psychoanalysis to narcistic conditions has yielded us. They are
certainly all too few, and they often lack that accuracy which can only
be acquired in a new field with the attainment of absolute familiarity.
We owe them all to the exploitation of the conception of ego-libido or
narcistic libido, by the aid of which we have extended to narcistic
neuroses those observations which were confirmed in the transference
neuroses. But now you will ask, is it possible for us to succeed in
subordinating all the disturbances of narcistic conditions and the
psychoses to the libido theory in such a way that in every case we
recognize the libidinous factor of psychic life as the cause of the
malady, and never make an abnormality in the functioning of the
instincts of self-preservation answerable? Ladies and gentlemen, this
conclusion does not seem urgent to me, and above all not ripe for
decision. We can best leave it calmly to the progress of the science. I
should not be surprised to find that the power to exert a pathogenic
influence is really an exclusive prerogative of the libidinous impulses,
and that the libido theory will celebrate its triumphs along the whole
line from the simplest true neurosis to the most difficult psychotic
derangement of the individual. For we know it to be a characteristic of
the libido that it is continually struggling against subordinating
itself to the realities of the world. But I consider it most probable
that the ego instincts are indirectly swept along by the pathogenic
excitations of the libido and forced into a functional disturbance.
Moreover, I cannot see any defeat for our trend of investigation when we
are confronted with the admission that in difficult psychoses the ego
impulses themselves are fundamentally led astray; the future will teach
us--or at least it will teach you. Let me return for one moment more to
fear, in order to eliminate one last ambiguity that we have left. We
have said that the relation between fear and the libido, which in other
respects seems clearly defined, does not fit in with the assumption that
in the face of danger real fear should become the expression of the
instinct of self-preservation. This, however, can hardly be doubted. But
suppose the emotion of fear is not contested by the egoistic ego
impulse, but rather by the ego-libido? The condition of fear is in all
cases purposeless and its lack of purpose is obvious when it reaches a
higher level. It then disturbs the action, be it flight or defense,
which alone is purposeful, and which serves the ends of
self-preservation. If we accredit the emotional component of actual fear
to the ego-libido, and the accompanying activity to the egoistic
instinct to self-preservation, we have overcome every theoretical
difficulty. Furthermore, you do not really believe that we flee
_because_ we experience fear? On the contrary, we first are afraid _and
then_ take to flight from the same motive that is awakened by the
realization of danger. Men who have survived the endangering of their
lives tell us that they were not at all afraid, they only acted. They
turned the weapon against the wild animal, and that was in fact the most
purposeful thing to do.
TWENTY-SEVENTH LECTURE
GENERAL THEORY OF THE NEUROSES
_Transference_
We are nearing the close of our discussions, and you probably cherish
certain expectations, which shall not be disappointed. You think, I
suppose, that I have not guided you through thick and thin of
psychoanalytic subject matter to dismiss you without a word about
therapy, which furnishes the only possibility of carrying on
psychoanalysis. I cannot possibly omit this subject, for the observation
of some of its aspects will teach you a new fact, without which the
understanding of the diseases we have examined would be most incomplete.
I know that you do not expect any guidance in the technique of
practising analysis for therapeutic purposes. You wish to know only
along what general lines psychoanalytic therapy works and approximately
what it accomplishes. And you have an undeniable right to know this. I
shall not actually tell you, however, but shall insist that you guess it
yourselves.
Only think! You know everything essential, from the conditions which
precipitate the illness to all the factors at work within. Where is
there room for therapeutic influence? In the first place, there is
hereditary disposition; we do not speak of it often because it is
strongly emphasized from another quarter, and we have nothing new to say
about it. But do not think that we underestimate it. Just because we are
therapeutists, we feel its power distinctly. At any rate, we cannot
change it; it is a given fact which erects a barrier to our efforts. In
the second place, there is the influence of the early experiences of
childhood, which are in the habit of becoming sharply emphasized under
analysis; they belong to the past and we cannot undo them. And then
everything that we include in the term "actual forbearance"--misfortunes
of life out of which privations of love arise, poverty, family discord,
unfortunate choice in marriage, unfavorable social conditions and the
severity of moral claims. These would certainly offer a foothold for
very effectual therapy. But it would have to be the kind of therapy
which, according to the Viennese folk-tale, Emperor Joseph practiced:
the beneficial interference of a potentate, before whose will men bow
and difficulties vanish. But who are we, to include such charity in the
methods of our therapy? Poor as we are, powerless in society, forced to
earn our living by practicing medicine, we are not even in a position to
treat free of charge those patients who are unable to pay, as physicians
who employ other methods of treatment can do. Our therapy is too long
drawn-out, too extended for that. But perhaps you are still holding to
one of the factors already mentioned, and think that you have found a
factor through which our influence may be effective. If the restrictions
of morality which are imposed by society have a share in the privation
forced upon the patient, treatment might give him the courage, or
possibly even the prescription itself, to cross these barriers, might
tell him how gratification and health can be secured in the renunciation
of that ideal which society has held up to us but often disregards. One
grows healthy then, by giving one's sexuality full reign. Such analytic
treatment, however, would be darkened by a shadow; it does not serve our
recognized morality. The gain to the individual is a loss to society.
