Freud’s Irma Dream, the Origin of Psychoanalysis, and a Bloody Nose. 

“One doesn’t discover new lands without consenting to lose sight, for a very long time, of the shore.” — André Gide

“Gloomy times, unbelievably gloomy. Above all, this Eckstein affair, which is rapidly moving toward a bad ending.” — Freud, Letter to Fleiss, April 11, 1895.

“I am obliged to add … that in scarcely any instance have I brought forward the complete interpretation of one of my own dreams.” — Freud, The Interpretation of Dreams.

Focus of the Study

Freud (1900) conceived the entirety of The Interpretation of Dreams “on the model of an imaginary walk” (p.122). Chapter Two begins with the analysis of the “dream specimen” (Erikson, 1954), otherwise known as the “dream of Irma’s injection” or the “Irma dream.” While the Irma dream has sparked a cottage industry in psychotherapeutic approaches to dream analysis, Freud’s original intention of using dreams as a heuristic device has instead become ironically an object of study about Freud himself.  If one is to return to Freud’s original premise and method of dream interpretation, after adapting some valuable insights of later psychotherapists, then a different and historically accurate interpretation of the Irma dream emerges, and the intended focus upon the therapeutic value of the process of discussing dreams is restored. I invite the reader to use the same “imaginary walk” as an approach to this paper and to my review of the major life circumstances from which the dream arises.  I then move to a review of a number of important papers which re-interpret the Irma dream. Each writer’s approach to the Irma dream offers new insights into Freud’s deeper motivations and professional struggles and helps us see the many changes in how clinicians listen and work with dreams. Following this, I move on to my contribution of reviewing the Irma dream as a window into Freud’s consulting room, interpreting the key transferences (most importantly identifying Irma’s transference to Freud), in addition to the countertransferences and resistances embedded in the structure if the specimen dream.

Approaching the 120-year mark, the dream of Irma’s injection has also become the medium through which clinicians have supported, expanded, and even attacked Freud’s theories,

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methods, and personal integrity (Masson, 1984). It has captured the imagination and interest of generations of analysts and psychohistorians, and provided a psychobiographical window into the Father of Psychoanalysis at the moment of his greatest and most enduring discovery. In truth, the controversy surrounding this dream stems not only from its controversial nature or historical interest, but also from Freud’s incomplete handling of it.

Hence, when I am referring to the Irma dream here, unless otherwise specified I am referring to both the dream text and its accompanying associations.

The Irma Dream

In the summer of 1895, the 39-year-old Sigmund Freud was vacationing at his summer house in Bellevue, a picturesque spot outside Vienna. He was taking a well-deserved break after an incredibly demanding and draining year of discovery and near disaster. His arrhythmia, product of an earlier influenza, had returned with a vengeance that was threatening his most cherished activity, cigar smoking. With Martha, his wife, pregnant a sixth time, financial pressure was mounting. Studies on Hysteria had been published in May to mostly poor reviews, further ensuring no immediate financial or professional stability. Its coauthor, Joseph Breuer, Freud’s longtime mentor and friend, had been expressing ambivalence toward the theoretical direction Freud was heading. As their relationship unraveled, however, the relationship between Freud and Wilhelm Fliess, a colleague and fellow researcher, was deepening. The near fatal errors in their collaboration on the Emma Eckstein case had not shaken Freud’s confidence in and respect for his closest ally and friend. It would have been difficult for him to imagine these foreboding early days of spring were setting the stage for his greatest achievement that summer.

Freud had informed an earlier widowed and close family friend, Anna Hammerschlag-Lichtheim (married name), of his impending vacation. At the time, he was treating her for symptoms of hysterical anxiety. Anna knew the Freuds well and in fact would be on vacation with her family in their nearby summer retreat. Before the summer hiatus from treatment, Freud had offered her a “solution” he had hoped would relieve her of her symptoms. He was convinced they had their root in her widowhood, and suggested she marry so she could have regular discharge of her sexual impulses. Anna disagreed with Freud’s rather banal solution and outwardly expressed her disappointment, remarking she had been hearing she should remarry from her friends and family for quite some time. They put the treatment on hold and planned to resume in the fall.

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That summer, Anna’s hysterical anxiety seemed to dissipate, but her physical distress continued. That is what Freud was told by his friend and junior colleague, Dr. Oscar Rie, on July 23rd. Rie, also a close friend of the Hammerschlags, had been staying at Anna’s summer home. Freud picked up on a subtle criticism in Rie’s remarks about the efficacy of Anna’s talking treatment. This made Freud think of Anna’s family, whom he held in great regard, though they too hinted of doubt about his methods. Perturbed by Rie’s remarks, Freud decided that evening to write a full case history and send it to Breuer as a means to “justify” himself Anna’s treatment against any such criticism. After working on the case history “into the night,” Freud went to sleep and dreamed:

A large hall—numerous guests, whom we were receiving. Among them was Irma. I at once took her on one side, as though to answer her letter and reproach her for not having accepted my “solution” yet. I said to her: “If you still get pains, it’s really only your fault.” She replied: “If you only knew what pains I’ve got now in my throat, stomach and abdomen—it’s choking me.” I was alarmed and looked at her. She looked pale and puffy. I thought to myself that after all I must be missing some organic trouble. I took her to the window and looked down her throat, and she showed signs of recalcitrance, like a woman with artificial dentures. I thought to myself there was no need for her to do that. She then opened her mouth properly and on the right I found a big white patch; at another place I saw extensive whitish gray scabs upon some remarkable curly structures which were evidently modeled on the turbinate bones of the nose. I at once called in Dr. M., and he repeated the examination and confirmed it. Dr. M. looked quite different from usual; he was very pale, he walked with a limp and his chin was clean shaven. … My friend Otto was now standing beside her as well, and my friend Leopold was percussing her through her bodice and saying: “She has a dull area low down on the left.” He also indicated that a portion of the skin on the left shoulder was infiltrated. (I noticed this, just as he did, in spite of her dress.) … M. said, “There’s no doubt it’s an infection, but no matter, dysentery will supervene and the toxin will be eliminated.” … We were directly aware, too, of the origin of the infection. Not long before, when she was feeling unwell, my friend Otto had given her an injection of a preparation of propyl, propyls … propionic acid … trimethylamin (and I saw before me the formula for this printed in heavy type). … Injections of that sort ought not to be made so thoughtlessly. … And probably the syringe had not been clean. (Freud, 1900, p. 107)

Five years later, the dream of Irma’s injection, or the Irma dream, appeared in chapter two of The Interpretation of Dreams (Freud, 1900). This was the true opening chapter (Welsh, 1994), and this dream had become the “dream specimen of psychoanalysis,” and perhaps the most studied dream of all time. It was the first, longest, most thoroughly analyzed dream in Freud’s opus. He presented his analysis as a prototype showing how dreams can be constructed and deconstructed,

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demonstrating the division between the conscious and unconscious minds. Further, and perhaps most significant, he showed how a dream can be scientifically and practically decoded using the associational method.

These factors alone would have made the dream of Irma’s injection a focus of study and debate, which it would become. However, Freud, in his letter to Fliess dated June 12th, 1900, further acknowledged the importance of this dream, playfully writing he was considering adding to the doorway of his summer home a commemorative marble tablet that read, “In this house on July 24th, 1895, the Secret of Dreams was revealed to Dr. Sigmund Freud…”

Although the Irma dream is designed mainly as a teaching tool, the dream and its analysis tease the reader with the possibility of putting Freud himself on the couch. The dream and its associations, and the omissions in the associations, present as a bundle of contradictions. As demonstrated in decades of commentary, Freud’s elaborate but ultimately limited associations to the material tell us little more than the dream text itself tells. Freud wanted to shift responsibility for his patient’s continuing poor condition to someone or something else, exonerating him from a sense of guilt or responsibility and allowing his conscientiousness to remain unchallenged. Freud (1900) concluded, “The dream represented a particular state of affairs as I should have wished it to be. Thus its content was the fulfillment of a wish and its motive a wish” (p. 118).

Without inference and speculation, even a thorough review of the associations turns up little beyond Freud’s initial conclusion that the dream reflects a wish to remove his sense of guilt, restore his sense of professional integrity, and seek revenge for the criticism he had heard earlier that evening. Freud openly acknowledged he had chosen to omit associations related to sexual feelings, both current and infantile. Although understandable, these omissions proved problematic and ironic, as the hallmark of Freud’s theory of human motivation involved current sexuality and, through its derivatives, unconscious infantile sexuality (aggression as a second drive would be postulated later). Maybe it was Freud’s characterization of the Irma dream as the “dream specimen of psychoanalysis” that was interpreted to mean, to future generations of analysts, that the dream and its associations were supposed to carry the weight of the entire theory and practice of psychoanalysis. In a sense, Freud set his dream up as the dream. This problematic labeling ignited the enormous debate and discussion about what this dream actually signifies about psychoanalysis and its dreamer. The idea was first expansively elaborated by Erikson (1954), who established the Irma dream as the ground zero of psychoanalysis, signifying

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the true beginning of Freud’s self-analysis. Adding to the dream’s historical significance is heretofore unpublished correspondence between Freud and confidant and colleague Wilhelm Fliess. Fliess, a prominent otolaryngologist (ENT) who practiced in Berlin, had formed a long friendship with Freud since they met at a conference in 1885, sharing a common interest in neurosis.

These letters, made public in the 1960s, reveal a disturbing treatment situation with the patient Emma Eckstein in the spring of 1895, and eerily illustrate a parallel narrative (Griffin, n. d.) between the manifest text of the Irma dream and the treatment of Emma, suggesting the identity of the key figure (Irma) in the dream (I examine this in more detail later). In addition, the letters seem to shed light on the many omissions in the associative analysis of the Irma dream, showing Freud did everything in his power to protect Fliess’ professional reputation, even to the point of deleting material from his associations to the Irma dream that reflected negatively on Fliess.

At the hub of the theoretical and technical debate, Freud seemed to contradict himself regarding the nature of and approach to the manifest content of the Irma dream. On one hand, he strongly affirmed that the manifest dream has little or no clinical value, but primarily serves a function akin to that of a neurotic symptom—to hide the deeper unconscious conflict or the consciously unacceptable wish. Yet even Freud (1900) acknowledged that the Irma dream seems to have been constructed with a degree of logic and organization. The truth is the Irma dream is anything but disguised. The text of the dream brings us right into the core of Freud’s insecurities and conflicts. How the dream dramatically unfolds illustrates the internal conflict of the dreamer as he faces numerous professional and personal difficulties. In regard to hiding, only the most unwilling observer would fail to recognize the obvious sexual innuendos in the dream text. If indeed the dream is designed to hide its meaning, the question arises as to why the dreamer uses the most blatant and obvious symbolism (e.g., the unclean syringe or, as Erikson [1954] translated, the “dirty squirter”). In all his later work, Freud never reconciled these contradictions, preferring to steadfastly hold to his initial conclusions, despite his own work and the work of his followers. As mentioned, it was only in 1954 that Erikson, in his essay on the Irma dream, took up the challenge of reconciling the manifest dream and the latent dream—of pointing to the ego-adaptive value of the manifest, which is also connected to the deeper instinctual elements that existed below the surface. (I examine this later as well.)

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Perhaps because of all the controversy and confusion it has raised, the Irma dream has facilitated a healthy amount of discussion that continues to challenge and to encourage further study. Had Freud presented all his associations, would we have been as inclined to return to the Irma dream with so much interest 120 years later? In our fervor to find the deeper truth of this dream, we often lose sight of the real value of the analytic method—not in the acquisition of information but in the process of its discovery. Saying everything that comes to mind, feeling feelings, and establishing an ongoing relationship with a significant other all have become part and parcel of the psychoanalytic method—something that Freud was yet to fully comprehend in spring and summer 1895. He was still under the impression that hysterical problems resulted from repressed or bottled-up libido, or from sexual trauma (seduction theory) that, brought to consciousness through interpretation, would mitigate hysterical symptoms. Only years later did Freud recognize that intellectual insight often did not provide relief or cure in and of itself. Something else was needed. Thus, when we look at the Irma dream, we must keep in mind that Freud was still defining the process of psychoanalysis, and that this process would become codified only years later, with the completion of The Interpretation of Dreams and his other writings. The Irma dream provides the first glimpse of Freud’s method, and of the man who created psychoanalysis. By example, the Irma dream gives us permission to look into our own inner world, and into the inner world of another. Freud provided a frame that enables us to systematically use our curiosity about our inner experience. The world would never look quite the same again.

            Personal Context

Effective dream-work begins with knowing something about the dreamer and his or her waking world, its people and the social environment (Hall, 1953). I begin this essay by describing some of the major events that form the backdrop for the Irma dream. An enormous amount of biographical material on Freud documents this key period in his life. We also now have the complete Freud–Fleiss correspondence. Freud’s remarkable letters add to the professional biographies, and his technical writings provide an extremely detailed portrait. It is not my aim here to cover all the personal data. For that, I refer the reader to the many excellent and comprehensive biographical texts (e.g., Gay, 1988; Phillips, 2014). I also encourage the reader to seek the books of correspondence. Here I limit my focus to the biographical data that

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provide the backdrop or the psychobiographical context for the dream as well as clues to mysteries that still haunt this crucial moment in psychoanalytic history.

In a brief passage in The Interpretation of Dreams (1900), Freud succinctly listed many of the key day residues and personal contexts that influenced his dream narrative:

Certain other themes played a part in the dream, which were not so obviously connected with my exculpation from Irma’s illness: my daughter’s illness and that of my patient who bore the same name, the injurious effect of cocaine, the disorder of my patient who was traveling in Egypt, my concern about my wife’s health and about that of my brother and of Dr. M., my own physical ailments, my anxiety about my absent friend who suffered from suppurative rhinitis. (p.119)

To Freud’s comments, I add the following sampling of key personal factors present at the time of the Irma dream.

