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The Zürich School of Psychiatry in theory and practice. Sabina Spielrein’s treatment at the Burghölzli Clinic in Zürich
The Zurich School of Psychiatry in theory and practice. Sabina Spielrein’s treatment at the Burgholzli Clinic in Zurich ~Angela Graf-Nold, Zurich (Translated from the German by Barbara Wharton)
Abstract: The remarkably caring and privileged treatment of Sabina Spielrein at the Burgholzli Hospital 1904/05 (as shown by the records) exemplifies the standards and key concepts of the Zurich School of Psychiatry, founded by Auguste Forel and represented by the then current director Eugen Bleuler, as well as the specific dynamics between Bleuler, his first assistant C. G. Jung, and Spielrein herself.
Bleuler, in accordance with the trauma theory of hysteria, steadfastly promoted the separation from her traumatizing family and supported her scientific education. Jung, deeply and emotionally involved, revealed how she had been traumatized, but in focusing on her masochistic feelings rather than on her victimization, he established a rather conflicted personal relationship with her, foreshadowing his later ambivalent attitude to Freud’s sexual theory.
Thus Sabina was discharged with a reasonable psychiatric and scientific education but an unreasonable need for personal dependency.
Keywords: Eugen Bleuler (1857–1939), Auguste Forel (1848–1931), Sigmund Freud (1856–1939), hysteria, C. G. Jung (1875–1961), sexual theory, Sabina Spielrein (1885–1942), trauma theory, Zurich School of Psychiatry.
If however it is well known that some geniuses perish by insanity, perhaps it is less clear to the doctors that, behind the appearance of some forms of hysteria and other mental disturbances, some geniuses, or at least talents, slumber and languish like a bird in a cage. (Forel 1889, author’s trans.)
Admission
On 17 August 1904, at 10.30 at night, nineteen year old Sabina was brought to the Burgholzli Treatment and Care Institution in Zurich by a medical police official and an uncle.1 The time of day and the presence of the official suggest that the admission was an emergency. Published by Blackwell Publishers Ltd, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA.
It is not indicated who called the medical police, where she had been staying immediately beforehand, and what made her emergency admission necessary. Her previous place of residence is given as Heller’s Sanatorium, Interlaken. Yet a letter from C. G. Jung to Dr Heller in Interlaken, with the request for a short report on Miss Sabina Spielrein, who Declares that she was in treatment with you, suggests that she did not come directly from there.
One thing is clear: C. G. Jung, the deputy to the Senior Physician at the time, admitted her. He checked the medical certificate given by a Dr B. (which is not among the hospital records), and Lublinski’s statements (the maternal uncle who accompanied her, himself a doctor by profession), took a good look at the young Patient, and questioned her about her situation.
She laughed and cried in a strangely mixed compulsive manner, noted Jung, and she had numerous tics, rotating her head in a jerky fashion, sticking out her tongue, and twitching her legs. She complained of a dreadful headache; she insisted that she was not mad but had just got very upset at the hotel. Who or what exactly had upset her is not noted, only that she could not bear any people or any noise.
In this short entry Jung’s objective approach, which is in accordance with scientific medical standards still valid today, and indeed in some ways exceeds today’s standards, is striking: in differentiating between facts and fantasies it allows the reader to reconstruct the psychodynamics of both the patient’s symptoms and the doctor’s reactions. Jung takes the medical certificates supplied by the other doctors (Dr B. and Lublinsk) into account,2 observes without passing judgement, and questions the patient herself. Then a thorough examination follows, which in Sabina Spielrein’s case is postponed until the following day.
Jung arranged for the young patient to be accommodated in the women’s ward with a private nurse. Sabina was a private patient with a room to herself. Her parents paid 1250 francs a quarter3 for her accommodation, a sum which corresponded exactly with the salary of the senior physician.4
The Burgholzli psychiatric institution 1870–1904 and the Zurich School of Psychiatry
Sabina Spielrein was thus one of roughly 400 patients in the palatial building complex on the Burgholzli hill which lay to the south of the city of Zurich covering 33 hectares. The hospital, which had been designed for 250 patients, was an exceptionally lavish construction if one takes into account the circum-stances in Zurich at the time. It was completed in 1870 after six years. From an administrative point of view it belonged to the recently founded University of Zurich and bore witness to the belief in progress of this young and aspiring university city. According to the maxim of Wilhelm Griesinger who had designed the clinic while he was professor of internal medicine at Zurich University before taking over the direction of the Charitz Clinic in Berlin, the slogan ran: Diseases of the mind are diseases of the brain; in other words, progress in treatment was expected mostly from the newly developing brain research. The Burgholzli was considered to be a treatment centre for acute Curable cases, whereas the Incurable chronic patients were consigned to the Rheinau asylum, an old monastery on a remote island in the Rhine about 60 km from Zurich, where they were Cared for.
In 1904, when Sabina Spielrein was admitted as a patient, the Burgholzli Clinic was under the direction of Eugen Bleuler. When he was elected to that post in 1898 as successor to Auguste Forel, he was the fifth director of the Burgholzli since its opening in 1870, and the first to come from the Zurich area and to speak the local dialect. He had had nearly twenty years experience of running an asylum; for in 1886, at the age of 29, and at the instigation of Forel, with whom he had previously spent a year as assistant, Bleuler had taken over the running of the asylum at Rheinau where, with only one medical colleague, he had been responsible for the 500 inmates of that institution.
