analysis transference or suggestion, there is still the danger that
through our influence on the patient the objective certainty of our
discoveries becomes doubtful. That which becomes a benefit to therapy
works harm to the investigation. This objection is most often raised
against psychoanalysis, and it must be admitted that even if it does not
hit the mark, it cannot be waved aside as stupid. But if it were
justified, psychoanalysis would be nothing more than an extraordinarily
well disguised and especially workable kind of treatment by suggestion,
and we may lay little weight upon all its assertions concerning the
influences of life, psychic dynamics, and the unconscious. This is in
fact the opinion held by our opponents; we are supposed especially to
have "balked into" the patients everything that supports the importance
of sexual experiences, and often the experiences themselves, after the
combinations themselves have grown up in our degenerate imaginations. We
can refute these attacks most easily by calling on the evidence of
experience rather than by resorting to theory. Anyone who has himself
performed a psychoanalysis has been able to convince himself innumerable
times that it is impossible thus to suggest anything to the patient.
There is no difficulty, of course, in making the patient a disciple of
any one theory, and thus causing him to share the possible error of the
physician. With respect to this he behaves just like any other person,
like a student, but he has influenced only his intelligence, not his
disease. The solving of his conflicts and the overcoming of his
resistances succeeds only if we have aroused in him representations of
such expectations as can agree with reality. What was inapplicable in
the assumptions of the physician falls away during the course of the
analysis; it must be withdrawn and replaced by something more nearly
correct. By employing a careful technique we seek to prevent the
occurrence of temporary results arising out of suggestion, yet there is
no harm if such temporary results occur, for we are never satisfied with
early successes. We do not consider the analysis finished until all the
obscurities of the case are cleared up, all amnestic gaps filled out and
the occasions which originally called out the suppressions discovered.
We see in results that are achieved too quickly a hindrance rather than
a furtherance of analytic work and repeatedly we undo these results
again by purposely breaking up the transference upon which they rest.
Fundamentally it is this feature which distinguishes analytical
treatment from the purely suggestive technique and frees analytic
results from the suspicion of having been suggested. Under every other
suggestive treatment the transference itself is most carefully upheld
and the influence left unquestioned; in analytic treatment, however, the
transference becomes the subject of treatment and is subject to
criticism in whatever form it may appear. At the end of an analytic cure
the transference itself must be abolished; therefore the effect of the
treatment, whether positive or negative, must be founded not upon
suggestion but upon the overcoming of inner resistances, upon the inner
change achieved in the patient, which the aid of suggestion has made
possible.
Presumably the creation of the separate suggestions is counteracted, in
the course of the cure, by our being continually forced to attack
resistances which have the ability to change themselves into negative
(hostile) transferences. Furthermore, let me call your attention to the
fact that a large number of results of analysis, otherwise perhaps
subject to the suspicion that they are products of suggestion, can be
confirmed from other unquestionable sources. As authoritative witnesses
in this case we refer to the testimony of dements and paranoiacs, who
are, naturally far removed from any suspicion of suggestive influence.
Whatever these patients can tell us about symbolic translations and
phantasies which have forced their way into their consciousness agrees
faithfully with the results of our investigations upon the unconscious
of transference-neurotics, and this gives added weight to the objective
correctness of our interpretations which are so often doubted. I believe
you will not go wrong if you give your confidence to analysis with
reference to these factors.
We now want to complete our statement concerning the mechanism of
healing, by including it within the formulae of the libido theory. The
neurotic is incapable both of enjoyment and work; first, because his
libido is not directed toward any real object, and second because he
must use up a great deal of his former energy to keep his libido
suppressed and to arm himself against its attacks. He would become well
if there could be an end to the conflict between his ego and his libido,
and if his ego could again have the libido at its disposal. The task of
therapy, therefore, consists of freeing the libido from its present
bonds, which have estranged it from the ego, and furthermore to bring it
once more into the service of the ego. Where is the libido of the
neurotics? It is easy to find; it is bound to the symptoms which at that
time furnish it with the only available substitute satisfaction. We have
to become master of the symptoms, and abolish them, which is of course
exactly what the patient asks us to do. To abolish the symptoms it
becomes necessary to go back to their origin, to renew the conflict out
of which they emerged, but this time with the help of motive forces that
were originally not available, to guide it toward a new solution. This
revision of the process of suppression can be accomplished only in part
by following the traces in memory of the occurrences which led to the
suppression. The decisive part of the cure is accomplished by means of
the relationship to the physician, the transference, by means of which
new editions of the old conflict are created. Under this situation the
patient would like to behave as he had behaved originally, but by
summoning all his available psychic power we compel him to reach a
different decision. Transference, then, becomes the battlefield on which
all the contending forces are to meet.
