Originally published in DISSOCIATION, 1989, 2(1), 3-16. Posted at trauma-pages.com with permission of the author (OvdH) and the Journal Editor (R. Kluft). Note that this online version may have minor differences from the published version.
Correspondence: Onno van der Hart, Department of Clinical Psychology, Utrecht University, Heidelberg 1, 3584 CS Utrecht, The Netherlands. Phone: +31(30)253-1785; fax +31(30)253-4718; Email: firstname.lastname@example.org
Barbara Friedman, M.A., M.F.C.C., is in private practice in Beverly Hills, California.
Note: This paper was written when Dr. Van der Hart was affiliated with the Department of Psychiatry, Free University, Amsterdam. The authors wishes to acknowledge the helpful comments of Drs. Paul Brown, Rutger Horst, and Richard Kluft.
A century ago there occurred a peak of interest in dissociation and the dissociative disorders, then labeled hysteria. The most important scientific and clinical investigator of this subject was Pierre Janet (1859-1947), whose early body of work is reviewed here. The evolution of his dissociation theory and its major principles are traced throughout his writings. Janet's introduction of the term "subconscious" and his concept of the existence of consciousness outside of personal awareness are explained. The viability and relevance of dissociation as the underlying phenomenon in a wide range of disorders is presented. It is proposed that Janet's theory and methodology of psychological analysis and dynamic psychotherapy are cogent and relevant for today's students and practitioners.
A century ago, Pierre Janet (1859-1947) became France's most important student of dissociation and hysteria. At that time, hysteria included a broad range of disorders now categorized in the DSM-III-R (American Psychiatric Association, 1987) as dissociative, somatization, conversion, borderline personality, and post-traumatic stress disorders. Through extensive study, observation and experiments using hypnosis in the treatment of hysteria, Janet discovered that dissociation was the underlying characteristic mechanism present in each of these disorders.
Unfortunately, his view of the importance of dissociation in hysteria and its treatment were abandoned when hypnosis fell into disrepute. This retreat from hypnosis at the end of the nineteenth century coincided with the publication and popularity of Freud's early psychoanalytic studies. Historically, Janet's considerable body of work was neglected in favor of the rising popularity and acceptance of Freud's psychoanalytical observations and conceptualizations.
Today, renewed clinical and scientific interest in dissociation and the dissociative disorders calls for reexamining the experimental, clinical, and theoretical observations made in psychiatry during the past century. While many psycho-analytically-oriented clinicians restrict their historical interest to the study of Breuer and Freud (1895), others have searched for the original sources in French psychiatry, especially those of Pierre Janet. Their efforts have been hampered by the difficulty of obtaining the original publications in French, and by the scarcity of these works translated in English translation.
In recent years a change has taken place with regard to Janet. The Société Pierre Janet in France has been reprinting his books since 1973. In the English-speaking world a small group of devotees has long recognized the value of Janet's contribution to psychopathology and psychology. With the reprint of Janet's Major Symptoms of Hysteria in 1965, the publication of Ellenberger's The Discovery of the Unconscious in 1970, and Hilgard's Divided Consciousness in 1977, the importance of Janet's contribution to the study of dissociation and related phenomena became better known to the English-speaking world (cf. Nemiah, 1974,1979,1980; Perry, 1984; Perry & Lawrence, 1984; Decker, 1986; Haule, 1986). Janet's contributions to the field are not limited to hysteria and dissociation, but encompass a wide range of subjects, as indicated by Ellenberger (1970) and a handful of other English language publications indicate (cf. Horton, 1924; Bailey, 1928; Mayo, 1948; Havens, 1966; Ey, 1968; Hart, 1983; Haule, 1984; Pitman, 1984, 1987; Pope, Hudson, & Mialet, 1985).
The purpose of this paper is to review Janet's books on hysteria and dissociation and to provide a summary of the central concepts in each of them. A brief description of Janet's career enables the reader to place these studies in their historical perspective. For a more complete biography, the reader is referred to Ellenberger's encyclopedic opus, The Discovery of the Unconscious (1970).
Pierre Janet was born in Paris on May 30, 1859, to an upper middle class family. He maintained a distinguished academic standing in the finest French schools, dividing his interests between science and philosophy. At twenty-two when he embarked upon his professional career as professor of philosophy in Le Havre, two events had had a profound effect upon him. The first, in 1881, was the International Electrical Exposition in Paris, where it became clear that the future would be dominated by science, technology and electricity. The second, in 1882, was the publication of Charcot's paper, which reestablished the scientific status of hypnosis (Ellenberger, 1970 p. 335).
At Le Havre Janet devoted his spare time to volunteer work with patients at the hospital and to psychiatric research. In search of a subject for his doctoral dissertation, he was introduced to Leonie, a 45-year old woman whom he proved could be hypnotized directly and from a distance. His experiments were reported in a paper read at the Société de Psychologic Physiologique in Paris in 1885, under the chairmanship of Charcot. Although these experiments (Janet, 1885, 1886a) gave Janet instant fame, he soon realized that many reports of his work were inaccurate. He became suspicious of parapsychological research, preferring instead to pursue systematic investigation of the phenomena of hypnosis and suggestion. Influenced by the work of Ribot and Charcot, Janet dedicated himself to the study of modification of states of consciousness in Léonie and hysterical patients in Le Havre's psychiatric hospital (Janet, 1886b, 1887, 1888). He jokingly named his little ward "Salle Saint-Charcot" in the popular fashion of naming French hospitals wards after saints (Ellenberger, 1970). Janet read everything he could on hypnosis, finding a wealth of important clinical descriptions in Bertrand, Deleuze, and Despine, the old masters of magnetism. He discovered that important theoretical notions had been developed by early researchers such as Main de Biran, Moreau de Tours, and Taine.
Janet found that the concept of dissociation is a concept first found in the work of Moreau de Tours in 1845. Its equivalent term psychological dissolution (désagrégation psychologique), also introduced by Moreau de Tours in 1845, was equally well received. Janet's extraordinarily exact and lucid descriptions of experimental and clinical observations (cf. Binet, 1890) of these concepts and his theoretical system continue to receive praise in modern reviews of his works (cf. Pope, Hudson, & Mialet, 1985; Pitman, 1987).
In 1889, Charcot invited Janet to the Salpêtrière, the famous psychiatric teaching hospital in Paris, where he became head of a psychological laboratory. While continuing his vocation as professor of philosophy and publishing a textbook in that field (Janet, 1894c), Janet began to study medicine, completing his studies in 1893 with his doctoral thesis (Janet, 1893b). During this period he published a number of papers describing his innovative therapeutic approaches to hysteria. As Ellenberger (1970, pp. 764-5) remarked, had Janet published the case histories of Lucie, Marie, Marcelle, Madame D., and the others he had successfully treated at that time, no one would ever have questioned his priority in discovering what was later called cathartic therapy. Recently, however, Van der Hart and Van der Velden (1987) showed that the Dutch physician Andries Hoek (1868) provided the first case study of cathartic hypnotherapy.