Auguste Forel: hypnosis and the monistic identity hypothesis
For his part Forel had taken over the direction of the Burghölzli in 1879 at the age of 31, when its reputation was at a low point and none of his international colleagues were any longer competing for the post. His three predecessors, all of them renowned in brain research, had complained of too much work and had worn themselves out in quarrels with the influential administrator, a former locksmith, who had curtailed the responsibilities of the directors and taken over important decisions concerning personnel and organization.
Forel was well informed about the battles of his predecessors. Though a native of the French-speaking part of Switzerland, Forel had studied in Zürich and followed his psychiatry teacher, Bernhard von Gudden, the first director of the Burghölzli, who resigned after two years in 1872, as assistant at the psychiatric clinic in Munich, Germany. As a senior physician back in Zurich at the Burghšlzli, he had witnessed the battles of his predecessor, the famous brain researcher, Eduard Hitzig. Forel would subsequently prove to be not only a passionate scientist and research worker but also an exceptionally influential and brilliant organizer. Before taking up his post he had, by means of a sit-in in the office of the relevant government official, achieved overall control of the medical administration over the heads of the management, something which all his predecessors had tried in vain to do.
He then organized the day-to-day running of the Clinic according to his own rigorous standards: he demanded of the doctors that they relinquish all private practice, and forbade them to accept gifts from [patients] relatives; he allowed only a joint kitty for tips for nurses and attendants (Forel 1935). Under Forel, as with his predecessors, there were Residential duties for medical and care personnel: apartments were available for the director and the senior physician; assistants and trainee doctors had rooms; nurses did not have rooms of their own but slept on camp beds in the patients rooms or in the corridors.
Even married people had only one day a week off. As far as patients were concerned, their letters were censored and visits were supervised.5
In relation to the scientific work, he set up a laboratory for brain anatomy where he carried out investigations into animals brains with the help of Gudden’s Microtom (in the development of which he had been involved as Gudden’s assistant in Munich). He succeeded in 1886, with the help of his assistant Eugen Bleuler, in making the discovery that nerve cells are related to each other not through anastomosis (as had been assumed) but through simple touch; this was a revolutionary discovery for the future development of neurology, a discovery that had been made simultaneously by His and was later popularized as the concept of the neuron-theory.
The capacity for precise observation was one which Forel owed to his first scientific passion the study of ants. And precise observation was the capacity on which he put most value where his students were concerned.6
Fore’s essential service to psychiatry lay above all, however, in the intro-duction of hypnosis as a therapeutic tool in day-to-day psychiatric practice, and in integrating it into his scientific theories. The change in his approach to psychiatry came with his young German wife, Emma Steinheil, whom he married in 1883. She made friends with several patients, as Forel points out, conducted a choir, visited patients and played music with them (Forel 1935). Under her influence he began to transfer his interest from brain research to his patients suffering under the conditions of everyday life: the sweatshops of the newly established silk industry, the discrimination against unmarried mothers, and the temptation to drown their sorrows in cider. The book De la Suggestion et de ses Applications ˆ la Therapeutique (1884) by Hippolyte Bernheim, Professor of Internal Medicine at Nancy, had fascinated him so much that in 1885 he arranged for Bernheim to give him a week’s personal induction into the technique, and immediately afterwards he began to experiment at the Burghölzli with both colleagues and patients. Forel’s results were in some cases spectacular and supported him in his monistic view of the unity of brain- and mind-phenomena, that is, the essential identity of the conscious and unconscious states of our psychology. He saw no real difference in essence between the anatomy and physiology of the brain on the one hand, and states of feeling and consciousness on the other; he proposed that it was the same phenomenon looked at now from the outside, now from the inside (the identity hypothesis). With this hypothesis Forel freed hypnosis from the twilight of scientific charlatanry and made it a subject of serious scientific research and reflection. In 1889 he published his textbook on hypnotism which remained a landmark text for thirty years and went through repeated revisions (Forel 1889). Sigmund Freud, who had translated Bernheim’s book into German in 1888, and had also visited Bernheim (with a recommendation from Forel) devoted a detailed and enthusiastic discussion to Forel’s book (Freud 1889, SE 1, pp. 91Ð102). In 1892 Forel founded the Zeitschrift fur Hypnotismus und Suggestionstherapie (Journal of Hypnotism and Suggestion Therapy) to which Freud too contributed as a co-editor.
The identity hypothesis had far-reaching consequences, not only for psycho-therapy but for all areas of life (as Forel constantly emphasized), it also applied to abstinence from alcohol which became one of his main concerns. When Forel was persuaded to abstain by his shoemaker, a member of a Christian lay organization for abstinence (Blue Cross), he noticed a striking improvement in his health and creativity (Forel 1935).7 With unstoppable enthusiasm he communicated his own experience by initiating a social movement for abstinence.
His crowded schedule led to symptoms of chronic overwork (persistent ringing in his ears) which defied all attempts at treatment. He was clearly over-burdened by all his activities in the field of abstinence: the founding of a treat-ment institution for alcoholics, directed by the shoemaker and independent of the state, the founding of an Order of Good Templars in Switzerland,8 and, last but not least, his political lobbying in organizing a new law in connection with the setting up of alcohol-free restaurants in Zurich and restricting the number of licenses for those which were allowed to serve alcohol. So in 1898, at the age of fifty, he decided to give up the directorship of the Burghölzli and his professorship at the University of Zurich; he wanted to devote more of his energy to his research into ants Ð and to completing his book on the Sexual question. He regarded the sexual question as an urgent problem of the time; he had the idea that The longing of the human soul and the social experiences of the different human races and historical periods could be reconciled with the findings of natural science and with the laws of psychological and sexual evolution which had come to light through these findings (Forel 1935, Foreword).