The full strength of the libido, as well as the entire resistance
against it, is concentrated in this relationship to the physician; so it
is inevitable that the symptoms of the libido should be laid bare. In
place of his original disturbance the patient manifests the artificially
constructed disturbance of transference; in place of heterogeneous
unreal objects for the libido you now have only the person of the
physician, a single object, which, however, is also fantastic. The new
struggle over this object is, however, raised to the highest psychic
level with the aid of the physician's suggestions, and proceeds as a
normal psychic conflict. By avoiding a new suppression the estrangement
between the ego and the libido comes to an end, the psychic unity of the
personality is restored. When the libido again becomes detached from the
temporary object of the physician it cannot return to its former
objects, but is now at the disposal of the ego. The forces we have
overcome in the task of therapy are on the one hand the aversion of the
ego for certain directions of the libido, which had expressed itself as
a tendency to suppression, and on the other hand the tenacity of the
libido, which is loathe to leave an object which it has once occupied.
Accordingly the work of therapy falls into two phases: first, all the
libido is forced from the symptoms into the transference, and
concentrated there; secondly, the struggle over this new object is
carried on and the libido set free. The decisive change for the better
in this renewed conflict is the throwing out of the suppression, so that
the libido cannot this time again escape the ego by fleeing into the
unconscious. This is accomplished by the change in the ego under the
influence of the physician's suggestion. In the course of the work of
interpretation, which translates unconscious into conscious, the ego
grows at the expense of the unconscious; it learns forgiveness toward
the libido, and becomes inclined to permit some sort of satisfaction for
it. The ego's timidity in the face of the demands of the libido is now
lessened by the prospect of occupying some of the libido through
sublimation. The more the processes of the treatment correspond to this
theoretic description the greater will be the success of psychoanalytic
therapy. It is limited by the lack of mobility of the libido, which can
stand in the way of releasing its objects, and by the obstinate narcism
which will not permit the object-transference to effect more than just
so much. Perhaps we shall obtain further light on the dynamics of the
healing process by the remark that we are able to gather up the entire
libido which has become withdrawn from the control of the ego by drawing
a part of it to ourselves in the process of transference.
It is to be remembered that we cannot reach a direct conclusion as to
the disposition of the libido during the disease from the distributions
of the libido which are effected during and because of the treatment.
Assuming that we have succeeded in curing the case by means of the
creation and destruction of a strong father-transference to the
physician, it would be wrong to conclude that the patient had previously
suffered from a similar and unconscious attachment of his libido to his
father. The father-transference is merely the battlefield upon which we
were able to overcome the libido; the patient's libido had been
concentrated here from its other positions. The battlefield need not
necessarily have coincided with the most important fortresses of the
enemy. Defense of the hostile capital need not take place before its
very gates. Not until we have again destroyed the transference can we
begin to reconstruct the distribution of the libido that existed during
the illness.
From the standpoint of the libido theory we might say a last word in
regard to the dream. The dreams of neurotics, as well as their errors
and haphazard thoughts, help us in finding the meaning of the symptoms
and in discovering the disposition of the libido. In the form of the
wish fulfillment they show us what wish impulses have been suppressed,
and to what objects the libido, withdrawn from the ego, has been
attached. That is why interpretation of dreams plays a large role in
psychoanalytic treatment, and is in many cases, for a long time, the
most important means with which we work. We already know that the
condition of sleep itself carries with it a certain abatement of
suppressions. Because of this lessening of the pressure upon it, it
becomes possible for the suppressed impulse to create in the dream a
much clearer expression than the symptom can furnish during the day. So
dream-study is the easiest approach to a knowledge of the libidinous
suppressed unconscious which has been withdrawn from the ego.
Dreams of neurotics differ in no essential point from the dreams of
normal persons; you might even say they cannot be distinguished. It
would be unreasonable to explain the dreams of the nervous in any way
which could not be applied to the dreams of the normal. So we must say
the difference between neurosis and health applies only during the day,
and does not continue in dream life. We find it necessary to attribute
to the healthy numerous assumptions which have grown out of the
connections between the dreams and the symptoms of the neurotic. We are
not in a position to deny that even a healthy man possesses those
factors in his psychic life which alone make possible the development of
the dream and of the symptom as well. We must conclude, therefore, that
the healthy have also made use of suppressions and are put to a certain
amount of trouble to keep those impulses under control; the system of
their unconscious, too, conceals impulses which are suppressed, yet are
still possessed of energy, and _a part of their libido is also withdrawn
from the control of their ego_. So the healthy man is virtually a
neurotic, but dreams are apparently the only symptoms which he can
manifest. Yet if we subject our waking hours to a more penetrating
analysis we discover, of course, that they refute this appearance and
that this seemingly healthy life is shot through with a number of
trivial, practically unimportant symptom formations.