Janet's clinical research art the Salpêtrière formed the basis of his theory of hysteria. These findings formed the thesis for his medical degree and were applauded both within France and internationally. Janet seemed to have a brilliant career ahead when, three weeks after his promotion to Doctor of Medicine, Charcot died suddenly. A new era in psychiatry began. Many of Charcot's ideas about the presumably physical nature of hypnosis were discarded in favor of the views of the Nancy School of Hypnosis (Bernheim); viz., that hypnosis was a psychological phenomenon based purely on suggestion. Precisely because of its established psychological nature, hypnosis itself became discredited.
Janet was soon the only one in the Salpêtrière using hypnosis in his research and clinical work. He published many studies on hysteria (cf. Janet, 1898a & b; Raymond & Janet, 1898), then turned his attention to another broad category of névroses: psychasthenia with its inherent obsessions, phobias, tics, etc. This resulted in the two volumes on Obsessions and Psychasthenia (Les Obsessions et la Psychasthénie) published in 1903 (cf. Pitman, 1984, 1987).
Meanwhile, the climate at the Salpêtrière worsened for Janet. Babinski, formerly loyal to Charcot, but invested exclusively in the neurological portion of Charcot's teaching, began to regard hysteria as essentially the result of suggestion, and even as a form of malingering; a disorder able to disappear entirely by the influence of persuasion (Babinski, 1901,1909). Déjerine regarded hypnosis as morally reprehensible (cf. Janet, 1919; Ellenberger, 1970). In 1910 when Déjerine became Director of the Salpêtrière, Janet, the champion of both hysteria and hypnosis, had to leave. Although not honored in his own country, Janet was very well received in North and South America where he visited and lectured regularly beginning in 1904. He received an honorary doctorate at Harvard's tricentenary celebration in 1936. His Harvard lectures in 1906 were published as The Major Symptoms of Hysteria (Janet, 1907) and are currently garnering much attention again.
A decade earlier, in 1896, Janet had become Professor of Psychology at the Collège de France, a famous institute of advanced learning in Paris. First as Ribot's substitute, then as his successor, Janet held this chair until 1934. Many of his courses have been published, complete or in summary (cf. Janet, 1919, 1920/21, 1926b, 1927, 1929b, 1929, 1932a&b, 1925a, 1936; Horton, 1924; Bailey, 1928). Obliged to present a new subject every year, Janet used his classes as a means of combining his psychopathological findings and normal psychology into a unified system. This endeavor began appearing in Psychological Automatism where he remarked that for those who know mental illness well, it is not difficult to study normal psychology (Janet, 1889).
Janet possessed a remarkable talent for integrating very different materials into a harmonious whole (Delay, 1960). One of these results was the formulation of his Psychology of Conduct (psychologie de la conduite), a major effort to synthesize a multitude of behavioral observations with an evolutionary philosophical approach. In his book, Les stades de liévolution psychologique, he presented a hierarchically ordered classification of human activity from simplest to most complex (Janet, 1926b). Although Janet's dissociation theory has been rediscovered, there is still little awareness of what treasures are hidden in his later work on the psychology of conduct and in his psychopathological studies, such as those on paranoid schizophrenia (Janet, 1932c, d & e, 1936b, 1937, 1945, 1947a). Janet's last unfinished work concerning the psychology of religious belief remains unpublished (Janet, 1947b). It is estimated that the published work of this great man, who according to his daughter, did not know the act of rest (Pichot-Janet, 1950), amounted to at least 17,000 printed pages (Prevost, 1973, p. 10).
Since Janet's primary purpose was to inspire his pupils independent thinking on the basis of empirical facts, he did not leave a school or ideological movement behind. Instead, time and again, open-minded researchers and clinicians discover that Janet made the same observations as they, and that his theoretical explanations of this information remain viable sources of inspiration. This discovery extends well beyond the field of dissociation.
The following is a chronological review of books which Janet published over a 30-year period. It begins with L'Automatisme Psychologique (Janet, 1889) which first appeared 100 years ago and ends with Les Médications Psychologiques (Janet, 1919). In reading his books, it becomes apparent that one series of works shows Janet's remarkable abilities of classification (abilities which are also reflected in his being an ardent botanist). In these studies he mapped the various manifestations of hysteria which then became the foundation of his hypotheses about their origins, nature and relationship. These hypotheses and observations form Janet's dissociation theory. In another series of studies the emphasis is on the psychological analysis of one or a few case descriptions in depth. The last book reviewed reflects Janet's attempt to delineate the various forms of psychotherapy he encountered in the literature and the dynamic psychotherapy which he himself practiced as a eclectic psychotherapist.
Psychological Automatism, Janet's first book in psychology, introduces his dissociation theory and his model of the functional and structural elements of the mind. It describes psychological phenomena observed in hysteria, hypnosis, suggestion, possession states, and spiritism, though it clearly goes beyond those topics (Janet, 1889). As the book's subtitle, Experimental-psychological essay on the inferior forms of human activity suggests, Janet began with the study of human activity in its simplest and most rudimentary forms. His goal was to demonstrate that this elementary activity forms the psychological automatism: automatic because it is regular and pre-determined, and psychological because it is accompanied by sensibility and consciousness (cf. Van der Hart & Horst, 1989).
In presenting his model of the mind, Janet distinguished between two different ways that mind functions: activities that preserve and reproduce the past and activities which are directed towards synthesis and creation (i.e., integration). Normal thought is produced by a combination of the two acts which are interdependent and regulate each other. Integrative activity "reunites more or less numerous given phenomena into a new phenomenon different from its elements. At every moment of life, this activity effectuates new combinations which are necessary to maintain the organism in equilibrium with the changes of the surroundings." In short, this function organizes the present. Reproductive activities only manifest integrations that were created in the past.
Janet felt psychological automatism was best studied in individuals who exhibit it in extreme degreesopsychiatric patients suffering from hysteria. In them, the integrative activity is significantly diminished, causing the development of symptoms that appear as magnifications of the activity designed to preserve and reproduce the past. Janet discovered that most of them suffered from unresolved (and therefore, dissociated) traumatic memories. In this population he studied catalepsy, paralysis, anesthesia, contractures, monoideic and polyideic somnambulisms, and successive existences (as he then termed multiple personalities). His analysis represented a departure from classical psychology which made a sharp distinction among intellect, affect and will. Janet concluded that even at the very lowest level of psychic life, where feeling or sensation exists, movement also exists. Thus there is no consciousness without activity; even an idea has the natural tendency to develop into an act.
In his structural view of the mind, Janet aligned with earlier French authors such as Maine de Brian, Moreau de Tours and Taine, believing that all human activity had a conscious component. He put this on a par with the inner regulating activities of the mind, the proprioceptive functions as Sherrington (1906) called them. His predecessors and contemporaries generally believed that psychological automatism consisted of acts performed unconsciously and therefore, mechanically (cf. Despine, 1880). Janet believed that the behavior patterns he observed were determined by conscious factors, even though they were maladaptive departures from the habitual response patterns of the personality. Using the term automatic did not exclude the notion of self-awareness, as the Greek terms autos (self) and maiomai (striving for, to exert oneself for) are paired in this concept (Van der Hart & Horst, 1989). Janet stated that in psychological automatism, consciousness did not belong to the personal consciousness, was not connected to the personal perception, and lacked the personality's sense of self (idée du moi). This consciousness existed rather at a subconscious level. As Ellenberger points out, few people realize that it was Janet who first coined the term subconscious (1970, p. 406). Janet thus differentiated among levels of consciousness. Since the study of elementary forms of activity was a study of basic forms of sensibility and consciousness, he therewith emphasized the unity of body and mind.