In his book Forel battled in a very concrete and practical way against the Victorian taboos of his age; he discussed all the biological aspects of the act of procreation, as well as the (albeit inadequate) methods of contraception avail-able at the time, and raised such modern social issues as full rights for women and equal status in law for illegitimate and legitimate children. The book appeared in 1905, at the same time as Freud’s Three Essays on the Theory of Sexuality.
Eugen Bleuler: psychiatry and psychology
In succeeding Forel in 1898 Bleuler had undoubtedly taken on a difficult legacy: it is true that through his utopian vision of progress and his passionate and effective commitment to his beliefs Forel had opened up new perspectives for psychiatry; he had also built up its popularity and social relevance as a profession. But his optimism for progress collided in many ways with the restrictive conditions of the everyday running of the institution. And the total commitment (which finally overwhelmed Forel) was to prove too much for every one of his successors. For as a result of Forel’s tireless activities several new duties had been added to the already excessive list of tasks facing a director of the Burghölzli. It was part of Bleuler’s job to be involved in the local and international committees of abstinence organizations and the supervision of the alcohol treatment centre set up by Forel. In addition there were numerous court reports, and, further, an even greater involvement with the university had become necessary; for through Forel’s intervention psychiatry had become an examination subject for students of medicine at Zurich, so that to the courses and lectures taken by the director of the Burghölzli had been added the administering of examinations and a more active collaboration in the Zurich medical faculty.
It is astonishing how uncomplainingly Bleuler and his wife too accepted these burdens. In 1901, as a 44 year-old bachelor, he married one of the most distinguished graduate philologists in Switzerland, the teacher and author Hedwig Waser.9 The young Mrs. Bleuler conscientiously put aside her academic and literary ambitions in favour of running social events for the hospital and organizing the Federation of abstaining women; she integrated her household, which soon included five children, into the society of the Burghölzli which now contained around 500 people. Often patients came to tea in the afternoon. A working day of 14Ð16 hours was the rule for Bleuler; even at night peace was not guaranteed: a staircase led from their apartment directly to one of the wards (Bleuler, M. 1951).
Bleuler seems to have been predestined to be an almost ideal successor to Forel, for he incorporated all the latter’s essential and characteristic ideas: a tireless zeal for work, membership of the international movement for abstinence (from alcohol), the tradition of brain research, the mastery of hypnosis as a therapeutic instrument, as well as a strong belief in the kind of progress which embraced social, ethical and epistemological values and which was orientated towards the philosophy of scientific monism.
In spite of all that, Forel would have preferred his senior physician Delbruck as his successor, and to the very end he could not reconcile himself to the governments choice of Bleuler (Forel 1935). This was not without significance for the Zurich school, for Forel continued to exercise great influence; he followed events at the Burghölzli in detail and commented on them in letters to pupils and colleagues worldwide; even in the numerous subsequent editions of his textbook on hypnosis he always referred to Bleuler and his colleagues in strikingly ambivalent terms.
There was nevertheless no doubt that Bleuler forged the worldwide reputation of psychiatry in Zurich, and that he provided, particularly through the special reception given to Freud, and the psychodynamically orientated descriptions of disease profiles, the essential impetus for the establishment of a distinctive school of clinical psychiatry in Zurich. The essence of these developments was that, compared with Forel, Bleuler’s interest and orientation were more psychological: even as director of the Rheinau institution he had been interested in the spoken utterances of his psychotic patients and had kept notes on them (Bleuler, M. 1988). Moreover as a bachelor he had lived very close to the patients, practically sharing their everyday life. From this experience he had become a passionate supporter of the active community for residents of institutions; for he had realized that all activities which were experienced by the patient as meaningful had a powerful therapeutic effect. Every patient had to contribute to the running of the hospital according to his capabilities. The active community as the central idea of Eugen Bleuler’s therapeutic approach was publicized by his son Manfred Bleuler (psychiatrist and successor as director of the Burgholzli from 1942 – 1969) (Bleuler, M. 1951). In his text-book Eugen Bleuler identifies as the most important tools for treating the psyche patience, calm, and inner goodwill towards the patients, three qualities that must be completely inexhaustible (Bleuler, E. 1916). He undoubtedly paid more than lip-service to this. Ludwig Binswanger too, who later served for a time as assistant to Bleuler, remarked in his memoirs that the spirit of unconditional acceptance of the person, of the healthy as well as the sick, which reigned in the hospital, was moreover the spirit of discipline, order and justice (Binswanger 1957).
On this basis Bleuler largely succeeded in running the major state institution of the Burgholzi as a therapeutic community.. It was in accordance with this concept that doctors, care staff and patients should live in the hospital and form a residential community, and that in the case of the doctors their wives too should be integrated into the institution. Bleuler’s wife, Hedwig, not only organized social events in the hospital, but also contributed to the scientific discussions, as did Jung’s wife, Emma. At least occasionally they participated in the neurological-psychiatric referral evenings, which took place fortnightly in the Burgholzi and in the private neurology laboratory of Bleuler’s friend and colleague, Constantin von Monakow (Abraham 1976, p. 62).
Constantin von Monakow (1853-1930) was a Russian emigre. With Forel’s support he had obtained his post-doctoral qualification in 1885 at the University of Zurich with a thesis on brain anatomy, and had subsequently set up a private neurology laboratory in Zurich and a private neurology outpatient clinic; in 1893 he opened a private clinic for in-patients too, with the profits from which he financed his researches (Monakow 1970; Jagella, Isler, Hess 1994).