Martha’s sixth pregnancy

Martha’s pregnancy appears to connect to Freud’s financial insecurities, anxiety over Martha’s health, and numerous issues regarding sexual behavior and contraception. With its first image, the dream itself seems to move quickly into the pregnancy theme. Elaborately interpreting the marital, sexual, and pregnancy elements in the dream, Elms (1980) posited that Freud’s reference to a “… large hall—numerous guests, whom we were receiving” (Freud, 1990, p.106), meant Martha’s pregnant abdomen or uterus, a “hall,” and the children, the “guests.” Erikson (1954) observed that the German word for receive can also mean “conceive.” The next phrase, “Among them was Irma,” continues that imagery, as Irma’s real name was Anna, the source of the name the Freuds decided to give their next child if it were a girl. Freud also noted that the opening dream image anticipated Martha’s birthday party on July 26^th. Birthday obviously can have two meanings here, as Erikson suggested.

Freud’s own health problems

The year before the Irma dream, Freud suffered from a cardiac condition that left him worried about his health. Further, he experienced a number of nasal and heart-related problems as a result of his use of cocaine, whereby he allowed his Fliess to perform two nasal operations. In the year

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leading up to the Irma dream, Freud had returned to smoking cigars, against Fliess’ advice. On June 22, 1894, Freud wrote:

I have not smoked for seven weeks, since the day of your prohibition. At first I felt, as expected, outrageously bad. Cardiac symptoms accompanied by mild depression, as well as the horrible misery of abstinence. The latter wore off after approximately three weeks, the former abated after about five weeks, but it left me completely incapable of working, a beaten man. After seven weeks, despite my promise to you, I began smoking again. (Masson, 1985, pp.87-88)

In the same “gloomy times” letter quoted at the beginning of this paper (written on April 11, 1895), Freud commented on the fragile state of his health:

I do not know whether I should hold this depressing business exclusively responsible for the fact that the condition of my heart remains so much below par for this year of illness. After an interruption of several months, I started to take strophantus again so as to have a less disgraceful pulse, something that so far has failed to materialize. Mood and strength are very à bas. I plan to spend Easter with Rie on the Semmering; there I shall perhaps pick up the pieces again. (Masson, 1985, p. 124)

Being a Jewish physician in Victorian Vienna

To get a better picture of the precarious reality Freud found himself in during the spring and summer of 1895, we need only consider the two cities that defined his training and practice during this crucial period: Paris and Vienna. The Paris of Charcot was a cosmopolitan city with a beauty on par only with the ugly reality of its festering anti-Semitism, which became full-blown in 1894, when Alfred Dreyfus, a Jewish military officer, was publicly court-marshaled for treason, mostly because he was a Jew.

Victorian Vienna was no better, and by measure it was worse. It was both the cradle of intellectual and cultural achievement in the arts and sciences, and a city that in 1897 elected as its mayor Karl Lueger, who was best known for his enthusiastic, hateful rhetoric against the Jews and provided inspiration for Adolf Hitler. Lueger served five terms.

Situated in a country and society that was exuding rabid antisemitism, Vienna must be regarded as a key backdrop for Freud’s Irma dream. Blum (1994), writing on another of Freud’s famous early cases, commented:

To understand the social and cultural milieu in which the Dora case is set, it is necessary to understand something about Jewish life in Vienna toward the end of

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the nineteenth century and the endemic and growing Anti-Semitism was probably greater in Vienna than in many of the other cosmopolitan cities of the Continent. (p. 1)

Freud had not been a stranger to the direct assaults and degradation of the Jews in his homeland and abroad. He reported many instances of prejudice, such as the searing story from his boyhood, of his father having his hat knocked off his head and being forced to cross from one side of a crowded street to the other, as Jews were not allowed to walk on the same side as a gentile. In Interpretation of Dreams (Freud, 1900) he writes,

I may have been ten or twelve years old, when my father began to take me with him on his walks and reveal to me in his talk his views about things in the world we live in. Thus, it was, on one such occasion, that he told me a story to show me how much better things were now than they had been in his days. “When I was a young man,” he said, “I went for a walk one Saturday in the streets of your birthplace; I was well dressed and had a new fur cap on my head. A Christian came up to me and with a single blow knocked off my cap into the mud and shouted: ‘Jew! Get off the pavement!’” “And what did you do?” I asked. “I went into the roadway and picked up my cap,” was his quiet reply. This struck me as unheroic conduct on the part of the big, strong man holding the little boy by the hand I had contrasted this situation with another which befitted my feelings better: the scene in which Hannibal’s father, Hamilcar Barca, made his boy swear before the household altar to take vengeance on the Romans. Ever since that time Hannibal had had a place in my fantasies.” (p. 197)

Freud knew full well that, as a Jewish physician embarking on the study of sexuality, he would be subjected to professional and personal persecution and possibly expulsion, particularly if his work proved insignificant or a failure (Erikson, 1954). Although not explicit in the dream, clearly Freud was walking both on a street where gentiles walked, and on a high wire. Any negative event would be enough to derail his practice and destroy his reputation, and give the anti-Semites the kindling to further inflame the Jewish hatred embedded in Austrian culture.

Freud’s relationship with Breuer

Breuer was one of the key figures in Freud’s early pre–Interpretation of Dreams work. He was Freud’s mentor and a senior member of Freud’s professional circle. Breuer and Freud co-published Studies on Hysteria in May 1895, two months before the Irma dream. Around the time of the dream, Freud’s strong positive relationship with Breuer began to wane, in favor of the relationship Freud had with Fliess, whom he experienced as much more open and accepting of

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his evolving theories. That evening before the dream, Freud was writing Anna’s case history for Breuer—representing the key day residue and catalyst.

Early theory-formation

At the time of the Irma dream, Freud was intensely immersed in working out the relationship between mind and body.  He was deeply preoccupied with understanding the forces behind neurotic symptoms, especially how the mid represses unacceptable impulses and memories.  Freud thought forbidden human sexuality was the link, but he was uncertain in terms of understanding the relationship and correspondingly developing an effective treatment strategy (hypnosis, suggestion, catharsis, cocaine, nasal surgery to name a few). He had not yet formulated the ideas of transference, and countertransference. The notion of resistance had been taking hold with his collaboration with Breuer and the treatment of hysteria and the resistance to hypnotic suggestion. Thus, his view of the cure was ostensibly to provide patients with insights, or sometimes through suggestion, which in turn would remove the repressive barrier and thus relieve their symptoms. (See more in Freud and Breuer, 1955.)

Freud’s intense camaraderie with Fliess and the “bloody nose”

The many letters Freud sent to Fliess clearly illustrate the depth and meaning of their relationship. It has been said that these letters in a way document Freud’s self-analysis, with Fliess as the central transference figure and, as later interpreted, with Fliess as the “idealized self-object.” Freud wrote beautiful, expressive letters. Here is an example of the great camaraderie they shared, on the birth of Freud’s daughter in December 1895: “Dearest Wilhelm … If it had been a son, I would have sent you the news by telegram, because he would have carried your name. Since it turned out to be a little daughter by the name of Anna.…”

Their relationship, which was both personal and professional, directly linked to what occurred in the Emma Eckstein case in March 1895. Freud had been treating Emma for hysteria for a year. Now, in an effort to cure her symptoms, he called in Fliess to operate on her nasal cavity. What was to happen would forever change how humans conceive themselves.

Irma’s identity, like most details of the dream, has been a mystery and the subject of much debate. Max Schur, as Freud’s personal physician, was granted complete access to the Freud–Fliess correspondence. It is assumed Fliess was Freud’s primary transference figure and

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confidant during that seminal period of his self-analysis, before The Interpretation of Dreams (1900) was published. In some ways, these letters document Freud’s self-analysis. They were candid, affectionate, and thoughtful. It was evident that Fliess’ importance to Freud was in play in the unfolding drama that resulted in the creation of psychoanalysis.

The letters reveal a profoundly troubling situation brewing in spring 1895, when Freud’s patient Emma Eckstein was suffering from hysterical symptoms. Although Freud firmly believed her condition was psychosexual in origin, he sought the counsel of his colleague and friend Fliess, whose hysteria theory involved a complex linkage between the female genitalia and various small bones in the nasal cavity. It is not necessary to explain that unusual theory here, but it suffices to say Freud wholeheartedly believed it (in fact he allowed Fliess to operate on himself two times), and subjected Emma to a nasal operation performed by Fliess. The life-threatening complications soon after the surgery, and Emma’s distress, lasted many months (for reasons that will soon be fully presented). Freud recognized his patient was in dire straits and called in another ear–nose–throat specialist, who performed another operation correcting the problem. But it left Freud shaken, not only in terms of the pain he had inflicted on his patient, but in terms of the effect the potential negative publicity of the bungled medical procedure could have on his closest friend’s professional status, and on himself and his work. Emma’s case was up until then Freud’s most significant personal and professional threat, a threat that could have forever ended Freud’s dream of discovering a new science of the mind.  At the end of February, (research indicates February 22^nd or 23^rd), Fliess operated on Emma Eckstein.

It was a simple, “harmless” medical procedure; just anesthetize the nose with cocaine, then with a few quick cuts, surgically remove several key bones in the nasal cavity. Fliess, with Freud attending, expressed no concern about it, and it went as planned. But, Emma experienced post-surgery complications from nearly the very beginning. Not only was there considerable pain and hemorrhaging, but pus also began coming from her nose indicating infection (this was in a pre-antibiotic age). Freud called in a specialist who inserted a drainage tube but the bleeding continued along with a “fetid odour.” Another surgeon, Ignaz Rosanes, was called in to assess the situation. As death began to knock, her skin turned pallid and chalky. Panicked, Freud and Rosanes performed a second surgery. They discovered a terrible reality. On March 4^th, Freud wrote: “Eckstein’s condition remains unsatisfactory: Persistent swelling, going up and down, “like an avalanche”; pain, so that the morphine cannot be dispensed with, bad nights.…the day

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before day before yesterday she had a massive hemorrhage, probably as a result of expelling a bone chip the size of a heller (coin), there were two bowls full of pus… (another specialist, Dr. Gersuny) inserted a drainage tube” (Masson, 1985, p. 113).

In the two letters he wrote to Fliess on March 8, 1895, we can visualize the horrific scene:

Just received your letter and am able to answer it immediately. Fortunately I am finally seeing my way clear and am reassured about Miss Eckstein and can give you a report which will probably upset you as much as it did me, but I hope you will get over it as quickly as I did.

I wrote you that the swelling and the hemorrhages would not stop, and that suddenly a fetid odor set in, and that there was an obstacle upon irrigation. (Or is the latter new [to you]?) I arranged for Gersuny to be called in; he inserted a drainage tube, hoping that things would work out once discharge was reestablished; but otherwise he was rather reserved. Two days later I was awakened in the morning—profuse bleeding had started again, pain, and so on. Gersuny replied on the phone that he was unavailable till evening; so I asked Rosanes to meet me. He did so at noon. There still was moderate bleeding from the nose and mouth; the fetid odor was very bad. Rosanes cleaned the area surrounding the opening, removed some sticky blood clots, and suddenly pulled at something like a thread, kept on pulling. Before either of us had time to think, at least half a meter of gauze had been removed from the cavity. The next moment came a flood of blood. The patient turned white, her eyes bulged, and she had no pulse. Immediately thereafter, however, he again packed the cavity with fresh iodoform gauze and the hemorrhage stopped. It lasted about half a minute, but this was enough to make the poor creature, whom by then we had lying flat, unrecognizable. In the meantime—that is, afterward—something else happened. At the moment the foreign body came out and everything became clear to me—and I immediately afterward was confronted by the sight of the patient—I felt sick. After she had been packed, I fled to the next room, drank a bottle of water, and felt miserable. The brave Frau Doktor then brought me a small glass of cognac and I became myself again…

…when I returned to the room somewhat shaky, she greeted me with the condescending remark, “So this is the strong sex.” (Masson, 1985, pp. 116-118)

March 13^th brought more positive news – “Things are finally going well with Eckstein.”  Freud remained convinced that her symptoms are hysterical in nature.  By March 20^th, her condition was again worsening. “At noon, when they lifted the packing to examine her, renewed hemorrhage, so that she almost died…I have given up hope for the poor girl and am inconsolable that I involved you and created such a distressing affair for you.” Then, for a period from the end

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of March to the beginning of April, things remained quiet.  However, Emma soon returned to critical condition:

As soon as the packing was partly removed, there was a new, life-threatening hemorrhage which I witnessed. It did not spurt, it surged. Something like a [fluid] level rising extraordinarily rapidly, and then overflowing everything. It must have been a large vessel, but which one and from where? Of course, nothing could be seen and it was a relief to have the packing back in again. Add to this the pain, the morphine, the demoralization caused by the obvious medical helplessness, and the tinge of danger and you will be able to picture the state the poor girl is in. We do not know what to do. Rosanes is opposed to the ligation of the carotid that was recommended. The danger that she will run a fever also is not far off. I am really very shaken to think that such a mishap could have arisen from an operation that was purported to be harmless. (Freud’s letter to Fleiss, April 11, 1895; Masson, 1985, p. 125)

As the complete correspondence shows, Freud swung back and forth emotionally, from calm reassurance to profound despair. Recovery from the near-fatal surgery was extremely slow and left her permanently disfigured. Freud found himself in an extremely vulnerable position. Not only had Emma been his patient, but he had referred her to Fliess and recommended the surgery that nearly proved fatal. Freud was deeply divided; worried about his patient but he also wanted to protect his cherished colleague Fliess from accusations of medical malpractice. In a letter that he wrote to Fliess afterward, Freud reassured his friend that “You did it as well as one could do it…Of course, no one is blaming you nor would I know why they should” (Freud’s letter to Fleiss, March 8, 1895).  Fortunately for Freud, despite the disfigurement from the surgeries, Emma was remarkably forgiving and apparently continued to hold Freud and Fliess and their work in high regard, which seemed to settle the situation.  In a slightly later letter Freud wrote:

Things finally going well with Eckstein, as they could have without the detour three weeks ago. It does speak well for her that she did not change her attitude toward either of us, she honors your memory beyond the undesired accident. (Freud’s letter to Fleiss, April 1895, in Masson, 1985, p.126)

Freud’s relationship with Anna Hammerschlag

At the center of the Irma dream is, of course, Anna. Although the investigation is seemingly unceasing, it is unequivocal that the patient in Freud’s dream that night was none other than Anna Hammerschlag, not Emma Eckstein (Fichtner, 2010; Hartman, 1983; Masson, 1984). The young widow and her family had been close to Freud and his family for many years (Hartman, 1983).  Anna had developed hysterical anxiety, which Freud for the most part cured in 1895,

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though several somatic symptoms persisted that summer. It has been written that Anna was one of Freud’s favorite patients (Jones, 1953), and in fact Freud named his sixth child after her (Hartman, 1983).

