ON PSYCHOTHERAPY.[53]
_Gentlemen_:
It is almost eight years since, at the request of your deceased
chairman, Prof. v. Reder, I had the pleasure of speaking in your midst
on the subject of hysteria. Shortly before (1895) I had published the
“Studien über Hysterie” together with Dr. J. Breuer, and on the basis of
a new knowledge for which we are thankful to this investigator, I have
attempted to introduce a new way of treating the neurosis. Fortunately,
I can say that the endeavors of our “Studies” have met with success, and
that the ideas which they advocate concerning the effects of psychic
traumas through the restraint of affects and the conception of the
hysterical symptom as a result of a displacement of excitement from the
psychic to the physical—ideas for which we have created the terms
“ab-reaction” and “conversion”—are today generally known and understood.
At least in German-speaking countries there are no descriptions of
hysteria which do not to a certain extent take cognizance of them, and
no colleague who does not at least partially follow this theory. And yet
as long as they were new these theories and these terms must have
sounded strange enough!
I can not say the same thing about the therapeutic procedure which we
have proposed to our colleagues together with our theory. It still
struggles for recognition. This may have its special reasons. The
technique of the procedure was at that time still rudimentary. I was
unable to give those indications to the medical reader of the book which
would enable him to perform such a treatment. But surely there were
other causes of a general nature. To many physicians psychotherapy even
today appears as a product of modern mysticism, and in comparison to our
physico-chemical remedies the application of which is based on
physiological insight, psychotherapy appears quite unscientific and
unworthy of the interest of a natural philosopher. You will therefore
allow me to present to you the subject of psychotherapy, and to point
out to you what part of this verdict can be designated as unjust or
erroneous.
In the first place let me remind you that psychotherapy is not a modern
therapeutic procedure. On the contrary it is one of the oldest remedies
used in medicine. In Lëwenfeld’s instructive work (Lehrbuch der gesamten
Psychotherapie) you can find the methods employed in primitive and
ancient medicine. Most of them were of a psychotherapeutic nature. In
order to cure a patient he was transferred into a state of “credulous
expectation” which acts in a similar manner even today. Even after the
doctors found other remedial agents psychotherapeutic endeavors never
disappeared from this or that branch of medicine.
Secondly, I call your attention to the fact that we doctors really can
not abandon psychotherapy if only because another very much to be
considered party in the treatment—namely the patient—has no intention of
abandoning it. You know how much we owe to the Nancy school (Liébault,
Bernheim) for these explanations. Without our intention, an independent
factor from the patient’s psychic disposition enters into the activity
of every remedial agent introduced by the doctor, acting mostly in a
favorable sense but often also in an inhibiting sense. We have learned
to apply to this factor the word “suggestion,” and Moebius taught us
that the failures of some of our remedies are to be ascribed to the
disturbing influences of this very powerful moment. You doctors, all of
you, constantly practice psychotherapy, even when you do not know it, or
do not intend it, but it has one disadvantage, you leave entirely to the
patient the psychic factor of your influence. It then becomes
uncontrollable, it can not be divided into doses and can not be
increased. Is it not a justified endeavor of the doctor to become master
of this factor, to make use of it intentionally, to direct and enforce
it? It is nothing other than that, that scientific psychotherapy expects
of you.
In the third place, gentlemen, I wish to refer you to the well known
experience, namely, that certain maladies and particularly the
psychoneuroses, are more accessible to psychic influences than to any
other medications. It is no modern talk but a dictum of old physicians
that these diseases are not cured by the drug, but by the doctor, to
wit, by the personality of the physician in so far as it exerts a
psychic influence. I am well aware, gentlemen, that you like very much
the idea which the aesthete Vischer, in his parody on Faust (Faust, der
Tragödie, III Teil) endowed with a classical expression: “I know that
the physical often acts on the moral.”
But would it not be more adequate and frequently more correct to
influence the moral part of the person with the moral, that is, with
psychic means?
There are many ways and means of psychotherapy. All methods are good
which produce the aim of the therapy. Our usual consolation, “You will
soon be well again,” with which we are so generous to our patients,
corresponds to one of the psychotherapeutic methods, only that on
gaining a profounder insight into the neuroses we are not forced to
limit ourselves to this consolation alone. We have developed the
technique of hypnotic suggestion, of psychotherapy through diversion,
through practice, and through the evocation of serviceable affects. I do
not disdain any of them, and would practice them all under suitable
conditions. That I have in reality restricted myself to a single
therapeutic procedure, to the method called by Breuer “cathartic,” which
I prefer to call “analytic,” is simply due to subjective motives which
guided me. Having participated in the elaboration of this therapy I feel
it a personal duty to devote myself to its investigation, and to the
final development of its technique. I maintain that the analytic method
of psychotherapy is one which acts most penetratingly, and carries
farthest; through it one can produce the most prolific changes in the
patient. If I relinquish for a moment the therapeutic point of view, I
can assert that it is the most interesting, and that it alone teaches us
something concerning the origin and the connection of the morbid
manifestations. Owing to insights which it opens for us into the
mechanism of the psychic malady, it can even lead us beyond itself, and
show us the way to still other kinds of therapeutic influences.
