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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).

  1. 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 speaking in her ear. She felt something moving on her back like a snail, and something grasped her side like a hand. Today many therapists would undoubtedly suspect flashbacks of night-time sexual infringements in relation to these descriptions (Herman 1981).

The analysis of the feelings connected with this hallucinatory experience on 5 January 1905, as noted by the doctor treating her, reveals a memory of New Year’s Day 1904 when there was a big row (angry scenes with the father). More precise facts are not given, only that many such scenes took place, which Sabina described with great affect. In particular there was a scene when she was already thirteen years old and her father tried to beat her: He took her into a special room and ordered her: lie down; she implored him not to beat her (he was trying to lift her skirt from behind). Finally he gave in, but he forced her to kneel down and kiss the picture of her grandfather and to swear always to be a good child. After this humiliating scene the boys (her brothers) were waiting outside to greet her.

According to this description the father’s chastisements were humiliating rituals, taking place behind closed doors, and for that reason alone containing an undertone of sexual infringement. Her father’s comments which offended her sense of shame also point in this direction. The reporter (C. G. Jung) notes regarding these that Sabina put particular emphasis on them in her accounts.

With what comments her father offended her sense of shame is not recorded. But we might assume that he used insults of a sexual nature in connection with the command lie down; these had the effect of making the young girl feel totally repulsive, like a dog or a devil.

Later she acknowledged what Jung regarded as the most important fact: Finally after a three-hour analysis (!) it turned out that since her fourth year she has experienced sexual arousal. She feels a pressure to urinate and has to press her legs together. We read that later she had an orgasmic discharge. Finally it was enough to see or hear her brother being beaten for her to want to masturbate; or someone had only to threaten her to make her immediately lie on her bed and masturbate. Recently it had taken increasingly slight suggestions to awaken the impulse in her, for example someone only had to laugh at her, thus indicating her humiliation, to cause her to have an orgasm, as the doctor conducting the analysis the style is Jung’s  writes.

These formulations suggest that Jung certainly sees the sexual activity as being on Sabina Spielrein’s side. At all events it is not clear from this passage that he holds the father responsible for his daughter’s confused feelings through his beatings of her, and through his offences against her sense of shame. For as the passage subsequently shows, she undoubtedly suffered much from the complex to which basically all her expressions of disgust and her negative behaviour could be traced. She sees herself as a thoroughly bad and corrupted person and for that reason she simply assumes that she should not be allowed to be in the company of other people. Any suggestion of forced sub-mission triggered the complex, and caused her to masturbate. And, during the act, pat. wishes on herself all manner of torments; she pictures these as vividly as possible, in particular being beaten on her bare bottom and, in order to increase her arousal, she imagines that it is taking place in front of a large audience.

His analysis of this act leaves the impression that Jung was not paying attention to the drama as a whole but was focusing on the lustful patient. In that context it should be stated that Jung’ lengthy analysis (lasting many hours) took place in January 1905 before he became personally acquainted with Freud, and before the publication of Freud’s Three essays on the theory of sexuality; Jung’s focus on infantile sexuality anticipates Freud’s change of focus after he turned away from the seduction theory.

It should also be pointed out that Jung’s analysis did not explain at all what he was at first trying to explain: the remarkable and alarming hallucinatory experience that something/someone was creeping about in her bed.

Whatever the analysis of Sabina’s core-complex had produced and what-ever conclusions were to be drawn from it, the malicious spectators of whom she was so afraid did not include Bleuler. On the day following Jung’s lengthy analysis, Bleuler personally wrote a letter to the father who demanded a regular weekly progress report from Sabina.23 Miss Spielrein’s condition was stable, reported Bleuler. The New Year, with its reminders of home, had however brought a serious state of agitation, which had now receded. Nevertheless she was still feeling exhausted and had asked her doctor to write to her parents on her behalf. As her memories of you agitate her greatly, continues Bleuler, we are of the opinion that Miss Spielrein should not write to you directly over the next few months. In order to relieve her of this responsibility we have therefore forbidden her to write to her father.