Emma and Anna resembled each other in many ways. Both were young and Jewish, their hysterical symptoms were similar, and both women (Anna more than Emma) were friendly with the Freuds. Anzieu (1986), in his extensive book on Freud’s self-analysis, actually deduced that Irma is Anna from the biographical material available at the time, before Schur’s analysis.

Most writers who have reinterpreted the Irma dream are not particularly concerned with Irma’s actual identity. Langs (1984) apparently wrote his essay while under the impression Irma was Emma. He commented at the end that he had only recently learned Irma’s true identity. However, this information appeared not to bear too much on his interpretation, as the women were similar in many ways and had, at least marginally, similar relationships with the Freuds. The acknowledgment by Langs (1984) best sums up the general attitude in the literature:

Irma was actually Anna Hammerschlag, and not as Schur evidently believed Emma Eckstein. However it is important to note first that Freud had a somewhat comparable personal relationship with both Emma Eckstein and Anna Hammerschlag and their families, so that the two women shared something in common in Freud’s relationship with them. Second, even though Anna Hammerschlag was the manifest figure in the dream, there is still a great deal of evidence that among the many women and men who she represented for Freud through condensation, Emma Eckstein was of extreme importance. (p. 450)

Although Langs (1984) made an excellent point about condensation and the patients’ similarities, these women are not interchangeable. Freud’s dream came in response to a particular patient with a particular set of transferences and countertransferences, as suggested in the dream text and in his associations. I address this point in more detail in the transference, countertransference and resistance sections of this paper.

The Irma Dream and the Clinical Use of Dreams: Differing Perspectives

Even if one disagrees with his theories, Freud’s work has forever changed the way we look at dreams. In publishing The Interpretation of Dreams (1900), Freud set in motion an intellectual and scientific movement that continues to flourish 120 years later. Perhaps of all the dreams Freud reported, the Irma dream gains its significance by virtue of its primacy and the depth

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treatment Freud gave to it. In a sense it serves as the foundation of psychoanalysis, with free association and wish fulfillment as its twin pillars.

It is obvious that Freud was incomplete in his interpretation of the Irma dream—he tells us so. Although Freud added a number of explanatory footnotes through the years in subsequent printings, he mostly let his understanding and interpretation stand as it was first published. If Freud was unaware of the deficits in his analysis (which is very doubtful), the circle of people whom he surrounded himself clearly made it known to him. In his 1911 letter to Freud, Carl Jung, then student of Freud, implored him to reconsider his holding back on the associative, more “personal” material:

I also miss a specific reference to the fact that the essential (personal) meaning of the dream (e.g., Irma, etc.) has not been given. I insist on my students learning to understand dreams in terms of the dynamics of libido; consequently, we sorely miss the personally painful element in your own dreams. Perhaps this could be remedied by your supporting the Irma dream with a typical analysis of a patient’s dream, where the ultimate real motives are ruthlessly disclosed, so that the reader we will realize (right from the start) that the dream does no disintegrate into a series of individual determinants. … In my seminars we always concentrate for weeks on The Interpretation of Dreams, and I have always found that inadequate interpretation of the main dream examples leads to misunderstandings and, in general, makes it difficult for the student to follow the argument since he cannot conceive of the nature of the conflicts that are regular sources of dreams. (The Freud/Jung letters, McGuire, 1974, pp. 393–394)

Freud replied:

You have very acutely noticed that my incomplete elucidation of my own dreams leaves a gap in the overall explanation of dreams, but here again you have put your finger on the motivation-which was unavoidable. I simply cannot expose anymore of my nakedness to the reader. Of each dream, consequently, I explain only as much as is needed to bring out a specific point; one throws light on the dissembling, the second on the infantile material, the third on wish fulfillment. In none do I bring out all the elements that can be expected of a dream, because they are my personal dreams. … So even if the critic and the seminar are perfectly right, the author cannot do anything about it. The book proves the principles of dream interpretation by its own nature, so to speak, through its own deficiencies. (The Freud/Jung letters, McGuire, 1974, pp. 394–395)

In the same letter, Freud goes on to discuss a new book on dreams that he is working on with the help of Otto Rank that would be designed to address the criticism that Jung mentions. This book never materialized.

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Freud also was confronted by Karl Abraham (in his January 1908 correspondence), with having omitted this erotic interpretation: “I should like to know whether the incomplete interpretation of the [“Irma’s Injection”] dream is intentional. I find that trimethylamine leads to the most important part, to sexual allusions, which become more distinct in the last lines” (Abraham and Freud, 1965, p. 19).

Freud responded to Abraham with slightly more detail:

Sexual megalomania is hidden behind it, the three women Mathilde, Sophie and Anna are my daughters’ three godmothers, and I have them all! There would be one simple therapy for widowhood, of course. All sorts of intimate things, naturally. (Abraham and Freud, 1965, p. 19)

Although Freud held fast to his position about the specimen dream, his followers had difficulty reconciling the various incongruities and contradictions that somehow lead to the conclusion that dreams are primarily expressions of infantile wishes. In truth, Freud did not accomplish what he set out to do with the Irma dream. His analysis does not prove that all dreams are wishes or they originate from unconscious infantile sources, or have no value in their remembered or manifest form, and even, a product of memories. Yet, despite this, the notion that an individual can methodically explore one’s inner self captured the imagination and interest of psychologists and philosophers in the decades ahead. As Grünbaum (1984) aptly pointed out, “the Irma dream gains its significance largely through its method.” Let us look at this method.

The basic tenets of dream analysis are to remember a dream, verbalize it, and then return to each section and say whatever comes to mind without restriction—that is, free associate. The train of associations will eventually lead to earlier memories and feelings that form the basis of the dreams latent content. The analyst should not be distracted by the manifest content, even if it appears important or makes sense, since it is merely a disguise, designed to hide the forbidden instinctual wish that lives underneath.

The beauty of Freud’s method lies in its simplicity. The dreamer’s task is clear and straightforward. Furthermore, and perhaps most important to clinicians, —the responsibility for the interpretation rests with the dreamer, and not with the clinician (although that has often been misunderstood). The dreamer establishes his or her own interpretation based on their own idiosyncratic memory traces, not the clinician’s intuition or expertise. It is this part that is essential to understanding why Freud steadfastly held to his theoretical and technical ideas

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concerning the clinical use of the manifest dream. The key element in the associational method is the process itself, not necessarily the content of what is uncovered. As Freud was to discover in the years ahead, something seems to happen to people when they are instructed to say everything. What happens is—they resist. It is the analysis of this resistance that opens the door of unconscious memories related to early development, and that facilitates the emergence of Freud’s other major discovery, transference.

From this position, if a clinician interprets a dream or intuits its meaning to a patient from the manifest text, the clinician short circuits the associative process, thus neutralizing the resistance and transference, the heart of psychoanalytic treatment. The effect of telling a patient the meaning of a dream, is like that of telling someone before entering a mystery movie the ending, at the point the person feels, why bother watching the movie. To give a dream its meaning removes the psychological energy and motivation for self-exploration. In this paradigm, the clinician is the active participant and the patient is passive. Other difficulties arise since the clinician is set up as an authority figure, much like the shamans of ancient times, having the secret ability to decipher mystical symbols and signs. The consequence of this is that the patient is encouraged to develop and unhealthy dependency, looking to the therapist for answers, thus withdrawing energy toward taking responsibility for their own functioning.

As with Erikson’s essay, many writers have returned to the specimen dream with the aim of presenting an alternative way of working with dreams in general. Thus, through the years the Irma dream has become a kind of template. Rather than adding any specific methodological innovations to dream analysis, nearly all the authors provide alternative conceptual models that suggest different ways of looking at dreams. As Elm’s points out, the many alternative interpretations do not necessarily compete, but are rather complementary, much like the function of a tailor’s multi-pane mirror. Each interpretation provides a unique point of view of the same subject. By no means does the following review represent a full accounting of the many approaches to the specimen dream, but rather a sampling reflecting some of the key re-interpretations.

From a classification standpoint, the various essays could be grouped into 6 key points of view, although the points of view are not exclusive: libido theory, ego psychology, cognitive/problem solving, self-psychology, modern psychoanalysis, and analytic psychology.

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Libido theory

Ironically, although it was Freud who gave us libido theory, his analysis of the Irma dream does not directly support this perspective. In fact Freud’s analysis yields much more easily to an ego-psychological perceptive with its emphasis on current emotional concerns, conscious and pre-conscious conflict and problem solving, rather than infantile instinctual impulses. Thus, we must go one of the founders of ego psychology, Erik Erikson, to find the first major interpretation of the Irma dream in relation to libido theory.

Erikson builds his interpretation from a number of key memories built around strong oedipal themes, competition for the woman’s favor, and a fear of castration (Chamber pot, “the boy will amount to nothing”). Erikson is the first to call attention to the highly sexualized underpinnings of the manifest text. Fluent in German, Erikson was able to flesh out the nuances of Freud’s use of language that was lost in Strachey’s translation. In so doing, he was able to pick up on a number of double meanings in Freud’s use of words that support the latent sexual feelings, such as the colloquial re-translation of the unclean syringe to the “dirty squirter.”

Anzieu (1986), in a comprehensive analysis, saw the Irma dream as the beginning steps in Freud’s self-analysis. Anzieu, in a thorough reconsideration, stresses the strong sexual conflicts as the key predominate latent features. Many writers have recognized the sexualized material in the manifest content, but only a few, such as Erikson, have been able to link the material to Freud’s early history, necessary if one is to conceptualize the dream in terms of libido theory. Mautner (1991), in a very thoughtful and well-researched analysis, convincingly demonstrated the link of the Irma dream to key early memories concerning unresolved sexual and aggressive feelings directed toward his younger sister (who happens to be named Anna). Mautner found support for her hypothesis by the very fact that Freud avoided focusing in the erotic-aggressive underpinnings of sibling relationships in his large body written work and correspondence. Just a cursory review the dream tells us that the dream starts on a note of intimately entering a woman (Irma), then leading to the middle section where men are in competition with each other, with Freud as the dominant figure and ending on a “dirty squirter” and a displaced sense of guilt. Thus, by projecting his guilt and self-reproach, he is freed to figure out the chemical involved in his patient’s illness “propyl, propyls … propionic acid … trimethylamine.” There is a bit of a pun in the language at the end of the dream, suggesting things to come, with the three chemical words using pro from the Greek “before, in front of” and the last word beginning with the tri

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from the Greek meaning “three,” leading to the question, what exists before three? Freud gets the last word and the hint to where he is going in his research, suggesting the earlier processes need to be worked out before you can have the confidence to face the “three,” that of course is the Oedipus complex, the next maturational step, which became the cornerstone of his theory of neurosis.

Ego psychology

We should always be aware to differentiate between the esoteric study of dreams, much like how archeologists study hieroglyphics, and the study of dreams for therapeutic purposes. Erikson used the Irma dream as an opportunity to offer a new way of approaching dream data from an ego psychological perspective. Despite his innovations, in no part of the article does he present any modifications in the technique of dream analysis, beyond Freud’s methods. His goal was primarily to challenge the habituated orientation of classical analysts and offer a different way to listen to dreams, and in so doing, enable the clinician to emotionally and intellectually resonate with the patient’s material in a deeper and more comprehensive way.

Erik Erikson, in his comprehensive essay, provides not only an alternative way to look at the Irma dream, but a way to work with dreams in general. Much like Freud’s original purpose for the Irma dream, Erikson returned to the dream specimen as a teaching tool. The Irma dream in Erikson’s hands becomes a template to present his Outline for Dream Analysis. In 1954, Erikson was one of the first of the neo-Freudian analysts to strongly advocate working with the manifest dream or remembered dream. It is true that others, most notably Jung and Stekel, had long been advocating the clinical use of the manifest content. However, it appears it was Erikson’s eloquent and practical presentation that provided a clear theoretical rationale to working with so-called surface phenomena while still keeping a foothold in traditional psychoanalytic metapsychology.

By extending his theoretical formulations from libido theory, with its emphasis on what lies below, to ego psychology and the question of identity and adaptation, Erikson (1954) provided a clinically sensible framework in finding the value to what is on the surface:

Unofficially, we often interpret dreams entirely or in parts on the basis of their manifest appearance. Officially, we hurry, at every confrontation with a dream to crack its manifest appearance, as if it were a useless shell and to hasten to discard this shell in favor of what seems to be a more worthwhile core. When such a method corresponded to

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a new orientation, it was essential for research as well as for therapy; but as a compulsive habituation, it has since hindered a full meeting of ego psychology and the problems of dream life. (p.17)

Erikson’s formulations on the Irma dream led to two main innovations that were picked up in various ways in the ensuing articles. The first innovation is that the dream in its manifest configuration and content serves as a vehicle for problem solving. Second, the manifest content could be looked at as a projection, embodying the major life crisis and developmental tasks.

The advent of ego psychology ushered in a new era of study emphasizing adaptation, behavior and identity. In other words, the shift of focus went form the study of the unconscious to the study of adaptive consciousness. Who we are, how we relate, how we problem solve, how we see ourselves, how we learn and live in our daily lives, became the fundamental questions that researchers began to examine.

