the cause of the disturbance to have been intense affectionate
emotions, which the patient has transferred to the physician. This is
certainly not justified either by the behavior of the physician or by
the relations the treatment has created. The way in which this affection
is manifested and the goals it strives for will depend on the personal
affiliations of the two parties involved. When we have here a young girl
and a man who is still young we receive the impression of normal love.
We find it quite natural that a girl should fall in love with a man with
whom she is alone a great deal, with whom she discusses intimate
matters, who appears to her in the advantageous light of a beneficent
adviser. In this we probably overlook the fact that in a neurotic girl
we should rather presuppose a derangement in her capacity to love. The
more the personal relations of physician and patient diverge from this
hypothetical case, the more are we puzzled to find the same emotional
relation over and over again. We can understand that a young woman,
unhappy in her marriage, develops a serious passion for her physician,
who is still free; that she is ready to seek divorce in order to belong
to him, or even does not hesitate to enter into a secret love affair, in
case the conventional obstacles loom too large. Similar things are known
to occur outside of psychoanalysis. Under these circumstances, however,
we are surprised to hear women and girls make remarks that reveal a
certain attitude toward the problems of the cure. They always knew that
love alone could cure them, and from the very beginning of their
treatment they anticipated that this relationship would yield them what
life had denied. This hope alone has spurred them on to exert themselves
during the treatments, to overcome all the difficulties in communicating
their disclosures. We add on our own account--"and to understand so
easily everything that is generally most difficult to believe." But we
are amazed by such a confession; it upsets our calculations completely.
Can it be that we have omitted the most important factor from our
hypothesis?
And really, the more experience we gain, the less we can deny this
correction, which shames our knowledge. The first few times we could
still believe that the analytic cure had met with an accidental
interruption, not inherent to its purpose. But when this affectionate
relation between physician and patient occurs regularly in every new
case, under the most unfavorable conditions and even under grotesque
circumstances; when it occurs in the case of the elderly woman, and is
directed toward the grey-beard, or to one in whom, according to our
judgment, no seductive attractions exist, we must abandon the idea of an
accidental interruption, and realize that we are dealing with a
phenomenon which is closely interwoven with the nature of the illness.
The new fact which we recognize unwillingly is termed _transference_. We
mean a transference of emotions to the person of the physician, because
we do not believe that the situation of the cure justifies the genesis
of such feelings. We rather surmise that this readiness toward emotion
originated elsewhere, that it was prepared within the patient, and that
the opportunity given by analytic treatment caused it to be transferred
to the person of the physician. Transference may occur as a stormy
demand for love or in a more moderate form; in place of the desire to be
his mistress, the young girl may wish to be adopted as the favored
daughter of the old man, the libidinous desire may be toned down to a
proposal of inseparable but ideal and platonic friendship. Some women
understand how to sublimate the transference, how to modify it until it
attains a kind of fitness for existence; others manifest it in its
original, crude and generally impossible form. But fundamentally it is
always the same and can never conceal that its origin is derived from
the same source.
Before we ask ourselves how we can accommodate this new fact, we must
first complete its description. What happens in the case of male
patients? Here we might hope to escape the troublesome infusion of sex
difference and sex attraction. But the answer is pretty much the same as
with women patients. The same relation to the physician, the same
over-estimation of his qualities, the same abandon of interest toward
his affairs, the same jealousy toward all those who are close to him.
The sublimated forms of transference are more frequent in men, the
direct sexual demand is rarer to the extent to which manifest
homosexuality retreats before the methods by which these instinct
components may be utilized. In his male patients more often than in his
women patients, the physician observes a manifestation of transference
which at first sight seems to contradict everything previously
described: a hostile or _negative_ transference.
In the first place, let us realize that the transference occurs in the
patient at the very outset of the treatment and is, for a time, the
strongest impetus to work. We do not feel it and need not heed it as
long as it acts to the advantage of the analysis we are working out
together. When it turns into resistance, however, we must pay attention
to it. Then we discover that two contrasting conditions have changed
their relation to the treatment. In the first place there is the
development of an affectionate inclination, clearly revealing the signs
of its origin in sexual desire which becomes so strong as to awaken an
inner resistance against it. Secondly, there are the hostile instead of
the tender impulses. The hostile feelings generally appear later than
the affectionate impulses or succeed them. When they occur
simultaneously they exemplify the ambivalence of emotions which exists
in most of the intimate relations between all persons. The hostile
feelings connote an emotional attachment just as do the affectionate
impulses, just as defiance signifies dependence as well as does
obedience, although the activities they call out are opposed. We cannot
doubt but that the hostile feelings toward the physician deserve the
name of transference, since the situation which the treatment creates
certainly could not give sufficient cause for their origin. This
necessary interpretation of negative transference assures us that we
have not mistaken the positive or affectionate emotions that we have
similarly named.