Psychological automatism could be manifested in total as well as in partial automatism. The former implies that the mind is completely dominated by a reproduction of past experience as in the case of somnambulistic states and hysterical crises. The latter occurs when the automatism occupies only a part of the mind; for instance, in cases of systematic anesthesia, where the touch of an object is not registered by the personal consciousness, but is to be found in a second consciousness; a hidden observer as Hilgard (1977) would say almost a century later.
In both total and partial automatism there exist subconscious psychological phenomenaosystems of fixed ideas and functionsowhich have escaped personal control and perception. These dissociated systems are isolated from the personal consciousness. Some of them continue to exist in rudimentary form without a sense of self, as is the case with catalepsy in which only a single thought and single automatic action appears to occupy the mind. Less primitive is the hysterical crisis, a dissociative episode complete with amnesia, in which the patient may reenact a traumatic event. Janet presented this in the case of Marie, reported in toto by Ellenberger (1970, pp. 361-364). She suffered from crises in which she continuously reexperienced the trauma of her first menstruation as well as permanent blindness in one eye from an earlier childhood trauma. Janet's treatment demonstrated how correcting Marie's cognitive distortions from the menstrual event at age 13 and modifying the content of the dissociated states in which her trauma at age 6 was reexperienced led to the disappearance of these states and their related symptoms.
Many dissociated elements and systems tend to combine themselves with other such phenomena to form more complex states. Certain dreams, certain fixed ideas, more or less subconscious, become centers around which a large number of psychological phenomena arrange themselves to become a distinct personality, complete with its own life history. These successive existences, as Janet called alternating personalities, may interact with external reality, and develop further by absorbing and retaining new impressions. Although he was not so clear in this respect, Janet's examples showed that these existences could also develop higher psychological functions such as autonomous will and critical judgment.
Binet (1890) pointed out this particular vagueness in Janet's work, which in our opinion, was related to a paradox Janet encountered. He had intended to study ways in which human activity in its simplest form manifested in hysterics. He found, however, that certain of these dissociated elementary forms of activity were highly developed, including the ability to reason, to make judgments, sustain memories, etc. Contrary to what he expected, integrative and creative activities were present at the level of personality (complete with sense of self), but remained outside of personal awareness in the normal waking state. It was this incongruityothat while studying the most simple he discovered the most complexothat gave the initial presentation of findings in this work its aura of apparent confusion.
Thus Janet's observations led from the hypothesis of the absence of the function of creative synthesis in the personality to the recognition of the presence of this function in a state which was dissociated from conscious awareness. Because this very function (often used to connote personality) was unavailable in the waking state but accessible in the hypnotic state, Janet was led first to the discovery of the dissociated personality and then to the necessity of a formulating of dissociation theory.
Janet related the origin of subconscious phenomena in hysterical patients to the narrowing of their field of consciousness. This concept refers to the reduction of the number of psychological phenomena that can be simultaneously united or integrated in one and the same personal consciousness. Some register in conscious awareness, others are relegated to a subconscious area in much the same way that central and peripheral items in a visual field are noticed. In Janet's view, narrowing the field of consciousness is one of the two basic characteristics of hysteria. The other is dissociation.
Dissociation and mental dissolution, terms originally introduced by Moreau de Tours (1845), denote the manner in which this narrowing of the field of consciousness occurs in hysterical patients. Dissociation occurs when different factors disturb the integrative capacity. This disturbance leads to the splitting off or doubling (dédoublement), separation and isolation of certain psychological regulating activities. These dissociated systems of activities (states of consciousness) vary in complexity from a simple image, thought or statement and its attendant feelings or bodily manifestations to the alter personalities of patients with multiple personality disorder. Alters have their own identities, life histories, and enduring patterns of perceiving, thinking about and relating to the environment which is distinct from the habitual personality's mode of being in the world (Van der Hart & Horst, 1989).
The dissociated activity clusters or personalities either alternate with the personal consciousness in controlling the body, or coexist with it. Indeed, in later work Janet (1909, 1910b) stated that in certain patients, a dissociated personality, which could be evoked in hypnosis, was in fact a healthier state of consciousness than the co-called waking state.
While clinicians such as Bemheim and Babinski regarded hyper-suggestibility as the basic characteristic of hysterical patients, Janet stated that hyper-suggestibility depended on the narrowing of the field of consciousness and the predisposition to dissociation. The patient is suggestible because dissociated parts of his mind lack the higher mental functions of critical judgment. By distracting the patient, the hypnotist is able to communicate directly with these parts. Ironically, Janet also encountered dissociated states which were not at all suggestible, but showed strong will and judgment of their own.
Janet introduced the concept of psychological misery to denote the mental status of patients in whom the field of consciousness was narrowed and whose integrative powers were strongly diminished, thus allowing dissociative phenomena to occur. In later writings he placed this mental misery in the broader framework of the oscillations of the mental level which take place in all human beings (Janet, 1905,1919/25, 1920/1,1934).
Physical illness, exhaustion, and vehement emotion such as the fear and anger inherent in traumatic experiences are primary causes of psychological misery. This state is marked by a serious decline of the integrative power of the mind and, in hysterical patients, an increase in dissociative phenomena. In Psychological Automatism as well as an earlier paper (Janet, 1886b), Janet showed that such intense emotional experiences may become dissociated (complete with amnesia) and may reappear in hysterical crises. They may also become subconscious centers around which other psychological phenomena arrange themselves, as in the cases of Marie and Lucie.
A short summary cannot do justice to the wealth of psychological observations and ideas contained in Psychological Automatism. There are many findings in this book which could stimulate future research. One intriguing example concerns the variations in sensory perception in different somnambulistic states. Janet noted that a patient may be predominantly visual in the waking state, auditory in one somnambulistic state, kinesthetic in another, and even have a state of "perfect somnambulism" in which the balanced integration of all senses exists. It is unfortunate indeed that this book has never been translated. One full century after its original publication in French, an English version would be timelier than ever.
This book originally consisted of two parts published separately under the same title with different subtitles. The first part was subtitled The Mental Stigmata of Hystericals (Les stigmates mentaux des hystériques) (Janet, 1893a). The second, subtitled The Mental Accidents of Hystericals (Les accidents mentaux des hystériques) (Janet, 1894a), was the commercial edition of his medical dissertation, Contribution à liétude des accidents mentaux chez les hystériques (Janet, 1893b). Both works, translated into English in 1901, are careful descriptive studies based on clinical observations of 120 of Janet's own patients and 20 of his colleagues', one of whom was Despine's patient Estelle (Despine, 1840). Recently Fine reported on this case (Fine, 1988).
On the subject of his own observations, Janet remarked that he was in the habit of writing down everything his subjects and patients said and did, a habit which earned him the nickname Doctor Pencil (cf. Janet, 1930). To his analyses of these systematized observations, Janet added his tentative theoretical interpretations which can be reduced to the same elements as his dissociation theory. These interpretations were experimentally tested in a small number of patients.