It stands to reason that what we think about during the day should be on our minds at night when we sleep. In a nutshell, this appears to be the key feature of a large percentage of the various reinterpretations of the Irma dream. Authors such as Elms, Langs, Schur, Erikson, Blum, Greenberg, and Pearlman pick up on a particular area of Freud’s life and review the dream text and associations to find correspondences, either direct or symbolic, that confirm their hypothesis. Interestingly, depending on the author and their particular theoretical orientation, any one piece of data can have numerous meanings. Here’s just a brief collection of interpretations about Irma’s throat examination by Freud: gynecologic examination, sexual intercourse, displaced homosexual wish, examination of Martha, examination of Anna O., examination of Emma Eckstein, self-examination, a representation of a typical medical examination, a sexual/ aggressive act against his younger sister, Anna, and an attempt to force an interpretation onto a patient. Based on the large biographical data available, what is interesting is that each interpretation appears to have some degree of validity.

Collectively reviewing the large body of interpretations, Freud had a lot on his mind on July 23, 1895. Somehow, the Irma dream embodies all these constructs. Remember, the throat examination is but one section of the dream, each other sequence just as loaded. No wonder Freud choose not to give a full accounting of the latent content—The Interpretation of Dreams would have been about 300 extra pages!

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The notion that any dream carries with it the embodiment of every major developmental task and life problem is both not provable and just plain ludicrous. Erikson’s position was: when we listen to a dream we should not only consider the so-called deeper meanings but view the dream in the context of the dreamer’s total life situation that’s total with a capital T.

Grinstein (1980) sticks closely to Freud’s associations in his re-analysis. He appears to work from the position that to know the dream one must know the dreamer. Essentially, Grinstein (1980) presents the key references listed in the dream text and associations, which enables the reader to get a clear sense and full meaning of the Irma material in the life context from which it emerged. He provides a thorough review of Freud’s significant relationships and key personal and professional events, and how they interweave into the manifest and latent material. Like a good detective, Grinstein follows up on most of the clues Freud teases us with. For example, Grinstein (1980) seems to be the only writer who picked up on Freud’s literary reference to Leopold and Otto, comparing them to the two characters of Brasig and Karl, from a well-known Austrian story by Fritz Reute called Ut mine Stomtid (An Old Story of My Farming Days), suggesting Freud’s reference to both oedipal and homoerotic elements.

Grinstein (1980) concisely provides an overview of the Eckstein Affair, Martha’s sixth pregnancy, the strain between Freud and Joseph Breuer, his protective and idealized relationship with Fliess, and the sexual countertransference towards the patient as the key factors that form the inter- and intrapersonal contexts for the dream. Grinstein (1980) concludes:

What seems to be the most significant insight that Freud gained from this dream was that by systematically following the associations to the various dream elements, it was possible to see the existence of impulses and emotions that were not readily apparent in the manifest content and in this way understand the meaning of the dream as a whole. (p.46)

Cognitive/problem-solving models

The problem solving dynamic of the manifest content highlighted by Erikson’s essay inspired a great many essays building on this notion of how the manifest dream demonstrates the minds attempt to come to terms with some waking dilemma (Hall, 1953). Kuper and Stone (1982) suggest an alternative method to dream analysis, which borrows from Levi-Strauss.  I label Kuper and Stone’s approach a problem-solving model, which somewhat resembles French and Fromm’s (1964) problem-oriented dream interpretation model. The authors primarily rely on

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the manifest text as the focal point of analysis. They suggest that how dreams emerge within an individual is analogous to how myths develop within a culture. They posit that the dream is structured as a “kind of argument, which proceeds from step to step by a quasi-logical dialectic” (Kuper & Stone, 1982, p. 1226). The framework they use has four basic assumptions:

1. Two conflicts or terms are in conflict or opposition in the manifest content.
2. The dream provides a medium of that conflict.
3. The dream follows a pattern or sequence of steps working toward the solution.
4. There is a coherent progression between stages.

The most original element in their interpretation involves the recognition of Freud’s unique position in terms of his struggle to create a new theory of human nature in opposition to the established medical practice and theory of his day. Thus, it becomes the focal conflict that the dream attempts to address. They call attention to the similarities between the activity in the manifest dream and a typical hospital medical examination that Freud must have engaged in countless times—which would account for the various consultants and competing diagnoses. Phenomenologically, the dream illustrates a number of back-and-forth discussions, in an attempt to come up with a suitable diagnosis. The key elements involve whether Irma’s symptoms are psychogenic or physical in nature, a result of something internal, or a result of some other factor, such as poor medical practice. The authors suggest the dream moves in a progressive manner, moving from the (external) superficial to the deeper truth (internal), from the top of the body (head) to the lower part (anus). The notion of the elimination of toxins appears to be a reference to Breuer and the cathartic method, while the presence of trimethylamine calls attention to sexual factors and Fliess. Kuper and Stone (1982) asserted that the dream “is constructed as a series of similes” (p. 1232), substituting physical constructs for psychological ones. Thus, the dream ultimately can be understood as an argument about the central concern in Freud’s professional life, understanding the connection between the mind and body. Freud’s solution, which is affirmed by the presence of trymethylamin in the dream, is that sexuality provides the connection between the mind and body.

Hudson (1986), in a similar approach to Kuper and Stone (1982) and to Wax (1996), viewed the dream as a myth or poetic invention. Hudson (1986) suggests three frames to uncover

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the meaning of dreams: the waking context, the style of the dream itself, and how the dreamer assimilates the dream into their life.

In the case of the Irma dream, Hudson (1986) approaches the dream as a symbolic dialectical argument, whereby the dream text is a form of response to a waking problem(s). The dreamer then lays out the problem and various counter responses and solutions, leading to some final solution. With the Irma dream, Hudson (1986) views the Emma Eckstein incident as the primary waking stimulus for the dream. Further, he discusses at length Freud’s intense idealized relationship with Fliess, and his personal sexual issues, as other key waking elements. Hudson (1986) posits that the central problem that Freud addresses in the dream text is his struggle to let go of his sexual passions, pointing to the fact that Freud in the dream blames the younger colleague Otto for having the “dirty squirter.” Essentially, Freud was symbolically giving up his sexual passion replacing it with his passion for the construction of psychoanalytic theory. Hudson (1986) finds support for his interpretation through biographical data indicating Freud may have given up sexual behavior after the birth of Anna.

Greenberg and Pearlman (1978) use Erikson’s ideas on the manifest content as a medium for problem solving and adaptation. Essentially, they return to Irma, this time with the benefit of Schur’s material, and attempt to find the correspondences between the Eckstein affair and the dream text. In their view, the Eckstein affair, which embodied Freud’s relationship with Fliess, was the central catalyst for the Irma dream. The authors observe an “amazing fit…between Freud’s discussion of the manifest and the latent content and the description of Emma’s difficulties” (Greenberg & Pearlman, 1978, p. 72). Other researchers, such as Griffin (2007), were able demonstrate a very compelling correspondence (supporting Schur’s analysis) between the manifest dream narrative with each member in the cast of dream characters linking to an actual person involved with the diagnosis and treatment of Eckstein. The conclusion emerging is that the dream of Irma’s injection is organized as a metaphorical reenactment, using substitute figures, of the dilemma of those dark days that spring.

The above authors primarily view the manifest dream as a metaphorical representation designed as a medium for problem solving, that “the manifest dream can portray, in a partially disguised manner, events and issues which are central to the dreamer’s current emotional concerns although the dreamer may not be aware of that fact” (Greenberg and Pearlman, 1978, p.71). The authors contend that the central emotional concern the dream was attempting to

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address involved Freud’s ambivalence toward his friend Fliess. They were convinced Freud must have felt “disappointment and anger” at Fliess for the Eckstein affair, which conflicted with Freud’s intensely positive feelings for Fliess. The dream text appeared to be aimed at finding blame elsewhere, thus exculpating Fliess, yet simultaneously knowing the truth.

Greenberg and Pearlman’s (1978) essay, as well as Griffin’s (2007) detailed analysis, does show how a dream text could be used in order to ascertain how the dreamer use’s ego defenses in an effort to resolve a pressing issue.

Although compelling, there are some caveats in their analysis.  First, the centerpiece of the dream is Anna Hammerschlag not Emma Eckstein. Thus, the dream emerges from a different interpersonal context, which the authors conveniently dispense with. The second, despite the fact that there is a strong correspondence between the manifest dream and the Eckstein affair, the correspondence is of course conjecture, nothing explicitly directly links the two narratives. In fact, Anzieu (1986) made a compelling case linking the key backdrop may be Anna O’s treatment, which also shares similar features, that also involves Breuer. The fact of the matter is that Freud had many cases during this period that he used Fliess as well as others as consultants, any of which could have served as a catalyst for the dream. The third area relates to the deduction that Freud was “disappointed and angry,” or disenchanted, with Fliess over the Eckstein incident, which years of written record does not support, and in fact the trove of letters over the next five years show the opposite was true.

Self psychology

The self psychological perspective organizes around the way an individual maintains his or her sense of integrity and identity in the context of the interpersonal environment. In this perspective, the self, at certain periods, is extremely vulnerable to injury. In response to an injury, depending on the degree and quality of assault, and at what period it comes in the individual’s life, the individual could suffer a range of hurt—from a minor injury, to lowered self-esteem, to major injury which could result in complete self-fragmentation. However, for others, a narcissistic injury could be the source of inspiration and creativity as a form of reparative counter- organizing event. For Kaplan (1984), the Irma dream was dreamt by Freud as a means to refortify himself in the face of a narcissistic injury, as a result of Rie’s comments about Irma’s condition. From this perspective, the fact that Freud was, in a manner of speaking, off balance,

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appeared to provide an opportunity to creatively address the Irma dream, and the notion of dreams in general, through which he developed his method of interpretation. Kaplan (1984), quoting Kohut, writes that when an artist “is threatened by a loss of a self, be it structural deficit or temporary enfeeblement, he attempts to feel whole again by offering his product as a perfect self to be confirmed by an admiring world” (Kaplan, 1984, p. 375). The product that Kaplan alludes to is, of course, psychoanalysis.

In a related perspective, Resnik (1987) offers a number of creative interpretations of the Irma dream. Resnik (1987) roots Freud’s interpretation and clinical attitude with the broader Victorian mentality, equating the medical notion of causality with the need to find blame, a prominent feature in the dream text.

Resnik (1987) calls attention to the powerful struggle to reconcile Freud’s attachment to his physiological-medical training and “his new ideas on the psyche,” which involved the psychogenic underpinning of physical disorder. Freud was in a profoundly unique and narcissistically vulnerable position during this period. On one hand, he was establishing a line of ideas that completely alienated him from the established line of medical thinking. On the other, he was advocating a theory and therapeutic techniques that were only partially effective, ones Freud himself had major doubts about. There appears to be a relationship between Freud’s medical orientation and its cause and effect notions, and the countertransference frustration that emerged in the dream and treatment. In essence, that Irma refused his solution was experienced as if she was foolishly unwilling to take her medicine. In this new treatment, the medicine is not a physical solution, but rather a verbal one. Her refusal or recalcitrance seemed to impact Freud’s self-esteem. Further, his sense of narcissistic injury was heightened since Irma was a member of a group of select friends close to the Freuds. In other words, a lot of Freud’s credibility was riding on Irma’s treatment. A failure with Irma would have repercussions on a personal level and a setback, as well as a failure, of his new theoretical direction.

Resnik (1987) bridges the notion of Freud’s narcissistic vulnerability to his underlying sense of physical vulnerability, which plagued him throughout his life. Many authors have noted that in the merger between Freud and Irma, Irma’s infiltrated shoulder led to Freud’s association to his own shoulder pains, which he attributed to rheumatism (one wonders if he also thought of his heart condition). Resnik (1987) asserts that “the Irma dream poses the problem of the psychoanalyst’s drama in relation to his own body, to his own sexuality, to his mental and

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physical health” (p.87). In an extended footnote at the end of Resnik’s 1987 essay, the discovery of the white patches in Irma’s throat appears to represent a projection of Freud’s own physical concerns, particularly a fear of cancer, prompted by his smoking (he just returned to smoking cigars again). Resnik (1987) brought up the interesting notion that the unconscious has some hyper attentive ability to recognize illness that would be out of the awareness of the conscious mind. He takes this view with the Irma dream. Resnik (1987) quotes cancer specialist and historical researcher, Jan Schaulzon, “The large white scab in the dream of Irma’s injection is, therefore, his own leucoplasic lesion” (p. 94). Resnik (1987) considers the white patches to be Freud’s anticipatory awareness of the mouth cancer, which, of course Freud developed about 25 years later. In some ways the Irma dream could been seen as an inventory of Freud’s narcissistically vulnerable areas, particularly in the area of his physical health, suggesting a strong identification with Irma in the manifest text.

Modern psychoanalysis

There have been two notable attempts to interpret the Irma dream from the position of pre-oedipal object relations and drive states (Spotnitz & Meadow, 1976; Geltner, 1984). This perspective, labeled modern psychoanalysis, emphasizes the role preverbal life of the infant in relation to their significant others as the primary organizing experience in human personality and the development of psychological illness. Strong emphasis is placed on the aggressive drive and its relation to maturational processes and illness.

Spotnitz and Meadow (1976) posit that “the dream symbolically represents what is going on in the psyche, including knowledge or organ neurosis. If we want to understand the deepest layers of the personality, the most direct path is to study the contents of dreams” (p.94). The authors draw a connection between the pre-verbal cognitive and communicative abilities of the infant and the mostly visually oriented qualities of the dream, suggesting a strong correspondence. In other words, dreams emerge from that part of the psyche “where there are no words.”

