INTRODUCTION This paper explores the development of Freud's thinking on the aetiology of the neurosis. It is shown that Freud in the years 1893 to 1897 formulated three distinct and mutually incompatible theories of neurosis centred respectively on (a) psychic trauma and defence, (b) sexual trauma (seduction), and (c) repressed sexuality (libido). For Freud the decisive step was the shift from the first to the second theory, not from the second to the third. It is examined how Freud gave priority to the libido/fantasy theory until he returned in 1926 to a general trauma theory with his second theory of anxiety. The fate of Freud's theory of neurosis in later psychoanalytic thinking is described as a process of dilution rather than an exploration of what is right and what is wrong in the theory. It is argued that the basic fault common to Freud's second and third theories is the insistence on an exclusive sexual aetiology of the neurosis. On the other hand, it is argued that Freud's first theory, centred on emotional trauma and defence, has turned out to be basically right and is therefore well suited to constitute a basis for a contemporary theory of neurosis (nonneurological mental disorders). Freud's (1892–1899b) abandonment of the seduction theory in September 1897 has generally been regarded as the pivotal turning point in his view of the aetiology of neurosis. Eagle ([11]) put it this way. In replacing his seduction hypothesis with positing fantasy and endogenous wishes as the primary source of neurosis, Freud moved from a trauma theory of neurosis in which an external event (e.g., seduction) constitutes the trauma to an inner conflict theory of the neurosis. (p. 67) As we see, Eagle, in accordance with the traditional and dominant view of the development of Freud's thought, equated trauma theory and seduction theory. What I want to show in this text is that the development from a general trauma theory formulated with Breuer in Studies on Hysteria (1893/95/1955) to the seduction theory ([17]) is of no less importance. Indeed, according to Freud himself, this is actually of much greater significance than the later development from the seduction (sexual abuse) hypotheses to sexual drive and inner conflict theory. Hence my title "Freud's Three Theories of Neurosis." I want to show that Freud in the space of less than 5 years formulated three distinct and mutually incompatible theories of hysteria/neurosis (non-neurological mental disorders). Greenberg and Mitchell ([26]) came close to the same conclusion in their analysis of Freud's theorizing. What they describe as the defence model, the seduction model, and the wish model are almost identical to my "three theories." However, they, too, failed to acknowledge the fundamental difference between trauma/defence theory and seduction theory, conceptualizing the defence, seduction, and wish models as stages on the way to a fully formed drive theory. During the first [phase], which lasted from his adoption of Breuer's cathartic method in the late 1880s until 1905, he worked with concepts of affect and of defense in a way that shares some of the sensibilities of the relational/structure model and which at times bears a striking resemblance to contemporary perspectives. ... The second phase begins with the abandonment of the seduction theory. (p. 25) I see my own text as a development of the seminal work of Mitchell and Greenberg. However, while I agree with their critique of drive theory, my focus will be more specifically on Freud's unique version of drive theory; the drive for discharge of sexual energy (libido). Having clarified the fundamental difference between the trauma/defence theory and the seduction theory, I go on to argue that the first of these theories has turned out to be basically right. Not only does Freud's and Breuer's trauma and defence theory "[share] some of the sensibilities of the relational/structure model" and show "a striking resemblance to contemporary perspectives," I also argue that it is well suited to serve as the basis for a contemporary conception of non-neurological mental disorders. The aim of this paper is to clarify a historical basis for a contemporary understanding of trauma and defence—extended to coping and resilience. I start by highlighting what was strikingly new and revolutionary in the theory of hysteria Freud formulated together with Breuer in Studies on Hysteria. HYSTERIA: A RESULT OF PSYCHIC TRAUMA AND DEFENCE Breuer and Freud start their Preliminary Communication (1893/1895/1955) on the psychical mechanism of hysterical phenomena by announcing their discovery of precipitating causes of hysteria using a method that went beyond simple interrogation, "because what is in question is often some experience which the patient dislikes discussing; but principally because he is genuinely unable to recollect it" (p. 3). This method "has taught us that external events determine the pathology of hysteria to an extant far greater than is known and recognized" (pp. 3–4). Breuer and Freud take it as read that what provokes the symptoms in cases of "traumatic" hysteria is the accident. Nevertheless, they continue, observations "seem to us to establish an analogy between the pathogenesis of common hysteria and that of traumatic neurosis, and to justify an extension of the concept of traumatic hysteria" (p. 5). What does this mean? In traumatic neuroses, they explain, the operative cause of the illness is "not the trifling physical injury [emphasis added] but the affect of fright—the psychical trauma" (pp. 5–6). Analogously, investigations of common hysteria reveal causes that can only be described as psychical traumas. "Any experience which calls up distressing affects—such as those of fright, anxiety, shame or physical pain—may operate as a trauma of this kind [emphasis added]" (p. 6). However, in common hysteria many years will often separate the traumatic event from the outbreak of the hysterical symptom, and they conclude, "Hysterics suffer mainly from reminiscences" (p. 7). And, most remarkably, they go on to