Stigmata and accidents were the terms given to the symptoms of hysteria. In distinguishing between them Janet employed a well established classification system that had its roots in the medical tradition of his time. The stigmata of hysteria are the essential constitutive symptoms of the illness, as enduring, persistent, and permanent as the illness itself. The patient who may feel himself weakened in some way, but who is unable to specify correctly the symptoms from which he suffers, presents with a relative indifference to his symptomatology. Janet suggests that clinicians should take the initiative in identifying these chronic stigmata, since patients do not usually report them. Accidents are acute, the transient, paroxystic symptoms which occur intermittently and are experienced by the patients as painful. These accidents can be understood as representations of psychological trauma (cf. Meares, Hamshire, Gordon, & Kraiuhin, 1985). Thus, hysterical anesthesia is a stigma, and an attack (acute episode) of hysteria is an accident. In later work Janet detached himself from this medically-based position, and the concept of personality became dominant in his explanatory view (Janet, 1929).
In Part One, Janet dealt with anesthesias, amnesias, abulias, disorders of the movements, and modifications of the characteroall of which he regarded as mental stigmata. For each of these negative symptoms (stigmata) he carefully described its different forms and manifestations. With regard to the anesthesias, he denoted systematic, localized and general. He regarded hysterical anesthesia as a strong and continuous distraction rendering the patients unable to attach certain sensations to their personalities because of the narrowing of the field of consciousness. These sensations thus existed in a subconscious manner. The same kind of analysis was made with regard to the amnesias. Using many examples, Janet showed that hysterical amnesia often developed in the wake of vehement émotions aroused and dissociated during traumatic experiences.
Abulia, a concept which receives little attention in current psychiatry and psychology, concerns a degeneration of the will which manifests in tendencies towards indolence, hesitancy, indecision, impotence to act, and inability to focus attention on ideas. Abulia is not limited to hysteria, but in this category of disorders it characteristically presents in the preservation of subconscious acts and the loss of personal perception of acts in current reality. As an essential component of many disorders, this stigma increases in dominance as the patient's state of mind deteriorates. There is a noticeable increase in the tendency to daydream, in apathy or anhedonia, in the patient's proneness to emotional outbursts. This exhaustion of one's vitality and intensification of abulia that Janet observed in his hysterical patients is commonly seen by clinicians today, especially those treating chronic PTSD (cf. Van der Kolk, Brown, & Van der Hart, 1989). Titchener (1986) speaks of a posttraumatic decline, of which apathy, a tendency to withdraw from normal interaction with the environment, and a hypochondriacal preoccupation with one's own body are characteristic.
As Janet described the manner in which hysteria modified the character of his patients, we recognize additional observations currently made under the rubric of posttraumatic decline: recurrent dreaming of the traumatic event, including day-dreaming; constricted affect or alexithymia; and simultaneously, extreme excitability with a tendency to emotional outbursts. It is important that we not limit abulia to being a specific stigma of hysteria. This pattern of 1) weakening of a patient's personal will, decisiveness and ability to initiate activity; 2) an increase in day-dreaming and apathy, and 3) exaggerated emotional responses underlies a number of currently identified disorders.
Janet concluded Part One with the statement that hysteria is a defect of the unity of the mind, manifesting itself on the one hand in a diminishing of the personal synthesis, and on the other, in the preserving of past phenomena which reappear in an amplified manner.
In Part Two, Janet first tried to unite the infinitely varied spectrum of hysterical accidents by referring to their shared mental aspects: suggestion, subconscious acts, and fixed ideas. He considered that the complete and automatic development of ideas occurred outside of the will and personal perception of the subject. "Suggestions, with their automatic and independent development, are the real parasites of the mind" (Janet, 1901, p. 267). The performance of acts which result from suggestions is isolated, separated from the personalityothat is why they should be called subconscious acts.
Patients suffering from hysteria in a Janetian sense are, as a rule, highly suggestible. Recent research with patients suffering from dissociative disorders and posttraumatic stress disorder confirms this (Bliss, 1986; Spiegel, Hunt, & Dondershine, 1988). Janet analyzed conditions in which patients are less suggestible. Two of the main conditions of lowered suggestibility were found in subjects who were preoccupied with a certain fixed idea of their own, and being cured. A cure implied a strongly diminished tendency towards dissociating and an increasingly integrated personality. Since no complexly-developed dissociated parts (selves) exist in an integrated personality, by definition, there are none to evoke. Artificial somnambulism, in the restricted sense of deep hypnosis, can barely be evoked, whereas, a lighter trance state in which continuity of the sense of self is maintained, continues to be possible. Although Janet did encounter some exceptions to his rule, he did not give up his position (which is not universally accepted today). Thus, near the end or the treatment, one of his patients, Marcelle, while under hypnosis reported via automatic writing that she was cured forever. As she still showed the dissociative phenomena of deep hypnosis and automatic writing, Janet was pessimistic about her prognosis (Janet, 1891/98a).
While suggestions are generally given by others, fixed ideas usually develop as the result of accidental causes, such as traumatic experiences and hysterical episodes. They tend to dominate the mind completely in dreams and somnambulistic states. They also disturb normal consciousness during the waking state by sending message to it. For example, Janet wrote of a woman walking on the street. She had short dissociative episodes in which she made a curious jumping motion. In hypnosis Janet discovered that she was reenacting her suicide attempt: a jump into the Seine. In an example of a contraction, a sailor continuously walked in a forward bent position, reenacting the trauma of having had a beam fall and press against his chest. Many case examples were cited to show how mental accidents such as dysesthesias, hyperesthesias, tics and choric movements, paralyses and contractures are based on fixed ideas. In most cases, patients are amnestic to these fixed ideas which also affect the stigmata (basic symptomatology) by diminishing the patients' powers of personal perception.
Hysterical attacks are violent, momentary, and periodically recurring events during which the patient's normal consciousness usually disappears. Janet categorized several types of emotional attacks: attacks of tics and clownism, attacks of fixed ideas and ecstasies, and complete attacks. During attacks the underlying fixed ideas are usually transformed into vivid hallucinations and bodily movements. Janet regarded anorexia nervosa in most cases as hysterical in nature. An example of the attack of a fixed idea would be the inner commands an anorexic hears when trying to eat, "Don't eat. You do not have the need to eat."
Janet described the various forms of somnambulism: abnormal states of consciousness, distinct from normal life, which often have their own memories, and for which the subject develops amnesia upon returning to his normal state. This amnesia is due to the fact that the organization of psychological phenomena of the somnambulistic state are united around certain sensations or fixed ideas which are not perceived by the normal sense of self (habitual personality). When the patient is cured, these states disappear, i.e., they have fused into one state, as Janet quoted from Despine (1840).
Finally, he distinguished the hysterical psychosis which is due to the dominance of abulia (decrease in the level of mental functioning) and an increase in mental confusion. Patients with this disorder tend to confound their waking dreams with normal perceptions and with memories, both normal and traumatic. Their hallucinations are particularly vivid and often involve all the senses (cf. Van der Hart & Witztum, 1989).
Janet concluded his psychological analysis of hysteria with the tentative definition that it is a form of mental dissolution characterized by the tendency to a permanent and complete splitting (dédoublement) of the personality.