He was investigating the reaction of brain functions to injuries to certain areas of the brain; from this he developed a theory which explained the difference between immediate and long-term consequences of injuries, contrasting this dynamic view of brain-functioning (the Diaschisis theory) with the static localization theory. Bleuler, who was working on the classification of psychiatric disease profiles and was interested in the psychological treatment of psychic trauma, felt he had common ground with Monakow both in his neurological and in his philosophical and therapeutic ideas; by comparing and contrasting himself with Monakow he developed his theory of schizophrenia.
As director of the Rheinau hospital Bleuler had developed the idea that a loosening of the association pathways in the brain underlay psychotic processes and he now hoped to substantiate his hypothesis with psychological association experiments of the type that were being set up in other psychological and psychiatric institutions. When C. G. Jung took over the organization of the psychology laboratory and the direction of the association experiments in
1904, an enthusiasm for research developed at the discussion evenings which Monakow observed with both interest and scepticism: The clinical material from the Burghšlzli was studied (especially by Jung, Maeder and Riklin) from the point of view of Freud’s theories, and many symptoms of dementia praecox were interpreted with great conviction as Freudian mechanisms, even by Bleuler (Monakow 1970, p. 244).
It is probable that the case of Sabina Spielrein was discussed here, and also that, later, she took part in the discussions. From this psychiatry/neurology society the Freud club broke away in 1907 much to Monakow’s disapproval; in addition to himself, as he emphasizes, doctors from the city and all kinds of unclassifiable ladies, and even students of both sexes were attracted to the club.10
Bleuler had been acquainted with Freud for some time. While still director at Rheinau he had reviewed Freud’s translation of Bernheim’s New Studies in Hypnotism and Charcot’s Policlinic Lectures. In 1896 Bleuler published a review of Studies on Hysteria by Breuer and Freud in the Munich Medical Weekly: the book, with its five detailed case studies (They could not publish more because, as almost always in such cases, sexual occurrences are revealed, opened up a completely new perspective on psychological mechanisms and was indeed one of the most important recent publications in the field of normal and pathological psychology, even if, from the therapeutic and theoretical point of view, essential questions still remained unanswered Ð thus for example there was no sufficient explanation of how abreaction worked and whether the cathartic method was not based on suggestion (Bleuler 1896, p. 524ff).
- Jung and the Burghšlzli
When in October 1900, as a student in his final year, C. G. Jung applied for the post which was about to become vacant at the Burghšlzli, there were as is often the case no other applicants. He took up his post in December 1900, as a trainee doctor on almost no pay only 1000 francs a year. Looking back at this time in a seminar in 1925, Jung describes how at first his work at the Burghšlzli caused him a considerable shock:
For six months I was struggling desperately to find my way in [psychiatry] and was all the time more and more baffled. I was deeply humiliated to see that my chief and my colleagues [the senior physician and one assistant] seemed to be sure of them-selves, and that it was only I who was drifting helplessly. My failure to understand gave me such feelings of inferiority that I could not bear to go out of the hospital. Here was I, a man with a profession which I could not rightly grasp. I therefore stayed in all the time and gave myself up to the study of my cases. (Jung Seminar 1925, p. 17 [cf. MDR p. 146])
Then Jung began his doctoral thesis, On the psychology and pathology of so-called occult phenomena, in which he proposed to broaden our knowledge of the relations between hysterical twilight states and the problems of normal psychology (Jung 1902, CW1 para. 35). In this work he focused on several cases of alterations in consciousness of various kinds which he had met in the hospital and which were reported in the literature, but principally on the case of somnambulism in a girl with poor inheritance (Spiritualistic Medium), Miss S.W (the pseudonym for his cousin Helly Preiswerk), with whom he had experimented in his student days. In one passage in this work (in a rather unimportant connection), Jung refers to Breuer and Freud’s Studies on Hysteria, and in two passages to Freud’s Interpretation of Dreams; in general he presented his view of the unconscious which was orientated, appropriately enough in his student years, towards Schopenhauer and Eduard von Hartmann in particular, and also followed Pierre Janet and Theodore Flournoy especially closely. Flournoy’s book on the trance states of a medium in Geneva, From India to the Planet Mars (1900), had deeply impressed him, and a friendship then began with Flournoy, the experimental psychologist from Geneva, which was to out-last his relationship with Freud. His insight into the psychological circumstances relating to the onset of hysterical and particularly of psychotic symptoms soon released him from his uncertainty and stagnation: even the strange stereotypical movements or the meaningless verbal expressions of the old psychotic patients suddenly took on a meaning once he had succeeded in determining the connection with their personal desires and conflicts. Thus he claimed this insight as his own personal discovery which he could share with no one:
At that time there was no psychological viewpoint to be found in the field of psychiatry. A label was put on each case; it was said to be a degeneration here, or an atrophy there, and then it was finished there was: nothing more to be done about it. It was only among the nurses that any psychological interest in the patients could be found, and among them there were some very shrewd guesses offered as to the conditions presented, but the doctors knew none of this. (Jung Seminar 1925, p. 17)
This account may be understood as an over-compensation for his feelings of inferiority described above; Forel for one complained later about Jung’s exaggerated pride in his discoveries11 and, as far as Bleuler was concerned, his publications as well as all the other colleagues who ever expressed an opinion about him, bear witness to his particular interest, understanding and commit-ment (cf. Ellenberger 1985, p. 893).