describe what in contemporary thought might be referred to as "relational and developmental trauma." In the case of common hysteria it not infrequently happens that, instead of a single, major trauma, we find a number of partial traumas forming a group of provoking causes. They have only been able to exercise a traumatic effect by summation and they belong together in so far as they are in part components of a single story of suffering [emphasis added]. (p. 6) What Breuer and Freud are suggesting is nothing short of a revolutionary new conception of trauma. The medical concept of (physical) trauma is extended to include the affect of fright—the psychical trauma. It was, of course, nothing new that life events can cause suffering. What was new was the idea that events in life can not only cause unhappiness but also illness, hysterical misery. I use here Freud's words in his famous last sentences of Studies of Hysteria, where he tells a patient how her illness is connected with events in life. But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life [before 1925 'nervous system'] that has been restored to health you will be better armed against that unhappiness. (Freud & Breuer, [25]/95/1955, p. 305) And just as they extend the physical concept of trauma, they do likewise to the idea of defence. From referring to the body's defence-reaction to physical trauma, they let it now embrace an automatically elicited process of defence in response to emotional, psychic trauma. According to Freud ([15]), the traumatic events were all of a distressing nature, calculated to arouse the affects of shame, of self-reproach and of psychical pain, and the feeling of being harmed; they were all of a kind that one would prefer not to have experienced, that one would rather forget. From all this there arose, as it were automatically, the thought of defence. (p. 269) Freud ([14]) elaborated his view of the centrality of defence in his paper on The NeuroPsychoses of Defence: "I was repeatedly able to show that the splitting of the contents of consciousness is the result of an act of will on the part of the patient" (p. 46). So, Freud ([15]) is clear from the start that he sees the process as intentional: The precipitating events are "all of a kind that one would prefer not to have experienced, that one would rather forget" (p. 269). The longer we have been occupied with these phenomena, the more we have become convinced that the splitting of consciousness which is so striking in the well-known classical cases ... is present to a rudimentary degree in every hysteria, and that a tendency to such a dissociation ... is the basic phenomena of this neurosis. (Breuer & Freud, 1893–[ 4], p. 12) There seems to me to be a striking resemblance between these early formulations of Freud and a contemporary view of dissociation as "the primary unconscious defensive process, replacing repression" (Stern, [38]), stressing that what is defended against is not so much a particular feeling but to be a certain person, "someone who felt disappointed, bereft, frightened, humiliated, shamed, or otherwise badly hurt or threatened" (p. 13). Speaking of trauma and defence in this text, I want to make it clear that I use the term trauma as shorthand for traumatic experience. It does not refer to specific events. Whether or not an event has a traumatic effect, it is never the result of the event alone. It depends on the affected individual's ability to cope with the event(s). Likewise, I use the term defence to denote all types of coping strategy and resilience an individual might avail herself of in response to very recent or older traumatic experience(s). FROM PSYCHICAL TRAUMA TO SEXUAL TRAUMA The development in Freud's thinking from a general trauma theory to a specific sexual aetiology of the neuroses started even before the final publication of The Studies in 1895. Freud first became convinced that the "simple neuroses," neurasthenia (neurasthenia proper and anxietyneurosis), were caused by an unsatisfying discharge of libido; masturbation and coitus interruptus. In a letter to Flies, February 8, 1893, he wrote, "Traumatic hysteria was well known; what we [Breuer and Freud] asserted beyond this was that every hysteria that is not hereditary is traumatic. In the same way I am now asserting that every neurasthenia is sexual" (1892– 1899/1950, p. 179). And on the obsessions: "In all the cases I have analysed it was the patient's sexual life that had given rise to a distressing affect of precisely the same quality as that attaching to the obsession" (1894, p. 52). It is easy, he adds, "to see that it is precisely sexual life which brings with it the most copious occasions for the emergence of incompatible ideas" (p. 52). Freud explains, "At the time [1893–95] ... I was still faithful to a purely psychological theory in regard to the psychoneurosis—a theory in which the sexual factor was regarded as no more significant than any other emotional source of feeling. ... We [Breuer and Freud] were led to the assumption that hysterical symptoms are the permanent results of psychical traumas (Freud, [20]/1953), p. 272). However, a year later, Freud writes in Heredity and the Aetiology of the Neuroses ([16]) that there are many concurrent or auxiliary causes of neuroses, but then continues: What, then, are the specific causes of neuroses? ... each of the major neuroses which I have enumerated has as its immediate cause one particular disturbance of the economics of the nervous system, and that these functional pathological modifications have as there common source the subject's sexual life, whether they lie in a disorder of his contemporary sexual life or in important events in his past life. (p. 149) This might be Freud's first formulation of the general, universal sexual theory of neuroses. He immediately goes on to ascertain that it is not a new idea to see nervous illness as caused by sexuality, because sexual disorders "have always been admitted among the causes of nervous illness" (p. 149), but what "gives its distinctive character to my line of