But, ladies and gentlemen, who has misinformed you to this degree? It is
inconceivable that the advice to give one's sexuality full reign can
play a part in analytic therapy, if only from the circumstance we have
ourselves described, that there is going on within the patient a bitter
conflict between libidinous impulse and sexual suppression, between
sensual and ascetic tendencies. This conflict is not abolished by giving
one of these tendencies the victory over its opponent. We see that in
the case of the nervous, asceticism has retained the upper hand. The
consequence of this is that the suppressed sexual desire gains breathing
space by the development of symptoms. If, on the other hand, we were to
give the victory to sexuality, symptoms would have to replace the sexual
suppression, which has been pushed aside. Neither of the two decisions
can end the inner conflict, one part always remains unsatisfied. There
are only a few cases wherein the conflict is so labile, that a factor
such as the intervention of the physician could be decisive, and these
cases really require no analytic treatment. Persons who can be so much
influenced by a physician would have found some solution without him.
You know that when an abstinent young man decides upon illegitimate
sex-intercourse, or when an unsatisfied woman seeks compensation from
another man, they have generally not waited for the permission of a
physician, far less of an analyst, to do this.
In studying the situation, one essential point is generally overlooked,
that the pathogenic conflict of the neurotic must not be confused with
normal struggles between psychic impulses of which all have their root
in the same psychological soil. The neurotic struggle is a strife of
forces, one of which has attained the level of the fore-conscious and
the conscious, while the other has been held back in the unconscious
stage. That is why the conflict can have no outcome; the struggling
parties approach each other as little as in the well-known instance of
the polar-bear and the whale. A real decision can be reached only if
both meet on the same ground. To accomplish this is, I believe, the sole
task of therapy.
Moreover, I assure you that you are misinformed if you assume that
advice and guidance in the affairs of life is an integral part of the
analytic influence. On the contrary, we reject this role of the mentor
as far as possible. Above all, we wish to attain independent decisions
on the part of the patient. With this intention in mind, we require him
to postpone all vital resolutions such as choice of a career, marriage
or divorce, until the close of the treatment. You must confess that this
is not what you had imagined. It is only in the case of certain very
young or entirely helpless persons that we cannot insist upon the
desired limitation. Here we must combine the function of physician and
educator; we are well aware of the responsibility and behave with the
necessary precaution.
Judging from the zeal with which I defend myself against the accusation
that analytic treatment urges the nervous person to give his sexuality
full reign, you must not gather that we influence him for the benefit of
conventional morality. We are just as far removed from that. We are no
reformers, it is true, only observers, but we cannot help observing with
critical eyes, and we have found it impossible to take the part of
conventional sex morality, or to estimate highly the way in which
society has tried to regulate the problems of sexual life in practice.
We can prove to society mathematically that its code of ethics has
exacted more sacrifices than is its worth, and that its procedure rests
neither on veracity nor wisdom. We cannot spare our patients the task of
listening to this criticism. We accustom them to weigh sexual matters,
as well as others, without prejudice; and when, after the completion of
the cure, they have become independent and choose some intermediate
course between unrestrained sexuality and asceticism, our conscience is
not burdened by the consequences. We tell ourselves: whoever has been
successfully educated in being true to himself is permanently protected
against the danger of immorality, even if his moral standard diverges
from that of society. Let us, moreover, be careful not to overestimate
the significance of the problem of abstinence with respect to its
influence on neuroses. Only the minority of pathogenic situations of
forbearance, with a subsequent condition of pent-up libido, can be
resolved without more ado by such sexual intercourse as can be procured
with little trouble.
And so you cannot explain the therapeutic influence of psychoanalysis by
saying that it simply recommends giving full sway to sexuality. You must
seek another solution. I think that while I was refuting this
supposition of yours, one of my remarks put you on the right track. Our
usefulness consists in replacing the unconscious by the conscious, in
translating the unconscious into the conscious. You are right; that is
exactly it. By projecting the unconscious into the conscious, we do away
with suppressions, we remove conditions of symptom formation and
transform a pathogenic into a normal conflict which can be decided in
some way or other. This is the only psychic change we produce in our
patients; its extent is the extent of our helpfulness. Wherever no
suppression and no analogous psychic process can be undone, there is no
place for our therapy.