Spotnitz and Meadow (1976) approach the Irma dream from the perspective of the pre-oedipal unconscious determinants. In their view, Freud had experienced a narcissistic injury as the day residue, but it appeared to resonate, perhaps on the deepest level of Freud’s being. Through an elaborate linkage, particularly through reversal, they view the dream as

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simultaneously expressing Freud’s pre-oedipal murderous and incestuous feelings toward his mother (illustrated through Freud’s treatment of Irma), coupled with a primitive sense of maternal rejection (illustrated in the same relationship this time with Irma as substituting for Freud). They find support for their interpretation through various bits of biographical data that organize around Freud’s self-hate and his sense of culpability in the death of his two year old brother.

Building on Spotniz’s and Meadow’s analysis, Geltner (1984) posited that the “manifest content of this (“Irma’s injection”) dream is dominated by symbolic expressions of pre-oedipal aggressive drives” (p. 195). He further states:

The numerous characters in the dream may represent different aspects of the dreamer, the dreamer’s pre-verbal objects, or both at the same time. The contradictory symbolism of the dream reflects the confused object relations of the pre-verbal period. “Irma’s injection” is a highly condensed memory of the vicissitudes of anxiety and aggression that Freud experienced in his pre-verbal relationship with his mother. (Geltner, 1984, p.197)

Geltner (1984) supported his interpretation by using Schur’s (1966, 1972) material about the Eckstein cases and Freud’s intense identification with Fliess, describing Fliess’ theories as a “delusional … symptom of homicidal wishes directed toward women” (Geltner, 1984, p. 194). Thus, by association, Freud’s involvement with Fliess, and his attempt to exculpate his colleague, reveals Freud’s unconscious aggressive impulses. He returned to the manifest content and translated the material based on pre-oedipal aggressive factors: “We can see that a significant portion of the manifest content of this dream is an expression of aggressive drives which are derived from every major pre-genital erotogenic zone-respiratory, oral epidermal, anal, and phallic” (Geltner, 1984, p. 197).

Geltner (1984) concluded his analysis by suggesting (borrowing a remark by Ella Sharpe) that the underlying wish to become an analyst may be aggressive. Thus, the Irma dream reflects Freud’s pre-oedipal aggressive impulses and counter defenses, that link to preverbal earlier object relations. Ultimately, the creative leap Freud makes in his discovery of dream interpretation is actually a reparative gesture, turning what once was destructive into something that heals.

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Although Geltner (1984) made a compelling case for his interpretation, he, like Erikson, appeared to substitute his associations to the dream as if they were Freud’s. Further, the fact that Geltner (1984) used Schur’s misidentification seems to skew the material and understanding into a particular direction that leaves out the actual dynamics between Freud and the real patient. Last, Geltner (1984) seemed to discard the fact of Freud’s long gestation that led to the discovery of the unconscious and dream interpretation, assuming that the impetus for Freud’s creative leap was mostly based on a reparative gesture seems too constricted.

Analytic Psychology

After this rather long and twisty stroll, the reader may be experiencing interpretation fatigue, coming to the insight that there is nothing better than creative dream analysis, and nothing more numbing than analyzing someone else’s dream, even if that someone else is Sigmund Freud. However, if the reader remains game for one more poke at the Irma dream, this will bring us full circle to Freud’s great prodigy, who later became his strongest critic, Carl Gustav Jung. Although Jung was not a player in the cast of Irma characters, his presence comes soon after and speaks to the enduring quandary of Freud’s dream specimen. Jung’s early influential role is best exemplified in a letter written by Freud to Jung, dated January 19, 1909, in which he declared, “We are certainly getting ahead; if I am Moses, then you are Joshua and we will take possession of the promised land of psychiatry, which I shall only be able to glimpse from afar” (McGuire, Ed., 1974, p.125-126).

Jung, a Swiss protestant clergyman, didn’t carry the emotional/psychological baggage of a Jew practicing psychoanalysis in Vienna. And, unlike Freud, he was a man of substantial means. Jung thought big and dreamed big, gods and the devils raging upon the swirling battlefield of the collective human experience, marching forward to the siren’s call. Freud’s theories were of a different notion. They came from a location of a personal intimate nature, a psychology of the hidden and individual’s quest to escape persecution from guilt. It is interesting to note Jung’s vision of manifest dreams as being representational, revelatory, he writes; “… the dream is a spontaneous self-portrayal, in symbolic form, of the actual situation in the unconscious” (CW 8, p. 505).

I guess for a successful protestant psychiatrist living in Switzerland, what’s to hide? Jung writes, “the manifest dream picture is the dream itself and contains the whole meaning of the

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dream…We say that the dream has a false front only because we fail to see into it” (Jung, 1931, p. 149). This, of course, is directly in opposition to Freud’s view of dream symbols, which hide the dreamer’s intent, akin to neurotic symptoms.

Jung’s ideas offer great color to the interpretation of the Irma dream. The dream is a dynamic narrative template, revealing as much as hiding. Jung saw dreams as carrying the energies of humanity, that the dream itself was an object that makes us human and connects us to our genetic histories. He writes, “Thus we speak on the one hand of a personal nature and on the other of a collective unconscious, which lives at a deeper level…The ‘big’ or ‘meaningful’ dreams come from this deeper level….Such dreams occur at the onset during a critical phase in life….For these archetypal products are no longer concerned with personal experiences but with general ideas” (Jung, 2010, p. 77). Jung would talk about the archetypal patterns inherent in the DNA of “big” dreams. Certainly, the dream of Irma’s injection is the very definition of a “big” dream.

Concerning initial dreams, Jung writes: “It frequently happens at the very beginning of the treatment that a dream will reveal to the doctor, in broad perspective, the whole programme of the unconscious” (Jung, 2010, p.106). Robert Bosnak (1986) adds:

If the dream of Irma’s injection is taken as the archetypal revelation of psychoanalysis, revealing the whole program of its unconscious, and not only as an expression of the person Sigmund Freud, then the images portray a preview in nuce of the psychoanalytic domain: the initial dream of psychoanalysis. In the metaphor of current genetics, a genetic code is a blueprint to be repeated in each ensuing cell; thus psychoanalysis would be an endless variation on the Irma dream. (p.110)

The Irma dream would be considered an origin, or birth, dream (Bosnak, 1986). We know this because of what had resulted from it, the birth of the associational method that was sine qua non of psychoanalysis. It is a dream narrative that reminds us of the primitive tribal council, a circle of elders helping in the process of a healing or perhaps a delivery. Thus, the notion of healing, in and of itself, the actual idea of healing is what is being delivered, and by extension, the archetype of the “healer” is presented.  By looking into the mouth of the primordial mother-earth (archetype), the elders had discovered a “dirty” truth. That is, that despite the obstacles, going inward liberates the individual to figuratively come out. We can go further into the archetypal notion of man entering a woman, and the result of that co-mingling (non-sexual) is the creation of something new. As Jung (1972) describes, “Woman with her very dissimilar psychology, is

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always a source of information about things for which man has no eyes” (p.188). The Irma dream is replete with the archetype of “Anima and Animus,” the demonstration of the feminine and masculine. Essentially, the Irma dream is a dialectic between Freud’s feminine and masculine archetypes. The “men” are confused about the nature of a woman, which is represented in the dream narrative. In other words, it could be considered that the feminine aspect of a man, the sensitive, loving, and care-giving, following traditional archetypes (Anima), represented through Irma, are hidden behind the probing authoritative physician-persona (Animus). This enabled Freud to face the feminine within himself, and so doing gave rise to the what was to become Freud’s new awareness. Confrontation and confusion about the feminine was a continuous dilemma for Freud even thirty years later. In The Question of Lay Analysis, Freud (1926) wrote, “The sexual life of adult women is a ‘dark continent’ for psychology” (p. 212).

For Jung, Freud’s dream would be considered a “big” dream, carrying the archetypal symbolic energy that is transmutative. A dream like this will happen, then the next day the dreamer’s world is forever changed, with the caveat that dreamer must pay close attention to it. “Big” dreams happen to everyone, from all walks of life, and what gives the dream its significance is the act of not ignoring it. Freud, on July 24, 1895, did not ignore the Irma dream. He did the exact opposite—he unpacked every element and discovered he was carrying an awfully big suitcase, enough to fill the next century and beyond. I believe the Irma dream itself filled almost one page, and the analysis fills thirteen, and of what he left out, he could have filled a few dozen more.

Freud and Jung vehemently disagreed on these, and other, matters which resulted in a complete falling out. Following a volley of angry correspondence with Jung, Freud waited two weeks and then wrote on January 3, 1913, “I propose that we abandon our personal relations entirely” (McGuire, 1974, p. 539). In the wake of their parting, both men held to one fundamentally similar belief—that the dream and its analysis were the centerpiece for understanding of the human condition.

Frame 3: Clinical Organization of the Material

The Irma dream is first a dream about a patient. It emerged in relation to a clinical situation when Freud was developing his theories and technique of psychoanalysis. Thus, I found

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that the most natural organizing frame for approaching this large collection of material is the grouping of interpretations (including my own) into the three basic psychoanalytic-clinical factors of transference, resistance, and countertransference. Within each large category are several related subcategories. The categories break down as follows:

1. Transference
   1. Irma toward Freud
   2. Freud toward Fliess
   3. Freud toward Breuer
   4. Freud toward himself
2. Resistance
   1. Irma toward Freud
   2. Freud toward himself
      1. Resistance to the discovery of psychoanalysis
      2. Resistance regarding the relationship with Fliess
3. Countertransference
   1. Induced
   2. Subjective-day residue
      1. Current emotional concerns
      2. Infantile/childhood issues

Transference

Building on Freud’s definition of transference, Greenson (1967) offers an expansive view of the phenomena which reflects more of the contemporary position.  He writes, “Transference consists of any components of an object relationship, i.e., it may be experienced as feelings, drives, wishes, fears, fantasies, attitudes, and ideas or defenses against them” (Greenson, 1967, p. 152).  The people who were the original sources of transference reactions are the meaningful and significant people of early childhood (Greenson, 1967, and Freud, 1912). And, important in this work, “Transference occurs in analysis and outside of analysis… All human relations contain a mixture of realistic and transference reactions” (Greenson, 1967, p. 152).

The Irma dream leads us to consider the possibility of four transference relationships: feelings Irma (Anna) had toward Freud; feelings Freud had toward friend and colleague Fliess;

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feelings Freud had toward Breuer, the senior member of his professional group; and feelings Freud had toward his own dream.

Irma’s transference toward Freud, the Janus face

When looking at the Irma dream in terms of transference, I am drawn to mythological figure described as the “Janus” face.  Perhaps I take inspiration from Freud himself, who regularly turned to ancient myths and fables to provide the psycho-historical context that energized his theory of human instincts.  The Janus figure was attributed to the Roman god of doorways and archways, after whom the month of January is named. The figure is mostly depicted as a double-faced head facing in opposite directions and is thought of as a deity of beginnings. This idea is of course especially noteworthy when thinking about the place in psychoanalysis that the Irma dream represents. The worship of Janus dated back to the earliest years of Rome, and the city had many freestanding ceremonial gateways called jani, used for symbolically auspicious entrances or exits (comings and goings). Thus, the Irma dream represents the auspicious entrance into unconscious process that Freud leads us into.

The Janus figure also reflects two sides of the same object, both connected, yet in opposition.  In Taoist tradition, this is best seen in the Yin-Yang image, visualized as two teardrops, one black one white, spooning-like, conjoined—though at opposite positions, they form one circle. In this symbol, the curves and circles of the Yin-Yang symbol imply a kaleidoscope-like movement. This suggested movement represents the ways in which Yin and Yang are mutually activating, interdependent, and continuously transforming, one into the other. One could not exist without the other, for each contains the essence of the other. Night becomes day, and day becomes night. Birth becomes death, and death becomes birth. Perhaps there is no better description of the transference-countertransference relationship, how one arises from the other, which in turn in turn influences the other, and in exchange something new emerges. As researched, the Yin-Yang is also a symbol that denotes the primordial notions of masculine and feminine, which indeed form the very bedrock of the Irma dream.

Since the Irma dream is a countertransference dream, it only represents one face of the Janus. The other face is represented by Anna’s actual transference, the other face as Freud’s Yin to Anna’s Yang. Unfortunately, since the “case history” Freud wrote to Breuer did not survive, we can only intuit the other face from the face we can see.

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At the heart of the matter is Irma’s (Anna’s) transference toward Freud, which is only inferred from the written material. We should keep in mind that the Irma dream arose in reaction to a patient, and thus can be viewed countertransferentially. As many contemporary authors have indicated, psychoanalytic treatment is truly a two-person or interpersonal experience (Langs, 1984; Modell, 1984). It is built on the intricate interactions between practitioner and patient. Thus, countertransference is not considered in a vacuum, but as part and consequence of the transference. In Irma’s case, we can only surmise some of the transference-oriented feelings that may have interplayed between Irma (Anna) and Freud. In other words, Freud’s dream did not occur in a bubble; it was built on the dynamic interface between Freud and Anna. Many authors (Langs, 1984; Resnik, 1987) have picked up on Freud’s struggle with the dual nature of his relationship with Irma (friend and patient), yet there is no doubt Irma (Anna) also had feelings about being treated by a close family friend, an older man, a man who had told her to discuss everything, including her sexual feelings, with him (remember, this was Victorian Vienna). It would be difficult to imagine that Irma (Anna) would not have had some concerns about confidentiality and boundaries—she was invited to Martha’s birthday party on July 26, and was a regular Sunday visitor—and about the efficacy of such a new and unusual treatment. We know that Irma’s (Anna’s) family, whom Freud greatly respected and admired, voiced reservations about the treatment, which undoubtedly was on their minds when they were in the consulting room. From the perspective of the relationship between transference and countertransference, can the dream material be telling us that Irma was having some difficulty with the treatment frame and confidentiality? At the beginning of the dream, Irma enters a large hall for a social gathering and is immediately thrust into an intrusive medical examination. Does the dream scenario tell us Freud was picking up on the contaminated treatment frame that was causing distress for his patient? Could Irma have complained about this in session?

