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Anna O and the ‘talking cure’

John Launer
DOI: http://dx.doi.org/10.1093/qjmed/hci068 465-466 First published online: 16 May 2005

‘At the time of her falling ill (in 1880) Fräulein Anna O was twenty-one years old’. Thus begins one of the most famous of all case histories.1 Its author was Dr Josef Breuer. A kind, cultivated and generous man, Breuer was one of the most distinguished physicians of his time, and he counted the great surgeon Theodor Billroth among his patients. He was also an eminent neurophysiologist and discovered the action of the vagus nerve on respiration, as well as the function of the semicircular canals. For some years he engaged a young man named Sigmund Freud to work in his laboratory at the university of Vienna, and it was Freud who eventually managed to persuade him to publish the details of Anna's illness and treatment.

Anna, according to Breuer, ‘had hitherto been consistently healthy and had shown no signs of neurosis during her period of growth. She was markedly intelligent, with an astonishingly quick grasp of things and penetrating intuition. She had great poetic gifts, which were under the control of a sharp and critical common sense.’ In spite of these attributes, Breuer reported, Anna fell prey, during her father's final illness and in the months after his death, to the most appalling symptoms of hysterical paralysis and anaesthesia in three out of her four limbs, together with a succession of other distressing psychiatric symptoms. At different times these included weakness, inability to turn her head, diplopia, a nervous cough, loss of appetite, hallucinations, agitation, mood swings, abusive and destructive behaviour, amnesia, somnolence, tunnel vision and partial aphasia (‘She no longer conjugated verbs’, Breuer recorded, ‘and eventually she used only infinitives, for the most part incorrectly formed from weak past participles’). Among her symptoms, she was at one time unable to speak in her native German, but could still read both French and Italian, translating them aloud into English as she did so. During part of her illness, she was unable to recognize or accept food from anyone except her physician, who spent somewhere in the region of a thousand hours with her between April 1881 and June 1882. She was able to satisfy herself of his identity only by holding his hands.

As described by Dr Breuer, his treatment of Anna gradually developed through three stages, as he responded to Anna's own apparent wishes. In the first stage, he recognized that she could relieve her distress by making up and telling fairy tales, ‘always sad and some of them very charming’—and he encouraged her to do so. She herself called this activity ‘chimney sweeping’ or her ‘talking cure’ (the origin of this famous term for all later forms of psychotherapy and counselling). In the second stage, Breuer was able to hypnotize Anna every morning, sometimes by holding up an orange, in order to help her to remember some of the painful emotions she had gone through when her father was dying. Each evening Breuer would return and Anna would recount, with vivid emotion, the exact events from precisely one year previously. In the final stage, Anna began to add to these accounts a description of the various occurrences that had evidently triggered each of her hysterical symptoms during the previous year. As she did so, the relevant symptom itself would disappear. For example, on recalling her disgust at seeing a dog drink from a lady companion's glass of water a year before, she was suddenly able to drink once more, having for some time been able to quench her thirst only by eating fruit such as melons.

Breuer's history of Anna O has given rise to a tremendous amount of debate. There seems to be much uncertainty about the true extent of Anna's clinical improvement following the treatment. We know that Anna was admitted to a sanatorium shortly after her apparent ‘cure’, still in a very disturbed state—although in later life she became a distinguished social worker and a noted campaigner for women's rights (under her real name of Bertha Pappenheim). Freud himself was the first to criticize Breuer for his naïveté, in particular for ignoring Anna's fairly obvious sexual feelings towards her physician. Breuer himself, if not actually infatuated with Anna, certainly seems to have been drawn into a kind of ‘folie à deux’, accepting her behaviour and her self-prescribed cures at face value, and discounting the effect of his own intense interest on her performance. It has also been suggested that Anna's theatrics drew heavily on the contemporary craze in Vienna for stage hypnotism.2 For many modern readers, it may be quite hard to avoid the impression of an annoying young woman running rings around a rather suggestible doctor.

However, it may be worth reflecting on this reaction a little, and applying some historical sensitivity to what we read. If Anna's hysteria appears to us now as a form of outrageous fabrication, it may be for the simple reason that she had lost the capacity either to know the truth or to tell it. In addition, within her own cultural world such ‘mad’ behaviour was one of the few permissible forms of protest open to young women who felt stultified by their family and social circumstances. (There was opposition, for example, to girls receiving secondary education. Billroth himself was against it, on the grounds that it might lead to demands for women to enter the university.) Seen from this kind of perspective, her girlish determination to engage her physician with a bizarre drama of symptoms and remedies does indeed represent a shocking state of mind, and a desperate plea for relief. When Breuer approached Anna's bedside with an apparently obsessive interest in the tiniest details of her behaviour, he was displaying the most objective and enlightened stance available to a medical man of his time, not to mention a great deal of patience and devotion. What Breuer did was in fact utterly original in relation to any form of mental distress: he listened not only in order to establish a diagnosis, but also to effect a treatment. Freud, for all his reservations about the case, realised how radical this was, and drew on it for the basis of his own talking cure. If, with hindsight, we regard Breuer's view of these events (and even Freud's) as somewhat selective and self-promoting, this may be no more the case than with many other scientific advances.

We live now in a world that is united, if at all, by the idea that talking does indeed cure. Whether as doctors or therapists, our daily experience is that letting people talk does make a difference. Few if any psychotherapists these days believe, like Breuer, that prompting patients to recall trivial events from the recent past will alleviate psychosomatic symptoms. Most believe that talking works because it provides people with a means of creating a coherent narrative from disconnected symptoms, events, memories and thoughts in the context of a relationship with someone compassionate and attentive. Whether this relationship lasts for a single medical consultation, or a long course of therapy, it may help to correct some of the hurt done by less well-attuned relationships, or by significant losses and setbacks, and to make sense of them. What is particularly interesting is that a growing amount of collaborative research, done by neuroscientists and psychiatrists working together, suggests that such processes may bring about demonstrable changes at a neurological level.3 If this is true, we may have come full circle. It would no doubt have delighted Dr Josef Breuer, physician and physiologist, who held Bertha Pappenheim's hands, listened to her fairy stories and took them seriously.

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