We can express the aim of our efforts by various formulae of rendering
the unconscious conscious, removing suppressions, filling out amnestic
gaps--it all amounts to the same thing. But perhaps this admission does
not satisfy you. You imagined that when a nervous person became cured
something very different happened, that after having been subjected to
the laborious process of psychoanalysis, he was transformed into a
different human being. And now I tell you that the entire result is only
that he has a little less of the unconscious, a little more of the
conscious within him. Well, you probably underestimate the significance
of such an inner change. The person cured of neurosis has really become
another human being. Fundamentally, of course, he has remained the same.
That is to say, he has only become what he might have been under the
most favorable conditions. But that is saying a great deal. When you
learn all that has to be done, the effort required to effect apparently
so slight a change in psychic life, the significance of such a
difference in the psychic realm will be credible to you.
I shall digress for a moment to ask whether you know what is meant by a
causal therapy? This name is given to the procedure which does not take
the manifestations of disease for its point of departure, but seeks to
remove the causes of disease. Is our psychoanalytical therapy causal or
not? The answer is not simple, but perhaps it will give us the
opportunity of convincing ourselves that this point of departure is
comparatively fruitless. In so far as analytical therapy does not
concern itself immediately with the removal of symptoms, it may be
termed causal. Yet in another respect, you might say this would hardly
follow. For we have followed the causal chain back far beyond the
suppressions to the instinctive tendencies and their relative intensity
as given by the constitution of the patient, and finally the nature of
the digression in the abnormal process of its development. Assume for a
moment that it were possible to influence these functions chemically, to
increase or to decrease the quantity of the libido that happens to be
present, to strengthen one impulse at the expense of another. This would
be causal therapy in its true sense and our analysis would have
furnished the indispensable preparatory work of reconnaissance. You know
that there is as yet no possibility of so influencing the processes of
the libido. Our psychic therapy interposes elsewhere, not exactly at
those sources of the phenomena which have been disclosed to us, but
sufficiently far beyond the symptoms, at an opening in the structure of
the disease which has become accessible to us by means of peculiar
conditions.
What must we do in order to replace the unconscious by the conscious in
our patient? At one time we thought this was quite simple, that all we
had to do was to reconstruct the unconscious and then tell the patient
about it. But we already know this was a shortsighted error. Our
knowledge of the unconscious has not the same value as his; if we
communicate our knowledge to him it will not stand _in place of_ the
unconscious within him, but will exist _beside_ it, and only a very
small change will have been effected. We must rather think of the
unconscious as _localized_, and must seek it in memory at the point
where it came into existence by means of a suppression. This suppression
must be removed before the substitution of the conscious for the
unconscious can be successfully effected. How can such a suppression be
removed? Here our task enters a second phase. First to find the
suppression, then to remove the resistance by which this suppression is
maintained.
How can we do away with resistance? In the same way--by reconstructing
it and confronting the patient with it. For resistance arises from
suppression, from the very suppression which we are trying to break up,
or from an earlier one. It has been established by the counter-attack
that was instigated to suppress the offensive impulse. And so now we do
the very thing we intended at the outset: interpret, reconstruct,
communicate--but now we do it in the right place. The counter-seizure of
the idea or resistance is not part of the unconscious but of the ego,
which is our fellow-worker. This holds true even if resistance is not
conscious. We know that the difficulty arises from the ambiguity of the
word "unconscious," which may connote either a phenomenon or a system.
That seems very difficult, but it is only a repetition, isn't it? We
were prepared for it a long time ago. We expect resistance to be
relinquished, the counter-siege to collapse, when our interpretation has
enabled the ego to recognize it. With what impulses are we able to work
in such a case? In the first place, the patient's desire to become well,
which has led him to accommodate himself to co-operate with us in the
task of the cure; in the second place, the help of his intelligence,
which is supported by the interpretation we offer him. There is no doubt
that after we have made clear to him what he may expect, the patient's
intelligence can identify resistances, and find their translation into
the suppressions more readily. If I say to you, "Look up into the sky,
you can see a balloon there," you will find it more readily than if I
had just asked you to look up to see whether you could discover
anything. And unless the student who for the first time works with a
microscope is told by his teacher what he may look for, he will not see
anything, even if it is present and quite visible.