The origin of this transference, the difficulties it causes us, the
means of overcoming it, the use we finally extract from it--these
matters must be dealt with in the technical instruction of
psychoanalysis, and can only be touched upon here. It is out of the
question to yield to those demands of the patient which take root from
the transference, while it would be unkind to reject them brusquely or
even indignantly. We overcome transference by proving to the patient
that his feelings do not originate in the present situation, and are not
intended for the person of the physician, but merely repeat what
happened to him at some former time. In this way we force him to
transform his repetition into a recollection. And so transference, which
whether it be hostile or affectionate, seems in every case to be the
greatest menace of the cure, really becomes its most effectual tool,
which aids in opening the locked compartments of the psychic life. But I
should like to tell you something which will help you to overcome the
astonishment you must feel at this unexpected phenomenon. We must not
forget that this illness of the patient which we have undertaken to
analyze is not consummated or, as it were, congealed; rather it is
something that continues its development like a living being. The
beginning of the treatment does not end this development. When the cure,
however, first has taken possession of the patient, the productivity of
the illness in this new phase is concentrated entirely on one aspect:
the relation of the patient to the physician. And so transference may be
compared to the cambrium layer between the wood and the bark of a tree,
from which the formation of new tissues and the growth of the trunk
proceed at the same time. When the transference has once attained this
significance the work upon the recollections of the patient recedes into
the background. At that point it is correct to say that we are no longer
concerned with the patient's former illness, but with a newly created,
transformed neurosis, in place of the former. We followed up this new
edition of an old condition from the very beginning, we saw it originate
and grow; hence we understand it especially well, because we ourselves
are the center of it, its object. All the symptoms of the patient have
lost their original meaning and have adapted themselves to a new
meaning, which is determined by its relation to transference. Or, only
such symptoms as are capable of this transformation have persisted. The
control of this new, artificial neurosis coincides with the removal of
the illness for which treatment was sought in the first place, namely,
with the solution of our therapeutic problem. The human being who, by
means of his relations to the physician, has freed himself from the
influences of suppressed impulses, becomes and stays free in his
individual life, when the influence of the physician is subsequently
removed.
Transference has attained extraordinary significance, has become the
centre of the cure, in the conditions of hysteria, anxiety and
compulsion neuroses. Their conditions therefore are properly included
under the term transference neuroses. Whoever in his analytic experience
has come into contact with the existence of transference can no longer
doubt the character of those suppressed impulses that express
themselves in the symptoms of these neuroses and requires no stronger
proof of their libidinous character. We may say that our conviction that
the meaning of the symptoms is substituted libidinous gratification was
finally confirmed by this explanation of transference.
Now we have every reason to correct our former dynamic conception of the
healing process, and to bring it into harmony with our new discernment.
If the patient is to fight the normal conflict that our analysis has
revealed against the suppressions, he requires a tremendous impetus to
influence the desirable decision which will lead him back to health.
Otherwise he might decide for a repetition of the former issue and allow
those factors which have been admitted to consciousness to slip back
again into suppression. The deciding vote in this conflict is not given
by his intellectual penetration--which is neither strong nor free enough
for such an achievement--but only by his relation to the physician.
Inasmuch as his transference carries a positive sign, it invests the
physician with authority and is converted into faith for his
communications and conceptions. Without transference of this sort, or
without a negative transfer, he would not even listen to the physician
and to his arguments. Faith repeats the history of its own origin; it is
a derivative of love and at first requires no arguments. When they are
offered by a beloved person, arguments may later be admitted and
subjected to critical reflection. Arguments without such support avail
nothing, and never mean anything in life to most persons. Man's
intellect is accessible only in so far as he is capable of libidinous
occupation with an object, and accordingly we have good ground to
recognize and to fear the limit of the patient's capacity for being
influenced by even the best analytical technique, namely, the extent of
his narcism.
