“But the physicians! It seems I am really unable to bring you to the
main point of our conversation. You are continually evading me. After
all, the question before us is whether physicians should be given the
exclusive right to employ psychoanalysis, that is, after they have
fulfilled certain conditions, if you should insist upon such. According
to your own statement, the majority of ‘quacks,’ dabbling with
psychoanalysis, does not consist of physicians. You also admit that the
greatest number of your disciples and followers are physicians. I have
heard that these do not share your point of view, in regard to
lay-analyses.
“Of course, it is to be expected that your disciples agree with you in
the question of sufficient training. Just the same, they hold the laymen
should be excluded from the practice of psychoanalysis. Is that really
the case? And if so, how do you account for it?”
You are correctly informed. Not all, but a great number of my medically
trained collaborators do not side with me in this matter, but insist
that psychoanalytical treatment of neurotics be exclusively reserved for
physicians. From this, you may gather that even within the limits of our
own camps, there prevails a difference of opinion. Although my point of
view is very well known, the divergence of opinion in matters of
lay-analyses, in no way interferes with an otherwise splendid harmony.
How to explain this position of some of my disciples?
I am not so sure, but I assume that professional pride is behind it. You
see, their process of development has been different from mine. That
they find themselves somewhat isolated from their colleagues, is still
annoying them. They would like to be considered, by the profession as a
whole, as members in good standing, so to say. Thus, in order to win the
tolerance of their Æsculapian brothers, they are willing to make a
sacrifice, whose value is apparently not clear to them.
Of course, I may be wrong here. To assume that fear of competition is
dictating their position, would not only amount to suspecting them of a
low motive, but also condemn them for a peculiar shortsightedness. After
all, as long as they are ready to initiate colleagues into
psychoanalysis, it can be of no importance to them whether they will
have to share prospective patients with them, or with laymen.
Probably, there is something else to be considered. They may be
impressed by certain features which, in the practice of psychoanalysis
assure the physician of an unquestionable advantage over the layman.
“There you are:—‘Assure the advantage’! At last, you admit this
advantage! I should think this admission settles our argument.”
I admit this advantage. Perhaps by doing so I shall prove to you that I
am not as passionately deluded as you think. I postponed mentioning
these conditions, because in airing them, additional theoretical
discussion is necessary.
“What are you driving at now?”
There is first the question of diagnosis. Before admitting a patient,
suffering from nervous disturbances, to psychoanalytical treatment, one
naturally desires to have as much assurance as possible that this
therapy is suitable in that particular case, that is, that the patient
has a good chance of being benefited by psychoanalysis. This can only be
the case, if he is actually suffering from neurosis.
“I should think that would be easily ascertained, by the symptoms he
complains about.”
You are putting your finger just on the point, where new complications
may arise. It is not always possible to be perfectly sure of such a
case. The patient, in spite of displaying all the visible symptoms of
neurosis, may actually be suffering from something else. The incipient
stage of a mental disease, for example, or the beginning of a process
destroying his brain. To distinguish between such symptoms is not always
easy or possible. Responsibility for such a decision must naturally be
assumed by the physician alone. And as mentioned before, it is not so
easy for him. For the longest time, an ailment may appear absolutely
harmless, until finally manifesting its malignant character. Nervous
people, as a rule, fear that they may be on the road to some mental
disease.
Assumed that a physician has not correctly diagnosed a case, or has been
unable to discover its true nature, nothing has been lost, no damage has
been done. Analytical treatment, although not doing any harm to the
patient, would have been superfluous in such a case. It might have given
any number of people a chance to lay the blame for the unfortunate
development of the case at the door of psychoanalysis. Unjustly so, to
be sure, but such a likelihood should be avoided nevertheless.
“That sounds hopeless. It apparently tears out, by the very roots,
everything you told me about the nature and development of a neurosis.”
Not at all. It only strengthens the fact that neurotics are a nuisance
and a dilemma for all parties concerned, including the psychoanalysts. I
may be able to alleviate your new apprehensions if I make myself
clearer. Probably it would be more correct to say of such cases, as we
now have under discussion, that they actually present neuroses. However,
these neuroses are not psychic but rather somatic, that is, they do not
originate from the soul, but rather from the body. Do you understand me?