Although the distinction between mental stigmata and mental accidents is not always clear, it is still the best work to date for instructing clinicians in recognizing the many manifestations of those symptoms which are best explained by Janet's own dissociation theory. It is also an excellent source of reference, demonstrating how much was known about dissociation in the psychiatric world over a century ago. The English edition was recently reprinted.
During and after his preparation of The Mental State of Hystericals, Janet published numerous articles in which he presented more detailed descriptions, narratives and analyses of patients. These papers were collected in the first volume of Névroses and Fixed Ideas (Névroses et Ideés Fixes: Études expérimentales sur les troubles de la volonté, de liattention, de la mémoire; sur les émotions, les ideés obsedantes et leur traitement) (Janet, 1998a). Ellenberger (1970) mentions several of these extreme and interesting cases in detail.
Fixed ideas (ideés fixes) are thoughts or mental images which take on exaggerated proportions, have a high emotional charge, and, in hysterical patients, become isolated from the habitual personality, or personal consciousness (Janet, 1894a/98a). When dominating consciousness, they serve as the basis for behavior. These ideas also manifest themselves in what we now term flashbacks or intrusive thoughts. Janet considered them dissociative phenomena which were parts of subconscious fixed ideas.
Fixed ideas can remain isolated or become linked with new impressions or other fixed ideas. They are perceived during dreams, dissociative episodes such as hysterical attacks, and in many of the communicating devices employed during hypnosis (which is the medium of choice for uncovering and exploring fixed ideas).
Janet made an important distinction between primary and secondary fixed ideas. A primary fixed idea is the total system or complex of images (visual, auditory, kinesthetic, etc.) of a particular traumatic event plus the corresponding emotions and behaviors. Secondary fixed ideas have the same characteristics as primary fixed ideas and present after the disappearance (through treatment) of the main fixed idea. Janet classified them into three groups: 1) Derivative fixed ideas result from association with the main fixed idea. For example, if death is the primary fixed idea, a morbid fear of cemeteries or funeral flowers could result. 2) Stratified fixed ideas result from traumata in the patient's life history which were sustained prior to the one which causes the full-blown hysterical or dissociative disorder. We experience this in treatment when the removal of a primary fixed idea is replaced by another fixed idea rather than by the complete elimination of the patient's problem. Stratified fixed ideas correspond to the present-day notion of layers of traumata. Janet advocated a procedure of treating each principal fixed idea until all are addressed, usually beginning with the most recent and proceeding to the earliest. 3) Accidental fixed ideas are absolutely new and produced by an incident in one's present daily life. If treated immediately, they are easy to eradicate. Their existence proves the nature of the patient's mental state of hypersensitivity. Today we would call an accidental fixed idea the conditioned or stress-activated response to a trigger. We recognize this in patients' overreactions or distorted responses to seemingly neutral stimuli in the current environment. In dissociative disorders, accidental fixed ideas would produce a variety of dissociative responses, depending on the nature of the dissociative disorder. In multiple personality disorder it is often seen as the switch to another personality (Friedman, 1988).
In treatment, if one discovers the primary fixed idea, one can treat the core of the traumatic problem. This may not, however, resolve the secondary set of problems and symptomatology which require their own treatment. Secondary fixed ideas can produce behaviors in response to previous traumata or in response to the primary fixed idea. If these behaviors alone are eliminated or corrected in treatment, the heart of the problem still exists. Obviously, both need to be considered in conscientious treatment to avoid relapse or partial cure.
The case of Justine provides a rich example of treatment on both levels (Janet, 1894b). Janet dedicated a 55-page report toJustine, a 40-year-old outpatient at the Salpêtrière. Following a serious contagious disease at age 6 and a subsequent bout of typhoid fever, she exhibited severe dissociative phenomena, changing from a sweet and gentle girl to an obstinate brat. She became phobic about snails and worms. To cure her of this at age 9, the family physician placed a large snail on her throat. Justine fell over backwards, losing consciousness and breaking several bones. Upon regaining consciousness, she was obsessed by the memory of the snail on her throat.
When her cat was badly injured and put to sleep, Justine reacted with an hysterical attack accompanied by a rash. More seizures and rashes occurred over time; in addition, Justine grew extremely fat. Her mother was a nurse who had to watch dying patients, and Justine sometimes helped her. After this she developed a morbid fear of disease and death. Finally, at 17, Justine saw the naked corpses of two patients who died of cholera, resulting in her violent fear of cholera. More than 10 years later, this image would haunt her during hysterical attacks. Several times a day she would become pale and sweat and shout repeatedly, "Cholera... it's taking me!" She had an ever-present, severe phobia for the word cholera.
In this case Janet observed the fixed ideas in detail, finding that there were primary and secondary fixed ideas. One of his techniques was to evoke and modify the image of this primary fixed idea during hypnosis. In treatment, Janet induced artificial somnambulism and discovered what occupied Justine's mind during an hysterical crisis. She saw the image of the two naked corpses, smelled the revolting stench of decay, heard the tolling of a bell and the cries of cholera, and perceived screaming, vomiting, diarrhea and cramps of the victims. This traumatic event involved all her sensory perceptions, forming one fixed idea, one psychological system that completely dominated her consciousness when it arose, leaving no room for other thoughts or actions. Janet found the only way to reach Justine was to enter her private ' drama as a participant. As she relived the scene in hypnosis, in applying his substitution technique Janet dialogued with her within this context to modify the contents (cf. Van der Hart, Brown, & Van der Kolk, 1989). Over a period of time he was able to suggest gradual transformations of the images: the corpses were provided with clothes, and one was given the identity of a Chinese general whom Justine had seen at a Universal Exposition. When she could see the general stand up and march comically, the images of the traumatic event ceased in hysterical attacks and persisted only in dreams. Janet addressed this by suggesting innocuous dreams. The trauma no longer occurred in dreams. This success resulted after one year of treatment.
In spite of the transformation of the proprioceptive primary fixed idea, Justine remained phobic to the word cholera. This fixed idea persisted on both the conscious and subconscious levels. While engaging in another activity, Justine could be observed whispering the word cholera. Janet directed his attention to the word itself, suggesting that it was the family name of the Chinese general, and dividing it into three parts: Cho-le-ra. He then had Justine associate the first syllable with different endings in automatic writing, such as chocolate. Next he used the sound of the first syllable, co- and paired it with different endings: comme, colon, cororiko, etc., until it was no longer associated with the word cholera. In the end, Justine could no longer remember the word that had tortured her, nor did a new cholera epidemic have any effect on her. This phase of treatment lasted ten months.
Janet was planning to rid Justine other hallucinations when they disappeared spontaneously. And still the patient was not cured. After the disappearance of the primary fixed idea, secondary fixed ideas began to develop. Instead of the fear of death and disease, Justine exhibited a morbid fear of coffins and cemeteries: derivative fixed ideas. She refused to eat fruit or vegetables: a derivative fixed idea in response to fears of cholera. She also suffered from a multitude of accidental fixed ideas. We can assume that Janet treated them immediately by disconnecting the stimulus (trigger) from Justine's automatic association of it to a trauma. His general approach of educating her mind, stimulating her integrative capacities, helped Justine to stop the development of these accidental fixed ideas herself.