Allow me now to correct some errors, and furnish some explanations
concerning this cathartic or analytic method of psychotherapy.
(_a_) I notice that this method is often mistaken for the hypnotic
suggestive treatment. I notice this by the fact that quite frequently
colleagues whose confidant I am not by any means, send patients to me,
refractory patients of course, with the request that I should hypnotize
them. Now, for eight years I have not practiced hypnotism (individual
cases excluded) as a therapeutic aim, and hence I used to return the
patients with the advice that he who relies on hypnosis should do it
himself. In truth, the greatest possible contrast exists between the
suggestive and the analytic technique, that contrast which the great
Leonardo da Vinci has expressed for the arts in the formulæ per via di
porre and per via di levare. Said Leonardo, “the art of painting works
per via di levare, that is to say, places little heaps of paint where
they have not been before on the uncolored canvas; sculpturing, on the
other hand, goes per via di levare, that is to say, it takes away from
the stone as much as covers the surface of the statue therein
contained.” Quite similarly, gentlemen, the suggestive technique acts
per via di porre, it does not concern itself about the origin, force,
and significance of the morbid symptoms, but puts on something, to wit,
the suggestion which it expects will be strong enough to prevent the
pathogenic idea from expression. On the other hand the analytic therapy
does not wish to put on anything, or introduce anything new, but to take
away, and extract, and for this purpose it concerns itself with the
genesis of the morbid symptoms, and the psychic connection of the
pathogenic idea the removal of which is its aim. This manner of
investigation has considerably furthered our understanding. I have so
early given up the technique of suggestion, and with it hypnosis,
because I despaired of making the suggestion as strong and persistent as
would be necessary for a lasting cure. In all grave cases I noticed that
the suggestions which were put on crumbled off again, and then the
disease, or one replacing it, reappeared. Besides, I charge this
technique with concealing from us the psychic play of forces, for
example, it does not permit us to recognize the resistance with which
the patients adhere to their malady, with which they also strive against
the recovery, and which alone can give us an understanding of their
behavior in life.
(_b_) It seems to me that a very widespread mistake among my colleagues
is the idea that the technique of the investigation for the causes of
the disease and the removal of the manifestations by this investigation
is easy and self-evident. I concluded this from the fact that of the
many who interest themselves in my therapy and express a definite
opinion on the same, no one has yet asked me how I do it. There can only
be one reason for it, they believe there is nothing to ask, that it is a
matter of course. I occasionally also hear with surprise that in this or
that division of the hospital a young interne is requested by his chief
to undertake a “psychoanalysis” with a hysterical woman. I am convinced
that he would not entrust him with the examination of an extirpated
tumor without previously assuring himself that he is acquainted with the
histological technique. Likewise I am informed that this or that
colleague has made appointments with a patient for psychic treatment,
whereas I am certain that he does not know the technique of such a
treatment. He must, therefore, expect that the patient will bring him
her secrets, or he seeks salvation in some kind of a confession or
confidence. I should not wonder if the patient thus treated would rather
be harmed than benefited. The mental instrument is really not at all
easy to play. On such occasions I can not help but think of the speech
of a world-renowned neurotic, who really never came under a doctor’s
treatment, and only lived in the fancy of the poet. I mean Prince Hamlet
of Denmark. The king has sent the two courtiers, Rosencrantz and
Guildenstern, to investigate him and rob him of his secret. While he
defended himself, pipes were brought on the stage. Hamlet took a pipe
and requested one of his tormentors to play on it, saying that it is as
easy to play as lying. The courtier hesitated because he knew no touch
of it, and as he could not be moved to attempt to play the pipe, Hamlet
finally burst forth: “Why, look you now, how unworthy a thing you make
of me! You would play upon me; you would seem to know my stops; you
would pluck out the heart of my mystery; you would sound me from my
lowest note to the top of my compass; and there is much music, excellent
voice, in this little organ, yet you cannot make it speak. ’Sblood! do
you think I am easier to be played on than a pipe? Call me what
instrument you will, though you can fret me, you cannot play upon me.”
(Act III, Scene 2.)