“I do. But I am at a loss to connect all this with the psychological
aspect.”
That can easily be done, if only complications of the living substance
are sufficiently taken into consideration. What was the inherent feature
of a neurosis? That the “I,” constituting the very essence of the soul,
so to speak, developed and improved by the influence of the outer world,
proved unable to fulfill its mediating functions between the “It” and
reality; that the “I,” on account of its weakness, shirked its duties in
regard to the “It,” thus incurring repressions from which it suffers. It
is because such weakness of the “I” regularly takes place in all of us
in childhood that events of our tender years exert such great importance
in later life.
In the few years of our childhood, we have to cover the enormous
distance of development from primitive man of the Stone Age to civilized
man of today. In addition to this tremendous burden, the child has to
ward off the urges of an early sexuality. Small wonder, then, that our
“I” takes recourse to repressions, thus exposing itself to childhood
neuroses, the effects of which in turn furnish the disposition for
nervous disturbances in more mature years.
Everything now depends upon how the growing up individual will be
treated by fate. If life is too hard, the divergence between urges and
the opposition of reality too great, the “I” may remain unsuccessful in
its endeavors to mediate between the two. This is the more probable, the
more the “I” is encroached upon by such infantile dispositions as it may
have acquired in tender years. Thus, the process of repression is
repeated; urges tear themselves free from the sovereignty of the “I” to
gain, by way of regression, a substitute for the gratification they
crave, while the poor “I” has become helplessly neurotic.
Let us hold on firmly to this: that the most important, the pivotal
point in the whole situation, so to speak, is the relative strength of
the “I” in all its phases. It is easy, then, to complete our whole
etiological survey, that is our endeavor to assign causes to the
phenomena observed. We already know the normal causes for nervousness to
be the infantile weakness of the “I,” the checking of early sexual
urges, and the influence of chance episodes in our childhood.
But is there no possibility that there are also some other contributory
factors, antedating childhood? For example, an inborn strength and
unruliness of those urges which constitute the “It,” presenting right
from the very start a task much too difficult for the “I”? Or could a
certain weakness, existing for reasons unknown, in the development of
the “I” be held responsible? Of course, all these possibilities will
exert an etiological importance, in some cases of surpassing value.
The specific driving power of the “It” must always be taken into
consideration, and wherever it is developed to an excessive degree,
there are only meagre chances for a successful application of our
therapy. Of the reasons that block the development of the “I,” we still
know too little to account for such cases of neurosis which arise on a
constitutional basis. It may be assumed that neurosis hardly ever
develops unless there are constitutional or congenital factors
increasing the possibility for such a condition. However, if it is
correct that the relative weakness of the “I” is the deciding factor for
the development of neuroses, then it would also appear possible that
later, physical disturbances may result in a neurosis provided it also
results in a weakening of the “I.”
This happens only too frequently. Such a physical disturbance may aim at
the “It,” intensifying its urges to an extent where the “I” is not able
to cope with them any more. As an example for such developments, the
changes induced in woman by the disturbances of menstruation and
menopause could perhaps be drawn upon. Other reasons that may weaken the
“I” are general physical disturbances, organic diseases of the central
nervous system. All of these may result in interference with those
sources from which the soul apparatus draws its strength, to lead, in
turn, to an encroachment of its more delicate functions, which are
necessary to maintain unimpaired the whole “I” organization. In all
these cases, neurosis presents about the same picture. However, while
manifesting the same psychological mechanism, neuroses develop on the
basis of a multifarious, frequently highly complicated etiology; that
is, they arise from a great number of various causes.
“That suits me better. At last you have spoken like a physician. And now
I am waiting for you to admit that so complicated a condition as a
neurosis should only be treated by a physician.”
I am afraid you are expecting too much. What we have just discussed
belonged in the realm of pathology. Psychoanalysis, however, is a
therapeutical process. I admit, no, I even insist, that a physician
should first diagnose each and every case where psychoanalysis seems
applicable. Fortunately, the greater number of neuroses are of a
psychical nature and not pathologically induced. As soon as the
physician has ascertained this, he may safely leave the treatment to the
lay-analyst. We have always followed this procedure within our
analytical societies. Thanks to this close coöperation between the
medically trained and non-trained members, errors almost never occur.