The difference between nervous health and neurosis is entirely a
practical one which is determined by the available capacity for
enjoyment and accomplishment retained by the individual. It varies
presumably with the relative proportion of the energy totals which have
remained free and those which have been bound by suppressions, and is
quantitative rather than qualitative. I do not have to remind you that
this conception is the theoretical basis for the certainty that neuroses
can be cured, despite their foundation in constitutional disposition.
This is accordingly what we may make out of the identity between the
dreams of the healthy and those of the neurotic for the definition of
health. As regards the dream itself, we must note further that we cannot
separate it from its relation to neurotic symptoms. We must recognize
that it is not completely defined as a translation of thoughts into an
archaic form of expression, that is, we must assume it discloses a
disposition of libido and of object-occupations which have actually
taken place.
We have about come to the end. Perhaps you are disappointed that I have
dealt only with theory in this chapter on psychoanalytic therapy, and
have said nothing concerning the conditions under which the cure is
undertaken, or of the successes which it achieves. But I shall omit
both. I shall omit the first because I had intended no practical
training in the practice of psychoanalysis, and I shall neglect the
second for numerous reasons. At the beginning of our talks I emphasized
the fact that under favorable circumstances we attain results which can
be favorably compared with the happiest achievements in the field of
internal therapy, and, I may add, these results could not have been
otherwise achieved. If I were to say more I might be suspected of
wishing to drown the voices of disparagement, which have become so loud,
by advertising our claims. We psychoanalysts have repeatedly been
threatened by our medical colleagues, even in open congresses, that the
eyes of the suffering public must be opened to the worthlessness of this
method of treatment by a statistical collection of analytic failures and
injuries. But such a collection, aside from the biased, denunciatory
character of its purpose, would hardly be able to give a correct picture
of the therapeutic values of analysis. Analytic therapy is, as you know,
still young; it took a long time to establish the technique, and this
could be done only during the course of the work and under the influence
of accumulating experience. As a result of the difficulties of
instruction the physician who begins the practice of psychoanalysis is
more dependent upon his capacity to develop on his own account than is
the ordinary specialist, and the results he achieves in his first years
can never be taken as indicative of the possibilities of analytic
therapy.
Many attempts at treatment failed in the early years of analysis because
they were made on cases that were not at all suited to the procedure,
and which today we exclude by our classification of symptoms. But this
classification could be made only after practice. In the beginning we
did not know that paranoia and dementia praecox are, in their fully
developed phases, inaccessible, and we were justified in trying out our
method on all kinds of conditions. Besides, the greatest number of
failures in those first years were not due to the fault of the physician
or because of unsuitable choice of subjects, but rather to the
unpropitiousness of external conditions. We have hitherto spoken only of
internal resistances, those of the patient, which are necessary and may
be overcome. External resistances to psychoanalysis, due to the
circumstances of the patient and his environment, have little
theoretical interest, but are of great practical importance.
Psychoanalytic treatment may be compared to a surgical operation, and
has the right to be undertaken under circumstances favorable to its
success. You know what precautions the surgeon is accustomed to take: a
suitable room, good light, assistance, exclusion of relatives, etc. How
many operations would be successful, do you think, if they had to be
performed in the presence of all the members of the family, who would
put their fingers into the field of operation and cry aloud at every cut
of the knife? The interference of relatives in psychoanalytical
treatment is a very great danger, a danger one does not know how to
meet. We are armed against the internal resistances of the patient which
we recognize as necessary, but how are we to protect ourselves against
external resistance? It is impossible to approach the relatives of the
patient with any sort of explanation, one cannot influence them to hold
aloof from the whole affair, and one cannot get into league with them
because we then run the danger of losing the confidence of the patient,
who rightly demands that we in whom he confides take his part. Besides,
those who know the rifts that are often formed in family life will not
be surprised as analysts when they discover that the patient's nearest
relatives are less interested in seeing him cured than in having him
remain as he is. Where, as is so often the case, the neurosis is
connected with conflicts with members of the family, the healthy member
does not hesitate long in the choice between his own interest and that
of the cure of the patient. It is not surprising if a husband looks with
disfavor upon a treatment in which, as he may correctly suspect, the
register of his sins is unrolled; nor are we surprised, and surely we
cannot take the blame, when our efforts remain fruitless and are
prematurely broken off because the resistance of the husband is added to
that of the sick wife. We had only undertaken something which, under the
existing circumstance, it was impossible to carry out.
