have given up nothing irreplaceable. Now let us link on to the facts a
few comments. The exercise of the hypnotic method makes as little demand
for effort on the part of the patient as it does on the physician. The
method is in complete harmony with the view of the neuroses generally
accepted by the majority of medical men. The practitioner says to the
nervous person: “There is nothing the matter with you; it is merely
nervousness, therefore a few words from me will scatter all your
troubles to the winds in five minutes.” But it is contrary to all our
beliefs about energy in general that a minimal exertion should be able
to remove a heavy load by approaching it directly without the assistance
of any suitably-devised appliance. In so far as the circumstances are at
all comparable, experience shows that this trick cannot be performed
successfully with the neuroses. I know, however, that this argument is
not unassailable; there are such things as explosions.
In the light of the knowledge we have obtained through psycho-analysis,
the difference between hypnotic and psycho-analytic suggestion may be
described as follows: The hypnotic therapy endeavours to cover up and as
it were to whitewash something going on in the mind, the analytic to lay
bare and to remove something. The first works cosmetically, the second
surgically. The first employs suggestion to interdict the symptoms; it
reinforces the repressions, but otherwise it leaves unchanged all the
processes that have led to symptom-formation. Analytic therapy takes
hold deeper down nearer the roots of the disease, among the conflicts
from which the symptoms proceed; it employs suggestion to change the
outcome of these conflicts. Hypnotic therapy allows the patient to
remain inactive and unchanged, consequently also helpless in the face of
every new incitement to illness. Analytic treatment makes as great
demands for efforts on the part of the patient as on the physician,
efforts to abolish the inner resistances. The patient’s mental life is
permanently changed by overcoming these resistances, is lifted to a
higher level of development, and remains proof against fresh
possibilities of illness. The labour of overcoming the resistances is
the essential achievement of the analytic treatment; the patient has to
accomplish it and the physician makes it possible for him to do this by
suggestions which are in the nature of an _education_. It has been truly
said therefore, that psycho-analytic treatment is a kind of
_re-education_.
I hope I have now made clear to you the difference between our method of
employing suggestion therapeutically and the method which is the only
possible one in hypnotic therapy. Since we have traced the influence of
suggestion back to the transference, you also understand the striking
capriciousness of the effect in hypnotic therapy, and why analytic
therapy is within its limits dependable. In employing hypnosis we are
entirely dependent upon the condition of the patient’s transference and
yet we are unable to exercise any influence upon this condition itself.
The transference of a patient being hypnotized may be negative, or, as
most commonly, ambivalent, or he may have guarded himself against his
transference by adopting special attitudes; we gather nothing about all
this. In psycho-analysis we work upon the transference itself, dissipate
whatever stands in the way of it, and manipulate the instrument which is
to do the work. Thus it becomes possible for us to derive entirely new
benefits from the power of suggestion; we are able to control it; the
patient alone no longer manages his suggestibility according to his own
liking, but in so far as he is amenable to its influence at all, we
guide his suggestibility.
Now you will say that, regardless of whether the driving force behind
the analysis is called transference or suggestion, the danger still
remains that our influence upon the patient may bring the objective
certainty of our discoveries into doubt; and that what is an advantage
in therapy is harmful in research. This is the objection that has most
frequently been raised against psycho-analysis; and it must be admitted
that, even though it is unjustified, it cannot be ignored as
unreasonable. If it were justified, psycho-analysis after all would be
nothing else but a specially well-disguised and particularly effective
kind of suggestive treatment; and all its conclusions about the
experiences of the patient’s past life, mental dynamics, the
Unconscious, and so on, could be taken very lightly. So our opponents
think; the significance of sexual experiences in particular, if not the
experiences themselves, we are supposed to have “put into the patient’s
mind,” after having first concocted these conglomerations in our own
corrupt minds. These accusations are more satisfactorily refuted by the
evidence of experience than by the aid of theory. Anyone who has himself
conducted psycho-analyses has been able to convince himself numberless
times that it is impossible to suggest things to a patient in this way.
There is no difficulty, of course, in making him a disciple of a
particular theory, and thus making it possible for him to share some
mistaken belief possibly harboured by the physician. He behaves like
anyone else in this, like a pupil; but by this one has only influenced
his intellect, not his illness. The solving of his conflicts and the
overcoming of his resistances succeeds only when what he is told to look
for in himself corresponds with what actually does exist in him.