There is another emergency when the analyst has to invite the assistance
of a physician. It is possible that, in the course of psychoanalytical
treatment, symptoms—mostly of physical nature—appear which may either be
part of the neurosis, or else manifestations of independent, organic
disturbances. Here, the decision must once more be left to the
physician.
“From all this, there follows that the analysts, even during the
analysis, cannot dispense with the physician. This is another argument
against lay-analyses.”
No, this possibility cannot be drawn upon as an argument against
lay-analyses, because in an analogous case the medically trained analyst
would not proceed any differently.
“I do not understand that.”
There is a rule that even a medically trained analyst, running across
such dubious symptoms in the course of the treatment, is not to depend
on his own judgment, but to consult some colleague, preferably a
specialist of internal diseases.
“Why this rule, apparently so superfluous?”
This rule is not superfluous at all. There are several reasons for it.
In the first place, it is hard to combine organic and psychical
treatment. In the second place, the particular condition of transference
frequently prevailing in analyses may make it inadvisable for the
analyst to subject his patient to physical examination. In the third
place, there are all the reasons in the world for the analyst to doubt
his own opinion, inasmuch as he is so intensely interested in the
psychical aspects of the case.
“I now understand your position towards lay-analyses. You insist that
there must be lay-analysts. However, as you have to admit their
insufficiency for the task, you compile everything that could serve to
excuse them, and make things in general easier for them. To be frank
with you, I cannot understand why we should have lay-analysts at all,
inasmuch as they would never be more than second-class therapeutists.
This need not include those few laymen who have already received their
training, but institutes for psychological training should not accept
laymen any more.”
I would assent to all this, if I could be shown that such restrictions
would benefit all parties interested. You will admit that these
interests are tri-fold:—There is the interest of the patient, the
interest of the physicians, and last but not least, the interest of
science which, in turn, includes the interest of all patients of the
future. Let us investigate these three points.
It does not matter whether the patient be analysed by a physician or a
layman, as long as any danger of mistaking his condition is excluded by
being properly examined by a physician before the beginning of the
treatment, or re-examined as soon as developments, in the course of the
analysis, make this advisable. It is much more important for the patient
that the analyst possesses those personal qualities which invite full
confidence, and that he has that knowledge and experience which alone
qualify him to apply psychoanalysis. To some people, it may seem that it
might undermine the authority of the analyst to have his patient know
that he is no physician and must obtain the advice of a medically
trained expert in certain matters. However, although we have never kept
a patient in the dark, as to the qualifications of an analyst, we have
come to the conclusion that the patients have no prejudice against a
non-medically trained analyst; they are only too glad to accept the
benefits of treatment, wherever they offer themselves—a fact resented by
the medical profession for the longest time.
It also must be considered that analysts, practising today, are men and
women with academic training and degrees, pedagogues, of great
experience and impressive personality. The analysis, to which all
candidates of psychoanalytical institutes are required to submit, is the
best means of testing their personal suitability for the performance of
so exerting an activity as an analysis presents.
In reference to the interest of the physicians, I do not believe that
medicine has anything to gain by annexing psychoanalysis. Today, medical
training requires five years, with almost a whole sixth year taken up
with examinations. Ever so often, new demands in regard to training are
made with which the young student must comply, if his medical education
is to be considered adequate. Generally speaking, while it is difficult
today to enter the medical profession, the practice of medicine is
neither very satisfactory nor very advantageous. And as soon as the
undoubtedly justified necessity is realized that the physician be also
informed of the psychological aspects of diseases, thus including in
medical training a partial preparation for psychoanalysis, there would
follow an extension of the medical curriculum and a corresponding
extension of the period of training. I do not know how physicians would
like such a development, arising from the monopoly they claim on
psychoanalysis. But these demands would then have to be fulfilled and at
a time when, in general, the material aspects of those strata of society
which contribute the greatest contingent to the medical profession, are
such that young physicians must establish a practice, as soon as
possible.
However, the medical profession may not intend to include preparation
for psychoanalysis into the medical curriculum proper. The general
opinion may be that it is much more practical for the young physician to
acquire psychoanalytical knowledge only after having completed his
medical education. It may be said that such a procedure would not
involve any actual loss of time, inasmuch as a young man under thirty
never gains that confidence of patients which is an indispensable
condition for benefiting a patient psychoanalytically. Of course, it
could be said that a young physician, too, who has just won his diploma,
cannot command too much respect, as regards his opinion of the physical
ailments of his patients, and that the young analyst could very well
utilize his time, by working in a psychological clinic, under the
supervision of an experienced practitioner.