The capacity for directing libidinous occupation with objects towards
persons as well must also be accorded to all normal persons. The
inclination to transference on the part of the neurotic we have
mentioned, is only an extraordinary heightening of this common
characteristic. It would be strange indeed if a human trait so
wide-spread and significant had never been noticed and turned to
account. But that has been done. Bernheim, with unerring perspicacity,
based his theory of hypnotic manifestations on the statement that all
persons are open to suggestion in some way or other. Suggestibility in
his sense is nothing more than an inclination to transference, bounded
so narrowly that there is no room for any negative transfer. But
Bernheim could never define suggestion or its origin. For him it was a
fundamental fact, and he could never tell us anything regarding its
origin. He did not recognize the dependence of suggestibility upon
sexuality and the activity of the libido. We, on the other hand, must
realize that we have excluded hypnosis from our technique of neurosis
only to rediscover suggestion in the shape of transference.
But now I shall pause and let you put in a word. I see that an objection
is looming so large within you that if it were not voiced you would be
unable to listen to me. "So at last you confess that like the
hypnotists, you work with the aid of suggestion. That is what we have
been thinking for a long time. But why choose the detour over
reminiscences of the past, revealing of the unconscious, interpretation
and retranslation of distortions, the tremendous expenditure of time and
money, if the only efficacious thing is suggestion? Why do you not use
suggestion directly against symptoms, as the others do, the honest
hypnotists? And if, furthermore, you offer the excuse that by going your
way you have made numerous psychological discoveries which are not
revealed by direct suggestion, who shall vouch for their accuracy? Are
not they, too, a result of suggestion, that is to say, of unintentional
suggestion? Can you not, in this realm also, thrust upon the patient
whatever you wish and whatever you think is so?"
Your objections are uncommonly interesting, and must be answered. But I
cannot do it now for lack of time. Till the next time, then. You shall
see, I shall be accountable to you. Today I shall only end what I have
begun. I promised to explain, with the aid of the factor of
transference, why our therapeutic efforts have not met with success in
narcistic neuroses.
This I can do in a few words and you will see how simply the riddle can
be solved, how well everything harmonizes. Observation shows that
persons suffering from narcistic neuroses have no capacity for
transference, or only insufficient remains of it. They reject the
physician not with hostility, but with indifference. That is why he
cannot influence them. His words leave them cold, make no impression,
and so the mechanism of the healing process, which we are able to set
in motion elsewhere, the renewal of the pathogenic conflict and the
overcoming of the resistance to the suppression, cannot be reproduced in
them. They remain as they are. Frequently they are known to attempt a
cure on their own account, and pathological results have ensued. We are
powerless before them.
On the basis of our clinical impressions of these patients, we asserted
that in their case libidinous occupation with objects must have been
abandoned, and object-libido must have been transformed into ego-libido.
On the strength of this characteristic we had separated it from the
first group of neurotics (hysteria, anxiety and compulsion neuroses).
Their behavior under attempts at therapy confirms this supposition. They
show no neurosis. They, therefore, are inaccessible to our efforts and
we cannot cure them.
TWENTY-EIGHTH LECTURE
GENERAL THEORY OF THE NEUROSES
_Analytical Therapy_
You know our subject for today. You asked me why we do not make use of
direct suggestion in psychoanalytic therapy, when we admit that our
influence depends substantially upon transference, i.e., suggestion, for
you have come to doubt whether or not we can answer for the objectivity
of our psychological discoveries in the face of such a predominance of
suggestion. I promised to give you a comprehensive answer.
Direct suggestion is suggestion directed against the expression of the
symptoms, a struggle between your authority and the motives of the
disease. You pay no attention during this process to the motives, but
only demand of the patient that he suppress their expression in
symptoms. So it makes no difference in principle whether you hypnotize
the patient or not. Bernheim, with his usual perspicacity, asserted that
suggestion is the essential phenomenon underlying hypnotism, that
hypnotism itself is already a result of suggestion, is a suggested
condition. Bernheim was especially fond of practising suggestion upon a
person in the waking state, and could achieve the same results as with
suggestion under hypnosis.
What shall I deal with first, the evidence of experience or theoretic
considerations?