For the rest, her recovery was proceeding well:

Miss Spielrein now occupies herself almost daily with scientific reading and she has also commenced practical scientific study in the anatomy laboratory.24 She wishes to convey her fond greetings.

Yours faithfully, the Director,

Bleuler.

Thus on doctor’s orders the father’s control over his daughter was massively restricted by Bleuler himself. Mr Spielrein was compensated for this severe curtailment of his power only by the satisfaction that Miss Spielrein was engaged in practical scientific studies, which must have flattered his ambition.

Mr Spielrein, who was paying a considerable sum for his daughter’s treat-ment, may have pictured her recovery somewhat differently. Bleuler’s letters to him which have been preserved are all worded in such a way as to give a strangely mixed impression of disapproval and painstaking friendliness. In September Mr Spielrein had been in ZŸrich to visit his daughter; and even then he must obviously have realized that he could no longer behave as freely with her as he imagined. Dear Sir, You may visit your daughter tomorrow, runs the terse text of a letter sent by Bleuler to his hotel. A few days later Bleuler is worrying about a dress Mr Spielrein wants to have made for his daughter. Bleuler wants the dressmaker commissioned by Mr Spielrein to take Sabina’s measurements personally, so that the dress will fit properly. Mr Spielrein’s visit to the Burghšlzli on 11 September 1904 is not mentioned in Sabina’s hospital notes. Three days earlier, on 8 September, Jung notes that Sabina used his return (after a week’s absence) to produce a few scenes: thus for example she climbed up the window grille in the corridor and forced him to pay her an evening visit; she sat in the doorway in her nightdress, wrapped in a blanket, and when no one took any notice of her she finally had a convulsive fit and let herself be taken back to bed completely exhausted. Next Bleuler writes again to Mr Spielrein in Rostov-on-Don: his daughter’s condition had not essentially changed, but a slight improvement was noticeable and some days pass quite peacefully. Happily they had now succeeded in stimulating Miss Spielrein’s interest in scientific pursuits so that she can be distracted for hours at a time from her pathological obsessions. During the morning she now often participates with great interest in the examination of patients and in the afternoon she goes for walks with her nurse.

She uses this opportunity to play childish jokes of a harmless nature. Sabina’s night terrors had been discussed with her father; Bleuler writes that they have become significantly fewer. Physically too she is well, though still easily tired. Finally he asks for payment of fees for the next quarter.

In an entry in the hospital notes for 29 September Jung enumerates some of Sabina’s childish pranks of a harmless nature: suicide attempts to frighten the nurses, running away, giving people scares, transgressing prohibitions, etc. She sometimes feels depressed after these excesses and has insight into her condition but not the slightest inclination to improve it. She asks him (Jung) not to show the slightest doubt about her recovery. Jung also remarks that Sabina has no powers of concentration when left to read on her own, but the doctor’s mere personal presence can often enable her to concentrate for hours. Jung must therefore sometimes have spent hours with her.

Two weeks later Bleuler again approaches the father: In the interests of Miss Spielrein’s treatment he is requested to answer the letter which she wrote to him on 1 October. She is slowly getting better, and happily she has decided to begin her medical studies in ZŸrich next spring.

Mr Spielrein who, according to Sabina’s reports, was accustomed to react with a total breakdown of communication even to minor conflicts, must have experienced Bleuler’s demands as meddling with his paternal rights, and as insulting and presumptuous. Was it not his affair, whether and how he answered his daughter’s letters, and also whether and where his daughter studied? Many of the Russian women students reported on the great battles they had with their fathers to be allowed to study abroad. And Mr Spielrein, who kept his daughter under such tight control, and responded to her wishes for independence at sixteen years with threats of suicide, must have suffered a serious crisis as a result of the increasing impertinences from ZŸrich.

