributing to psychopathology is no longer taken seriously today. Instead, the role of dissociation due to childhood trauma is increasingly recognized as more fundamental in many mental disorders.
The psychoanalytic literature provides considerable evidence for Freud’s penchant for exaggeration and overstatement, especially when describing the importance of his discoveries. That tarnishes but does not negate his achievements. Freud was a brilliant writer and gifted thinker in his own right, and a passionate and highly effective advocate for the value of psychotherapy. He contributed enormously to building on the foundation laid by Breuer, developing and applying the fundamental concepts of repression, resistance, transference, the value of dreams and fantasies as a highway to the unconscious, and developing an important body of work that was to exercise an enduring influence. Through the clarity and eloquence of his writings, the field developed enormously, attracting many talented people to extend his ideas and increasing the stature of psychotherapy, while broadening its audience. Freud almost single-handedly made psychotherapy a subject of universal interest and importance, provoking an important conversation that we are still having, and whose absence would have impoverished our discourse. However, it is important to assign credit proportionate to the facts and arrive at a just appreciation of Breuer, who was unfairly maligned during his lifetime.
The Legacy of Josef Breuer
Breuer’s theoretical description of the cause, mechanism and treatment of hysteria is strikingly consistent with modern approaches to psychotherapy. If we compare Breuer’s model of psychopathology, as outlined in his theory of hysteria, with Freud’s views, as expressed in his formulation of psychoanalysis, there are three clear differences: psychic trauma vs. sexual conflict as the fundamental cause of psychopathology, hypnoid states (dissociation) vs. repression (defense) as the mechanism, and catharsis/associative correction vs. interpretation/analysis, as the means of recovery. In every point that Breuer’s theory differs from Freud, the modern view of psychotherapy has increasingly come to favor Breuer.
Translated into contemporary language, Breuer’s theory of hysteria can be expressed as follows. The inability to feel and express the feelings appropriate to a traumatic situation (defined as any situation where the individual is exposed to the threat of physical or emotional injury) leads to dissociation, which is the root cause of psychopathology. The dissociated feelings are isolated in a separate state of consciousness, and lead to the creation and development of an alternate psychic organization (personality structure), i.e., the false self, which exists in parallel with the normal personality (primary ego or real self). The more severe and numerous the incidents of trauma the individual is exposed to, the greater the number and intensity of feelings that have to be repressed, and the greater the degree of repression and dissociation. Recovery and healing requires the ability to selectively access those dissociated experiences, in a calibrated way, and integrate them with the individual’s normal state of consciousness. That requires experiencing and expressing the affects contained in the dissociated (hypnoid) states through catharsis, so that the energy bound up in them is available to waking consciousness (i.e., the normal self).
Consider the following statement by the eminent psychiatrist and author, Irvin Yalom, in his book The Gift of Therapy: “Psychotherapy may be thought of as an alternating sequence of affect expression and affect analysis. In other words, you encourage acts of emotional expression but you always follow with reflection upon the emotions expressed.” If you replace affect expression by catharsis and affect analysis by associative correction, Yalom’s statement is effectively indistinguishable from Breuer’s views on the treatment of hysteria.
When Breuer developed the cathartic method to treat Anna O., he initiated several radical changes. First, he shifted the focus of therapy from suggestion by the therapist to self-discovery by the patient. Second, he enhanced the autonomy of the patient by reducing the emphasis on the authority of the therapist. He also expanded the scope of therapy from a narrow focus on treating symptoms to considering all aspects of the personality of the patient, thereby founding psychotherapy as a distinct discipline in its own right, separate from neurology. While conventional wisdom assigns Freud credit for all these factors, the fact is all of them were present in Breuer’s treatment of Anna O., long before his collaboration with Freud began. Breuer not only completed the first effective treatment in the history of psychotherapy, in the process he developed the foundations for its theoretical framework and clinical techniques. This is not just an academic matter—the entire profession of psychotherapy, along with every psychotherapist practicing today and every client who has ever benefitted from psychotherapy owes an unacknowledged debt to Breuer.
Breuer had the combination of analytical rigor and artistic intuition that is fundamental to every major scientific revolution. The value of grounding speculations in neuroscience/physiology when theorizing about psychotherapy, as Breuer did, in contrast to Freud’s unbridled speculation, is that it defines constraints any theory must satisfy. This helps the investigator to eliminate a whole class of theories, increasing the probability that any conjectures and hypotheses generated will be consistent with reality and therefore valid and useful in explaining the essential features of the phenomena in question. Freud went directly from anatomy to philosophy without ever developing a deep understanding of physiology. That's why he never gained an intuitive understanding of psychology, viewing the various disciplines in isolation, making his theorizing overly speculative and ultimately sterile. Breuer had an integrated view of all disciplines and therefore profound insight about their point of convergence. This is reflected in the fact that Breuer had several distinguished achievements as a scientist long before his collaboration with Freud began, while Freud had been struggling to establish his scientific credibility and had a relatively undistinguished career both as a scientist and as a physician prior to meeting Breuer.
Breuer’s key achievements, and the reasons he deserves to be considered the father of psychotherapy can be summarized as follows. He was the first person to treat mental illness using long-term depth psychotherapy, and in the process, invented the talking cure, i.e., the treatment approach that is the foundation of all psychotherapy. He was the first to discover and work out the physiological basis of the principle of constancy (in terms of intracerebral excitation), which is the basis of dynamic psychotherapy. He was the first person to identify and assert the fundamental role of trauma in the origin of mental illness. He was the first person to develop the concept of hypnoid states, which provides a rigorous, cohesive and compelling model for the unconscious, grounded in physiology, and is the unifying link between hypnosis, free association, mindfulness and focusing, as well as modern techniques such as neurofeedback and EMDR. He was the first person to develop a cohesive theoretical framework explaining psychopathology, in terms of trauma, dissociation and hypnoid states. Finally, he was the first person to realize the critical importance of emotional expression and talking about symptoms for treatment and to articulate the reasons, abreaction and associative correction, respectively for their effectiveness
For all these reasons, it is appropriate to consider Breuer as the first psychotherapist. This view is endorsed by Yalom, whose historical novel, When Nietzsche Wept, features Breuer as the fictional psychotherapist who treats the philosopher Friedrich Nietzsche. Yalom explains his choice of Breuer as follows: “my task was to find a contemporary therapist for Nietzsche. I combed historical documents to learn that in 1882 there was no such thing as a psychotherapist; the field of psychotherapy did not yet exist. Freud was only twenty-seven, a medical intern, and had yet to enter the field of psychiatry.” Yalom eventually concluded that “there was indeed one therapist in 1882 Europe—history’s first dynamic psychotherapist—and that was Josef Breuer. Though Studies on Hysteria, containing Breuer’s description of Anna O., the first dynamic psychotherapy patient, was published in 1895 (and a preliminary communication two years earlier), Breuer had actually treated Anna O. in 1882.”
The greatness of Breuer is he had the curiosity and openness of mind to recognize that his patient had a lot to teach him and the humility and intelligence to be willing to learn from her, to place his expertise and authority in a subordinate position to the client's self-knowledge. Breuer noted as much in his 1907 letter to Forel, “The main contribution that can be credited to me is that I recognized what an enormously instructive, scientifically important case chance had assigned to me for treatment, and that I persevered in attentive and faithful observation and did not disturb the simple apprehension of the important facts with preconceived notions. In this way I learned many things, things valuable from a scientific view.”