Anything that has been inferred wrongly by the physician will disappear
in the course of the analysis; it must be withdrawn and replaced by
something more correct. One’s aim is, by a very careful technique, to
prevent temporary successes arising through suggestion; but if they do
arise no great harm is done, for we are not content with the first
result. We do not consider the analysis completed unless all obscurities
in the case are explained, the gaps in memory filled out, and the
original occasions of the repressions discovered. When results appear
prematurely, one regards them as obstacles rather than as furtherances
of the analytic work, and one destroys them again by continually
exposing the transference on which they are founded. Fundamentally it is
this last feature which distinguishes analytic treatment from that of
pure suggestion, and which clears the results of analysis from the
suspicion of being the results of suggestion. In every other suggestive
treatment the transference is carefully preserved and left intact; in
analysis it is itself the object of the treatment and is continually
being dissected in all its various forms. At the conclusion of the
analysis the transference itself must be dissolved; if success then
supervenes and is maintained it is not founded on suggestion, but on the
overcoming of the inner resistances effected by the help of suggestion,
on the inner change achieved within the patient.
That which probably prevents single effects of suggestion from arising
during the treatment is the struggle that is incessantly being waged
against the resistances, which know how to transform themselves into a
negative (hostile) transference. Nor will we neglect to point to the
evidence that a great many of the detailed findings of analysis, which
would otherwise be suspected of being produced by suggestion, are
confirmed from other, irreproachable sources. We have unimpeachable
witnesses on these points, namely, dements and paranoiacs, who are of
course quite above any suspicion of being influenced by suggestion. All
that these patients relate in the way of phantasies and translations of
symbols, which have penetrated through into their consciousness,
corresponds faithfully with the results of our investigations into the
Unconscious of transference neurotics, thus confirming the objective
truth of the interpretations made by us which are so often doubted. I do
not think you will find yourselves mistaken if you choose to trust
analysis in these respects.
We now need to complete our description of the process of recovery by
expressing it in terms of the Libido-theory. The neurotic is incapable
of enjoyment or of achievement—the first because his Libido is attached
to no real object, the last because so much of the energy which would
otherwise be at his disposal is expended in maintaining the Libido under
repression, and in warding off its attempts to assert itself. He would
be well if the conflict between his Ego and his Libido came to an end,
and if his Ego again had the Libido at its disposal. The task of the
treatment, therefore, consists in the task of loosening the Libido from
its previous attachments, which are beyond the reach of the Ego, and in
making it again serviceable to the Ego. Now where is the Libido of a
neurotic? Easily found: it is attached to the symptoms, which offer it
the substitutive satisfaction that is all it can obtain as things are.
We must master the symptoms then, dissolve them—just what the patient
asks of us. In order to dissolve the symptoms it is necessary to go back
to the point at which they originated, to review the conflict from which
they proceeded, and with the help of propelling forces which at that
time were not available to guide it towards a new solution. This
revision of the process of repression can only partially be effected by
means of the memory-traces of the processes which led up to repression.
The decisive part of the work is carried through by creating—in the
relationship to the physician, in “the transference”—new editions of
those early conflicts, in which the patient strives to behave as he
originally behaved, while one calls upon all the available forces in his
soul to bring him to another decision. The transference is thus the
battlefield where all the contending forces must meet.
All the Libido and the full strength of the opposition against it are
concentrated upon the one thing, upon the relationship to the physician;
thus it becomes inevitable that the symptoms should be deprived of their
Libido; in place of the patient’s original illness appears the
artificially-acquired transference, the transference-disorder; in place
of a variety of unreal objects of his Libido appears the one object,
also ‘phantastic,’ of the person of the physician. This new struggle
which arises concerning this object is by means of the analyst’s
suggestions lifted to the surface, to the higher mental levels, and is
there worked out as a normal mental conflict. Since a new repression is
thus avoided, the opposition between the Ego and the Libido comes to an
end; unity is restored within the patient’s mind. When the Libido has
been detached from its temporary object in the person of the physician
it cannot return to its earlier objects, but is now at the disposal of
the Ego. The forces opposing us in this struggle during the therapeutic
treatment are on the one hand the Ego’s aversion against certain
tendencies on the part of the Libido, which had expressed itself in
repressing tendencies; and on the other hand the tenacity or
‘adhesiveness’ of the Libido, which does not readily detach itself from
objects it has once invested.