And now for the fact! In a large number of forms of nervous illness, in
hysteria, conditions of anxiety and compulsion neuroses, one hypothesis
is correct. By finding the suppression, revealing resistance,
interpreting the thing suppressed, we really succeed in solving the
problem, in overcoming resistance, in removing suppression, in
transforming the unconscious into the conscious. While doing this we
gain the clearest impression of the violent struggle that takes place in
the patient's soul for the subjugation of resistance--a normal
psychological struggle, in one psychic sphere between the motives that
wish to maintain the counter-siege and those which are willing to give
it up. The former are the old motives that at one time effected
suppression; among the latter are those that have recently entered the
conflict, to decide it, we trust, in the sense we favor. We have
succeeded in reviving the old conflict of the suppression, in reopening
the case that had already been decided. The new material we contribute
consists in the first place of the warning, that the former solution of
the conflict had led to illness, and the promise that another will pave
the way to health; secondly, the powerful change of all conditions since
the time of that first rejection. At that time the ego had been weak,
infantile and may have had reason to denounce the claims of the libido
as if they were dangerous. Today it is strong, experienced and is
supported by the assistance of the physician. And so we may expect to
guide the revived conflict to a better issue than a suppression, and in
hysteria, fear and compulsion neuroses, as I have said before, success
justifies our claims.
There are other forms of illness, however, in which our therapeutic
procedure never is successful, even though the causal conditions are
similar. Though this may be characterized topically in a different way,
in them there was also an original conflict between the ego and libido,
which led to suppression. Here, too, it is possible to discover the
occasions when suppressions occurred in the life of the patient. We
employ the same procedure, are prepared to furnish the same promises,
give the same kind of help. We again present to the patient the
connections we expect him to discover, and we have in our favor the same
interval in time between the treatment and these suppressions favoring a
solution of the conflict; yet in spite of these conditions, we are not
able to overcome the resistance, or to remove the suppression. These
patients, suffering from paranoia, melancholia, and dementia praecox,
remain untouched on the whole, and proof against psychoanalytic therapy.
What is the reason for this? It is not lack of intelligence; we require,
of course, a certain amount of intellectual ability in our patients; but
those suffering from paranoia, for instance, who effect such subtle
combinations of facts, certainly are not in want of it. Nor can we say
that other motive forces are lacking. Patients suffering from
melancholia, in contrast to those afflicted with paranoia, are
profoundly conscious of being ill, of suffering greatly, but they are
not more accessible. Here we are confronted with a fact we do not
understand, which bids us doubt if we have really understood all the
conditions of success in other neuroses.
In the further consideration of our dealings with hysterical and
compulsion neurotics we soon meet with a second fact, for which we were
not at all prepared. After a while we notice that these patients behave
toward us in a very peculiar way. We thought that we had accounted for
all the motive forces that could come into play, that we had
rationalized the relation between the patient and ourselves until it
could be as readily surveyed as an example in arithmetic, and yet some
force begins to make itself felt that we had not considered in our
calculations. This unexpected something is highly variable. I shall
first describe those of its manifestations which occur frequently and
are easy to understand.
We see our patient, who should be occupying himself only with finding a
way out of his painful conflicts, become especially interested in the
person of the physician. Everything connected with this person is more
important to him than his own affairs and diverts him from his illness.
Dealings with him are very pleasant for the time being. He is especially
cordial, seeks to show his gratitude wherever he can, and manifests
refinements and merits of character that we hardly had expected to
find. The physician forms a very favorable opinion of the patient and
praises the happy chance that permitted him to render assistance to so
admirable a personality. If the physician has the opportunity of
speaking to the relatives of the patient he hears with pleasure that
this esteem is returned. At home the patient never tires of praising the
physician, of prizing advantages which he constantly discovers. "He
adores you, he trusts you blindly, everything you say is a revelation to
him," the relatives say. Here and there one of the chorus observes more
keenly and remarks, "It is a positive bore to hear him talk, he speaks
only of you; you are his only subject of conversation."
Let us hope that the physician is modest enough to ascribe the patient's
estimation of his personality to the encouragement that has been offered
him and to the widening of his intellectual horizon through the
astounding and liberating revelations which the cure entails. Under
these conditions analysis progressed splendidly. The patient understands
every suggestion, he concentrates on the problems that the treatment
requires him to solve, reminiscences and ideas flood his mind. The
physician is surprised by the certainty and depth of these
interpretations and notices with satisfaction how willingly the sick man
receives the new psychological facts which are so hotly contested by the
healthy persons in the world outside. An objective improvement in the
condition of the patient, universally admitted, goes hand in hand with
this harmonious relation of the physician to the patient under analysis.
But we cannot always expect to have fair weather. There comes a day when
the storm breaks. Difficulties turn up in the treatment. The patient
asserts that he can think of nothing more. We are under the impression
that he is no longer interested in the work, that he lightly passes over
the injunction that, heedless of any critical impulse, he must say
everything that comes to his mind. He behaves as though he were not
under treatment, as though he had closed no agreement with the
physician; he is clearly obsessed by something he does not wish to
divulge. This is a situation which endangers the success of the
treatment. We are distinctly confronted with a tremendous resistance.
What can have happened?