Unfortunately it is ot known whether or how Mr Spielrein replied to his daughter’s letter and to the director’s. At all events Bleuler did not give up. On 25 October he forwarded to Mr Spielrein two letters from Sabina; this meant that no private communication from the father to Sabina could take place while she was under the protection of the clinic. Bleuler knew how to mitigate his presumption vis-a-vis the father with news of Sabina’s slow improvement: she was already going for accompanied walks outside the institution. In addition, he reports, she is currently assisting one of our doctors25 on a scientific project which she finds of great interest. Bleuler again mentions her decision to study medicine in Zurich, and makes it clear that there is no question of her returning to Russia. And even a reunion with her family, before she has commenced her studies, would in our opinion be strongly contraindicated, writes Bleuler.

Your daughter needs to develop independence and self-reliance and must therefore remain unencumbered by all emotional anxiety for her family and all restricting aspects of family life. This can only be achieved by her spending some time in a new and different environment where she can devote herself wholeheartedly to an absorbing activity. Your daughter too is of the opinion that these are the conditions necessary for her recovery.

That was indeed a new and unfamiliar tone for Mr Spielrein; it is hardly to be supposed that he liked it, though he may have been flattered by the Swiss doctors confidence in his daughter’s scholarship. Sabina must also have felt bad in her new role in relation to her father. Had she betrayed him? Shown him up, disregarded him? Would he survive, when previously he had always threatened suicide? How will he tolerate her letters? Will she herself survive if she stands up to him?

Mr Spielrein[s reaction to Bleuler was apparently a letter in which he stated that he had concluded from Sabina’s letters in October that there had been a massive deterioration in her condition; possibly he also threatened to demand her discharge and transfer. On 28 November C. G. Jung took up the correspondence with the father on behalf of the director in order to excuse Sabina’s letters and to hold out the prospect of her recovery: fortunately there had been no such alteration in his daughter’s condition as he seemed to have concluded from her letters. Since he, Jung, had returned from his three-week military service, her recovery had progressed. Miss Spielrein could now concentrate much better. Recently she had participated with some success at a social function at Prof. Bleuler’s. Of course there were also days when she succumbed to her childish moods; it was in one of those moods that she had written her recent letters. She admitted it to me immediately afterwards and sincerely regrets this unconsidered course of action. Her letters therefore do not imply a deterioration in her condition

This statement is in direct contradiction to the remarks recorded in the hospital notes: in November 1904 Sabina’s condition took another severe turn for the worse in connection with Jung’s absence, although Bleuler’s goodwill, patience and calm were quite inexhaustible: Owing to the absence of the senior physician , pat. left almost entirely to herself for the last week and much worse, writes Bleuler on 4 November. Has many physical complaints, insists she cannot think and cannot follow the lecture at the clinic etc [the lecture in clinical psychiatry]; she demanded a sleeping draught, and then threatened to create a scene in the night if she did not get it. Indeed she did start making a noise at 1.00 a.m. When the nurse tried to get her back to bed she resisted by kicking her: When the head nurse was called she stupidly resolved the situation by forcing pat. back to bed. After that some peace. So Bleuler apparently did not object to being fetched by the head nurse at 1 o’clock in the morning to take control of the situation! During the day Sabina had been unwell; she did go to the clinic [the clinical lecture], but afterwards remained clinging to the wall as if nailed there, perhaps in the expectation that Bleuler would pass. He then took her back to the ward, got her to tell him what happened the previous night, and noticed how she seemed to get considerably better as she did so. Nevertheless she still asked for a sleeping remedy but did not take it, because, as Bleuler comments, perhaps someone had told her that he would be pleased if she did not take it. Bleuler also states that she made a diagnosis of epilepsy from a letter handed out at the lecture and supported it correctly. A week later Bleuler’s entries report dramatic suicide threats; she hid knives, and left behind farewell letters, took possession of the gas workers ladder on the ward and put obstacles [benches] in the corridor for him to jump over. She enjoys watching Bleuler jump, but will not attempt the smallest jump herself: it would hurt the soles of her feet, Bleuler states. She composes songs which she cannot recite for laughing, and in which the hospital doctors26 play the main parts.

