are very soon confronted with a second fact, for which we were quite
unprepared. After the treatment has proceeded for a while we notice that
these patients behave in a quite peculiar manner towards ourselves. We
thought indeed that we had taken into account all the motive forces
affecting the treatment and had reasoned out the situation between
ourselves and the patient fully, so that it balanced like a sum in
arithmetic; and then after all something seems to slip in which was
quite left out of our calculation. This new and unexpected feature is in
itself many-sided and complex; I will first of all describe some of its
more frequent and simpler forms to you.
We observe then that the patient, who ought to be thinking of nothing
but the solution of his own distressing conflicts, begins to develop a
particular interest in the person of the physician. Everything connected
with this person seems to him more important than his own affairs and to
distract him from his illness. Relations with the patient then become
for a time very agreeable; he is particularly docile, endeavours to show
his gratitude wherever he can, exhibits a fineness of character and
other good qualities which we had perhaps not anticipated in him. The
analyst thus forms a very good opinion of the patient and values his
luck in being able to render assistance to such an admirable
personality. If the physician has occasion to see the patient’s
relatives he hears with satisfaction that this esteem is mutual. The
patient at home is never tired of praising the analyst and attributing
new virtues to him. “He has quite lost his head over you; he puts
implicit trust in you; everything you say is like a revelation to him,”
say the relatives. Here and there one among this chorus having sharper
eyes will say: “It is positively boring the way he never speaks of
anything but you: he quotes you all the time.”
We will hope that the physician is modest enough to ascribe the
patient’s estimate of his value to the hopes of recovery which he has
been able to offer to him, and to the widening in the patient’s
intellectual horizon consequent upon the surprising revelations entailed
by the treatment and their liberating influence. The analysis too makes
splendid progress under these conditions, the patient understands the
suggestions offered to him, concentrates upon the tasks appointed by the
treatment, the material needed—his recollections and associations—is
abundantly available; he astonishes the analyst by the sureness and
accuracy of his interpretations, and the latter has only to observe with
satisfaction how readily and willingly a sick man will accept all the
new psychological ideas that are so hotly contested by the healthy in
the world outside. A general improvement in the patient’s condition,
objectively confirmed on all sides, also accompanies this harmonious
relationship in the analysis.
But such fair weather cannot last for ever. There comes a day when it
clouds over. There begin to be difficulties in the analysis; the patient
says he cannot think of anything more to say. One has an unmistakable
impression that he is no longer interested in the work, and that he is
casually ignoring the injunction given him to say everything that comes
into his mind and to yield to none of the critical objections that occur
to him. His behaviour is not dictated by the situation of the treatment;
it is as if he had not made an agreement to that effect with the
physician; he is obviously preoccupied with something which at the same
time he wishes to reserve to himself. This is a situation in which the
treatment is in danger. Plainly a very powerful resistance has risen up.
What can have happened?
If it is possible to clear up this state of things, the cause of the
disturbance is found to consist in certain intense feelings of affection
which the patient has transferred on to the physician, not accounted for
by the latter’s behaviour nor by the relationship involved by the
treatment. The form in which this affectionate feeling is expressed and
the goal it seeks naturally depend upon the circumstances of the
situation between the two persons. If one of them is a young girl and
the other still a fairly young man, the impression received is that of
normal love; it seems natural that a girl should fall in love with a man
with whom she is much alone and can speak of very intimate things, and
who is in the position of an adviser with authority—we shall probably
overlook the fact that in a neurotic girl some disturbance of the
capacity for love is rather to be expected. The farther removed the
situation between the two persons is from this supposed example, the
more unaccountable it is to find that nevertheless the same kind of
feeling comes to light in other cases. It may be still comprehensible
when a young woman who is unhappily married seems to be overwhelmed by a
serious passion for her physician, if he is still unattached, and that
she should be ready to seek a divorce and give herself to him, or, where
circumstances would prevent this, to enter into a secret love-affair
with him. That sort of thing, indeed, is known to occur outside
psycho-analysis. But in this situation girls and women make the most
astonishing confessions which reveal a quite peculiar attitude on their
part to the therapeutic problem: they had always known that nothing but
love would cure them, and from the beginning of the treatment they had
expected that this relationship would at last yield them what life had
so far denied them. It was only with this hope that they had taken such
pains over the analysis and had conquered all their difficulties in
disclosing their thoughts. We ourselves can add: ‘and had understood so
easily all that is usually so hard to accept.’ But a confession of this
kind astounds us; all our calculations are blown to the winds. Could it
be that we have omitted the most important element in the whole problem?