approach is that I elevate these sexual influences to the rank of specific causes, that I recognize their action in every case of neurosis" ([16], p. 149). What had made Freud so convinced that the source is always to be found in sexual life? In On the History of the Psycho-Analytic Movement he answers this question with three off-record oral comments by Breuer, Charcot, and Chrobak, respectively: "These things are always secrets d´alcôve!" (Breuer); "It's always a question of the genitals— always, always, always" (Charcot), and finally Chrobak´s prescription: "Penis normalis dosim repetetur!" (1914/1957, pp. 13–14). It is also worth remembering that Starr and Aron recently found evidence that a sexual conception of hysteria and treatment by genital stimulation had existed more or less continuously from antiquity to the time Freud was writing (Aron & Starr, [ 2]; Starr & Aron, [37]). (The widespread practice of medical doctors in the late nineteenth century to treat hysteria by genital stimulation, masturbation to orgasm, was recently explored in Tanya Wexler's film Hysteria.) "I owe my results," Freud writes, "to a new method of psycho-analysis, Josef Breuer's exploratory procedure." (This is the first published appearance of the word psychoanalysis, used here to describe Breuer's work with Anna O) "By means of that procedure ... hysterical symptoms are traced back to their origin, which is always found in some event of the subject's sexual life appropriate for the production of a distressing emotion [emphasis added]" ([16], p. 151). We note the change from positing events of any kind that result in distressing emotions to a narrower set of causes restricted to sexual life. We should also note there is nothing in Freud's formulations so far that do not apply just as well to both the second theory (seduction/sexual abuse) and the third (repressed libido). Indeed, these formulations could arguably be said to represent Freud's fourth theory; neurosis is caused by sexuality, one way or the other. However, Freud moves on and states "that at the bottom the same thing was present in all the cases submitted to analysis—the action of an agent which must be accepted as the specific cause of hysteria" ([16], p. 151). This agent is a memory relating to sexual life that presents two characteristics. The event of which the subject has retained an unconscious memory is a precocious experience of sexual relations with actual excitement of the genitals, resulting from sexual abuse committed by another person; and the period of life at which this fatal event takes place is earliest youth— the years up to the age of eight to ten, before the child has reached sexual maturity. A passive sexual experience before puberty: this then, is the specific aetiology of the hysteria. ([16], p.152) And the memory, Freud goes on to explain, "will operate as though it were a contemporary event. What happens is, as it were, a posthumous action by a sexual trauma" (p. 154). However, while Freud now sees hysteria as the result of a passive sexual experience (seduction, abuse), the obsessional neurosis he sees as the result of an act that has given pleasure. "The obsessional ideas ... are nothing other than reproaches addressed by the subject to himself on account of this anticipated sexual enjoyment" ([16], p. 155). We note how Freud's account of obsessional neurosis resembles his later theory of repressed libido. But contrary to his later view, Freud is now convinced, he says, "that nervous heredity by itself is unable to produce psychoneuroses if their specific aetiology, precocious sexual excitation, is missing" ([16], p. 156). So, according to Freud, by means of the psychoanalytic method initiated by Breuer, experiences were finally reached which belonged to childhood and concerned specifically sexual life. And this was so even in cases in which an ordinary emotion, not of a sexual kind, had led to the outbreak of the disease. Unless these sexual traumas of childhood were taken into account it was impossible either to elucidate the symptoms ... or to prevent their recurrence. In this way the unique significance of sexual experiences in the aetiology of the psychoneuroses seemed to be established beyond doubt; and this fact remains to this day one of the corner-stones of my theory [emphasis added]. (1906 [1905]/1953), p. 273) However, the task of finding a sexual core was not easy by any means, as Freud expressed in a letter to Flies dated February 7, 1894, and cited in The Neuro-Psychoses of Defence (1894). "You are right. The connection between obsessional neurosis and sexuality is not always so obvious. ... If anyone less mono-ideistic [emphasis added] than I am had looked at it, he would have overlooked it" (p. 57, Footnote 2). "The theory culminated in this thesis: if the vita sexualis is normal, there can be no neurosis" (Freud, [20]/1953, p. 274). Freud refers to the seduction theory as "the form taken by the theory in some of my shorter preliminary publications during the years 1895 and 1896" (p. 273). FROM SEXUAL TRAUMA TO SEXUAL CONSTITUTION In my review below of Freud's further thinking on the aetiology of the neurosis, I follow his formulations in My views on the part played by sexuality in the aetiology of the neuroses (1906[1905]/1953). Here he explains how his earlier material contained a disproportionately large number of cases in which seduction by adults or other older children had played the chief part. I thus over-estimated the frequency of such events (though in other respects they were not open to doubt). Moreover, I was at that period unable to distinguish with certainty between falsifications made by hysterics in their memories of childhood and traces of real events. Since then I have learned to explain a number of phantasies of seduction as attempts at fending off memories of the subject's own sexual activity (infantile masturbation). When this point had been clarified, the 'traumatic' element in the sexual experiences of childhood lost its importance [emphasis added]. (p. 274) After correcting his overestimation