Janet focused in Justine's case almost exclusively on her traumatic memories regarding the cholera deaths, and on related secondary fixed ideas. He believed that stratified fixed ideas did not play an important role in this case. Today, we would probably pay more attention to the exploration of childhood traumata. For example, we would want to discover if Justine's childhood phobias of worms and snails were related to experiences of sexual abuse.
A final contribution introduced in this work is the phenomenon of the patient's deep involvement with the therapist, known as rapport magnétique by the magnetizers (Janet, 1897). Janet recognized this intense involvement as a very complex phenomenon. Although erotic elements were present in the rapport, they were not the main therapeutic concern. He viewed the relationship more in terms of an attachment theory in which the need for guidance played the significant role. In treatment the therapist first assumes the responsibility of directing the patient's mind, then gradually reduces that direction to a minimum. This treatment approach corresponds to modern procedures in which the therapist takes the initiative in building up patients' ego strengths and resources and guides their decision-making processes. As patients acquire the missing skills and employ them in a functional manner, the therapist gradually disengages from the process. Janet believed that therapists should educate their patients to accept the therapists' authority and guidance and then systematically reduce their domination of the patients, ultimately teaching patients to do without the therapist. If therapists neglected this point, only temporary cures resulted.
This process could be complicated by la passion somnambulique, the patient's overpowering need to be hypnotized by his own therapist. This passion can become an addiction and be just as dangerous (cf. Haule, 1986). Janet concluded that high suggestibility is the mark of a great weakness of mind which can lead patients to become cathected to both the therapist and the hypnotic state. "Such patients not only crave to be hypnotized, but have a permanent need to confess to the psychiatrist whose picture they keep constantly in their subconscious mind, and to be scolded and directed by him" (Ellenberger, 1970, p. 369). Janet realized that this craving to be hypnotized and guided by the therapist created a problem. At the same time, he deemed the somnambulistic influence indispensable to the cure. In this dilemma, Janet recognized the value of the initial bonding with the therapist, and how the boundary issues in the therapeutic alliance can be confused by the patient's desire for a symbiotic relationship.
His solution was to maintain a delicate balance in both areas. Therapists should utilize the high hypnotizability of the patient without permitting the somnambulistic passion to develop to a dangerous point that makes treatment impractical. In the same way that therapists gradually withdraw from the guidance process and turn it over to the patient, they can use the hypnotic state as a treatment technique without allowing themselves or the altered state itself to become the dominant focus of the patient's attention. Today we know that there is often a point in treatment when it is appropriate to explain this addiction to dissociation to patients with dissociative disorders. We can then teach patients to recognize the onset of the desire to dissociate and teach them the coping skills that would reduce the need to dissociate, or to substitute another activity for the trance state.
Janet discussed this in the case of Justine (Janet, 1984b). As her treatment progressed, Janet spaced her sessions from several times a week at the beginning to once a month in the third year. By then Justine had frequent visions of Janet in which she heard his voice offering her good advice. This counsel was not a repetition of what Janet had said in sessions, but originated from Justine and was of a novel and wise nature. Although it developed as a result of her association with Janet, it appeared more in the form of introjection than a dependency state.
Janet was quick to point out that reduction of sessions alone did not cure the dependency factor nor the somnambulistic addiction. He told the story of Morel's inpatient who was cured and discharged from the mental hospital. Afterwards, she came to see him at infrequent but regular intervals. When Morel died, she had a relapse and had to be committed permanently. "Let us hope that this accident will not happen too soon to our patients," Janet concluded (Janet, 1894b/98a, p.212).
This book, with its wealth of relevant material does not exist in English, nor has the French edition been reprinted recently. Fortunately, photocopies of many of the original papers which were collected for this volume should not be too hard to obtain.
The second volume of Neuroses and Fixed Ideas (Fragments des leçons cliniques de mardi sur les névroses, les maladies produites par les émotions, les ideés obsédantes et leur traitement) was written in collaboration with Raymond, Charcot's successor at the Salpêtrière (Raymond & Janet, 1989). It contains 152 case presentations shown at the famous Tuesday clinical lessons at the hospital. The first half of the book focuses on mental disturbances such as abulias, mental confusions, deliriums (hysterical psychoses), sleep attacks, somnambulisms, fugues, and obsessions and impulses. Obsessions and related phenomena became the main subject of Janet's studies during these years, resulting in the publication of Obsessions and Psychasthenia (Janet, 1903). The second half concentrates on psychosomatic disorders such as disturbances of the sensibility, tics, paralyses, disturbances of language, and visceral spasms. In many concisely described cases the authors show how a disorder developed after patients had been exposed to some kind of traumatic event to which they responded very emotionally. This volume is a resource of the early, and sometimes very first, documentations of treatment approaches which are so like those found in current literature, one would believe they had been developed only recently (cf. Van der Hart, 1988, p. vii).
This book, published in English in 1907, contains the 15 lectures Janet delivered at Harvard Medical School in 1906. It demonstrates his fine didactic teaching qualities quite clearly. It is both a highly readable introduction to the phenomenology of hysteria, and a succinct summary of his extensive studies in the field. In teaching about somnambulism, Janet showed his penchant for paradox, 'Things happen as if an idea, a partial system of thoughts, emancipated itself, became independent and developed itself on its own account. The result is, on the one hand, that it develops far too much, and on the other hand, that consciousness appears no longer to control it" (p. 42). He advised his students not to be concerned with the obscurity of this remark: "After you have repeated it exactly in the same way with regard to a thousand different phenomena, it will not be long before you find yourself understanding it clearly" (p. 43). By focusing most lessons on various accidents of hysteria rather than on the stigmata, Janet greatly facilitated this understanding in his students.
The lectures contain descriptions and comparisons of the different types of somnambulism. In the generic sense, somnambulism refers to that state of mind in which people are so absorbed in their inner experience that congruent contact with external reality is lost. When they do respond to something in the outer environment, it is perceived as playing a role within the domain of the inner experience. The simplest form of somnambulism is monoideic. This refers to that state of mind in which a single fixed idea (often a traumatic memory) dominates the abnormal state.
In complex somnambulisms like fugues and multiple personality disorder, reality is not distorted to that degree. The patient in a fugue usually has numerous recollections and exhibits adequate social behavior in order to make the journey that characterizes fugues. Patients with MPD can function adequately in society while simultaneously sustaining an hallucination. For example, they might perceive themselves as wearing a dress when actually wearing a sweater and pants, or hold the self-perception that they are of a different gender than their biological body, yet they enter the appropriate public restrooms.
As he had done previously (Janet, 1894a), Janet classified the multiple personalities according to their intellectual and memory capacities. He noted the obvious differences in intellectual capacities of adult alter personalities maintaining jobs and those of traumatized child alters. Regarding memory, he spoke of certain alters having access only to their own past experiences, while other alters can access the memories of additional alters. All sorts of combinations of intellectual functioning and memory among alters are possible, Janet noted, predating our discoveries in this area by almost 100 years.