And actually it is so; the more experience we gain the less possible
does it become for us to contest this new factor, which alters the whole
problem and puts our scientific calculations to shame. The first few
times one might perhaps think that the analytic treatment had stumbled
upon an obstruction in the shape of an accidental occurrence, extraneous
to its purpose and unconnected with it in origin. But when it happens
that this kind of attachment to the physician regularly evinces itself
in every fresh case, under the most unfavourable conditions, and always
appears in circumstances of a positively grotesque incongruity—in
elderly women, in relation to grey-bearded men, even on occasions when
our judgement assures us that no temptations exist—then we are compelled
to give up the idea of a disturbing accident and to admit that we have
to deal with a phenomenon in itself essentially bound up with the nature
of the disease.
The new fact which we are thus unwillingly compelled to recognize we
call TRANSFERENCE. By this we mean a transference of feelings on to the
person of the physician, because we do not believe that the situation in
the treatment can account for the origin of such feelings. We are much
more disposed to suspect that the whole of this readiness to develop
feeling originates in another source; that it was previously formed in
the patient, and has seized the opportunity provided by the treatment to
transfer itself on to the person of the physician. The transference can
express itself as a passionate petitioning for love, or it can take less
extreme forms; where a young girl and an elderly man are concerned,
instead of the wish to be wife or mistress, a wish to be adopted as a
favourite daughter may come to light, the libidinous desire can modify
itself and propose itself as a wish for an everlasting, but ideally
platonic friendship. Many women understand how to sublimate the
transference and to mould it until it acquires a sort of justification
for its existence; others have to express it in its crude, original,
almost impossible form. But at bottom it is always the same, and its
origin in the same source can never be mistaken.
Before we enquire where we are to range this new fact, we will amplify
the description of it a little. How is it with our male patients? There
at least we might hope to be spared the troublesome element of sex
difference and sex attraction. Well, the answer is very much the same as
with women. The same attachment to the physician, the same
overestimation of his qualities, the same adoption of his interests, the
same jealousy against all those connected with him. The sublimated kinds
of transference are the forms more frequently met with between man and
man, and the directly sexual declaration more rarely, in the same degree
to which the manifest homosexuality of the patient is subordinated to
the other ways by which this component-instinct can express itself.
Also, it is in male patients that the analyst more frequently observes a
manifestation of the transference which at the first glance seems to
controvert the description of it just given—that is, the hostile or
_negative_ transference.
First of all, let us realize at once that the transference exists in the
patient from the beginning of the treatment, and is for a time the
strongest impetus in the work. Nothing is seen of it and one does not
need to trouble about it as long as its effect is favourable to the work
in which the two persons are co-operating. When it becomes transformed
into a resistance, attention must be paid to it; and then it appears
that two different and contrasting states of mind have supervened in it
and have altered its attitude to the treatment: first, when the
affectionate attraction has become so strong and betrays signs of its
origin in sexual desire so clearly that it was bound to arouse an inner
opposition against itself; and secondly, when it consists in
antagonistic instead of affectionate feeling. The hostile feelings as a
rule appear later than the affectionate and under cover of them; when
both occur simultaneously they provide a very good exemplification of
that ambivalence in feeling which governs most of our intimate
relationships with other human beings. The hostile feelings therefore
indicate an attachment of feeling quite similar to the affectionate,
just as defiance indicates a similar dependence upon the other person to
that belonging to obedience, though with a reversed prefix. There can be
no doubt that the hostile feelings against the analyst deserve the name
of ‘transference,’ for the situation in the treatment certainly gives no
adequate occasion for them; the necessity for regarding the negative
transference in this light is a confirmation of our previous similar
view of the positive or affectionate variety.
Where the transference springs from, what difficulties it provides for
us, how we can overcome them, and what advantage we can finally derive
from it, are questions which can only be adequately dealt with in a
technical exposition of the analytic method; I can merely touch upon
them here. It is out of the question that we should yield to the demands
made by the patient under the influence of his transference; it would be
nonsensical to reject them unkindly, and still more so, indignantly. The
transference is overcome by showing the patient that his feelings do not
originate in the current situation, and do not really concern the person
of the physician, but that he is reproducing something that had happened
to him long ago. In this way we require him to transform his
_repetition_ into _recollection_. Then the transference which, whether
affectionate or hostile, every time seemed the greatest menace to the
cure becomes its best instrument, so that with its help we can unlock
the closed doors in the soul. I should like, however, to say a few words
to dispel the unpleasant effects of the shock that this unexpected
phenomenon must have been to you. After all, we must not forget that
this illness of the patient’s which we undertake to analyse is not a
finally accomplished, and as it were consolidated thing; but that it is
growing and continuing its development all the time like a living thing.