She complains that she cannot work, that life is pointless, and again talks openly of suicide; she wants the curtain cords to be returned to her room so that she can create a scene during the night and demonstrates how she will try to strangle herself with them.

On 20 November Jung notes that there has again been a rapid deterioration following his return: all kinds of pranks, torments the nurse so horribly that she has to be withdrawn, kicks the stepladder around the corridor, scratches the floor. She refuses to go into town, complains of pains in her feet, refuses to eat in order to starve herself to death, says she desires with all her might to get ill, that she needs to be unconscious for at least two months before she can get well again. In October, before his three-week absence, Jung had grappled intensively with Sabina’s father complex.

In October he pasted a bill from the Heller sanatorium, where she had been before her admission to the Burghšlzli, together with some sketches of Sabina’s, into the hospital notes. Most striking was this drawing: a female person, lying in helplessness and panic, on whom a man is sitting. It is Dr Heller giving a patient electrical treatment. The position is a remarkably sexual one, Jung writes and continues: Pat. reveals many other masochistic features, for example her relationship with her father towards whom she feels a strange disgust. The chastisements form the central complex. Even from him she constantly demands that he inflict pain on her, treat her badly in some way; he was never merely to ask something of her, but to command it. The remarkable treatment given by Dr Heller had obviously re-awakened for Sabina a situation of being violated. Jung links Sabina’s drawing to her relationship with her father Ð however, he does not bring out the father’s sadism and the sexual connotations of his behaviour, nor Sabina’s helplessness and panic, but only her masochism.

Another theme in October is provided by the pains in Sabina’s feet, which were thoroughly abreacted after a days bed rest. The analysis revealed a connection with an unpleasant walk after a row between her parents: afterwards the father stayed in bed for two days sick with rage, neither speaking nor eating.  When a relative then arrived on a visit, Sabina had to ask her father to get up, and also to go for a walk, so as to behave as though nothing were wrong. It was then that the pains in her feet started, so that for some time she could not walk. In addition, when she had to travel with her mother to Vienna in various difficult circumstances she got the same pains. Sabina now knew that she must gradually accustom herself to a freer life. She is afraid of going out and of the future; so she tries to postpone going out as long as possible through the pain in her feet.

Finally Sabina’s Mars fantasies also form a theme. She entertains other patients by telling them fantastic tales about Mars.

She insists that every evening she travels to Mars, on to which she projects all her contrasexual fantasies. On Mars people do not eat but are fed through osmosis. They do not procreate, but children quickly develop in the unconscious of individuals and one day appear ready-made and without further difficulty.

Jung seems to have found Sabina’s fantasy stories rather annoying; he comments that she maintains the correctness of this story in front of him rather like a stubborn child who does not want to give up a toy. Had Sabina given Jung Flournoy’s From India to the Planet Mars to read, and then tried to impress him with similar stories?27 Or was Mars the safe fantasy world contrasting with her real situation?28 Bleuler too knew about Sabina’s Mars stories, but she clearly did not want to elaborate further on them with him because no one believes her, as Bleuler comments in November 1904.

On 22 January 1905, on behalf of the director, Jung approaches Mrs. Spielrein personally with his report, asking her to visit Zurich. He explains to her too that Sabina has to be forbidden to write to her father since she has recently become so agitated over sending him birthday greetings. A weekly report such as the father wants is impossible on account of the burden of work on the doctors. The patient is now slowly getting used to the city again, going for walks, and eating with other people. Yesterday she voluntarily joined the table of the assistant doctors at lunch, and this can be seen as a significant success. For the rest she would very much like to see her mother again, a wish which even the doctors support. A meeting with other members of the family is not to be recommended for the time being. He will then be able to report to her verbally on her daughter’s state of health.

It can be assumed that Mr Spielrein, as a Jewish father, could in no way accept that only his wife was welcome to take part in conversations with his daughter and her doctors. And for Mrs. Spielrein too her position must have been rather uncomfortable.