of the frequency of seduction (sexual abuse), "'infantile sexual traumas' were replaced by the 'infantilism of sexuality'" (Freud, [20]/1953, p. 275). Instead of going back to his previous theory, which gave aetiological significance also to nonsexual traumatic events (distressing emotions of all sorts), Freud remains convinced that "no neurosis is possible with a normal vita sexualis" and starts instead to develop a view that places decisive aetiological weight on sexual constitution. When the frequency of seduction in childhood was no longer assumed, Freud explains, there was no need any more to emphasise external influences on sexuality. Accidental influences derived from experience having thus receded into the background, the factors of constitution and heredity necessarily gained the upper hand once more; but there was this difference between my views and those prevailing in other quarters, that on my theory the 'sexual constitution' took the place of a 'general neuropathic disposition'. (Freud, [20]/1953, pp. 275–276) Freud then refers to his recently published Drei Abhandlungen zur Sexualtheorie (1905), where he describes the varieties of "this sexual constitution as well as the composite character of the sexual instinct in general and its derivation from contributory sources from different parts of the organism" (Freud, [20]/1953, p. 276). His investigations into the mental life of normal persons have yielded, he writes, the unexpected discovery that their infantile history in regard to sexual matters was not necessarily different from that of the neurotic, and that seduction in particular had played the same part in it. "As a consequence, accidental influences receded still further into the background as compared with 'repression' (as I now began to say instead of 'defence') [emphasis added]" (Freud, [20]/1953, p. 276). The important thing was no longer the childhood experience of sexual stimulation, but how the child had reacted to these experiences, whether he had responded to them with "repression" or not. "The psycho-analysis of hysterics showed that they fell ill as a result of the conflict between their libido and their sexual repression and that their symptoms were in the nature of compromises between the two mental currents [emphasis added]" (p. 277). With this formulation, Freud's third theory of neuroses is clearly stated. Freud, however, wants to downplay the difference between his second and third theory. I think it is worth emphasizing the fact that, whatever modifications my views on the aetiology of the psychoneuroses have passed through, there are two positions which I have never repudiated or abandoned—the importance of sexuality and of infantilism. Apart from this, accidental influences have been replaced by constitutional factors and 'defence' in the purely psychological sense has been replaced by organic 'sexual repression'. (pp. 277–278) Freud's stressing of the dual basis of his view of the aetiology of the neuroses—sexuality and infantilism—is worth noting. While his insistence that only sexuality can cause neurosis is highly disputable, his new and revolutionary insistence on the importance of "infantilism"—that normally neurosis is rooted in the earliest years of life—has stood the test of 100 years of research and clinical experience. In my judgment, Freud's "infantilism," his developmental view of neurosis, is the prime reason why psychoanalytic theory—including attachment theory— remains an influential theory in mental health research. Nowhere does Freud minimize or deny the difference between the seduction theory and his new theory of libidinal drive and repression more than in his opening remarks of The Dora Case. In 1895 and 1896 I put forward certain views upon the pathogenesis of hysterical symptoms and upon the mental processes occurring in hysteria. Since that time several years have passed. In now proposing, therefore, to substantiate those views [emphasis added] by giving a detailed report of the history of a case and its treatment. ... (1905 [1901]/1953, p. 7) The changes in Freud's views are striking, however, to everyone but himself. This is, not least, apparent in his case presentations. Whereas his case histories up to now reflected trust in the patients, his mistrust is remarkable in his discussion of the Dora case, as feminist critique has indeed highlighted. It is as if Dora is saying "My illness is not caused by masturbation" and Freud is replying "Yes, it is." Freud goes on to stress that, in his opinion, all that matters is sexuality. "Wherever a commonplace emotion must be included among the determinants of the onset of the illness, analysis invariably shows that it is the sexual component of the traumatic experience ... which has produced the pathogenic result" (Freud, [20]/1953, p. 278). It is my impression that Freud adopts this dogmatic stance mainly in questions concerning his "sexology." In others he adopts a scientific stance, recognizing that the fate of his suggestions will be decided by future research and clinical experience. For example, on the subject of drives, he writes I have proposed that two groups of such primal instincts should be distinguished: the ego, or selfpreservative, instincts and the sexual instincts. But this supposition has not the status of a necessary postulate ... it is merely a working hypothesis, to be retained only so long as it proves useful. (1915, p. 124) Jung ([29]) testified to Freud's dogmatic stance on sexuality in his autobiography. Referring to their first meeting he writes, There was no mistaking the fact that Freud was emotionally involved in his sexual theory to an extraordinary degree. When he spoke of it, his tone became urgent, almost anxious, and all signs of his normally critical and sceptical manner vanished. ... I had a strong intuition that sexuality for him was a numinosum (a sacred thing). This impression was confirmed by a conversation that took place about 3 years later (1910), again in Vienna. I still remember vividly what Freud said to me: "My dear Jung, promise me never