If we take the position that the Irma dream is a countertransference dream, then we can consider concordantly that the dream may offer clues to the actual transference that Anna presented toward Freud. Anna was a strikingly attractive woman with soft, round features and large eyes, suggesting a more Sephardic lineage than the Ashkenazi Jews of the region. It was clear that Anna was speaking to Freud about matters of sexuality and marriage and was feeling disappointed in Freud’s interpretation of her circumstances. If we view the dream as Freud’s reactive container for his patient’s in-session comments and out-of-session contact, it is

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reasonable to speculate that Anna had some erotic fascination with Freud. It would not be especially unusual for this to occur in the intimate setting of a doctor’s consulting room, chiefly if the nature of the treatment involved the expression of secret longings.  At age 34 Anna Hammerschlag held her luminous, graceful beauty, and Sigmund Freud, now just past 39, was at the crest of masculine elegance. In the dream, he says, “I took her to the window and looked down her throat, and she showed signs of recalcitrance, like a woman with artificial dentures.” We can visualize an almost romantic encounter in which the older man pulls the demur young woman aside, by a window, and looks at her with intent, and the woman obliges with hesitant longing. Jane Austen regularly filled her novels with such romantic images. Here, we can interpret that Anna may have been embarrassed to talk about something, if we deduce that patients are often hesitant or reluctant to discuss sexual or romantic matters involving the analyst.

Next, Freud remarked, “I thought to myself there was no need for her to do that.” We can hear the analyst wanting to assure his patient that their exchange will remain confidential (despite their being part of the same social circle), that she can say everything to him, and that their extra-analytic relationship will not get in the way of the process. The next line is, “She then opened her mouth properly and on the right, I found a big white patch; at another place I saw extensive whitish gray scabs upon some remarkable curly structures which were evidently modeled on the turbinate bones of the nose.” “Turbinate bones of the nose” is a direct reference to Fliess and the sexual-nasal origin of hysteria. The complete sentence reads like a description of the opening of the female genitals, with the “curly structures” resembling the ovaries, the clitoris, or other aspects of the female anatomy. The idea would be that the dream represents a displacement upward, meaning that Anna would be talking about these personal areas that she would be naturally be “recalcitrant” to mention.

The business that follows in the dream suggests the wish that Anna expressed—to marry her doctor and have his child (Anna is a friend to Martha, who was four months pregnant). Could Anna, having lost her husband, have envied Martha’s position in Freud’s life and expressed that to her handsome doctor/analyst? Also, Freud’s solution was for Anna to marry, but how could she? The man she loved (Freud) was already married (as a note, Anna never remarried). In the dream, Freud does not return her love, does not act on her desire, but puts her off: “It’s really only your fault.”

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He then calls in Dr. M. (Breuer), which is central to the dream and represents the key day residue, the catalyst of the dream. The case study that Freud wrote for Breuer “into the night” on July 23, 1895, was about Anna. My educated guess is that Freud presented in that case study his treatment of a dangerously attractive, sexually open woman, not unlike Anna O (Bertha Pappenheim), whereby it was possible for the physician to avoid acting on the erotic transference, and to maintain professional neutrality in the face of the patient’s seduction, in order to cure her of her hysteria. This was, of course, a direct criticism of Breuer, who had bungled Anna O’s case because he had been unable to handle the intense erotic transference. In the dream, Freud dressed down Breuer, made him look younger (“clean shaven”), and suggested his relative immaturity, as in his handling of Anna O. case. What a great ironic pleasure that Freud found himself with a “real” Anna and, unlike his eminent senior colleague, was able to maintain his position of physician in the face of intense erotic pressure. The central motif of the Irma dream is that Freud remains her doctor, despite the intense eroticized transference. In the second half of the dream, Freud holds fast to the role of a doctor trying to cure a patient who desires him.

Perhaps the reader is screaming “Wild analysis!” or “Completely fabricated nonsense!” I do not intend to fancifully unmask the dream, but to demonstrate that the countertransference offers us a glimpse of the possible transference. It is the effort that Freud makes to maintain and contain the analytic “doctor’s” position in the face of the eroticized transference that gave him the courage to establish psychoanalysis in the act of free association on July 24, 1895. Through this imaginative endeavor, both sides of the Janus can now be seen.

Freud’s transference toward Fliess

Whether Freud’s relationship with Fliess can be viewed in transferential terms has been debated, as these men were not in an analytic relationship in any formal sense (this can also be said of Freud’s relationship with Breuer). Further, even if we concede that Freud experienced his relationship with Fliess as a form of transference, we can accept his correspondence as a form of psychotherapeutic talk, or at least a partial documentation of the transference. We can be sure that Freud’s relationship with Fliess during the time of the Irma dream was emotionally and intellectually significant. We can come to a middle ground and say to what extent most

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significant relationships carry a degree of earlier, infantile elements and distortion. Thus, most relationships of this sort carry transferential elements.

It seems most probable that several authors have seized on the idea that Freud developed a more formal transference toward Fliess, as evidenced by the intense positive, admiring, and idealizing feelings he expressed in his correspondence and as suggested through other biographical material (“Dearest Wilhelm …”). To say it plainly, many authors have a difficult time believing Freud could have been so passionately and unconditionally caring toward Fliess unless he were in the throes of a displacement of infantile longing or, moreover, homoerotic fascination. In other words, he must not have been in his right mind to associate and ally himself with such an eccentric. Of course, this is a complete misperception of who Fliess was, not only as a friend to Freud but as a highly regarded physician of the era. In both subtle and not so subtle ways, Fliess’ theories and—by extension, Fliess himself—have been characterized as “crackpot.” Particularly, the theory about the connection between sexuality and the turbinate bones of the nose that leads to the nasal origin of hysteria and the theories regarding human sexual cycles. Further, from the perspective of Freud’s correspondence, one can easily question Fliess’ bungling the Eckstein operation, which alone can shed doubt on Fliess’ competence as a medical practitioner. With abundant information like this, one can imagine that Freud more than likely experienced some sort of idealizing transference in order to continue to maintain such a positive view of his colleague and his theories. Perhaps Freud knew that he was out on a limb with his work, and he felt reassured that Fliess seemed willing to climb even further out on that limb.

Of course, this view is a distortion in and of itself. Despite the abundance of material, the full nature and quality of Freud’s relationship with Fliess remain a mystery. It is known that the men shared an intense passion for their respective interests. Each seemed completely accepting of the other’s theories and served as a sounding board for the other. Freud even allowed Fliess to operate on his nose, twice. Fliess was described as a knowledgeable, creative, charismatic, passionate figure who clearly matched Freud’s excitement in their age of discovery. Although history seemed to prove Fliess the crackpot and Freud the genius, in actuality Freud’s theories were viewed as just as bizarre as Fliess’ at the time. Ironically, we may look back on Fliess’ theories with disdain, yet still admire traditional Eastern physicians who practice reflexology. In truth, is it any more bizarre to apply pressure to certain areas of the foot to alleviate a variety of

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physical and mental complaints than it is to posit a relationship between the nose and physical or psychological illness? To assume that Freud should have rejected Fliess on the basis of Fliess’ theoretical beliefs alone, or on other medically oriented factors, instead of admiring him, is to fail to recognize the relatively primitive level of medicine that existed at the time. From the written account that has survived, it appears that both men were intensely dedicated to their research in the hope of alleviating human suffering. As far as history is concerned, it just so happened that Freud was monumentally more correct than Fliess.

The interpretation that the Irma dream reflects Freud’s transference toward Fliess found its strongest advocate in Schur (1966). Schur was Freud’s personal physician for more than 10 years and was allowed complete access to the Freud–Fliess correspondence before publication. As mentioned, Schur discovered several letters revealing the disastrous treatment of Emma Eckstein and used these as foundation for a reanalysis of the Irma dream. Schur posited that the actual events involving Eckstein were quite similar to those described in the text (manifest content) of the Irma dream. Schur’s compelling discussion called attention to numerous parallels between the events in the letters and the manifest dream content. Greenberg and Pearlman (1978) also built their essay on this point. Yet, as Hartman (1983) pointed out, despite the strong correspondence of the two scenarios, there is no direct connection. All of Schur’s interpretations were based on inferences and on expanding the notion of “day residue” to include current emotional concerns. In addition, Schur, in his attempt to make his case mistakenly, identified Irma as Emma, when in truth Irma was Anna.

Despite Schur’s misidentification, the unpublished Freud–Fleiss letters that he brought to light painted a powerful and dramatic portrait of a young Freud in the midst of personal and professional struggles, and on the verge of profound breakthroughs that he would carry with him the rest of his life. Reading these letters makes it easy to see why Schur ascribed transference to the Freud–Fliess relationship even in the period before Freud’s self-analysis. The letters express severe anxiety and guilt over Emma’s treatment, along with an unconditional, loving regard for Fliess. Despite the awful reality of Emma’s medical dilemma, Freud steadfastly supported Fliess’ competence and ideas and considered his friend beyond reproach. Schur seemed to use this theme as the central interpretative frame when he turned to the Irma dream.  It is easy to observe through the letters that Freud felt deeply held by Fliess, which in turn allowed Freud to maintain Fliess as an idealized self–object, so to speak.  The status of self–object ascribed to Fliess was

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essential in enabling Freud the wherewithal to maintain his research despite both inner and outer resistances.

Schur’s analysis encompasses how Freud used his relationship with Fliess as his primary transference object during his self-analysis. There appears to be a correlation with Freud’s working through of his infantile complexes (homosexual, sibling, oedipal) and the de-intensification of his feelings for Fliess. The end result of this process was the publication of The Interpretation of Dreams (1900), which also corresponded with the ending of his relationship with Fliess.

Freud’s transference toward Breuer

Freud’s feelings toward Breuer seem to be the most obvious point of analysis and reexamination, yet they are given relatively little attention in the essays. Breuer was a leading neurologist in Vienna and became Freud’s senior colleague and mentor. A respected Jewish physician and researcher with a large private practice, in many ways Breuer represented an ego ideal for the young Freud, who was just starting out when they met. They shared a strong, creative, supportive relationship until they published their joint book, Studies on Hysteria (1895/1955), two months before the Irma dream. That publication heralded a parting of the ways, as Breuer could no longer support Freud’s theoretical direction vis-à-vis the sexual origin of hysteria and other areas. During this period, however, Freud maintained a strong, professional, paternalistic attachment to his senior colleague. It took the pair a year to actually break off relations. We need not infer that Breuer was on Freud’s mind the night before the Irma dream; Freud told us so. “The same evening I wrote out Irma’s case history, with the idea of giving it to Dr. M. (a common friend who was at the time a leading figure in our circle) in order to justify myself” (Freud, 1900, p. 106).

Dr. M was clearly identified as Breuer, and the aim of the case history was reported to be to seek Breuer’s confirmation. One need not look far for day residues. The most obvious and immediate one was the case history Freud wrote for Breuer the evening of July 23, 1895.

The dream text also supports the idea that Freud’s relationship with Breuer was one of the key organizing frames of the dream, as demonstrated in Irma’s transference toward Freud. Freud first consults Breuer in the dream. In real life, Breuer was a distinguished, though sickly-looking, man who sported a long beard. In Victorian Vienna, a long beard was a sign of status, and a bearded

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man was treated with respect. In the dream text, however, Breuer (Dr. M) does not have a beard and walks with a limp. Before I mention other interpretations, I want to note that, of all six characters in this manifest dream—including Martha—only Breuer appears with a radically altered manner. Irma’s appearance is slightly changed from real life, but not to the degree Breuer’s is. Of all Freud’s associations to the dream text, his references to Breuer have the clearest transferential elements, particularly in light of Erikson’s (1954) notion of Freud’s sense of humiliation and inferiority, present in the early memory of urinating in his parents’ bedroom, whereby his father remarks, “That boy will amount to nothing.” It is easy to consider that, if Breuer in a symbolic sense stood for Freud’s father, making him beardless would be turning the tables on him; the father is castrated and humiliated, and the son is freed to sexually engage a woman, such as Irma, thus completing the oedipal triangle (Irma is the mother symbol, which could account for choosing the substitute name Ir-ma, suggesting a maternal wish). The dream text easily yields this interpretation. At the end of the dream, Freud continues to defend against his own oedipal strivings, ascribing them to a younger sibling, in the form of Otto, who has the unclean syringe and is, in the colloquial translation, the “dirty squirter” (Erikson, 1954).

As we turn to Freud’s associations, we also find strong evidence of the transferential relationship with Breuer. This is one of the dominant influences organizing the Irma dream. Even a cursory review of Freud’s associations indicates Breuer’s importance to Freud. Breuer first appears in the associative material in reference to another patient Breuer was treating. This patient suffered from an organic problem, diphtheritic membrane, that Freud believed was hysterical in origin. Here lies the key conflict: organic problems versus psychogenic problems as represented in the relationship between Breuer and Freud.

Freud’s theories went against the established understanding of diagnosis and treatment. To support the integrity of his theory, Freud had to diagnose accurately, ruling out any organic problem that would neutralize the effectiveness of his treatment—something he was often unable to do. In the dream, and in the associations, he uses the relationship with Breuer as the focus of this struggle, which has both personal and professional ramifications. On a more personal level, and as suggested in the material, Freud relies on the paternalistic figure of Breuer, a “leading figure in our circle” (p. 139). Freud looks to Breuer for support, confirmation, and guidance. Yet, Breuer also begins to symbolize the old guard, the more established medical authority that Freud is outgrowing. Thus, Freud brings Breuer in as his foundation, then expresses his ambivalence by

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presenting Breuer in a degrading way (“clean shaven”), and later ignores Breuer’s opinion (“Could it be that I was trying to make fun of Dr. M’s [Breuer’s] fertility in making far-fetched explanations…?”- Freud, 1900, p. 114). The dream and the associations read like an argument, between Breuer and Freud, about the efficacy of Freud’s theory of hysteria. Ironically, it was Breuer’s confirmation that Freud was seeking when he wrote the case history the evening before the dream, yet Breuer came to represent the many doubters who saw Freud’s theories as far-fetched. Freud wrote, in his associations about Breuer, “I could no longer feel any doubt, therefore, that this part of the dream was expressing derision at physicians who are ignorant of hysteria” (p. 148). It is interesting that Freud lumped Breuer in with physicians who were ignorant of hysteria, as he and Breuer were coauthors of Studies on Hysteria, published in May of that year!