When no reply had been received from Mrs. Spielrein after three weeks, Bleuler tried again, copying Jung’s letter partly word for word, partly with small but not insignificant alterations. Her visit was important because Sabina would then be able to unburden herself on various matters. Apart from that, her recovery was progressing; she now voluntarily joins the table of the assistant doctors at lunch daily. And: She is largely free of hysterical symptoms and she can therefore be regarded as having recovered.

It can be assumed that Mrs. Spielrein did come. In the hospital records however there is no mention of her visit.

An entry in the hospital records on 29.1.1905 comments on Sabina Spielrein’s inability to say the trigger word beat while taking part in the association experiments with acquaintances; in addition, she went into a kind of daze with the same strange feeling in her head as she had felt on her first night at the Burghšlzli: on an evening visit Jung found the patient lying on the sofa with a remarkably sensuous dreamy expression on her face. When he said some-thing she suddenly laughed and said: Now I can hear your voice double, I feel as if I had two heads, and as if the whole of my left side were moving of its own accord. Jung’s enquiry revealed that Sabina had fallen into this state while reading Forel’s book on hypnotism. When he picks up the book to find the passage that triggered off the father complex she suddenly makes her defensive movements and gestures of disgust and points to the passage in which Forel illustrates the phenomenon of suggested false memory with an anecdote from an autobiographical tale by the Swiss author Gottfried Keller. Keller describes how as a seven year-old boy he had made up a false story in which he accused four older boys at his school of kidnapping him and beating him to make him call the teachers names and use foul language. Was it the trigger word beat in this story which was the crucial factor, or was she tormented by doubts about the accuracy of her memories? At all events she soon seemed to recover. Three months later, on 29 April 1905, Jung commented: In the last few weeks distinctly improved and increasingly calm. Now listens to lectures conscientiously and with interest (zoology, botany, chemistry, physics). Fluctuations in mood still occur from time to time, particularly in connection with letters from home.

All the more remarkable, it seems, is Jung’s unaddressed medical certificate, apparently meant for the university authorities: Miss Sabina Spielrein from Russia has been at the clinic since 17.8.1904; she will probably remain here some time longer and intends to attend lectures at the university. Undoubtedly this certificate hardly encourages confidence; Jung stresses the length of time she has already spent in hospital and leaves her intentions for studying vague and even dubious.

It was Bleuler who, a few days later, gave Sabina Spielrein the backing she needed to enroll at the university as a regular student by giving her a clear certificate. Miss Spielrein, resident at this institution and wishing to register at the medical faculty, is not mentally ill, states Bleuler. She was here because of her nerves and her hysterical symptoms. We must therefore recommend her for matriculation.

The discharge

On 1 June 1905 Sabina Spielrein was discharged. She now lives independently in town and attends lectures, we read in the hospital records.

A week before her discharge, on 23.5.1905, Jung had again written to her father to assure him on Sabina’s behalf that it was not from lack of love or gratitude that she was refraining from writing to him, but because she feels better and more relieved if she does not have continually to recall images and memories of home. Furthermore it is characteristic of her nervous dis-position that she links all kinds of pathological obsessional fantasies to his person. It is not clear what conscious or unconscious intention underlay Jung’s addressing the father in this way. Was he forced by Sabina, who worried intensely about her father’s rage? Did he himself feel obliged to explain the situation in this way? Was it merely to propitiate the father in order to win his support for Sabina’s studies? Admittedly her condition was still not quite normal, Jung continues, but it was time for her to leave to commence an independent existence. We will talk to her about it and will inform you of your daughter’s decision.