Let us begin with our experiences. I was a pupil of Bernheim's, whom I
sought out in Nancy in 1889, and whose book on suggestion I translated
into German. For years I practised hypnotic treatment, at first by means
of prohibitory suggestions alone, and later by this method in
combination with investigation of the patient after the manner of
Breuer. So I can speak from experience about the results of hypnotic or
suggestive therapy. If we judge Bernheim's method according to the old
doctor's password that an ideal therapy must be rapid, reliable and not
unpleasant for the patient, we find it fulfills at least two of these
requirements. It can be carried out much more rapidly, indescribably
more rapidly than the analytic method, and it brings the patient neither
trouble nor discomfort. In the long run it becomes monotonous for the
physician, since each case is exactly the same; continually forbidding
the existence of the most diverse symptoms under the same ceremonial,
without being able to grasp anything of their meaning or their
significance. It is second-rate work, not scientific activity, and
reminiscent of magic, conjuring and hocus-pocus; yet in the face of the
interest of the patient this cannot be considered. The third requisite,
however, was lacking. The procedure was in no way reliable. It might
succeed in one case, and fail with the next; sometimes much was
accomplished, at other times little, one knew not why. Worse than this
capriciousness of the technique was the lack of permanency of the
results. After a short time, when the patient was again heard from, the
old malady had reappeared, or it had been replaced by a new malady. We
could start in again to hypnotize. At the same time we had been warned
by those who were experienced that by frequent repetitions of hypnotism
we would deprive the patient of his self-reliance and accustom him to
this therapy as though it were a narcotic. Granted that we did
occasionally succeed as well as one could wish; with slight trouble we
achieved complete and permanent results. But the conditions for such a
favorable outcome remained unknown. I have had it happen that an
aggravated condition which I had succeeded in clearing up completely by
a short hypnotic treatment returned unchanged when the patient became
angry and arbitrarily developed ill feeling against me. After a
reconciliation I was able to remove the malady anew and with even
greater thoroughness, yet when she became hostile to me a second time it
returned again. Another time a patient whom I had repeatedly helped
through nervous conditions by hypnosis, during the treatment of an
especially stubborn attack, suddenly threw her arms around my neck. This
made it necessary to consider the question, whether one wanted to or
not, of the nature and source of the suggestive authority.
So much for experience. It shows us that in renouncing direct suggestion
we have given up nothing that is not replaceable. Now let us add a few
further considerations. The practice of hypnotic therapy demands only a
slight amount of work of the patient as well as of the physician. This
therapy fits in perfectly with the estimation of neuroses to which the
majority of physicians subscribe. The physician says to the neurotic,
"There is nothing the matter with you; you are only nervous, and so I
can blow away all your difficulties with a few words in a few minutes."
But it is contrary to our dynamic conceptions that we should be able to
move a great weight by an inconsiderable force, by attacking it directly
and without the aid of appropriate preparations. So far as conditions
are comparable, experience shows us that this performance does not
succeed with the neurotic. But I know this argument is not unassailable;
there are also "redeeming features."
In the light of the knowledge we have gained from psychoanalysis we can
describe the difference between hypnotic and psychoanalytic suggestion
as follows: Hypnotic therapy seeks to hide something in psychic life,
and to gloss it over; analytic therapy seeks to lay it bare and to
remove it. The first method works cosmetically, the other surgically.
The first uses suggestion in order to prevent the appearance of the
symptoms, it strengthens suppression, but leaves unchanged all other
processes that have led to symptom development. Analytic therapy attacks
the illness closer to its sources, namely in the conflicts out of which
the symptoms have emerged, it makes use of suggestion to change the
solution of these conflicts. Hypnotic therapy leaves the patient
inactive and unchanged, and therefore without resistance to every new
occasion for disease. Analytic treatment places upon the physician, as
well as upon the patient, a difficult responsibility; the inner
resistance of the patient must be abolished. The psychic life of the
patient is permanently changed by overcoming these resistances, it is
lifted upon a higher plane of development and remains protected against
new possibilities of disease. The work of overcoming resistance is the
fundamental task of the analytic cure. The patient, however, must take
it on himself to accomplish this, while the physician, with the aid of
suggestion, makes it possible for him to do so. The suggestion works in
the nature of an _education_. We are therefore justified in saying that
analytic treatment is a sort of _after-education_.
I hope I have made it clear to you wherein our technique of using
suggestion differs therapeutically from the only use possible in
hypnotic therapy. With your knowledge of the relation between suggestion
and transference you will readily understand the capriciousness of
hypnotic therapy which attracted our attention, and you will see why, on
the other hand, analytic suggestion can be relied upon to its limits. In
hypnosis we depend on the condition of the patient's capacity for
transference, yet we are unable to exert any influence on this capacity.
The transference of the subject may be negative, or, as is most
frequent, ambivalent; the patient may have protected himself against
suggestion by very special adjustments, yet we are unable to learn
anything concerning them. In psychoanalysis we work with the
transference itself, we do away with the forces opposing it, prepare the
instrument with which we are to work. So it becomes possible to derive
entirely new uses from the power of suggestion; we are able to control
it, the patient does not work himself into any state of mind he pleases,
but in so far as we are able to influence him at all, we can guide the
suggestion.