to abandon the sexual theory. It is the most essential. You see, we must make of it a dogma, a steadfast bulwark." He said that to me with great emotion, in the tone of a father saying, 'And promise me this one thing, my dear son: that you will go to church every Sunday"... First of all, it was the words "bulwark" and "dogma" that alarmed me. ... As I saw it, a scientific truth was a hypothesis that might be adequate for the moment, but was not to be preserved as an article of faith for all time. (p. 144, my translation) I agree with Jung. The highly detrimental effect of Freud's theory of sexuality results from its being turned into a dogma, and furthermore that this dogma is placed, so to speak, at the heart of psychoanalytic theory and therapy with far-reaching consequences for the other, non-dogmatic aspects of theory and therapy. If he had hypothesized instead that sexuality was a core factor in the aetiology of all or most neuroses, the effect would not have been so detrimental because it would have allowed for research and debate. FURTHER ELABORATIONS ON THE SEXUAL THEORY OF NEUROSIS Not only had Freud come to see sexuality as the cause of the neurosis, he also saw it as constituting the essence of the neuroses. It is scarcely possible to avoid picturing these processes as being ... of a chemical nature; so that in what are termed the 'actual' neurosis we may recognize the somatic effects of disturbances of the sexual metabolism, and in the psychoneuroses the psychical effects of those disturbances as well. (Freud, [20]/1953, p. 279) This explains why Freud now saw repression, as opposed to defence, not only as a psychological defence, but an organic defence. In parallel with the development of the third theory—or rather as an integral and indispensable part of it—Freud developed his notion of the Oedipus complex. In a letter to Fliess, October 15, 1897, he writes, "A single idea of general value dawned on me. I have found, in my own case too, being in love with my mother and jealousy of my father, and I now consider it a universal event in early childhood" (Masson, [30], p. 272). And in Totem and Taboo (1912–13), he states that "we have arrived at the point of regarding a child's relation to his parents, dominated as it is by incestuous longings [emphasis added], as the nuclear complex of neurosis" (as cited in Radnytsky, [31], p. 60). What I find fascinating about this formulation is that it shows how Freud again combines a revolutionary new discovery—seeing "a child's relation to his parents ... as the nuclear complex of neurosis"—with the highly disputable assertion that it is "dominated ... by incestuous longings." He combines important new insights—quite correct ones in my opinion— with an insistence on the libido theory. Here I just want to round off the subject of the Oedipus complex by quoting from a footnote by Freud in 1920 to Three Essays on the Theory of Sexuality: "Every new arrival on this planet is faced by the task of mastering the Oedipus complex; anyone who fails to do so falls a victim to neurosis. ... Its [The Oedipus complex's] recognition has become the shibboleth that distinguishes the adherents of psycho-analysis from its opponents" (1905, p. 226). The causes of neurotic illness, Freud explains, fall into a "complemental series" within which the two factors—sexual constitution and experience—are represented in such a manner that if there is more of the one there is less of the other. "In this series I can perhaps allow a certain preponderance in significance to the predisposing factors" (Freud, [23] [1916–[23]]/1963, p. 347). As we see, apart from a certain preference for constitution, Freud now takes a balanced position on outer versus inner causes. Having thus far explained the cause of neuroses as an interaction of a sexual constitution (fixation) and sexual experience, there remains a decisive role, Freud adds, for non-sexual influences in the aetiology of the neuroses. These influences, he answers, are the non-sexual instinctual forces, the 'ego-instincts.' The pathogenic conflict is thus one between the ego-instincts and the sexual instincts. Symptoms, according to Freud ([23] [1916/1917]/1963), sometimes represent events that really took place and influenced the fixation of the libido, but "sometimes they represent phantasies of the patient's which are not, of course, suited to playing an aetiological role [emphasis added]" (p. 367). Nonetheless he decided to give fantasies not representing real events a decisive aetiological role. "It remains a fact that the patient has created these phantasies for himself, and this fact is of scarcely less importance for his neurosis than if he had really experienced what the phantasies contain" (p. 368). So it is precisely the "phantasies of the patient's which are not, of course, suited to playing an aetiological role" (p. 367) that do get to play an aetiological role. "The phantasies possess psychical as contrasted with material reality, and we gradually learn to understand that in the world of the neurosis it is psychical reality which is the decisive kind" (p. 368). Among the oft-repeated phenomena in the youthful history of neurotics, Freud ([23] [1916/1917]/1963) adds, there are a few of particular importance. "As specimens of this class I will enumerate these: observation of parental intercourse [the primal scene], seduction by an adult [sexual abuse] and threat of being castrated" (pp. 368–369). Fantasies of being seduced are of particular interest, Freud finds, because they so often are not fantasies but real memories. Seduction by an older child or one of the same age, according to Freud, is even more frequent than by an adult. But in the case of girls who produce such an event with their father as the seducer, there can be no doubt either of the imaginary nature of the accusation or of the motive that has led to it. A phantasy of being seduced when no seduction has occurred is usually employed by a child to screen the autoerotic period of his sexual activity. He spares himself shame about masturbation by