The beginning of the treatment puts no stop to this development; but, as
soon as the treatment has taken a hold upon the patient, it appears that
the entire productivity of the illness henceforward becomes concentrated
in one direction—namely, upon the relationship to the physician. The
transference then becomes comparable to the cambium layer between the
wood and the bark of a tree, from which proceeds the formation of new
tissue and the growth of the trunk in diameter. As soon as the
transference has taken on this significance the work upon the patient’s
recollections recedes far into the background. It is then not incorrect
to say that we no longer have to do with the previous illness, but with
a newly-created and transformed neurosis which has replaced the earlier
one. This new edition of the old disease has been followed from its
inception, one sees it come to light and grow, and is particularly
familiar with it since one is oneself its central object. All the
patient’s symptoms have abandoned their original significance and have
adapted themselves to a new meaning, which is contained in their
relationship to the transference; or else only those symptoms remain
which were capable of being adapted in this way. The conquest of this
new artificially-acquired neurosis coincides with the removal of the
illness which existed prior to the treatment, that is, with
accomplishing the therapeutic task. The person who has become normal and
free from the influence of repressed instinctive tendencies in his
relationship to the physician remains so in his own life when the
physician has again been removed from it.
The transference has this all-important, absolutely central significance
for the cure in hysteria, anxiety-hysteria, and the obsessional
neurosis, which are in consequence rightly grouped together as the
‘transference neuroses.’ Anyone who has grasped from analytic experience
a true impression of the fact of transference can never again doubt the
nature of the suppressed impulses which have manufactured an outlet for
themselves in the symptoms; and he will require no stronger proof of
their libidinal character. We may say that our conviction of the
significance of the symptoms as a substitutive gratification of the
Libido was only finally and definitely established by evaluating the
phenomenon of transference.
Now, however, we are called upon to correct our former dynamic
conception of the process of cure and to bring it into agreement with
the new discovery. When the patient has to fight out the normal conflict
with the resistances which we have discovered in him by analysis, he
requires a powerful propelling force to influence him towards the
decision we aim at, leading to recovery. Otherwise it might happen that
he would decide for a repetition of the previous outcome, and allow that
which had been raised into consciousness to slip back again under
repression. The outcome in this struggle is not decided by his
intellectual insight—it is neither strong enough nor free enough to
accomplish such a thing—but solely by his relationship to the physician.
In so far as his transference bears the positive sign, it clothes the
physician with authority, transforms itself into faith in his findings
and in his views. Without this kind of transference or with a negative
one, the physician and his arguments would never even be listened to.
Faith repeats the history of its own origin; it is a derivative of love
and at first it needed no arguments. Not until later does it admit them
so far as to take them into critical consideration if they have been
offered by someone who is loved. Without this support arguments have no
weight with the patient, never do have any with most people in life. A
human being is therefore on the whole only accessible to influence, even
on the intellectual side, in so far as he is capable of investing
objects with Libido; and we have good cause to recognize, and to fear,
in the measure of his narcissism a barrier to his susceptibility to
influence, even by the best analytic technique.
The capacity for the radiation of Libido towards other persons in object
investment must, of course, be ascribed to all normal people; the
tendency to transference in neurotics, so-called, is only an exceptional
intensification of a universal characteristic. Now it would be very
remarkable if a human character-trait of this importance and
universality had never been observed and made use of. And this has
really been done. Bernheim, with unerring perspicacity, based the theory
of hypnotic manifestations upon the proposition that all human beings
are more or less open to suggestion, are ‘suggestible.’ What he called
suggestibility is nothing else but the tendency to transference, rather
too narrowly circumscribed so that the negative transference did not
come within its scope. But Bernheim could never say what suggestion
actually was nor how it arises; it was an axiomatic fact to him and he
could give no explanation of its origin. He did not recognize the
dependence of ‘suggestibility’ on sexuality, on the functioning of the
Libido. And we have to admit that we have only abandoned hypnosis in our
methods in order to discover suggestion again in the shape of
transference.
But now I will pause and let you take up the thread. I observe that an
objection is invading your thoughts with such violence that it would
deprive you of all power of attention if it were not given expression.
“So now at last you have confessed that you too work with the aid of
suggestion like the hypnotists. We have been thinking so all along. But
then, what is the use of all these roundabout routes by way of past
experiences, discovering the unconscious material, interpreting and
retranslating the distortions, and the enormous expenditure of time,
trouble, and money, when after all the only effective agent is
suggestion? Why do you not suggest directly against the symptoms, as
others do who are honest hypnotists? And besides, if you are going to
make out that by these roundabout routes you have made numerous
important psychological discoveries, which are concealed in direct
suggestion, who is to vouch for their validity? Are not they too the
result of suggestion, of unintentional suggestion, that is? Cannot you
impress upon the patient what you please and whatever seems good to you
in this direction also?”