It seems to me that the aforementioned demand amounts to a waste of
energy which, in view of economic conditions, does not seem justified.
Although analytical training invades the field of medical training, it
neither includes this training, nor is included by it. If a
psychoanalytical college were to be organized, which today may strike
one as being a fantastic idea, the curriculum of this institution would
have to include much of what is taught in medical schools. Aside from
the Psychology of the Depths, which would naturally always be the main
subject taught, Biology would have to be included in the course, and
Science of Sex would also be one of the major subjects. In addition,
adequate instruction would have to be given on such disturbances which
belong in the realm of Psychiatry. Psychoanalytical training would have
to include a number of subjects which have no connection with medicine,
and never enter the physician’s practice, such as History of
Civilization, Mythology, Psychology of Religion, and Literature. Without
being well acquainted with these subjects, the analyst will be unable to
grasp the problems that will face him in the course of his practice.
Most of the subjects, however, belonging to medical training, will not
be of any use to him and although all this knowledge is highly valuable
for those who need it, it would not assist the analyst to understand a
neurotic condition nor to alleviate it. In case the objection is made
here that specialists in other fields of medical endeavor, also do not
need all the details they acquire in the course of their training, it
must be said that such a case could not be considered analogous. For
many branches of medicine, such facts as, for example, Pathology
presents, are of great importance. The analyst, however, reaches out for
a variety of experiences, with different phenomena, underlying different
laws. Although philosophy may succeed in bridging the chasm between body
and soul, as far as our own experience is concerned, this chasm,
nevertheless, exists, presenting itself in an especially striking light,
as regards our practical endeavors.
It seems unjust and impractical to force a person to take a roundabout
route via medical training, if this person be bent upon relieving
another individual from the agonies of a phobia or a fixed idea.
Moreover, such a procedure would be ineffective, as long as
psychoanalysis in general is not suppressed.
Just imagine that somewhere in the country, there is a certain mountain
top that can be reached by two different roads, the one being short and
straight, and the other long and winding. An attempt is made to block
the short road by a “no-trespass” sign. There is some chance of this
sign being respected, if the short road is steep and difficult to climb,
whereas the long road is easy to travel. However, if the detour should
be the more difficult road, you can easily surmise how little the
trespassing sign would be respected.
I am very much afraid it will be just as difficult to force the laymen
to study medicine, as it is for me to induce physicians to study
psychoanalysis. Human nature is like that.
“If you are correct in your assumption that analytical treatment cannot
be administered without a special training, but that on the other hand
the medical curriculum could not bear the burden of psychoanalytical
training, and that medical knowledge, to the greatest extent, is
superfluous for the analyst, how will we ever achieve the ideal medical
personality, the physician who can cope with all the demands of his
profession?”
I am unable to foresee how to solve these difficulties, and I do not
feel called upon to make any suggestions. I only perceive two things
clearly: firstly, that the analysis seems to constitute a dilemma, but
certainly the neurotic is also a dilemma; secondly, that for the time
being, all interests would be served if physicians resolve to tolerate a
class of therapeutists who will relieve them of the arduous treatment of
those tremendously frequent psychical neuroses, in addition benefiting
the patients by remaining in constant contact with them.
“Is that your last word in reference to the problem of lay-analyses, or
is there something else?”
There is a third interest to be considered:—that of science. Although
what I have to say in that respect may not mean much to you, it
nevertheless means a good deal to me.
We do not consider it advisable that psychoanalysis be swallowed up by
medicine, finally to be shelved in a text-book of psychiatry, under the
chapter heading of Therapy, together with such other treatments as
Hypnotic Suggestion, Auto Suggestion, Persuasion which, due to lack of
knowledge, were indebted for their short lives to the indolence and
ignorance of the broad masses. Psychoanalysis deserves a better fate,
which, let us hope, it will really attain.
As the Psychology of the Depths, the teaching of the Unconscious,
psychoanalysis may prove indispensable to all sciences which deal with
the development of human culture, and such of its great achievements as
art, religion, and civilized society. Psychoanalysis has already
appreciably assisted these sciences in the solution of their problems.