retrospectively phantasysing a desired object into these earliest times. You must not suppose, however, that sexual abuse of a child by its nearest male relatives belongs entirely to the realm of phantasy. Most analysts will have treated cases in which such events were real and could be unimpeachably established [emphasis added]. (p. 370) We see Freud stressing again and again how scenes of seduction and sexual abuse in childhood can be real or fantasised and how such events are among the essential elements of neurosis. So far so good! However, the astonishing conclusion he reaches is this: "The outcome is the same, and up to the present we have not succeeded in pointing to any differences in the consequences, whether phantasy or reality has had the greater share in these events of childhood [emphasis added]" (p. 370). It is hard to imagine why this line of reasoning was largely accepted by the psychoanalytical community and the broader fields of psychology and psychiatry for most of the twentieth century; that in terms of consequences it makes no difference whether fantasy or reality has played the greater part in events of childhood. There were, however, important exceptions to this. As we know, Ferenczi ([12]), in his later years, came to regard traumatic experiences, not least sexual abuse, as being of utmost importance. In Norway, Schjelderup in the thirties rejected libido theory and put his faith in trauma theory (Sletvold, [34], [35]). And by the 1990s, hardly anyone was disputing the necessity of differentiating fantasy from reality (Dalenberg et al., [ 9]; Davies & Frawley, [10]; van der Kolk, [39]). Freud never denied the reality of sexual abuse, but he created a theory that said that it had no practical consequence whether one paid attention to it or not. What made it possible for him to believe that fantasies, contrary to common sense, as he himself admitted, could have such grave consequences? Freud's ([23]) answer was that these primeval fantasies are a phylogenetic endowment. It seems to me quite possible that all things that are told to us to-day in analysis as phantasy—the seduction of children, the inflaming of sexual excitement by observing parental intercourse, the threat of castration (or rather castration itself)—were once real occurrences in the primaeval times of the human family, and that children in their phantasies are simply filling in the gaps in individual truth with prehistoric truth. I have repeatedly been led to suspect that the psychology of the neuroses has stored up in it more of the antiquities of human development than any other source [emphasis added]. (p. 371) To sum up so far. Freud's first error was in my mind his decision to pursue an exclusively sexual aetiology and nature of the neuroses. His second error was to conclude that sexual constitution (sexual-drive-based fantasies and wishes) and traumatic experiences amount to the same thing. This latter error, it seems to me, has had the most detrimental effect inasmuch as (childhood) traumas were neglected for greater parts of the twentieth century both in psychotherapy and more generally. (I am not, of course, saying that Freud bears sole responsibility for this.) FREUD'S SECOND THEORY OF ANXIETY AND HIS RETURN TO TRAUMA THEORY Freud's conception of anxiety as a direct result of an unsatisfactory sexual life dates back to his very first formulations of the aetiology of the neurosis. "It is no use denying the fact ... that I have on many occasions asserted that ... the libido belonging to the instinctual impulse is transformed into anxiety" (1926 [1925]/1959). However, in his revised theory (1926 [1925]/1959), anxiety is no longer the result of libidinal repression but rather a sign or symptom of a danger situation. In this way he severs the innate connection between anxiety and sexuality and re-opens the path from danger (trauma) to anxiety and neurosis independently of sexuality. Contrary to his earlier view, Freud now declares: "It is always the ego's attitude of anxiety which is the primary thing and which sets repression going. Anxiety never arises from repressed libido" (1926 [1925]/1959). In this new conception, anxiety is not the result of repressed libido but a reaction to a situation of danger. The dangerous situation Freud had been considering was that of castration or something traceable to castration. But then Freud reasons further and acknowledges challenges to libido theory. If anxiety is a reaction of the ego to danger, we shall be tempted to see the traumatic neuroses ... as a direct result of a fear of death (or a fear of life) and dismiss from our minds the question of castration.... Most of those who observed the traumatic neuroses of the last war [First World War] took this line, and triumphantly announced that proof was now forthcoming that a threat to the instinct of self-preservation could by itself produce a neurosis without any admixture of sexual factors [emphasis added]. (1926 [1925]/1959). Starr and Aron ([37]) had a thorough discussion of the challenges to Freudian theory posed by the war neuroses of the First World War. Freud, however, goes on to state that he knows of no proof that war neurosis can be explained "without any admixture of sexual factors," specifically castration fear. Referring to Spitz's famous studies of the catastrophic effects of maternal deprivation on children during World War II, Eagle ([11]) reminded us of how it was possible to explain the effects of seemingly non-sexual events with an admixture of sexual factors. Spitz ([36]) was able to do this by suggesting that maternal deprivation prevents the discharge of libidinal and aggressive drives. "The loss of the love object interrupts the discharge of both drives" (p. 90). But clearly Freud is on the defensive on this question as he goes on to ask what makes a danger situation traumatic, and suggests that it might be helplessness. Let us call a situation of helplessness of this kind that has been actually experienced a traumatic situation. ... Taking this sequence, anxiety—danger—helplessness (trauma), we