It seems though that for Jung the psychogenesis of psychiatric symptoms took on a personal significance which was different from the meaning they had for Forel and Bleuler. While for them a tireless sense of order and an optimistic belief in social and scientific progress seemed to play a predominant role, Jung was personally touched by the symptoms of individual patients; he writes in his memoirs:
Through my work with patients I realized that paranoid ideas and hallucinations contain a germ of meaning. A personality, a pattern of hopes and desires lies behind the psychosis. At bottom we discover nothing new and unknown in the mentally ill; rather we encounter the substratum of our own natures. (Jung/Jaffe 1961, p. 148)
It is easy to see that he must often have felt misunderstood. An indication of this state of affairs is the fact that Forel and Bleuler often complained about the pressure of work and the overcrowding of the hospital, but never about the lack of time available to the doctors to devote to individual patients.
As at the time when Forel began his work at the Burghšlzli in 1879 with 300 patients, when Jung began in 1900 only two experienced doctors (the director and the senior physician) and two inexperienced ones (an assistant and a trainee) had the care of some 400 hospital patients. As Ellenberger reports, Bleuler did a ward round three or four times a day; but it is easy to calculate how long he would have spent on these visits even if he had tried to make them more than mere sentry duty. It is true that a meeting of the medical team took place every morning at which individual patients were discussed. Nevertheless in these circumstances the direct personal relationship of the individual doctor with the individual patient must indeed have been the exception rather than the rule. A more intensive relationship with the patient, as Jung had observed, was rather the province of the nurses, male and female who at that time were completely untrained.
It is consistent with the circumstances therefore that Jung complained about his work situation. On 6 October 1901, together with the assistant doctor, Otto Diem, he addressed a letter to Director Bleuler, at the central medical office of the canton of Zurich with a petition for the creation of a post for a third assistant doctor. Jung and Diem justified their petition on five hand-written pages (in Jung’s hand-writing) by pointing to the progress made in scientific and humane treatment, the almost complete absence of all coercive measures such as the bed bath, the straitjacket, and the bed strap since 1895, and the essential, precise, but also laborious and painstaking examinations which were necessary to do justice to the requirements of modern science to only a limited extent; they pointed out that in 1895 the number of staff had stood at 56, and in 1900 at 86, and drew attention to the rising numbers of admissions and discharges of patients, and to the increased work occasioned by court reports. Finally the creation of an additional post would be in the interests of the institution if it made the strenuous and responsible task of younger psychiatrists more personally satisfying.12 Bleuler supported the venture in a covering letter and the senior executive officer endorsed the proposal; but the canton government turned it down. As a result, Otto Diem resigned his post in February 1902. C. G. Jung, who was just finishing his dissertation, stayed and, on 1 April, rose to the position of first assistant. In May 1902, after completing his dissertation, he became engaged to 22 year-old Emma Rauschenbach, the daughter of a manufacturer, whom he had known from his youth. On 23 July he too tendered his resignation and was released on 1 October 1902.13 Neither in Memories, Dreams, Reflections nor in any of the biographies of Jung is this resignation mentioned.
Jung was clearly planning to build his future, both professional and private, outside the Burghšlzli. First he went to Paris to attend the lectures of Janet at the university there, to learn English at the Berlitz school,14 to go to the theatre and to concerts, and among other things to meet his cousin Helly about whom he had just written in his dissertation (very critically and not altogether respectfully). She now had hardly any recollection of the time of her trances, and was very successful in her profession as a dressmaker in the workroom of a famous couturier.15
Jung married in February 1903 and moved into an apartment on the Zolli-kerstrasse in Zurich with his wife Emma, not very far from the Burgholzli. By May 1903 he was working at the Burghšlzli again, deputizing for medical assistants who were away on military service.
Shortly after this, when the senior physician Ludwig von Muralt fell ill with tuberculosis and had to go on leave, C. G. Jung took over as his deputy too. Von Muralt’s leave was extended several times, and Jung’s plans to go to Basel as a senior physician seemed to be coming to nothing. Whether it was the indignation among the Basel clergy over Jung’s dissertation that was so strong that he decided it was impossible, as Stefanie Zumstein-Preiswerk16 believes or whether it was because a German doctor by the name of Wolff had taken over the position of director at the mental hospital there: on 22 August C.G. Jung writes to his old friend Andreas Vischer about a Basel calamity which had wrecked for ever his academic career in Switzerland. He continues:
I might as well sit under a millstone as under Wolff who will stay up there immovably enthroned for thirty years until he is as old as Wille [Jung’s tutor in psychiatry at Basel university]. For no one in Germany is stupid enough to take Wolff seriously, as Kraepelin has appropriately said, he is not even a psychiatrist. I have been robbed of any possibility of advancement in Basel now.17
Jung wrote this letter from a position which was indeed remarkable:
I’m sitting here in the Burghšlzli and for a month I’ve been playing the part of the director, the senior physician and the first assistant. All the personnel in question are away and I have amalgamated all the roles into one person. So almost every day I’m writing twenty letters, giving twenty interviews, running all over the place and getting very annoyed. I have even lost another fourteen pounds in the last year as a result of this change of life, which otherwise is not a bad thing of course. On the contrary, all that would be fine (for what do we want from life more than real work?) if the public uncertainty of existence were not so great.18
Jung did not have to worry about real work at the Burghšlzli, and soon he was relieved of his public uncertainty: when the senior physician who was on sick leave finally resigned in September, Jung took over his position in October 1904 on a regular basis and moved into the senior physician’s apartment in the Burghšlzli with his wife Emma (who was expecting their first child in December). In his academic career too not much was standing in his way: four months later, in December 1904, he submitted his application for the post of lecturer at ZŸrich university.19
Anamnesis (August 1904)
In August 1904, when he was wrestling with the personal question of whether he should settle at the Burghšlzli again or seek his professional future else-where, he was carrying the sole medical responsibility for all the patients; he therefore took the anamnesis of the newly admitted nineteen year-old patient Sabina Spielrein.