But all this is insignificant, compared to what may be achieved through
psychoanalysis in the future, when students of History, Psychology of
Religion, and Etymology, will avail themselves to the fullest extent of
the assistance psychoanalysis will be able to render them.
The employment of psychoanalysis for the treatment of neuroses is only
one of its possibilities, and time may yet prove that this is not even
the most important of them. At any rate, it would be unfair to sacrifice
all other advantages of psychoanalysis, simply because there is just one
phase where the application of psychoanalysis encroaches upon the
preserves of medicine.
Here another aspect manifests itself which cannot be interfered with,
without causing damage. If the representatives of the different sciences
should really take up the study of psychoanalysis, to apply it in their
own spheres of interest, it would not suffice for them to merely avail
themselves of such results as have been recorded in psychoanalytical
literature. They will have to come to an understanding of psychoanalysis
in the only way possible, that is, by submitting themselves to analysis.
Thus, to the neurotics in need of analysis, a second class of persons
would be added: those who undergo analysis for intellectual reasons and
who would welcome that intensification of their efficiency which would
result incidentally from analysis. To undertake these analyses, a number
of analysts would be necessary for whom medical knowledge would be of
specially limited importance. However, these instructor-analysts—as they
ought to be called—are in need of an especially thorough training, which
they can only obtain if they are given opportunities to study
interesting and convincing cases. Inasmuch as healthy persons do not
feel the necessity and curiosity to be analysed, neurotics would have to
be the objects of study for the instructor-analysts. Their study would
be guided by expert analysts, with a special eye to their future,
non-medical work. Of course, all this necessitates a certain amount of
freedom of action, and would not brook petty interference.
Perhaps you do not believe in these strictly theoretical endeavors of
psychoanalysis, and are not ready to admit their importance, in
connection with the practical side of the problem of lay-analyses. In
that case, let me remind you that there is another field for the
application of psychoanalysis, outside the hunting ground of the
“quack”—a field which physicians will hardly claim as their own. I
allude to the application of psychoanalysis to pedagogy.
As soon as a child manifests the first signs of an undesirable
development, by being moody, stubborn and inattentive, neither the child
specialist nor the school physician will be able to do anything for him;
not even when a child shows such clear signs of nervous disturbances as
timidity, lack of appetite, vomiting, and sleeplessness. A treatment
which combines analytical influence with pedagogic measures and is
applied by persons who are not above delving into the child’s own world
and who understand how to penetrate the soul life of the child, will
succeed not only in dissolving nervous disturbances, but also in
reversing incipient traits of character.
The importance which we were forced to attach to apparently unimportant
neurotic conditions of children, in view of the fact that they very
often serve as a disposition for disturbances in later life, would prove
that the analyses of children constitute a splendid means of
prophylaxis. Although psychoanalysis still has its enemies, I do not
know what means are at their disposal to hinder the activity of a
pedagogic analyst, or analytical pedagogue, and I doubt whether this
could be done so easily.
To return once more to the problem of the analytical treatment of
adults, suffering from nervous disturbances, we have not yet exhausted
all points of view. Civilized life of today exerts an almost unbearable
pressure, which necessitates corrective measures. Does it seem too
fantastic to expect that psychoanalysis, in spite of the many
difficulties it encounters, should be called upon to furnish this
corrective agent? Maybe some American millionaire will one day donate
enough money for the psychoanalytical training of the social workers of
his country, thus creating an emergency corps, to fight neurotic
conditions brought about by present-day life.
“You mean some sort of a new Salvation Army?”
Why not? After all, our fancy always follows existing patterns. The
stream of eager students that will then flood towards Europe, will, of
course, have to pass Vienna, because there the development of
psychoanalysis may have prematurely died, on account of governmental
interference. You smile? I’m not saying this to sway your judgment. I
know you don’t believe me, and I surely cannot guarantee that my
predictions will come true. But there is one thing I know: it is not at
all important what the opinions of individuals and of individual
governments may be, in respect to the problem of lay-analyses. All this
can only have limited effects. What is really important is that
potentialities for the development of psychoanalysis cannot be affected
by ordinances and prohibitions.