can now summarize what has been said. A danger-situation is a recognized, remembered, expected situation of helplessness. Anxiety is the original reaction to helplessness in the trauma and is reproduced later on in the danger-situation as a signal for help. (1926 [1925]/1959). There is a striking resemblance between Freud's reasoning here and the trauma theory developed by the Norwegian psychoanalyst Harald Schjelderup in the thirties (Sletvold, [34], [35]). He, too, saw the sense of helplessness in a danger situation as the main constituent of the traumatic situation. It is also interesting to note how Freud, in his "modification of earlier views" (1926 [1925]/1959) reintroduced the concept of defence that for 30 years had been replaced by repression. It will be an undoubted advantage, Freud contends, to revert to the old concept of defence, "provided we employ it explicitly as a general designation for all the techniques which the ego makes use of in conflicts which may lead to a neurosis" (p. 163) While Freud seems to be returning to his original theory of trauma and defence, it is still necessary to underline that he in no way is giving up his libido theory. But by seeing anxiety as no longer exclusively connected to libido, but rather as a response to any kind of danger situation, and neuroses as constituted from danger, anxiety, helplessness and defence, I think we are allowed to say that Freud again embraces his first theory of neurosis. It should also be noted that historically three explanations for hysteria/neurosis have been suggested: sexuality, heredity/constitution and trauma. Freud grappled with all three throughout his life. AFTER FREUD: THE DILUTING OF LIBIDO THEORY The response of Freud's psychoanalytic colleagues to his theory was in my view quite paradoxical. Nobody seemed to accept the libido theory wholeheartedly, but neither did anybody criticise it openly—after Adler and Jung—or point to what they found wrong in it. To my knowledge, there were only two exceptions, one in favour and one against. Wilhelm Reich ([33]) was adamant in his defence of libido theory and added to it concepts such as orgastic potency, orgasm reflex, and sex economy. He was also quick to criticise his colleagues for turning away from libido theory. However, like Freud, Reich entertained opposing views; referring to the first psychoanalytic views based on the conflict between need and the outer world he wrote: "The psychic process reveals itself as the result of the conflict between instinctual demand and the external frustration of this demand. Only secondary does an inner conflict between desire and self-denial result from this opposition" (Reich, [32]/49/1972, p. 287). Only one person rejected libido theory outright, and that was, as already mentioned, Harald Schjelderup (Sletvold, [34], [35]). He was convinced that behind what might seem to be expressions of oedipal and castration complexes lay traumatic experiences often of a nonsexual nature. The deepest causes of neuroses, he suggested, are to be found in traumatic experiences of any kind that leave the child in a helpless situation. An oppressive upbringing and constitution were other contributing factors. The psychoanalytical mainstream (and, I would add, psychiatry and clinical psychology) began a process of what I characterize as the dilution of Freud's theory. It was accomplished by looking away from the core of the theory, the unique significance of sexual experiences, to focus instead on supplementary and secondary aspects of the theory. This took three main forms. 1. A reformulation of libido theory into a theory of sexuality and aggression. • • 2. A reformulation of it as drive theory. 3. A reformulation of it as inner conflict theory. Sexuality and Aggression I consider this version first, as it is seemingly closest to the original in that it refers explicitly to sexuality. For example, Morris Eagle ([11]) described the Freudian view of psychopathology as "the product of conflict between sexual and aggressive [emphasis added] wishes and prohibitions and defenses against them" (p. 190). However, as we have seen, Freud never places aggression alongside sexuality. Even if he did come to ponder aggression more in his later writings and specifically theorized a death instinct, he never gave it an independent role in the aetiology of the neuroses; "we have always believed that in a neurosis it is against the demands of the libido and not against those of any other instinct the demands of the ego is defending itself" (1926 [1925]/1959). The consequence of juxtaposing aggression and sexuality was, however, formidable. It is almost immediately read as synonymous with love and hate, not least because Freud himself often used love as an alternative word for sexuality. Further, love and hate naturally become more or less synonymous with positive and negative emotions. So the libido theory is reformulated as a view foregrounding emotion. Not a bad thing at all! But Freud's explanation of how we acquire nervous illness is lost on the way. Drive Theory The widespread perception of Freud's view as a drive theory omits any direct mention of sexuality/libido. However, drive theory is not a theory of what causes neurosis (psychopathology); it is a way of conceptualizing motivation. It is quite correct to say that Freud was a drive theorist. But this view was by no means specifically Freudian. Conceptualizing human motivation in terms of drives or instincts was something he shared with almost everyone who theorized about human motivation a 100 years ago. In particular, it was shared by behaviourists (Hull, [28]), as Eagle ([11]) recently reminded us. What divided Freud from Adler, Jung, and the behaviourists was not drive theory as such but the particular significance he ascribed to the discharge of sexual drives or libido. Freud hypothesized a process in which stimuli create a state of excitation in the body that needs to be discharged and that ideally returns the body to a state of zero excitation. This conception, inspired by the electrochemical