As mentioned earlier, the essence of Janet's concept of hysteria lay in the distinguishing of two layers of symptoms: accidental or contingent symptoms (accidents) and basic, permanent symptoms (stigmata). There are two types of mental stigmata: 1) proper, which appear exclusively in hysteria; and 2) common, which are shared by hysteria and other mental disorders, notably psychasthenic neuroses. Proper stigmata include narrowing of the field of consciousness, the existence of subconscious phenomena, suggestibility, anesthesia, and amnesia. Common stigmata encompass feelings of incompleteness, lowering of the mental level of functioning, emotional disturbances, troubles of the will, and an inability to begin and end activities.
The lowering of the mental level, which Janet introduced in Obsessions and Psychasthenia (Janet, 1903), is a key concept in his work. In L'Automatisme Psychologique (Janet, 1889) when he spoke of "psychological misery," Janet established the important role of the breakdown of higher mental functions in the development of mental disorders. In the last chapter of The Major Symptoms of Hysteria Janet gave this notion its place in his theory of hysteria by defining hysteria as a form of mental depression (lowered mental level of functioning) characterized by the narrowing of the field of consciousness and an increased tendency toward the dissociation of the system of ideas and functions that constitute the personality (sense of self). Lastly, in this book, Janet considered briefly the factors which may cause this lowering of the mental level. Among them were emotional disturbances, e.g., as a response to trauma, and severe physical illness.
So significant were Janet's observations of the presence of physical illness in contributing to the causation of hysteria, that at Janet's centennial Henri Baruk (1960), a leading French psychiatrist, hailed Janet as having given the clinical basis to the development of modern psychophysiology and expected future discoveries in neurophysiology to derive from Janet's work as well. Because of this emphasis on the presence of severe physical illness in the formation of psychopathology, clinicians now working with dissociative disorders might inquire about this when taking patient histories. An area to explore would be the corollaries of the presence/absence of physical illness in cases of dissociative disorders with the present trauma or physical and sexual abuse reported today.
In his Foreword to the 1920 edition of this book, Janet related the development of hysteria to his more recent studies of "the oscillations of the mental level." He dealt with the role of "driving back"othe mechanism of repressiono which he addressed in more detail in Les Médications Psychologiques (Janet 1919/25). Janet considered this "incapable of giving a complete explanation of the hysterical neurosis." If there is something like repression, it occurs more in psychasthenia than in hysteria. Janet considered repression to be a result of exhaustion and a severe lowering of the mental level of functioning: not the cause, but the consequence of the psychasthenic depression.
The 1920 edition of The Major Symptoms of Hysteria was reissued in 1965 and is still available. We consider it an indispensable introductory work, not only for students of psychotrauma and the dissociative disorders, but for all students of psychiatry, clinical psychology, and neurology.
Aligned with the previous work is the delightful little book, Les Névroses (Janet, 1909). It is considered Janet's most concentrated and synthetic work to date (Ey, 1968). Unfortunately, neither a recent reprint nor any translation is available.
In this book Janet systematically compared and contrasted the symptoms of hysteria and psychasthenia; the latter being another fundamental condition of a variety of mental disorders, such as obsessive-compulsive disorder and the phobias (cf. Janet, 1903; Pitman, 1984, 1987). He contrasted the hysterical fixed ideas (as in somnambulism) with the psychasthenic obsessions; the hysterical amnesias with the psychasthenic doubts; the paralyses with the phobias, and so on. While the subconscious fixed idea of an hysteric develops itself completely outside of the individual's personal perception and memory, the obsession of a psychasthenic takes place in collaboration with one's whole personality. Furthermore, it does so without developing itself as completely as a fixed idea. Instead, the psychasthenic is continuously doubting his idea. Janet defined psychasthenia as a form of mental depression characterized by the reduction of psychological tension (see below), by the diminution of the individual's ability to act on and perceive reality, by the substitution of inferior and exaggerated operations in the form of doubts, agitations, anxieties, and by the obsessional ideas which express these disturbances (p. 367).
The often misunderstood notions of psychological force and tension played instrumental roles in many of Janet's psychopathological studies (cf. Janet, 1919/25, 1920/1, 1932a). We return to his Obsessions and Psychasthenia (Janet, 1903) for an elaboration of these concepts. Psychological force is the quantity of basic psychic energy available to an individual. It exists in two forms: latent and manifest. Mobilizing one's energy means transforming one's force from latent to manifest. We can observe a person's psychological force through the number, duration and speed of his actions. The concept refers to one's basic capacity for psychological functioning. Psychological tension refers to the capacity to use one's psychic energy. The higher one's mental level, i.e., the more operations one can synthesize, the higher one's psychological tension. (Obviously, Janet's "tension" has no similarity of meaning to our everyday use of this term.) The fact that patients differ in regard to their available sources of psychological force and psychological tension has important treatment implications (cf. Janet, 1919/25; Ellenberger, 1970; Van der Hart, Brown, & Van der Kolk, 1989).
Janet's original theoretical model of the mind put forth in his first book, L'Automatisme Psychologique, denoted only two levels of mental functions for which one's psychic energy was used, that of synthesis and automatic function. As his work progressed, his experience led him to expand his conceptual model. He developed the ideas of psychological force and tension, as well as a hierarchy of mental functions to five levels, each of which had a coefficient of reality (Janet, 1903). The highest level of mental activity was the reality function (fonction du réel). This is the function of reality in which one grasps the maximal reality of a situation. It involves the focusing of one's attention on simultaneously perceiving fully the data of external reality of one's own ideas and thoughts. The familiar corollary today is "being completely in the moment." This act requires a synthesis ("presentification"): the formation of the present moment in the mind. 'The natural tendency of the mind is to roam through the past and the future; it requires a certain effort to keep one's attention in the present, and still more to concentrate it on present action," as Ellenberger (1970, p. 378) remarked. Janet said, 'The real present for us is an act of a certain complexity which we grasp as one single state of consciousness in spite of this complexity, and in spite of its real duration, which can be of greater or lesser extent. . . Presentification consists of making present a state of mind and a group of phenomena" (Janet, 1903,1, p. 491).
The five levels of Janet's hierarchy of mental functions, which may be used to examine mental health, in descending order are, 1) the reality function; 2) disinterested activity (habitual, indifferent and automatic actions); 3) functions of imagination (abstract reasoning, fantasy, daydreaming, and representative memory); 4) emotional reactions; and 5) useless muscular movements. The first three levels were considered the superior functions, the last two levels inferior; each set requiring a lesser degree of involvement with reality in order to be performed.
A "reduction in psychological tension" (or lowering of the mental level) refers to the lessening of one's ability to use one's psychic energy at a high level of perceptive and integrative functioning. Specifically, it refers to the diminished two-fold ability of the individual to 1) perceive fully the details of current reality, coupled with the self-awareness of one's feelings and ideas in that moment, and 2) to act on this reality with intentional imminent behavior. Instead of engaging with reality in a maximally integrative way, people with psychasthenic depression substitute inferior mental operations in the forms of doubts, agitations, anxieties, and obsessional ideas. The dominance of each of type of lowered operational function in response to reality characterizes a different type of disorder, or in Shapiro's terminology, neurotic style (Shapiro, 1965). As noted previously, in hysteria the reduction of psychological tension is characterized by the narrowing of the field of consciousness and an increased tendency to dissociation, and by the emancipation of systems of ideas and functions which when integrated constitute the personality (Janet, 1909, p. 345).