Mr. Spielrein, who was surely hardly accustomed to wait on his daughter’s decisions, immediately sent the eldest of her three brothers to study in Zurich

and in her newly won independence Sabina again felt pursued by family demands. Obviously Bleuler saw it that way too. The day before her discharge he wrote to her father: Miss Spielrein was very agitated at being expected to look after her brother. If she is to remain in her improved state she must be absolutely free from any obligations to her family. The last letter to the father from the Burghšlzli comes significantly from Jung. A week after Sabina Spielrein’s discharge, on 7.6.1905, Jung gives the father her new address which unfortunately is near her brother’s apartment, and asks him to find other lodgings for the brother since it is of the utmost importance for his daughter’s health to have as little contact with her brother as possible. The brother complex was not explicitly discussed in the hospital records, but the brothers seem to have functioned as substitutes for the father. When we recommended Zurich as a location for your son we were as yet unaware of the obsessive fantasies which are attached by the patient to her brother, otherwise we would have been more hesitant in recommending Zurich to you, writes Jung. In addition he asks him to send money direct to his daughter now. But should you require some supervision in this matter I would be pleased to be at your service and to receive the money for Miss Spielrein on her behalf.

It is striking that Jung does not refer to Bleuler’s letter of 31 May, which would have been quite enough to keep Mr Spielrein’s demands within bounds. There was undoubtedly in Jung’s directives in contrast with Bleuler’s clear statements a violation of boundaries: did he really think that the father would find another lodging for the brother? And why is he at his service to receive money for Sabina on her behalf?

Did that not mean that he was tending in place of the father to take control of her instead of supporting her independence? Had Jung really understood Sabina’s father complex, if he was so eager to assume guardianship of her in financial matters? How much did he really value her capabilities? Was her discharge from the hospital really a release into freedom?

Sabina Spielrein at least seems to have fought her own battles over her free-dom. On 24 April 1905, the day before the start of lectures, she began to keep a diary in Russian, which she hid from Jung. She was worried about studying and awaited this happy moment in a state of somehow deathly darkness.

My head aches, I feel sick and weak. I don’t believe in my strengths, in fact I don’t believe in anything. Jung is going along the corridor. Soon he’ll come in here: I must hide the book so as not to let him see what I’m doing, but why don’t I show him? The devil alone knows! (Wackenhut & Willke 1994, p. 185f)

At the university especially she felt isolated from her fellow students; she felt she was much more thorough, more serious, with a more developed critical capacity, more independent. Yet she doubted her capacity to work in a scientific way.

First, will my health allow me to? And most important of all: will I be talented enough? Meanwhile life without science is unimaginable to me. What would be left for me without science? Marriage? The thought fills me with dread: sometimes my heart aches for tenderness, for love, but it is only a deceptive, fleeting, superficial moment which hides the most pitiful prose É I wish I had a good friend, to whom I could bare my soul, I want the love of an older person who could love me and understand me as parents love their child (inner resemblance). And for me it is as if my parents were not parents at all É But that story is too well known for me to want to describe it.

And without warning she continues: If only I were as wise as my Jung[a]! Damn! I just want to know whether anything can be made of me, she asks, and says: And how stupid it is, that I’m not a man: they have it so much easier with everything. It’s outrageous that the whole of life goes their way. I won’t be a slave!

A month later, on 8 June 1905, a week after moving into her own apart-ment, and the day after Jung’s letter to her father, she is not at all concerned about her brother’s proximity but she is anxious about being close to people:

Somehow I’m afraid to get close to people. I fear for my freedom. The only thing I have now is my freedom, and I’m protecting this last treasure with all my strength. I cannot bear the tiniest criticism of my personality, not even in the form of a simple instruction: it feels like a punishing sermon É

Nevertheless:

Only from Jung can I tolerate everything. It is unbelievably painful to me when he reprimands me. I want to weep, to implore him to stop, because I feel my personality being suppressed, but on the other hand I can’t resist him at all. (ibid., p. 186)

No doubt Jung had moved Sabina deeply. To him she had confessed her shameful secrets, her hidden thoughts and feelings. And it was probably thanks to his patience, and his intense devotion to and enthusiasm for the emotional life which she experienced from him that life without science became unimaginable for her.