The well-documented tension in the Freud–Breuer relationship set the stage for their falling out (Schur, 1972). Within the year, they went their separate ways, never to collaborate on another project. As I suggested in the section on Irma, Freud’s case history was not only a desire for confirmation but an attempt to finally point out that the treatment of Anna O failed because of Breuer’s inability to tolerate the eroticized transference. When Anna O expressed her tortured love for Breuer and claimed she was carrying his child (another pregnancy theme), Breuer abruptly terminated treatment, resulting in her stay in a sanatorium. The convergence of names (Anna O, Anna H) must have given Freud a great sense of irony while he was writing Anna H’s case history and demonstrating the correct way to treat a hysteric female patient.

We can speculate that the Irma dream symbolically reflects the shift in attachments from Breuer to Fliess as Freud’s primary transference figure. The dream begins with Freud attempting to impose his theoretical ideas on a patient. A debate between him and the most established and respected figure in his circle ensues. Others join the debate, offering competing diagnoses, and subtly Freud closes the dream with a strong reference to Fliess (trimethylamin) and a fairly obvious reference to phallic sexual behavior (thoughtless use of an unclean syringe). In personal correspondence, Breuer acknowledged his difficulty following the direction Freud was heading. Freud needed someone else to provide a “holding environment” or to function as a “self object” to complete the task ahead—someone who could both challenge and unconditionally support his theoretical excursions, someone like Fliess. In the dream, Freud does not mention Fliess by name, but associates to Fliess as a “person whose agreement I recalled with satisfaction

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whenever I felt isolated in my opinions” (Freud, 1900, p. 117). This is supported in the various accounts of the waking context over the next year. Freud’s relationship with Breuer waned while his attachment to Fliess grew.

Although there are many alternative interpretations of the Freud–Breuer relationship, the oedipal theme surprisingly has not been fully explored. For example, in his review of almost ten interpretations, Elms (1980) did not mention the oedipal theme with Breuer.

            Freud’s transference toward himself

The last area of transference involves Erikson’s (1954) notion of Freud’s transference to his own dream. There is some debate as to when Freud started his self-analysis. Although there is documentation that it began in early 1897, many authors have viewed his systematic analysis of the Irma dream as the true beginning of his self-analysis (Welsh, 1994). If we assume that Freud was capable of analyzing himself, then by extension we can assume he became the object of his own transference.

Of all the essays on the Irma dream, Erikson’s (1954) provides the fullest understanding of how the dream served as a medium for Freud’s transference to himself, which ultimately set the stage for his greatest discovery. Erikson wrote, “To overcome mankind’s resistance, the dreamer had to learn to become his own patient and subject of investigation; to deliver associations to himself; to unveil horrible insights to himself; to identify himself with himself in the double roles of observer and observed” (p. 46). Erikson then pointed out cultural and social factors, such as sex roles and their interplay in the transference paradigm, as suggested in the relationship between Irma and Freud. Thus, the paradigm as illustrated in the dream becomes the actual paradigm that defines Freud’s probing relationship between the various aspects of his selfhood. Unveiling the mystery of Irma symbolically is seen as unveiling the mystery of dreams and by extension the mystery of human nature. Erikson (1954) remarked on Freud’s transference to himself as “one of the central meanings of the Irma dream” (p. 173). From my perspective (moving away from Erikson’s lofty analysis), Freud essentially tells himself to not act on the transference—to remain steadfast as a physician, no matter what. That brings us full circle to Freud’s original interpretation, about the wish to maintain “professional conscientiousness.”

Countertransference

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Erikson (1954) wrote, “If anything, this dream, dreamed by a doctor about a patient, would promise to contain inferences to countertransferences” (p. 42). Countertransference is defined as the feelings the analyst has in response to the patient’s transference. In a more liberal interpretation, it is all the thoughts and feelings an analyst has regarding the patient, both in and out of session. Recently, research has targeted the analyst’s dreams about the patient as an example of countertransference. Using the Irma dream as a key example, Whitman, Kramer, and Baldridge (1969) wrote, “Dreams may be used by the therapist for their own continuing self-analysis as well as for the understanding of their countertransference attitudes: understanding of the self and understanding of the patient meet in the countertransference dream” (p. 725).

A helpful way of approaching countertransference feelings is to group them into two types, induced (or objective) and subjective. Induced countertransference generally refers to the analyst’s emotional and, in some cases, physical reactions, to the patient’s transference. For example, a therapist begins a session feeling wide awake and attentive. About six minutes into the patient’s verbalizations, the therapist feels drowsy and distracted. The therapist’s reactions to the patient could be considered an induced countertransference, as the reactions correspond to the patient’s presentation. On the other hand, subjective countertransference more involves the unresolved infantile complexes and early relational paradigms that emerge in the context of a therapeutic relationship, but that are not necessarily created by it. In this example, a male analyst’s female patient reminds him of his older sister, for whom he has an erotic fascination. Unknowingly, the therapist allows the session to run over so he can have more contact with the patient. Thus, his reactions are not based on some quality or feeling state in the patient, but rather they are a product of unresolved issues related to his personal or subjective life experience.

Of course, these definitions are oversimplified. Anyone who has been in practice will note that these categories are not exclusive and that most induced reactions have some subjective component, and vice versa. These definitions are merely teaching tools that can help clarify the different attributes related to countertransference phenomena.

Induced (objective) countertransference

As already stated, the Irma dream is a countertransference dream. Freud had this dream about a particular patient at a particular point in her treatment. Langs (1984) comprehensively pointed

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out that one of the central elements in the dream involves Freud’s concern about the therapeutic frame.

During the summer of 1895 I had been giving psychoanalytic treatment to a young lady (a widow) who was on very friendly terms with me and my family. It will be readily understood that a mixed relationship such as this may be a source of many disturbed feelings in a physician and particularly in a psychotherapist. (Freud, 1900, p. 106)

The biographical data support the fact that many of Freud’s early patients were family friends or acquaintances. Freud had not yet refined his psychoanalytic method enough to fully recognize the need for therapeutic neutrality (Langs, 1984). He seemed aware that his treatment was not well thought of by Irma’s (Anna’s) family, and thus he was even more defensive when he heard Otto’s (Dr. Rie’s) remarks. As indicated earlier here, Irma also shared her family’s concerns about her treatment with Freud. Further complicating the frame issue, Irma (Anna) was invited to Martha’s birthday party. In addition, Freud named his sixth child after Anna. Clearly, he had much affection for this patient (Fichtner, 2010; Hartman, 1983).

According to its text, the dream starts as a social gathering and quickly transforms into a makeshift consulting area. If we interpret from the position of Freud’s countertransference anxiety over contamination of the treatment, the shift in the configuration of the dream reflects his wish to move from a social setting to a more comfortable professional consultation setting.

Moving further into the manifest, we see Irma resist Freud’s efforts to examine her and have her accept his solution. If we consider this as a paradigm of the treatment relationship, then Freud’s aggressiveness and frustration may indeed be viewed as induced countertransference in response to an uncooperative patient. As Erikson (1954) put it, “patient and doctor had thus found themselves in a deadlock which made a righteous disciplinarian out of the doctor and a stubborn child out of the patient” (p. 34).  Further, Anna’s rejection of Freud’s solution seems to induce a sense of panic about the efficacy of his diagnostic abilities. He seeks the support of senior and junior colleagues. However, in the case of the senior colleague Dr. M, there is a great deal of ambivalence. Freud brings him into the dream as backup, but then degrades him through a form of emasculation (loss of beard). As discussed earlier, because we know Dr. M is Breuer, it is evident that when Freud was writing the case history to give to Breuer, on some level he imagined (because of a more recent falling out over theoretical issues) that Breuer would not be as wholeheartedly supportive of the treatment as Freud would have hoped.

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As Erikson (1954), Mautner (1991), Geltner (1984), Resnik (1987), Anzieu (1986), and others believe, the Irma dream is replete with sexual symbolism, starting with Freud’s sexual feelings for his patient, disguised in the medical examination, and then displaced (thus disowned) onto a junior colleague symbolized by infiltration and the dirty syringe. Anzieu (1986) wrote, “The nose and throat examination is a gynecological examination in disguise” (p. 145). As Freud acknowledges, he chose not to divulge these countertransference feelings out of issues of confidentiality and propriety. If we combine the idea of the contaminated frame and the analyst’s sexual feelings, certainly the potential for acting on sexual feelings becomes that much more intensified, and thus defended. Interestingly, Freud’s solution for Irma’s condition, which she flatly refused, was precisely that, to get married and have more sex—to take action. Could that have been a reflection of Freud’s wish, sublimated into the position of analyst?

Subjective countertransference

This category brings us more into Freud’s character and disposition, which emerge in relation to his patient but are not a result of the patient’s transference. Freud’s own interpretation of the dream reflects a subjective countertransference element involving his “conscientiousness.” Freud basically viewed the dream as a wish to seek revenge against his friend Otto for criticizing him, and as a means to support his conscientious self-image. Ironically, Freud, in his associations, pointed to several situations involving feelings of guilt related to a failed or inappropriate treatment that led to the death of at least two people. In a more surface interpretation, it could be understood that, because of the past treatment failures, including the recent Eckstein case, Freud carried a degree of apprehensiveness that he could not help, or perhaps might even harm, his patients. Schur (1966) strongly affirmed this theme and directly connected it to the Eckstein case—that Freud with Fliess harmed a patient—which Schur viewed as the key general day residue organizing the dream. Thus, from a subjective standpoint, Freud was more than likely, as suggested in his associations, to be fearful of that potentiality, particularly with respect to someone as close as Irma (Anna) was to him and his family.

Geltner (1984) picked up on the conscientious element from a different angle, using Sharpe’s (1978) formulation about the underlying unconscious aggressive wish that forms the basis of the desire to become a psychoanalyst. Much like the idea of sublimation, whereby a person’s aggressive wish is transformed into the wish to help, Freud’s need to reassure himself of his

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conscientiousness was essentially a defense against his unconscious sexual and aggressive impulses.

Geltner (1984) supported his formulation by returning to the manifest dream and finding expression of aggressive impulses in nearly every part of it. From this perspective, Freud’s fear of harming his patient actually masks his destructive wish. Thus, to defend against such an intolerable wish, Freud devised a dream interpretation method that uses free-association, creatively turning the aggression into something that could help, rather than harm.

Other authors have sought an answer to the dream through a careful review of Freud’s social history. Erikson (1954) called attention to several of Freud’s key memories of early childhood—including, as mentioned earlier, the memory of urinating into a chamber pot in his parents’ bedroom, and Freud’s father chastising young Sigmund: “That boy will never amount to anything.” Apparently, this memory resonated throughout Freud’s life and has become a kind of emblematic symbol of the need to prove oneself as someone who would amount to something and thus earn his father’s love and respect. This is easily seen in the context of the dream and in the context of the fear that he may have failed his father, as Irma was not cured, and proved unworthy, as his father had branded him.

Mautner (1991) worked from a different collection of pivotal memories, and suggested an altogether different interpretation. Mautner’s careful review of the literature brought to light how little attention Freud had given to the role of sibling relationships in human development. Freud appeared preoccupied with the effect of parents’ erotic fascination with their children and later, in reverse, with the effect of children’s erotic fascination with their parents—to the complete avoidance of the erotic fascination that could exist between siblings. Mautner (1991) interpreted Freud’s avoidance of the subject as resulting from unconscious denial, based on an early memory of unacceptable sexual aggression perpetrated against his next younger sibling, Anna. Mautner concluded that Freud was “haunted by a repressed memory of an act of erotic aggression against his sister Anna when he was five years old and she was three years old” (p. 275). The author reinterpreted the manifest content of the Irma dream as a replay of the earlier childhood assault against Freud’s younger sister. From a countertransference perspective, we can question whether something about Irma reminded Freud of that early organizing event. Adding further (albeit circumstantial) support to this formulation, it just so happened that the names of Freud’s younger

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sister and Freud’s patient were the same, Anna. This interpretation also was supported by Stewart’s (1969) analysis.

Elms (1980), in his analysis, viewed one of the focal conflicts in the dream to be Freud’s relation to his pregnant wife and his ambivalence about his own sexual behavior. Anzieu (1986) also interpreted this theme, suggesting that Irma’s symptoms in the dream text—“choking,” “pale and puffy,” “pains in the abdomen”—were signs of pregnancy. In a few instances, Freud’s associations also link Irma and Martha.

Another important theme that several authors have picked up is Freud’s concerns about his physical health. The general thrust of the interpretations in this area is his preoccupation with his patients’ physical complaints as displacement of his own health concerns. In his associations, Freud links Irma’s infiltration of her shoulder with his rheumatism. Perhaps one of the most interesting interpretations from a health perspective came from Resnik (1987), who translated the image of the white patches in Irma’s throat into a forewarning of the cancer Freud was to develop 25 years later. Only a few months before the Irma dream, Freud, against Fliess’ advice, began smoking cigars again. He may have been aware of the risk smoking posed to his health.