What you charge me with in this way is exceedingly interesting and must
be answered. But I cannot do that to-day; our time is up. Till next
time, then. You will see that I shall be answerable to you. To-day I
must finish what I began. I promised to explain to you through the
factor of the transference why it is that our therapeutic efforts have
no success in the narcissistic neuroses.
I can do it in a few words, and you will see how simply the riddle is
solved, and how well everything fits together. Experience shows that
persons suffering from the narcissistic neuroses have no capacity for
transference, or only insufficient remnants of it. They turn from the
physician, not in hostility, but in indifference. Therefore they are not
to be influenced by him; what he says leaves them cold, makes no
impression on them, and therefore the process of cure which can be
carried through with others, the revivification of the pathogenic
conflict and the overcoming of the resistance due to the repressions,
cannot be effected with them. They remain as they are. They have often
enough undertaken attempts at recovery on their own account which have
led to pathological results; we can do nothing to alter this.
On the basis of our clinical observations of these patients we stated
that they must have abandoned the investment of objects with Libido and
transformed object-Libido into Ego-Libido. By this we differentiated
them from the first group of neurotics (hysteria, anxiety, and
obsessional neurosis). Their behaviour during the attempt to cure them
confirms this suspicion. They produce no transference, and are,
therefore, inaccessible to our efforts, not to be cured by us.
TWENTY-EIGHTH LECTURE
THE ANALYTIC THERAPY
You know what we are going to discuss to-day. When I admitted that the
influence of the psycho-analytic therapy is essentially founded upon
transference, i.e. upon suggestion, you asked me why we do not make use
of direct suggestion, and you linked this up with a doubt whether, in
view of the fact that suggestion plays such a large part, we can still
vouch for the objectivity of our psychological discoveries. I promised
to give you a comprehensive answer.
Direct suggestion is suggestion delivered directly against the forms
taken by the symptoms, a struggle between your authority and the motives
underlying the disease. In this struggle you do not trouble yourself
about these motives, you only require the patient to suppress the
manifestation of them in the form of symptoms. In the main it makes no
difference whether you place the patient under hypnosis or not.
Bernheim, with his characteristic acuteness, repeatedly stated that
suggestion was the essence of the manifestations of hypnotism, and that
hypnosis itself was already a result of suggestion, a suggested
condition; he preferred to use suggestion in the waking state, which can
achieve the same results as suggestion in hypnosis.
Now which shall I take first, the results of experience or theoretical
considerations?
Let us begin with experience. I sought out Bernheim in Nancy in 1889 and
became a pupil of his; I translated his book on suggestion into German.
For years I made use of hypnotic treatment, first with prohibitory
suggestions and later combined with Breuer’s system of the fullest
enquiry into the patient’s life; I can therefore speak from wide
experience about the results of the hypnotic or suggestive therapy.
According to an old medical saying an ideal therapy should be rapid,
reliable and not disagreeable to the patient; Bernheim’s method
certainly fulfilled two of these requirements. It was much more rapid,
that is, incomparably more rapid in its course than the analytic, and it
involved the patient in no trouble or discomfort. For the physician it
eventually became monotonous; it meant treating every case in the same
way, always employing the same ritual to prohibit the existence of the
most diverse symptoms, without being able to grasp anything of their
meaning or significance. It was a sort of mechanical drudgery—hodman’s
work—not scientific work; it was reminiscent of magic, conjuring, and
hocus-pocus, yet in the patient’s interests one had to ignore that. In
the third desideratum, however, it failed; it was not reliable in any
respect. It could be employed in certain cases only and not in others;
with some much could be achieved by it, and with others very little, one
never knew why. But worse than its capricious nature was the lack of
permanence in the results; after a time, if one heard from the patient
again, the old malady had reappeared or had been replaced by another.
Then one could begin to hypnotize again. In the background there was the
warning of experienced men against robbing the patient of his
independence by frequent repetitions of hypnosis, and against
accustoming him to this treatment as though it were a narcotic. It is
true, on the other hand, that at times everything fell out just as one
could wish; one obtained complete and lasting success with little
difficulty; but the conditions of this satisfactory outcome remained
hidden. In one case, when I had completely removed a severe condition by
a short hypnotic treatment, it recurred unchanged after the patient (a
woman) had developed ill feeling against me without just cause; then
after a reconciliation I was able to effect its disappearance again and
this time far more thoroughly; but it reappeared again when she had a
second time become hostile to me. Another time I had the following
experience; during the treatment of an especially obstinate attack in a
patient whom I had several times relieved of nervous symptoms, she
suddenly threw her arms round my neck. Whether one wished to do so or
not, this kind of thing finally made it imperative to enquire into the
problem of the nature and source of one’s suggestive authority.