The therapeutic work thus falls into two phases; in the first all the
Libido is forced away from the symptoms into the transference and there
concentrated, in the second the battle rages round this new object and
the Libido is made free from it. The change that is decisive for a
successful outcome of this renewed conflict lies in the preclusion of
repression, so that the Libido cannot again withdraw itself from the Ego
by a flight into the Unconscious. It is made possible by changes in the
Ego ensuing as a consequence of the analyst’s suggestions. At the
expense of the Unconscious the Ego becomes wider by the work of
interpretation which brings the unconscious material into consciousness;
through education it becomes reconciled to the Libido and is made
willing to grant it a certain degree of satisfaction; and its horror of
the claims of its Libido is lessened by the new capacity it acquires to
expend a certain amount of the Libido in sublimation. The more nearly
the course of the treatment corresponds with this ideal description the
greater will be the success of the psycho-analytic therapy. Its barriers
are found in the lack of mobility in the Libido, which resists being
released from its objects, and in the rigidity of the patient’s
narcissism, which will not allow more than a certain degree of
object-transference to develop. Perhaps the dynamics of the process of
recovery will become still clearer if we describe it by saying that, in
attracting a part of it to ourselves through transference, we gather in
the whole amount of the Libido which has been withdrawn from the Ego’s
control.
It is as well here to make clear that the distributions of the Libido
which ensue during and by means of the analysis afford no direct
inference of the nature of its disposition during the previous illness.
Given that a case can be successfully cured by establishing and then
resolving a powerful father-transference to the person of the physician,
it would not follow that the patient had previously suffered in this way
from an unconscious attachment of the Libido to his father. The
father-transference is only the battlefield on which we conquer and take
the Libido prisoner; the patient’s Libido has been drawn hither away
from other ‘positions.’ The battlefield does not necessarily constitute
one of the enemy’s most important strongholds; the defence of the
enemy’s capital city need not be conducted immediately before its gates.
Not until after the transference has been again resolved can one begin
to reconstruct in imagination the dispositions of the Libido that were
represented by the illness.
In the light of the Libido-theory there is a final word to be said about
dreams. The dreams of a neurotic, like his “errors” and his free
associations, enable us to find the meaning of the symptoms and to
discover the dispositions of the Libido. The forms taken by the
wish-fulfilment in them show us what are the wish-impulses that have
undergone repression, and what are the objects to which the Libido has
attached itself after withdrawal from the Ego. The interpretation of
dreams therefore plays a great part in psycho-analytic treatment, and in
many cases it is for lengthy periods the most important instrument at
work. We already know that the condition of sleep in itself produces a
certain relaxation of the repressions. By this diminution in the heavy
pressure upon it the repressed desire is able to create for itself a far
clearer expression in a dream than can be permitted to it by day in the
symptoms. Hence the study of dreams becomes the easiest approach to a
knowledge of the repressed Unconscious, which is where the Libido which
has withdrawn from the Ego belongs.
The dreams of neurotics, however, differ in no essential from those of
normal people; they are indeed perhaps not in any way distinguishable
from them. It would be illogical to account for the dreams of neurotics
in a way that would not also hold good of the dreams of normal people.
We have to conclude therefore that the difference between neurosis and
health prevails only by day; it is not sustained in dream-life. It thus
becomes necessary to transfer to healthy persons a number of conclusions
arrived at as a result of the connections between the dreams and the
symptoms of neurotics. We have to recognize that the healthy man as well
possesses those factors in mental life which alone can bring about the
formation of a dream or of a symptom, and we must conclude further that
the healthy also have instituted repressions and have to expend a
certain amount of energy to maintain them; that their unconscious minds
too harbour repressed impulses which are still suffused with energy, and
that _a part of the Libido is in them also withdrawn from the disposal
of the Ego_. The healthy man too is therefore virtually a neurotic, but
the only symptom that he _seems_ capable of developing is a dream. To be
sure when you subject his waking life also to a critical investigation
you discover something that contradicts this specious conclusion; for
this apparently healthy life is pervaded by innumerable trivial and
practically unimportant symptom-formations.
The difference between nervous health and nervous illness (neurosis) is
narrowed down therefore to a practical distinction, and is determined by
the practical result—how far the person concerned remains capable of a
sufficient degree of capacity for enjoyment and active achievement in
life. The difference can probably be traced back to the proportion of
the energy which has remained free relative to that of the energy which
has been bound by repression, i.e. it is a quantitative and not a
qualitative difference. I do not need to remind you that this view
provides a theoretical basis for our conviction that the neuroses are
essentially amenable to cure, in spite of their being based on a
constitutional disposition.