It was Bleuler, however, not Jung, who laid down the outlines of her treat-ment. Her treatment was in accordance with ideas that had already been introduced at the Burghšlzli by Forel: she was treated as a victim of severe traumatization. Her substantial symptoms were diagnosed as hysterical, and hysteria (a controversial term at that time as it is now) was seen as a traumatic neurosis in the sense of Breuer and Freud. Notwithstanding all the changes which the concept of traumatic neurosis has undergone in the last hundred years, the essential therapeutic principle described by Bleuler is still valid: to treat patients with patience, calm and inner goodwill, and to create an environ-ment which prevents the patients acting-out and promotes their resources and talents.

What was unusual in Sabina Spielrein’s case was how unreservedly Bleuler stood up for her; she could rely on his unwavering backing for her apparently almost hopeless struggle for independence from her father and from her whole family by whom she felt literally possessed. In spite of her childish pranks, her tormenting of the nurses, and her continuing threats of suicide Bleuler invited her not only to lunch with the doctors but to his own home; he admitted her to his lectures, involved her in the ongoing psychological research, and finally recommended her unconditionally to be enrolled at the university to study medicine. No doubt Bleuler’s demanding principle that Sabina’s acting out of tyrannical and violent impulses be met with goodwill and forbearance, and that at the same time she be respected as a future colleague and co-worker, reached the limits of what was tolerable to doctors and nurses, and to other patients at the clinic.

Compared with Bleuler’s, Jung’s attitude to Sabina and his engagement with her was as intense but much less consistent. Although Sabina made it clear to him that she had been traumatized since her early childhood it remains unclear whether and how Jung comprehended her traumatization. However we may judge his analysis and his conclusions today, the result of his ambitious scrutiny of Sabina’s complexes was that the trauma as well as the perpetrator faded into the background. A close relationship developed between them which would later prove to be as powerful as it was critical.

It is easy to understand why she awaited the happy moment of her dis-charge in a state of somehow deathly darkness. Her situation seemed almost hopeless: at twenty years old, and with serious social anxieties, how would she, a Russian Jewess, manage to integrate herself into a society which was foreign to her in nearly all its aspects? How would she not only cope with the demands of the university but at the same time take on a role there as a woman pioneer among medical students? How would she separate from her father and family despite the fact that she had no one to stand by her and would remain in economic dependence?

She was discharged as recovered, not as cured. She had a place as a student in Zurich, and she took pleasure in studying. But she was not yet free. Who would give her support in the future, and would she find someone to love her as parents love their child?

Notes

All details of Sabina Spielrein’s stay at the Burghšlzli in Zurich have been taken (when not otherwise indicated) from the hospital records published by B. Minder in Luzifer-Amor. Zeitschrift zur Geschichte der Psychoanalyse (1994), 14.

Patients could be admitted to the hospital only with a medical certificate dated not more than two weeks previously; certificates from doctors related to the patient were not valid. Only addicted persons could be admitted of their own volition (Forel, A. 1894, Bleuler (1916) 4th edit. 1923, p. 162).

Letter from E. Bleuler to Mr Spielrein 26.9.1904.

Zurich State Archive, government resolution 20.10.1904.

Organizational rules, Annual Report, Burghšlzli Mental Hospital, 1869Ð1905.

Adolf Meyer (1866Ð1950), who as Director of the Johns Hopkins University in Baltimore played a leading role as a mentor in American psychiatry, was a former doctoral candidate of Forel’s and remained in active contact with him all his life; in 1893 he reported to Forel on a course in psychiatry which he was giving to students: I get the doctors to enact the part of a group of patients and I direct the proceedings. In the course of the demonstration they must not use any technical language; the description of clinical observations must be expressed in concrete terms without recourse to pseudo-psychological or pseudo-physiological paraphrases.

 

One semester and several clinics after I worked at the Burghšlzli, that was all the psychiatry I brought back with me to America. I must say it is now proving to be a good foundation and I hope that in time I will progress far enough to call myself your pupil without your having to protest as such presumption.

The frequent correlation between alcoholism, venereal disease and mental illness led Forel to the hypothesis that alcohol, even in small doses, causes damage to the germ cells (blastophthoria), with specific damage to the mental and physical health of the next generation. He acknowledged (1924) that this hypothesis is not proven (Meier, Rolf 1986, p. 82).