The nurse who had spent the night in her room reported that it had been fairly quiet; Sabina had merely expressed anxiety several times and had asked for a light. Once she said she had two heads, and that her body felt foreign to her. A similar experience of splitting was to occur again shortly before the end of the treatment.
The statements of the uncle, whom he questioned first, were evaluated by Jung as meagre and evasive; he connected this, together with the uncle’s insufficient command of the German language, to the fact that he was an old Russian Jew. Which questions he evaded and in what way, and/or what was typical of an old Russian Jew in that, is not recorded. In any case Sabina’s great agitation which had led to the emergency admission the previous evening is not clarified. Regarding Sabina’s earlier history Jung discovers that she was always rather hysterical. She had been an intelligent pupil and had been prominent in her achievements. She had been ill for about three years. She had spent a month at the Heller sanatorium in Interlaken where she was very dis-satisfied. She should have gone to Monakow, but he did not take her because she was too disturbed.
So it can be assumed that Monakow referred Sabina Spielrein to the Burghšlzli: probably Uncle Lublinsk was consulted as the only relative; the entries on the clinic form relating to this were all later amended and elaborated.
Jung records the constant alternation of laughter and tears, jerking of the head and seductive glances.
The anamnesis which Jung takes from Sabina Spielrein herself the following day is difficult, like walking on eggshells. Nevertheless he obviously succeeds in breaking through the negativism of his patient in a powerful battle. Jung’s request to say everything if she wants to get better was met by Sabina with the threat that, if she had to say everything, it would upset her so much that things would go really bad later. Then he would see what would happen. She insists several times that she would and could never talk about it, and in any case does not want to be cured at all.
Sabina seems to have given her somatic anamnesis and external details of her life without much of a battle. Her delicate constitution was stressed (stomach pains, angina a thousand times, precocious, sensitive).
Precocious seems to mean intellectual precociousness. For Jung notes that Sabina did not work very hard at the Gymnasium but [was] intellectually very advanced. At five she attended a Froebel infant school in Warsaw, more than 1000 km from Rostov-on-Don, her home town, and the family’s last place of residence. It is not recorded whether that entailed her staying in a children’s home and being separated from her family. After that she was taught at home until she entered a Gymnasium. She did not like it because the teachers were very stupid. She also played the piano a lot and had singing lessons. Above all she was interested in the natural sciences and wanted to study medicine.
Zurich was then the Mecca of Russian women students who, in the course of the political reforms in Russia, in particular the abolishment of serfdom in 1861, were gripped by a sense of a new era beginning and were striving for education and a new allocation of roles in society. A Russian university statute issued in 1863 excluded women absolutely from all higher education. A young Russian woman, Nadescha Suslowa, the daughter of a serf, had enrolled at Zurich university and, as the first woman student there and as a fellow student of Forel completed her studies and gained her doctorate in 1867 successfully and without hindrance. When this became known in Russian circles a whole stream of young Russian women poured into ZŸrich. In ZŸrich they lived together partly in Russian colonies which were keenly involved in the political upheavals in their homeland (Bankowski-ZŸllig 1988). Among them was a strikingly large number of Jewish students, men as well as women, who to an extent were harshly discriminated against in universities in Russia.
Sabina was the eldest of five children of an obviously wealthy Jewish businessman. She had three younger brothers; a little sister, whom she loved more than everything in the world, died of typhoid at the age of six, when Sabina herself was 16. Her mother was a dentist (whatever that meant at the time) but she had practised her profession only casually.
The parents clearly took the education of their daughter very seriously, although it is hardly thinkable that they were interested in changing the roles between the sexes Ð or indeed that they supported the ideals of the Russian revolution. For undoubtedly the relationships which held sway in the family were extremely patriarchal.
The real battle which Jung fought and won with Sabina was to coax a confession from her. And, as in the case histories in the Studies on Hysteria of Breuer and Freud, the confession is not about a reprehensible deed of her own but about being repeatedly shamed and anguished: she confesses that her father has hit her several times on her bare buttocks, most recently in her eleventh year, from time to time in front of her siblings.
It is possible to follow the process by which Jung wins the battle: he takes Sabina Spielrein through her ambivalence. As a result of his helping her to relate alternately to her own feelings and behaviour and to her father’s, she succeeds for a moment in differentiating herself internally from him and in rediscovering her own congruence:
Pat. loves her father painfully. She cannot turn to him, he does not really understand her, he says hurtful things to her.
Because of her strong narcissism she cannot give in to her father, and when her father is sad, she cannot talk to him and she is again deeply hurt. He has hit pat. and she had to kiss his hand in return.
At this point, observes Jung, innumerable tics and gestures of abhorrence occurred.
After the confession of her father’s beatings, it strikes him that at this point the tics are in keeping with the affect. They express abhorrence and revulsion.
That the tics disappeared after this is not the point. On the contrary Jung established in the next few days that they appear at points in the conversation which have a certain connection with her complexes. This remark refers to the association experiments in which Jung was then intensely involved together with Franz Riklin. At that particular time the associations of normal subjects was being prepared in which according to Jung the idea was to examine the influences on the association process of attention which by countless threads links the associative process with all other phenomena of the psychic and physical domain in consciousness (Jung 1904, para. 4). Jung counted mimicked reactions to the stimulus word as indications of the presence of a feeling toned complex, that is, the sum of ideas referring to a particular feeling-toned event (ibid., para. 167, fn.).
It should also be noted that Jung does not use hypnosis or suggestion (as Freud suggested in his Studies on Hysteria) to elicit the confession; with Sabina Spielrein he works on the complex by accompanying her and participating with her in free association. In other words, he takes up a position in relation to the patient in which participation and observation are balanced.