(_c_) You will have surmised from some of my observations that the
analytic cure contains qualities which keep it away from the ideal of a
therapy. Tuto, cito, iucunde; the investigation and examination does not
really mean rapidity of success, and the allusion to the resistance has
prepared you for the expectation of inconveniences. Certainly the
psychoanalytic method lays high claims on the patient as well as the
physician. From the first it requires the sacrifice of perfect candor,
it takes up much of his time, and is therefore also expensive; for the
physician it also means the loss of much time, and due to the technique
which he has to learn and practice, it is quite laborious. I even find
it quite justified to employ more suitable remedies as long as there is
a prospect to achieve something with them. It comes to this point only:
if we gain by the more laborious and cumbersome procedure considerably
more than by the short and easy one, the first is justified despite
everything. Just think, gentlemen, by how much the Finsen therapy of
lupus is more inconvenient and expensive than the formerly used
cauterization and scraping, and yet it means a great progress, merely
because it achieves more, it actually cures the lupus radically. I do
not really wish to carry through the comparison, but psychoanalysis can
claim for itself a similar privilege. In reality I could develop and
test my therapeutic method in grave and in the gravest of cases only; my
material at first consisted of patients who tried everything
unsuccessfully, and had spent years in asylums. I hardly gained enough
experience to be able to tell you how my therapy behaves in those
lighter, episodically appearing diseases which we see cured under the
most diverse influences, and also spontaneously. The psychoanalytic
method was created for patients who are permanently incapacitated, and
its triumph is to make a gratifying number of such, permanently
capacitated. Against this success all expense is insignificant. We can
not conceal from ourselves what we were wont to disavow to the patient,
namely, that the significance of a grave neurosis for the individual
subjected to it is not less than any cachexia or any of the generally
feared maladies.
(_d_) In view of the many practical limitations which I have encountered
in my work, I can hardly definitely enumerate the indications and
contraindications of this treatment. However, I will attempt to discuss
with you a few points:
1. The former value of the person should not be overlooked in the
disease, and you should refuse a patient who does not possess a certain
degree of education, and whose character is not in a measure reliable.
We must not forget that there are also healthy persons who are good for
nothing, and that if they only show a mere touch of the neurosis, one is
only too much inclined to blame the disease for incapacitating such
inferior persons. I maintain that the neurosis does not in any way stamp
its bearer as a dégéneré, but that frequently enough it is found in the
same individual associated with the manifestations of degeneration. The
analytic psychotherapy is therefore no procedure for the treatment of
neuropathic degeneration, on the contrary it is limited by it. It is
also not to be applied in persons who are not prompted by their own
suffering to seek the treatment, but subject themselves to it by order
of their relatives. The characteristic feature upon which the usefulness
of the psychoanalytic treatment depends, the educability, we will still
have to consider from another point of view.
2. If one wishes to take a safe course he should limit his selection to
persons of a normal state, for, in psychoanalytic procedures, it is from
the normal that we seize upon the morbid. Psychoses, confusional states,
and marked (I might say toxic) depressions, are unsuitable for analysis,
at least as it is practiced today. I do not think it at all impossible
that with the proper changes in the procedure it will be possible to
disregard this contraindication, and thus claim a psychotherapy for the
psychoses.
3. The age of the patient also plays a part in the selection for the
psychoanalytic treatment. Persons near or over the age of fifty lack, on
the one hand, the plasticity of the psychic processes upon which the
therapy depends—old people are no longer educable—and on the other hand,
the material which has to be elaborated, and the duration of the
treatment is immensely increased. The earliest age limit is to be
individually determined; youthful persons, even before puberty, are
excellent subjects for influence.
4. One should not attempt psychoanalysis when it is a question of
rapidly removing a threatening manifestation, as, for example, in the
case of an hysterical anorexia.
You have now gained the impression that the sphere of application of the
analytic psychotherapy is a very limited one, for you really heard me
enumerate nothing but contraindications. Nevertheless, there remain
sufficient cases and morbid states, such as all chronic forms of
hysteria with remnant manifestations, the extensive realms of compulsive
states, abulias, etc., on which this therapy can be tried.
It is pleasing that particularly the worthiest and highest developed
persons can thus be most helped. Where the analytic psychotherapy has
accomplished but little one can cheerfully assert that any other
treatment would have certainly resulted in nothing.
(_e_) You will surely wish to ask me about the possibility of doing harm
through the application of psychoanalysis. To this I will reply that if
you will judge justly you will meet this procedure with the same
critical good-feeling as you have met our other therapeutic methods, and
doing this you will have to agree with me that a rationally executed
analytic treatment entails no dangers for the patient. One who, like a
layman, is accustomed to ascribe to the treatment everything occurring
during the disease, will probably judge differently. It is really not so
long since our hydrotherapeutic asylums met with similar opposition.