So much, therefore, in the way of knowledge of the characteristics of
health may be inferred from the identity of the dreams dreamt by
neurotic and by healthy persons. Of dreams themselves, however, a
further inference must be drawn—namely, that it is not possible to
detach them from their connection with neurotic symptoms; that we are
not at liberty to believe that their essential nature is exhausted by
compressing them into the formula of ‘a translation of thoughts into
archaic forms of expression’; and that we are bound to conclude that
they disclose dispositions of the Libido and objects of desire which are
actually in operation and valid at the moment.
We have now come very nearly to the end. Perhaps you are disappointed
that under the heading of psycho-analytic therapy I have limited myself
to theory, and have told you nothing of the conditions under which the
cure is undertaken, or of the results it achieves. I omit both, however:
the first, because in fact I never intended to give you a practical
training in the exercise of the analytic method; and the last, because I
have several motives against it. At the beginning of these discussions I
said emphatically that under favourable conditions we achieve cures that
are in no way inferior to the most brilliant in other fields of medical
therapy; I may perhaps add that these results could be achieved by no
other method. If I said more I should be suspected of wishing to drown
the depreciatory voices of our opponents by self-advertisement. Medical
“colleagues” have, even at public congresses, repeatedly held out a
threat to psycho-analysts that by publishing a collection of the
failures and harmful effects of analysis they will open the eyes of the
injured public to the worthlessness of this method of treatment. Apart
from the malicious, denunciatory character of such a measure, however, a
collection of that kind would not even be valid evidence upon which a
correct estimate of the therapeutic results of analysis might be formed.
Analytic therapy, as you know, is still young; it needed many years to
elaborate the technique, which could only be done in the course of the
work under the influence of increasing experience. On account of the
difficulties of imparting instruction in the methods the beginner is
thrown much more upon his own resources for development of his capacity
than any other kind of specialist, and the results of his early years
can never be taken as indicating the full possible achievements of
analytic therapy.
Many attempts at treatment made in the beginning of psycho-analysis were
failures because they were undertaken with cases altogether unsuited to
the procedure, which nowadays we should exclude by following certain
indications. These indications, however, could only be discovered by
trying. In the beginning we did not know that paranoia and dementia
præcox, when fully developed, are not amenable to analysis; we were
still justified in trying the method on all kinds of disorders. Most of
the failures of those early years, however, were not due to the fault of
the physician, or to the unsuitability in the choice of subject, but to
unpropitious external conditions. I have spoken only of the inner
resistances, those on the part of the patient, which are inevitable and
can be overcome. The external resistances which the patient’s
circumstances and surroundings set up against analysis have little
theoretic interest but the greatest practical importance.
Psycho-Analytic treatment is comparable to a surgical operation and,
like that, for its success it has the right to expect to be carried out
under the most favourable conditions. You know the preliminary
arrangements a surgeon is accustomed to make—a suitable room, a good
light, expert assistance, exclusion of the relatives, and so on. Now ask
yourselves how many surgical operations would be successful if they had
to be conducted in the presence of the patient’s entire family poking
their noses into the scene of the operation and shrieking aloud at every
cut. In psycho-analytic treatment the intervention of the relatives is a
positive danger and, moreover, one which we do not know how to deal
with. We are armed against the inner resistances of the patient, which
we recognize as necessary, but how can we protect ourselves against
these outer resistances? It is impossible to get round the relatives by
any sort of explanation, nor can one induce them to hold aloof from the
whole affair; one can never take them into one’s confidence because then
we run the danger of losing the patient’s trust in us, for he—quite
rightly, of course—demands that the man he confides in should take his
part. Anyone who knows anything of the dissensions commonly splitting up
family life will not be astonished in his capacity of analyst to find
that those nearest to the patient frequently show less interest in his
recovery than in keeping him as he is. When as so often occurs the
neurosis is connected with conflicts between different members of a
family, the healthy person does not make much of putting his own
interest before the patient’s recovery. After all, it is not surprising
that the husband does not favour a treatment in which, as he correctly
supposes, his sins will all come to light; nor do we wonder at this, but
then we cannot blame ourselves when our efforts remain fruitless and are
prematurely broken off because the husband’s resistance is added to that
of the sick wife. We had simply undertaken something which, under the
existing conditions, it was impossible to carry out.