The International Order of Good Templars (IOGT) was founded in the USA in 1851 as a pioneer organization for abstinence from alcohol and for the community of nations; in 1892 Forel founded a Swiss section, and in 1906 the National Order of Good Templars (IOGTN), which still exists.

Hedwig Bleuler-Waser (1869Ð1940): LebensrŸckblick, in Schweizer Frauen der Tat Bd.2 (Looking back over my life in: Swiss Women of Action, Vol 2).

Monakow recalls particularly a very crowded meeting at which Bleuler and his wife were so enthusiastic about psychoanalysis that they were even celebrating the movement in verse and where a medallion of Freud was passed round (Monakow 1970, p. 244).

Jung and Maeder analysed a paranoid woman with confused speech whom I had treated earlier at the Burghšlzli hospital; I had partly uncovered the meaning of the madness behind her apparent speech confusion É I had already presented such patients, and other similar ones, in my clinic at the beginning of the nineties and drawn attention to elliptical speech patterns (Forel, Hypnotismus, 6th edit. 1921, p. 233).

Letter 6.10.1901, Zurich State Archive.

Letter of resignation 23.7.1902. Minutes of senior executive meetings 1902, Zurich State Archive.

. Jung to Andreas Vischer (undated letter, kindly lent by S. Zumstein-Preiswerk).

As Jung said in retrospect in 1925, he had missed the point of the situation: his own connection with it. The girl had of course fallen hopelessly in love with me, but I paid very little attention to it and none at all to the role I was playing in her psychology (Jung 1995, Seminar).

Zumstein-Preiswerk: personal communication.

Letter to Andreas Vischer, 22.8.1904 (kindly lent by S. Zumstein-Preiswerk).

Ibid.

  1. G. Jung to Andreas Vischer 12.12.1904: Then I completed my doctoral thesis which now lies before the faculty (Letter kindly lent by S. Zumstein-Preiswerk).

In her childhood diary 1895Ð98 (Wackenhut & Willke 1995) Sabina describes a trip with her mother to Berlin and Karlsbad. She complains that she is completely responsible for her mother who is too nervous to cope alone. The incident mentioned here is not reported in the published diary.

The fact that academic achievement had been extremely important to her parents is also evident from the diary entries 1895Ð98, which were checked by her father (Wackenhut & Willke 1995).

Jung, C. G. 1902, p. 86 (78?). In the footnote to this passage Jung refers to the Studies on Hysteria by Breuer and Freud.

When Sabina was at school her father made her keep a diary regularly and he used to check it. The diaries have been partly preserved and were published in 1994 in German translation (Wackenhut & Willke 1995).

Sabina Spielrein, as has been shown, worked in the psychology laboratory at the Burghšlzli; it seems that Bleuler described her as working in the anatomy laboratory in order to prevent her father doubting the seriousness of her medical activities. Franz Riklin and Jung were working at that time on The associations of normal subjects.

In addition to Bleuler and Jung, from 1 October 1904 Karl Abraham (1881Ð1924) had also become part of the team.

The reference is to an article about the medium Helen Smith, who among other things spoke the Martians language.

Jung’s notes on Sabina’s Mars fantasies are reminiscent of another patient with a moon fantasy whom Jung treated privately in 1910 and often made a subject of discussion: the girl, from a cultured family, heard voices, refused food and no longer spoke; at fifteen she had been seduced by her brother and abused by his school-friend, Jung writes; from that time she became increasingly isolated and hid away from people, until at the age of seventeen she was admitted to the clinic in a catatonic state. In her fantasies she lived on the moon with women and children in a sublunar dwelling, threatened by a vampire. After much resistance and several dramatic relapses she came to realize that life on earth was unavoidable and resigned herself gradually to her fate (Jung/Jaffe 1961, p. 150ff. For the implications of Jung’s interpretation of this case cf. Hšfer 1993, pp. 307 & 312Ð18).

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