Thus one who was advised to go to such an asylum became thoughtful
because he had an acquaintance who entered the asylum as nervous and
there become insane. As you surmise we deal with cases of initial
general paresis who in the first stages could still be sent to
hydrotherapeutic asylums, and who there merged into the irresistible
course leading to manifest insanity. For the layman the water was the
cause and author of this sad transformation. Where it is a question of
unfamiliar influences, even doctors are not free from such mistaken
judgment. I recall having once attempted to treat a woman by
psychotherapy who passed a great part of her existence by alternating
between mania and melancholia. I began to treat her at the end of a
melancholia and everything seemed to go well for two weeks, but in the
third week she was again merging into a mania. It was surely a
spontaneous alteration of the morbid picture, for two weeks is no time
in which anything can be accomplished by psychotherapy, but the
prominent—now deceased—physician who saw the case with me could not
refrain from remarking that this decline must have been due to the
psychotherapy. I am quite convinced that he would have been more
critical under different conditions.
(_f_) In conclusion, gentlemen, I must say to myself that it will not do
to lay claim to your attention so long in favor of the analytic
psychotherapy without telling you of what this treatment consists, and
on what it is based. To be sure I can only indicate it as I have to be
brief. This therapy is founded on the understanding that unconscious
ideas—or rather the unconsciousness of certain psychic processes—are the
main causes of a morbid symptom. We share this conviction with the
French school (Janet) which moreover by gross schematization reduces the
hysterical symptom to an unconscious idée fixe. Do not fear now that we
will thus merge too far into the obscurest philosophy. Our unconscious
is not quite the same as that of the philosophers and what is more, most
philosophers wish to know nothing of the “psychical unconscious.” But if
you will put yourselves in our position, you will understand that the
interpretation of this unconscious, in patients’ psychic life, into the
conscious, must result in a correction of their deviation from the
normal, and in an abrogation of the compulsion controlling their psychic
life. For the conscious will reaches as far as the conscious psychic
processes and every psychic compulsion is substantiated by the
unconscious. You need never fear that the patient will be harmed by the
emotion produced in the entrance of his unconscious into consciousness,
for you can theoretically readily understand that the somatic and
affective activity of the emotion which became conscious can never
become as great as those of the unconscious. For we only control all our
emotions by directing upon them our highest psychic activities which are
connected with consciousness.
We can still choose another point of view for the understanding of the
psychoanalytic treatment. The revealing and interpreting of the
unconscious takes place under constant resistance on the part of the
patient. The emerging of the unconscious is connected with displeasure
and owing to this displeasure it is continuously repulsed by the
patient. It is upon this conflict in the patient’s psychic life that you
encroach, and if you succeed in prevailing upon him to accept something,
for motives of better insight, which he has thus far repulsed
(repressed) on account of the automatic adjustment of displeasure, you
have achieved in him a piece of educational work. For it is really an
education if you can induce a person to leave his bed early in the
morning despite his unwillingness to do so. As such an after training
for the overcoming of inner resistances you can conceive the
psychoanalytic treatment in quite a general manner. But in no sphere of
the nervous patients is such an after training so essential as in the
psychic elements of their sexual life. For nowhere have culture and
education produced as much harm as here, and it is here, as experience
will show you, that the controlling etiologies of the neuroses are
found. The other etiological element, the constitutional contribution,
is really given to us as something immutable. But this gives rise to an
important demand on the doctor. Not only must he be of unblemished
character—“morality is really a matter of course” as the principal
person in Th. Vischer’s “Auch Einer” used to say—but he must have
overcome in his own personality the mixture of lewdness and prudishness
with which so many others are wont to meet the sexual problems.
This is perhaps the place for another observation. I know that the
emphasis which I laid on the sexual rôle in the origin of the
psychoneuroses has become widely known. But I also know that restriction
and nearer determinations are of little use with the great public; the
multitude has little room in its memory, and generally retains from a
statement the bare nucleus, thus creating for itself an easily
remembered extreme. The same might also have happened to some physicians
when the faint notion that they have of my theory is that I trace back
the neurosis in the last place to sexual privation. Of such there is
surely no dearth under the vital conditions of our society. But if that
supposition were true would it not seem obvious that in order to avoid
the roundabout way of the psychic treatment and tend directly towards
the cure, we should directly recommend sexual participation as the
remedy? I really do not know what could induce me to suppress these
conclusions if they were justified. But the state of affairs is
different. The sexual need or privation is merely one of the factors
playing a part in the mechanism of the neurosis, and if it alone existed
the result would not be a disease but a dissipation. The other equally
indispensable factor, which one is only too ready to forget, is the
sexual repugnance of neurotics, their inability to love; it is that
psychic feature which I have designated as “repression.” It is only from
the conflict between the two strivings that the neurotic malady
originates, and it is for this reason that the advice for sexual
participation in the psychoneuroses can really only seldom be designated
as good.
Allow me to conclude with this guarded remark. Let us hope that with an
interest for psychotherapy, purified of all hostile prejudice, you will
help us to do some good in the treatment of the severe cases of
psychoneuroses.