In the final chapter of Les Névroses, Janet attempted to give a general definition of the neuroses. He saw them as illnesses affecting the various functions of the organism, mainly by an impairment of the superior parts of these functions. The higher the functions are arrested in their evolution, in their adaptation to the present moment, to the present state of the outside world and present intrapsychic state of the individual. At the same time there is no deterioration of the inferior parts of these functions. In short, neuroses are disorders of the various functions of the organism marked by arrested development of the function without a deterioration of the function itself (p. 392).
In 1911 an enlarged edition of The Mental State ofHysterical was published. "The Mental Stigmata" and 'The Mental Accidents" comprised the first part, the second consisted of various articles which were published between 1898 and 1910. One interesting paper dealt with the analysis and treatment of his patient Marcelline, whom Janet saw as a prototype of double personality (Janet, 1910b). A most important paper was "Amnesia and Dissociation of Memories by Emotion" (L'Amnésie et la dissociation des souvenirs par l'émotion) presenting the case of Irène (Janet, 1904), to which Janet referred often in his later work (cf. Janet, 1919/ 25,1928a&b,1925b).
Irène was a 20-year-old woman who took care of her terminally ill mother, whose death she experienced as very traumatic. Soon afterwards she became amnestic for the event of her mother's demise as well as the three months preceding it. She was unable to work, developed severe abulia, and lost all interest in those around her. She was frequently affected by delirious crises in which she very dramatically reexperienced the critical scenes of her mother's last hours and death. Irène was "attached" to the traumatic event in a way that she could not get beyond. She was unable to adapt to a life without her mother; her behavior resulted from "nonrealization" as Janet (1935b) called it.
Janet's difficult but successful treatment approach consisted of helping Irène restore her memories, first in hypnosis and then in the waking state. She had to translate her traumatic memories into a narrative, a personal account of the event and how it affected her personality. When she succeeded in this and showed that she actually realized her mother's death and could relate her personal account of this event, Janet noted that her other symptoms, like profound abulia, disappeared. Her mental level of functioning increased, and she became capable of adaptive actions again.
The third part of this book consisted of "the most beautiful and the most original systematic study written on the treatment of hysteria at the end of the last century" (Faure, 1983). In this section, Psychological Treatment of Hysteria (Janet, 1898b), Janet emphasized the use of five hypnotic techniques: 1) extended hypnosis; 2) utilizing the temporary absence of symptoms during hypnosis (e.g., letting anorectic patients eat and drink); 3) giving symptom-oriented suggestions; 4) identifying fixed ideas; and 5) treating fixed ideas. The latter two are Janet's most significant and original techniques (cf. Van der Hart, Brown & Van der Kolk,1989).
Janet discovered that for certain patients, the act of telling their fixed ideas (both in the hypnotic and waking states), functioned as a successful "confession," permitting them to terminate their attachment to the fixed idea. He further observed that this was often insufficient for more severely disturbed patients to detach from their fixed ideas. With them, he tried to break down the fixed idea's entire system of images, feeling, and actions gradually, systematically substituting emotionally neutral or positive content for the traumatic phenomena.
Janet considered the dissolution of fixed ideas indispensable to the cure, but by itself, often insufficient. In his first writings he indicated that special attention was needed to aid patients in attaining higher levels of personality organizations, i.e., increased psychological tension. If they remained at a low level, new emotions could be overwhelming, easily giving rise to new fixed ideas and dissociation. Janet described many hypnotic and non-hypnotic techniques aimed at raising a patient's mental level. He also concluded that hysterical patients usually needed long-term treatment to address the complexity of returning them to an adequate level of functioning.
His treatment sessions often entailed having the patient perform everyday life tasks that required graduated amounts of the activity of synthesis. This might range from painting or listening to music to translating poetry and sculpting: in essence, art and occupational therapy. At the same time, Janet often advocated a simplification of the patient's home life and interpersonal functioning: stress reduction. His formulae, concrete suggestions and rationale for adding energy and decreasing the patient's energy expenditure, further developed in Les Médications Psychologiques, are the bedrock of a comprehensive treatment approach to the massively traumatized or severely dissociated patient (cf. Van der Hart, Brown, & Van der Kolk, 1989).
The final work in this review is Les Médications Psychologiques (Janet, 1919). Psychological Healing (Janet, 1925), as the English version is entitled, had a special place in Janet's work. The two-volume, 1265 page, English edition presents an extraordinarily interesting history of psychotherapy, emphasizing the role of hypnosis and presenting a marvelous survey of Janet's multidimensional treatment approaches. It is here that we find the practical relevance of his concepts of psychological force and tension in designing individualized treatment strategies.
With regard to dissociation, Janet proffers a very valuable chapter on the study and treatment of traumatic memories (in which he is rather critical of Freudian notions). Janet summarizes his approach to this matter thus: "Strictly speaking, then, one who retains a fixed idea of a happening cannot be said to have a 'memory' of the happening. It is only for convenience that we speak of it as a 'traumatic memory.' The subject is often incapable of making with regard to the event, the recital which we speak of as memory; and yet he remains confronted by a difficult situation in which he has not been able to play a satisfactory part, one to which his adaptation had been imperfect, so that he continues to make efforts at adaptation. The repetition of this situation, these continual efforts, give rise to fatigue, produce an exhaustion which is considerable factor in his emotions" (Janet, 1925, p. 663).
Psychological Healing is an important source of inspiration and information for the study and treatment of a wide variety of mental disturbances, especially the dissociative and posttratumatic stress disorders.
It has been Janet's great, though much-neglected contribution to psychiatry that he formulated the dynamic principles constituting a theory of dissociation: 1) The nature of the structural elements and functions that comprise personality; 2) The nature of the perception of reality and its disturbance in hysteria by the narrowing of the field of consciousness; 3) The nature of conscious activity, especially partial automatism in which a part of one's personality is split off from self-awareness and follows an autonomous subconscious development; 4) The hierarchical classification of the capacity to use psychic energy; and 5) The clear and detailed cases which demonstrate so comprehensively his concepts and treatment strategies for dissociative phenomena in a broad rage of disorders.
Modern clinicians have greatly furthered our understanding of the role of dissociation in the development of severe dissociative disorders as defined in the DSM-III-R (American Psychiatric Association, 1987) such as multiple personality disorder (MPD) (cf. Kluft, 1985; Bliss, 1986; Braun, 1986; Putnam, 1988). This understanding has led to important advances in the treatment of patients with these pathologies. It remains apparent, however, that dissociation is also characteristic of a substantial group of mental disorders in which it is still largely unrecognized or confused with other psychological phenomena.
It is the legacy of Pierre Janet that he has left us only the body of his work. He had no disciples, founded no school or group, did no proselytizing. And yet, "Janet's work can be compared to a vast city buried beneath ashes, like Pompeii. ... It may remain buried forever. It may remain concealed while being plundered by marauders. But it may also perhaps be unearthed some day and brought back to life" (Ellenberger, 1970, p. 409). For those whose special interests lie in dissociation, the rewards may be well worth the dig.
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