Although evident in the text and in the associations, Freud’s paternalistic countertransference has not been recognized in the literature, perhaps because the dominance of libido theory which tends to filter all data through infantile complexes. Psychoanalytically oriented clinicians would not necessarily pick up on the paternalistic countertransference in the relationship also because of the influence of Schur’s (1966) analysis, which misidentified the patient Irma as Emma, further obscuring the paternalistic element. It is true that Emma Eckstein and Anna Hammerschlag had much in common, but they were not interchangeable. Freud’s relationship with the Hammerschlags was extremely complex, deep and meaningful, whereas the biographical data do not support a comparable relationship with the Ecksteins. The idea of a paternalistic countertransference emerges from three areas. The first is Freud’s longstanding relationship with Samuel Hammerschlag, who was his religious instructor. “From his obituary of Samuel Hammerschlag, we know of Freud’s great veneration for his teacher of Jewish religion. However, not only Hammerschlag himself, but his whole family, had a formative influence on young Freud, who was deeply impressed by their humanity” (Fichtner, 2010). In many ways, Samuel represented a caring father figure for Freud, lending him money and offering support. The second area, by extension, is Freud’s strong caring feelings for Samuel’s daughter, Anna, as

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shown in his correspondence with Martha during the time they were dating (Hartman, 1983). Careful review of Freud’s associations indicates several instances of his linking Anna with his daughter Mathilde. Freud seems to convey deep concern about Irma’s condition, not unlike the feelings he expressed about his daughter when she was ill. The third area, perhaps most telling, is that Freud named his sixth child after Anna.

A final important theme, as indicated earlier, is the idea that Freud was attempting to demonstrate to Breuer that he was the better doctor for not either succumbing or panicking to his patient’s erotic advances. This theme stands at the top of the list for further consideration.

Resistance

Returning to Greenson (1967), “Resistance means opposition… Resistance is in essence a counterforce in the patient, operating against the progress of the analysis, the analyst, and the analytic procedures and processes (p. 60). As with transference, a broader, more contemporary view, sees the phenomena of resistance as ubiquitous reflective of the internal paradigms common in all people that oppose facing and unwanted truth.

Irma’s resistance toward Freud

The key resistance was seen in Irma’s unwillingness to accept Freud’s solution to her anxiety neurosis. As indicated, it is difficult to reconstruct the therapeutic relationship between Irma (Anna) and Freud with only this one sided of data. We can only infer from Freud’s countertransference dream and the brief comment that was recorded about Anna’s disappointment in Freud’s “solution” to her hysteria that give us a clue to Anna’s resistance. Although suggestive, it still leaves too much open for speculation. What we do know is that Irma flatly discarded Freud’s solution to her anxiety neurosis, which he believed was caused by her widowhood. The solution was basically to find a husband. Hartman (1983), using interview material reported by Anna Hammerschlag’s niece, described Anna’s response to Freud’s solution as, “Is that all? Why couldn’t you have said that right from the start?”

If we look to the dream as analogous to the actual treatment, there are many points that offer some ideas about the patient’s possible resistances. It is evident from the introduction to the dream the notion of going to a family friend and talking about sexual fantasies, must have been uncomfortable for Anna. The recalcitrance that Irma shows in the dream, suggests a degree of

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embarrassment and shyness, related to what’s in her mouth. This easily could be translated to mean; what is spoken. The patient may have known that other authority figures, who were also friends of hers, were cognizant of her treatment by Freud and she may have feared she could not be completely sure about the confidentiality of the treatment—which in many was like a confession.

Further, it is interesting that Freud blames Otto for the unclean syringe. It was Otto who injected Irma. We knew for a fact that Otto (Oskar Rie) was staying over Irma’s summer house, and they were both single and about the same age. From the perspective of the patient’s resistance, could Anna have had trouble talking about sexual feelings for Oscar Rie? Of course this is speculative and interesting, but clearly suggests that without a complete account of the treatment, most interpretations are products of the interpreter’s imagination with no basis in fact.

Freud’s resistance toward himself

Building from Erikson’s notion of Freud’s transference toward himself, it is an easy step to move from the self transference idea to the idea of self resistance. Saying it this way makes it sound obscure and technical. In truth, self-resistances are common phenomena in everyone’s daily life. We all have experienced blockages, whether with writing, talking in public, exercising, and the like. There are many tasks before us that we somehow manage to avoid or delay. When we turn to Freud in terms of his self-analysis and theory building, it is easy to understand the many external and internal factors that contributed to the resistances that emerged in his attempt to create psychoanalysis. As Schur (1972) wrote,

We rightly consider Freud’s self-analysis as a unique and unsurpassable feat. This statement requires an explanation for those who are not familiar with the obstacles everyone who enters analysis has to overcome. (We must bear in mind however that such an analysis is conducted by an expert who himself has gone through the same procedure in his training analysis.) The obstacles arise in the form of resistances against the uncovering of manifold conflicts through which we all have to pass during our formative years; against recovering painful memories of the past; finding that we all harbor thoughts and wishes which are considered evil, base, dangerous, and have committed deeds of that kind; by the reluctance to change deeply ingrained character traits and even give up painful symptoms. The resistances are commensurate with the strength of the defenses through which we have dealt more or less successfully with all our conflicts. Resistances are as much a part a part of the “secrets of nature” which Freud had discovered as the forces against the resistance’s (and defenses) are directed. (p.74)

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What is important to note is the degree in which Freud’s personal inner self was enmeshed with his scientific struggle to cure mental illness and understand human nature. In many ways, Freud’s struggle to reconcile the private subjective experience with the outer, public, method of treatment continues to remain a key feature and a dilemma for analysts practicing today. It was this particular dilemma that led Janet Malcom to coin the phrase, which became the title of her book, Psychoanalysis, the Impossible Profession (Malcolm, 1981).

If we return to the manifest text of the Irma dream, with the idea that Freud’s interaction with Irma is actually a metaphor for his self-analysis and an attempt to discover the nature of the mind, the obstacles to the examination and developing an adequate diagnosis can be translated to embody the various defensive operations that form the basis of Freud’s internal resistances. The conflicts over public failure and questions of the efficacy of his treatment, the struggle to develop an adequate therapeutic frame and method, the fears about his own health and dying, the ambivalence over the need for confirmation from the established medical community, his own strong sexual feelings emergent in response to the intimate contact with another person over time, to name a few, are evident in the dream text and associations. From an object relations perspective, the idea that Freud’s inner self is projected as in the image of a woman evokes interesting speculation about the underlying gender and earlier maternal identifications, which could be the source of powerful unconscious primitive anxiety and by extension more resistance’s split off and buried behind the grave of Oedipus. It is not too far afield to draw a parallel between Freud’s struggle to uncover the dark regions of his own mind and his life long struggle to come to terms with female sexuality, which he had labeled the “dark continent.”

Freud’s self-resistances can also be considered in relation to his primary transference figure, Fliess. If we accept Schur’s hypothesis about the Eckstein affair, then it would be possible to believe that Freud was resisting the awareness of Fliess culpability and role in the etiology of the Irma dream as suggested in the avoidance of directly mentioning Fliess in either the dream or the associations. In the text itself, despite the fact that Freud refers to Fliess through the mention of the turbinate bone and appearance “in heavy type” (as if the dream ego is saying, get the point!) of the word trimethylamin, one of the key features of Fliess theory of sexual metabolism, Freud makes no direct reference to Fliess. Sometimes in dreams what is significant is not who is pictured, but who is not. Interestingly, the dream brings together the key figures in Freud’s inner circle: Joseph Breuer, Anna Hammerschlag, Martha Freud, Oscar Rie, Ludwig Rosenberg

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(married to Rie’s sister). Yet, perhaps the one that in some ways is most important is conspicuously absent—Wilhelm Fliess. If we approach this from the idea of resistance, the fact that Fliess was not pictured could suggest the presence of anxiety about Fliess, which is dealt with through repression.

Greenberg and Pearlman (1978) suggest:

…Freud failed to make the connexion between the Irma dream and the Emma episode. If one considers Freud’s associations analogous to analytic material, then this inability is consistent with the idea that in the dream he found a solution which enabled him to remain unaware of his disappointment and anger with Fliess.” (p. 73-74)

Conclusion

When Freud, in a letter to his closest friend Wilhelm Fliess, wrote that on July 24, 1895 a marble tablet should be erected to commemorate his discovery of the secret of dreams, Freud had cast the Irma dream into psychoanalytic myth. It is difficult, if not impossible, to say whether Freud actually wrote those words as serious recognition of his point of creation, or as a playful tongue in cheek remark written in a personal correspondence between two best friends and collaborators. It is evident that the dream and its subsequent analysis had monumental importance signaling the initiation of Freud’s self-analysis and the beginning of psychoanalysis proper.

Freud uses the Irma dream as the first “dream specimen” in The Interpretation of Dreams. Yet, despite Freud’s thoughtful and revealing analysis and discussion, he does not by design adequately complete what he appears to set out to do. Throughout The Interpretation of Dreams, Freud unequivocally regards dreams as wishes, originating from infantile memories and fantasies. Despite his unwavering view, he does not provide adequate support for his hypothesis in his analysis of the Irma dream. As revealing as his analysis was, Freud understandably avoided presenting certain elements, particularly his associations to sexually related material. By doing so, Freud had thrown down the gauntlet to future analysts to try to find the deeper truth of the Irma dream as well as opening the door to criticism (e.g., Reiser, 1990; Sloane, 1979, and others). I believe that Freud’s critics fail to recognize that the Irma’s Injection was mislabeled as a “dream specimen” to carry the full weight of psychoanalysis rather than just a teaching tool

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demonstrating the associative process. In many ways, all subsequent attempts to re-analyze the Irma dream were in opposition to Freud’s actual methodology of dream interpretation. Throughout his career, Freud steadfastly cautioned against using the manifest dream as a text to be read, but merely a starting point for associations which eventually reveal the latent or hidden meaning.

The Irma dream provides a rare personal glimpse of a seminal thinker at the verge of one of his most significant breakthroughs. The Irma dream holds a special mystique to the subsequent generations of analysts by giving us the opportunity to commune with the father of psychoanalysis. Through the Irma dream, each writer attempting to interpret the material establishes their own personal transference to Freud, as well as countertransference to Freud as our patient. The underlying unconscious, or perhaps preconscious, motivation to return to the Irma dream represents a simultaneous wish to get close to the father of psychoanalysis as well as an opportunity to put him on the couch.

From a historical perspective, the Irma dream provides a hint to the direction Freud was to take in regard to his profound shift in his theory of hysteria, which occurred over the next few years. The shift I am referring to is the move away from the seduction/trauma-based theory to the theory of libido. Although Freud cautioned against the approach of analysis through symbol interpretation, and often contradicted himself on this matter, if we were to “read” the text on a manifest narrative level, essentially the text is built around the idea of trying to find a diagnosis for Irma’s ailments. (After all, Freud was a physician!) Irma complains of a number of symptoms, perhaps hysterical in origin. Freud then blames her for her ailments since she did not accept his solution. Consultants are brought in, and other organic diagnoses are presented. Later in the dream, we see a strong reference to the word trimethylamin (which we spoke of earlier). If we were to put these elements together, we sense Freud’s struggle to determine the origin of her illness.

Metaphorically, Freud seems to be saying that he is not sure (at this point) about the origins of hysteria, but he believes there is a relationship between the patient’s symptoms and their sexual metabolism. If we recall that the basis of the seduction theory was on the idea that during the patient’s childhood, the patient was subjected to the erotic interests of their parents, thus her (his) hysteria was a result of a traumatic external event, akin to the “dirty squirter.” If we now turn to libido theory, we see just the opposite; it is the child’s repressed erotic interest in the

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parent that ultimately results in the hysterical symptom. Thus, hysteria is understood as a result of internal biological forces rather than an external event. If we return to the dream text, we can easily see Freud emphasizing that the patient’s problem is a result of something from within, that is, “her own fault.” The manifest text presents as an argument that Freud is making to the naysayers that doubt his theoretical and clinical direction. It was this dream, on July 24, 1895, that gave him the confidence to creatively find his own “solution” to the analysis of the waking mind.

The Irma dream has also served as a wonderful teaching tool through this past century. Freud labeled the Irma dream the dream specimen. It was the first dream he subjected to a rigorous analysis. In so doing, Freud embarked on a journey that culminated with The Interpretation of Dreams and a revolutionary way of conceptualizing the human condition. Thus, it comes as no surprise that the Irma dream continues to fascinate and capture our imagination, becoming much like the Rosetta stone of psychoanalysis. Each new decade brings new constructs that enable us to return to the Irma dream with fresh eyes to discover its great paradoxical truth: What we seek out in the Irma dream is merely what we have already found. The creative act of interpreting the dream from our own free associations is exactly what Freud taught us to do in the first place.

There are few public figures who have been the subject of so much scrutiny and speculation. Interestingly, the fact that there is an enormous body of written material both about and by Freud, including voluminous personal correspondence, that one would imagine we would have answered most questions about him by now. Yet, that is not the case. The enormous body of material has merely stimulated more discussion about who he was and the meaning and value of his creative efforts. In all his writings and other biographical data, nothing presents as revealing or as fascinating as the Irma dream (the “I-d”, wink wink) and its analysis. It holds its interest not only for what it reveals but for what is does not say.

Analysis of the dream through the years has taken on the air of a murder mystery or crime investigation with each writer/researcher searching for the correct leads to reconstruct the context that gave rise to Freud’s personal creation and the birth of psychoanalysis. The Emma Eckstein’s “bloody nose” episode and the revealing Freud–Fliess correspondence provides the “smoking gun” in this mystery, showing us how precarious his theory and career were at the time. If Emma had died or was seriously disabled who’s to say what would have happened?

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Would Freud have retreated into guilt-driven obscurity, his theories and credibility vanishing in one bungled unnecessary surgery? Would Freud become just another crackpot physician in the Victorian era espousing arcane theories that become footnotes to some historical text, much like what happed to Wilhelm Fliess? And, what if Emma Eckstein had not remained loyal and allied to Freud, what if she turned on him, what would have happened? We needn’t stretch our imagination too far to appreciate how easily it would have been to empower the rabid anti-Semites in the medical establishment whom would have used this to destroy this upstart Jewish doctor. Fortune and fate became perfectly aligned in spring 1895; instead, Eckstein not only remained allied to Freud, but in truth became his first student and the first practitioner of the new method of psychoanalysis before the publication of The Interpretation of Dreams.

For the next 120 years, we may continue to argue about the content of Freud’s theories and their relationship to his biography. Yet, in so doing, we must always acknowledge that it is his risking of everything and teaching us the process of self-discovery that will always be his legacy.

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