But Sabina continues to battle with her negativism: she could and would never talk about it, and in any case did not want to be cured at all. Jung met this resistance with remarkable benevolence, interpreting it as an expression of her sensitivity: Is extremely sensitive, accuses the writer of not having the time to listen to everything, of not really being interested, of only pretending, etc. Jung himself thus showed how extremely sensitive he was towards Sabina Spielrein.
On the following two days Jung continued the anamnesis with Sabina and also spoke to her mother. Sabina tells him more about her relationship with her parents and her brothers, in the course of which a truly shocking picture unfolds: three years before, that is when she was just 16, she had said: I could give up parents in favour of the company of other people (by which she meant, in her youthful striving for independence, that her relation to other people was more important to her than her relations within the family). Hearing this, her father went wild and threatened suicide. The fathers suicide threats were present all the time as an instrument of power: it pains her that he is unhappy, always talking about dying. It also hurts her that he insults and tyrannizes other members of the household. The fact that he insults and tyrannizes her is not reiterated; and the idea that sexual power too is involved in the chastisements is not directly pointed out, though Jung records: the peak of the experience was that her father was a man and even now he occasionally makes indecent remarks.
The statement that a similar relationship existed with the mother, as Jung writes, can be linked only in a general way to the relationship dominated by terror that prevailed with her father. Even during this last year her mother tried to beat her in front of her brothers and her brothers friends. Sabina’s desperation had taken on extreme proportions even while she was still at school: Once when, at thirteen, her mother punished her, she hid and doused herself with ice-cold water in winter in order to catch her death of cold. At the age of 15 she tried to starve herself to death in Karlsbad20 because she had made her mother angry.
Jung seems to have questioned the mother about the history of Sabina’s illness without at all confronting her with her daughter’s statements. Mrs. Spielrein focused (as had the uncle) above all on Sabina’s intelligence and achievements (precocious, intelligent, German and French already at the age of six, worked hard at the Gymnasium).21 In similar vein was her statement that in her twelfth year Sabina had periods of apathy, and pitied all human beings. But at fifteen she realized the reason for living and started to work. She wanted the company only of good, educated and clever people. Her state-ment that Sabina had recently fallen in love with her old uncle, who was a doctor sounds particularly strange (in love with Uncle Lublinsk who had accompanied her?). The mother had listed all his faults for her and as a result Sabina was deeply disappointed and upset.
Whatever Jung has omitted from his notes, Mrs. Spielrein must have left behind a very disturbed impression, so that he wrote hysterical! on the cover sheet, underlined it, and noted hysterical absences of a childish nature. If how-ever one studies the information about the family on the cover sheet (details of which are all amended and elaborated), and if one imagines Sabina’s position in this family, one can understand the upset and despair which seized her when her mother tried to spoil even her love for her old uncle: one brother has hysterical fits of weeping, another has tics and is very hot-tempered, the third is melancholic, severely hysterical, and does wrong in order to suffer. How was she to survive there when her father (neurasthenic, hot-tempered to the point of madness and constantly threatening suicide) tried to keep her with him?
Unusually for an anamnesis the patient’s religious upbringing comes into the discussion. It seems typical of Sabina’s family relationships that the religious values (which were mediated above all by her mother) were geared towards deterrence and anxiety. Sins are recorded in heaven in red: a person is responsible for her sins from the age of seven. Sabina’s reaction seems however to have been more personal: from the age of seven or eight she started to talk with a spirit.
As a child she was very pious and prayed a good deal. After a while God answered her in the form of an inner voice which spoke more through her feelings than in clear sentences. It seemed to her however that this inner voice was speaking to her in German (Russian is her mother-tongue; at that time she was learning German). Gradually the idea came to her that the voice was not God but an angel sent to her by God because she was an extraordinary person É She often felt as though she understood the meaning of the words even before they were spoken. (Minder 1992; original italics)
It is very likely that Jung was powerfully affected by this subject matter: as we know from his biography, his grandfather on his mother’s side, a professor of theology, a specialist in ancient languages, and a leading clergyman in the reformed church in the university city of Basel, spoke with spirits. In addition Jung knew from his own history the feeling of being an extraordinary person which he first registered in the context of a minor humiliation (Jung/Jaffe 1962, p. 39f.). Furthermore the fact that Sabina’s spirit’ spoke in a foreign language must have reminded him of Flournoy’s medium Helen, as well as of his cousin Helen who, as he had described in his dissertation, had changed in her trances from a superficial young girl into a wise old man speaking in elevated language.
Diagnosis: Hysteria
Jung and Bleuler gave the diagnosis of hysteria for Sabina both at the beginning and at the end of her treatment. This diagnosis had previously only seldom been made at the Zurich clinic (Minder counts eight cases of hysteria with which Jung had had contact at the Burghšlzli up to that time) (Minder 1992). Yet there was no doubt that hysteria was then something like the main paradigm for clinical psychiatric research. A 900-page monograph had just been published by Otto Binswanger, a doyen of German psychiatry (Binswanger 1904).
