Sigmund Freud (18561939). A General Introduction to Psychoanalysis. 1920.
Part Three: General Theory of the Neuroses
XXVIII. 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.
Let us begin with our experiences. I was a pupil of Bernheims, 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 Bernheims method according to the old doctors 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 patients 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.
Now you will say, regardless of whether we call the driving force of our 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 physicians 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 physicians 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 egos 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 patients 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 patients 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 clumsyor perhaps so slyas 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 daughters 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.
It may be possible that the prejudice against psychoanalysis is already on the wane. The continual spread of psychoanalytic doctrine, the increase of the number of physicians in many lands who treat analytically, seems to vouch for it. When I was a young physician I was caught in just such a storm of outraged feeling of the medical profession toward hypnosis, treatment by suggestion, which today is contrasted with psychoanalysis by sober men. Hypnotism did not, however, as a therapeutic agent, live up to its promises; we psychoanalysts may call ourselves its rightful heirs, and we have not forgotten the large amount of encouragement and theoretical explanation we owe to it. The injuries blamed upon psychoanalysis are limited essentially to temporary aggravation of the conflict when the analysis is clumsily handled, or when it is broken off unfinished. You have heard our justification for our form of treatment, and you can form your own opinion as to whether or not our endeavors are likely to lead to lasting injury. Misuse of psychoanalysis is possible in various ways; above all, transference is a dangerous remedy in the hands of an unconscientious physician. But no professional method of procedure is protected from misuse; a knife that is not sharp is of no use in effecting a cure.
I have thus reached the end, ladies and gentlemen. It is more than the customary formal speech when I admit that I am myself keenly depressed over the many faults in the lectures I have just delivered. First of all, I am sorry that I have so often promised to return to a subject only slightly touched upon at the time, and then found that the context has not made it possible to keep my word. I have undertaken to inform you concerning an unfinished thing, still in the process of development, and my brief exposition itself was an incomplete thing. Often I presented the evidence and then did not myself draw the conclusion. But I could not endeavor to make you masters of the subject. I tried only to give you some explanation and stimulation.