Instead of many cases, I shall tell you of just one in which, because of
professional precautions, I was destined to play a sad role. Many years
ago I treated a young girl who for a long time was afraid to go on the
street, or to remain at home alone. The patient hesitatingly admitted
that her phantasy had been caused by accidentally observing affectionate
relations between her mother and a well-to-do friend of the family. But
she was so clumsy--or perhaps so sly--as to give her mother a hint of
what had been discussed during the analysis, and changed her behavior
toward her mother, insisting that no one but her mother should protect
her against the fear of being alone, and anxiously barring the way when
her mother wished to leave the house. The mother had previously been
very nervous herself, but had been cured years before in a hydropathic
sanatorium. Let us say, in that institution she made the acquaintance of
the man with whom she was to enter upon the relationship which was able
to satisfy her in every respect. Becoming suspicious of the stormy
demands of the girl, the mother _suddenly_ realized the meaning of her
daughter's fear. She must have made herself sick to imprison her mother
and to rob her of the freedom she needed to maintain relations with her
lover. Immediately the mother made an end to the harmful treatment. The
girl was put into a sanatorium for the nervous and exhibited for many
years as "a poor victim of psychoanalysis." For just as long a period I
was pursued by evil slander, due to the unfavorable outcome of this
case. I maintained silence because I thought myself bound by the rules
of professional discretion. Years later I learned from a colleague who
had visited the institution, and had seen the agoraphobic girl there,
that the relationship between the mother and the wealthy friend of the
family was known all over town, and apparently connived at by the
husband and father. It was to this "secret" that our treatment had been
sacrificed.
In the years before the war, when the influx of patients from all parts
made me independent of the favor or disfavor of my native city, I
followed the rule of not treating anyone who was not _sui juris_, was
not independent of all other persons in his essential relations of life.
Every psychoanalyst cannot do this. You may conclude from my warning
against the relatives of patients that for purposes of psychoanalysis we
should take the patients away from their families, and should limit this
therapy to the inmates of sanatoriums. I should not agree with you in
this; it is much more beneficial for the patients, if they are not in a
stage of great exhaustion, to continue in the same circumstances under
which they must master the tasks set for them during the treatment. But
the relatives ought not to counteract this advantage by their behavior,
and above all, they should not antagonize and oppose the endeavors of
the physician. But how are we to contend against these influences which
are so inaccessible to us! You see how much the prospects of a treatment
are determined by the social surroundings and the cultural conditions of
a family.
This offers a sad outlook indeed for the effectiveness of psychoanalysis
as a therapy, even if we can explain the great majority of our failures
by putting the blame on such disturbing external factors! Friends of
analysis have advised us to counterbalance such a collection of failures
by means of a statistical compilation on our part of our successful
cases. Yet I could not try myself to do this. I tried to explain that
statistics would be worthless if the collected cases were not
comparable, and in fact, the various neuroses which we have undertaken
to treat could, as a matter of fact, hardly be compared on the same
basis, since they differed in many fundamental respects. Besides, the
period of time over which we could report was too short to permit us to
judge the permanency of our cures, and concerning certain cases we could
not have given any information whatever. They related to persons who had
kept their ailments, as well as their treatment, secret, and whose cure
must necessarily be kept secret as well. The strongest hindrance,
however, lay in the knowledge that men behave most irrationally in
matters of therapy, and that we have no prospect of attaining anything
by an appeal to reason. A therapeutic novelty is received either with
frenzied enthusiasm, as was the case when Koch first made public his
tuberculin against tuberculosis, or it is treated with abysmal distrust,
as was the really blessed vaccination of Jenner, which even today
retains implacable opponents. There was a very obvious prejudice against
psychoanalysis. When we had cured a very difficult case we would hear it
said: "That is no proof, he would have become well by himself in all
this time." Yet when a patient who had already gone through four cycles
of depression and mania came into my care during a temporary cessation
in the melancholia, and three weeks later found herself in the
beginnings of a new attack, all the members of the family as well as the
high medical authorities called into consultation, were convinced that
the new attack could only be the result of the attempted analysis.
Against prejudice we are powerless; you see it again in the prejudices
that one group of warring nations has developed against the other. The
most sensible thing for us to do is to wait and allow time to wear it
away. Some day the same persons think quite differently about the same
things than before. Why they formerly thought otherwise remains the dark
secret.