Both Bleuler and Jung had given special thought to the theme. In his dissertation Jung had explained many of the so-called occult phenomena in the example of his cousin Helen as hysterical symptoms. In doing so he had drawn particularly on the contemporary French psychiatric and psychological literature (Charcot, Janet, Binet, Flournoy) in which the hysterical phenomena of somnambulism and of dual consciousness, as well as the automation of various psychic functions (normally those lying just beneath the conscious will) and also spectacular achievements (speaking otherwise unknown languages, clairvoyance) were discussed. Jung saw in the performances of his sixteen year-old cousin as a spirit medium somnambulistic episodes in which she lived out her wishful adolescent dreams and enacted her barely conscious know-ledge of relationships in romantic fantasies. The various subconscious personalities represented different (partly suppressed) aspects of her past and reminded Jung vividly of Freud’s investigations of dreams which uncovered the independent life of repressed thoughts.22
In 1904, just as he began work with Sabina, Jung used a reply to a review of his dissertation, which had appeared in book form in 1902, to set out again his views on hysterical misreading, or rather of the hysterical process in general. His patient’s hysterical misreading could be explained by the assumption of a split in consciousness and demonstrates in a nutshell the splitting off of psychic functions from the ego-complex, which is so characteristic of hysteria, and consequently the strong tendency of the psychic elements towards autonomy (Jung 1904, para. 159). And more remarkably Jung attaches great im-portance to the discovery that: [t]he analysis of the clinical picture is not [as the reviewer thinks] based on the French writers, but on Freud’s investigations of hysteria (ibid., para. 165)! Holding this point of view Jung was undoubtedly in agreement with his medical mentor and his chief, Eugen Bleuler, even if Bleuler’s interest went in a more practical direction. Indeed in his text-book which appeared in 1916 Bleuler does not mention Freud’s and Breuer’s investigations of hysteria. Nevertheless he states: Psychoanalysis, which makes diseased mechanisms accessible to consciousness and abreacts them, cures many cases (Bleuler, E. 1916).
In his textbook on hypnotism of 1902 Forel too had cited Freud among a number of authors (Charcot, Breuer, Vogt and many before them) who had produced evidence that even severe cases are generated through ideas and are disposed of through ideas (Forel 1902, p. 136). And in another passage he states that in hysterical disturbances one must according to Freud’s procedure, always look for earlier causative emotional trauma. But he warned against any infringement of tact or propriety through offensive questioning. He also said that one should not construct a dogma out of an isolated occurrence as Freud does (ibid., p. 168). Forel does not give the name sexual abuse to the isolated occurrence in question. Bleuler too speaks only in general terms about the psychogenesis of hysteria. He counts the hysterical syndrome, with its more moderate neurotic symptoms and striking psychic connections, among psychopathic reaction formations (situational psychoses). Above all he emphasizes the mixture of psychic and physical symptoms (twilight states, anaesthesias, hyperaesthesias, paralyses, convulsions, vomiting), all of which were produced through similar reactions in similar people and at best were denoted as psychogenic. Hysterics were emotional people (Affektmen-schen) who in their given circumstances could not realize their aspirations in a normal way and in addition characteristically show a stronger capacity to split, or rather a greater incapacity to keep their suppressed strivings at bay (Bleuler, E. 1916, p. 421).
In Forel’s view hysteria does not present an isolated clinical picture but a complex of symptoms or a syndrome which was based above all on pathological dissociation (suggestibility and autosuggestibility). As a result of this, when consciousness has become restricted, intensely active, spontaneous somnambulistic links are formed which can drag the personality along with them and eventually divide into a dual ego, giving rise to the most wonderful phenomena, but also resulting in dramatic, hysterical lying and the dream-like lability of those patients (Forel 1902, p. 138).
Forel had already found Charcot’s theory of hysteria questionable; Charcot’s stigmata were to be valued not as diagnostic signs but rather as artefacts which as a result of powerful (auto) suggestibility had become fixated. In treatment waking suggestion was much better than hypnosis which was to be applied only with great caution. The old rule stands: friendly, consistent and firm. It was important to win the cooperation of the hysterical patient and at the same time to inspire their respect: one must never mock them, and never show any mistrust, dislike or contempt towards them, otherwise one would greatly harm them (ibid., p. 138).
Bleuler himself names as the most important psychic tools patience, calm, and inner goodwill towards the patients, three qualities that must be inexhaustible (Bleuler, E. 1916, p. 389). His more concrete principles were as pragmatic as they were idealistic: To remove the basis of hysterical outbursts and other symptoms which have merely an attention-seeking nature by deliberately ignoring them, and to alter the conditions in which syndromes grew and were nourished, writes Bleuler. But above all if possible to create a purpose in life for the patients by taking account not only of external relationships, but also of the internal ones which have caused the patients to reject their sense of purpose in life (ibid., p. 389).
For the often predominant wish to be ill must be overcompensated by positive strivings which assume health.
Treatment (September 1904ÐJune 1905)
Sabina Spielrein’s treatment seems in many respects to have been a test-case for both Bleuler and Jung: a test-case for their new collaboration after Jung’s resignation in 1903, and a test-case for Bleuler’s idea of an institution as a therapeutic community in which everyone is occupied according to his ability and is supported with goodwill, patience, and calm; a test-case too for Jung’s efforts, now newly supported by the association experiments, to understand what actually takes place inside the mentally ill (Jung/Jaffe 1961, p. 135).
On 23 August Jung noted a remarkable experience that Sabina Spielrein had had in what was obviously a semi-conscious state: She felt as if someone were pressing in upon her, as if (someone) something were creeping around in her bed, something human. At the same time she felt as if someone were shouting in her ear. And: All the time she felt she was totally repulsive, like a dog or a devil. And especially: Her hands felt as though they did not belong to her.
This entry is neither interpreted nor commented on.
But on 5 January, when Sabina’s condition had already greatly improved, and the decision had been made that she would take up her medical studies in Zurich in spring 1905, her condition suddenly deteriorated considerably and the symptom reappeared: In the night a great fright: there might be a cat or someone else in her room, someone was suddenly speakin