linking of neurons, was replaced by the idea of optimal regulation (rather than zero excitation) with Cannon's ([ 7]) introduction of the principal of homeostasis. So the idea of the (optimal) regulation of body states rather than discharge gradually became the accepted view of what bodily needs or drives push for. Today, the idea of optimal regulation includes in addition to physiological body states emotional body states as well, and is often referred to as the principle of affect regulation. Inner Conflict Theory Conflict was, as we have seen, an aspect of what Freud considered a necessary condition for the creation of a neurosis, but this applied only to such conflicts in which sexuality constituted a part. So it is right to say that Freud championed a theory of inner conflict, but not of inner conflicts of any kind. The latter, however, was the version of the Freudian conception of neurosis that the Diagnostic and Statistical Manual of Mental Disorders (3rd ed. [DSM-III]; American Psychiatric Association, [ 1]) took as its point of departure when it abandoned the entire concept of neurosis. They defined neurosis as an etiological process constituted by an "unconscious conflict arousing anxiety and leading to the maladaptive use of defensive mechanisms" (p. 9). But then they added that there are other theories about how neurotic disorders develop; "there are social learning, cognitive, behavioral, and biological models that attempt to explain the development of various neurotic disorders" (p. 10). Thus, the term neurotic disorder is used in DSM-III without any implication of a special etiological process. Neurotic disorder, defined descriptively, is roughly equivalent to the psychoanalytic concept of "symptom neurosis." This is distinguished from "character neurosis" which is roughly equivalent to the DSM-III concept of Personality Disorder. (p. 10) As we know, DSM-III replaced the idea of a neurotic process with a cluster of symptoms, a catalogue of complaints and problems, without any consideration of aetiology and process. The only exception was the introduction of post-traumatic stress disorder (PTSD), thus indirectly reinforcing the idea that traumatic experiences do not generally play a part in the development of neurotic disorders. The ICD adopted the same way of thinking not long after. From the time medicine started to apply scientific methods, efforts have been directed not only at classifying symptoms but understanding causes and processes, and basing diagnostics on such understanding. Freud wanted to establish such a medical and scientific understanding of the causes and nature of the neuroses. It is the ambition of this text is to help revitalize that project. CONCLUSION Traumatic experience and defence (again conceptualized as splitting/dissociation rather than repression) are today widely accepted as causes of neuroses. This holds true not least within relational and interpersonal psychoanalysis (Brothers, [ 6]; Bromberg, [ 5]; D. B. Stern, [38]). By recognizing how the aetiology of neuroses lies in emotional trauma and defence, often dating back to early childhood, a foundation is laid for a developmental and process view of mental health diagnostics/case formulations. Much of the knowledge on which a contemporary theory of trauma, defence, coping and resilience relies is already in place. It is found inter alia in attachment research, trauma research, infant research, neuroscience, and in clinical experience within contemporary psychoanalysis and psychotherapy. Even though Breuer and Freud held a broad definition of psychical trauma, an expansion of the scope of emotional trauma is derived from micro-analytic research on traumatic and defensive processes in infant–caregiver interaction that is not available to ordinary observation. For example, Beebe & Lachmann ([ 3]) link disorganized infant attachment at 4 months to young adult dissociation. Their studies show that maternal "disrupted communication" predicts young adult attachment insecurity and dissociation. In addition, disrupted maternal communication itself predicts a number of other problematic outcomes in young adulthood. At the same time the most severe form of dissociation, DID, seems etiologically connected to the most severe forms of abuse and neglect, not least sexual abuse (Howell, [27]). And recently, Crastnopol ([ 8]) has been analysing the micro-traumas of everyday life. This expansion of our understanding of traumatic emotional and relational experience in no way undermines the essential truth of Breuer and Freud's formulations, but rather extends their reach and exploratory scope. It is my hope that bringing Freud's (and Breuer's) original formulations to the attention of a wider field will strengthen our contemporary understanding of the development of mental health. REFERENCES 1 American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed). Washington, DC: Author. 2 Aron, L., & Starr, K. E. (2013). A psychotherapy for the people. Toward a progressive psychoanalysis. London, UK: Routledge, Taylor & Francis Group. 3 Beebe, B., & Lachmann, F. M (2014). The origins of attachment - infant research and adult treatment. New York, NY: Routledge, Taylor & Francis Group. 4 Breuer, J., & Freud, S. (1993–1895). Studies on hysteria. Standard Edition, 2, 1–251. London, UK: Hogarth Press, 1955. 5 Bromberg, P. M. (2011). The shadow of the Tsunami and the growth of the relational mind. New York, NY: Routledge, Taylor & Francis Group. 6 Brothers, D. (2008). Toward a psychology of uncertainty: Trauma-centered psychoanalysis. New York, NY: Analytic Press. 7 Cannon, W. B. (1932). The wisdom of the body. New York, NY: W. W. Norton. 8 Crastnopol, M. (2015). Micro-trauma. A psychoanalytic understanding of cumulative psychic injury. London, UK: Routledge, Taylor & Francis Group. 9 Dalenberg, D. J., Brand, B. L., Gleaves, D. H., Dorahy, M. J., Loewenstein, R. J., Caedena, E., ... Spiegel, D. (2012). Evaluation of the evidence for the trauma and fantasy models of dissociation. 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