Autobiographical note 90 страница

1 Let us now resume our task of enumerating the factors which we have found to exercise an influence on sexual development, whether they are themselves operative forces or merely manifestations of such forces.

PRECOCITY One such factor is spontaneous sexual precocity, whose presence at least can be demonstrated with certainty in the aetiology of the neuroses though, like other factors, it is not in itself a sufficient cause. It is manifested in the interruption, abbreviation or bringing to an end of the infantile period of latency; and it is a cause of disturbances by occasioning sexual manifestations which, owing on the one hand to the sexual inhibitions being incomplete and on the other hand to the genital system being undeveloped, are bound to be in the nature of perversions. These tendencies to perversion may thereafter either persist as such or, after repressions have set in, become the motive forces of neurotic symptoms. In any case sexual precocity makes more difficult the later control of the sexual instinct by the higher mental agencies which is so desirable, and it increases the impulsive quality which, quite apart from this, characterizes the psychical representations of the instinct. Sexual precocity often runs parallel with premature intellectual development and, linked in this way, is to be found in the childhood history of persons of the greatest eminence and capacity; under such conditions its effects do not seem to be so pathogenic as when it appears in isolation.

TEMPORAL FACTORS Other factors which, along with precocity, may be classed as temporal also deserve attention. The order in which the various instinctual impulses come into activity seems to be phylogenetically determined; so, too, does the length of time during which they are able to manifest themselves before they succumb to the effects of some freshly emerging instinctual impulse or to some typical repression. Variations, however, seem to occur both in temporal sequence and in duration, and these variations must exercise a determining influence upon the final result. It cannot be a matter of indifference whether a given current makes its appearance earlier or later than a current flowing in the opposite direction, for the effect of a repression cannot be undone. Divergences in the temporal sequence in which the components come together invariably produce a difference in the outcome. On the other hand, instinctual impulses which emerge with special intensity often run a surprisingly short course - as, for instance, the heterosexual attachment of persons who later become manifest homosexuals. There is no justification for the fear that trends which set in with the greatest violence in childhood will permanently dominate the adult character; it is just as likely that they will disappear and make way for an opposite tendency. (‘Gestrenge Herren regieren nicht Lange.’)¹

We are not in a position to give so much as hint as to the causes of these temporal disturbances of the process of development. A prospect opens before us at this point upon a whole phalanx of biological and perhaps, too, of historical problems of which we have not even come within striking distance.

¹ [‘Harsh rulers have short reigns.’]

PERTINACITY OF EARLY IMPRESSIONS The importance of all early sexual manifestations is increased by a psychical factor of unknown origin, which at the moment, it must be admitted, can only be brought forward as a provisional psychological concept. I have in mind the fact that, in order to account for the situation, it is necessary to assume that these early impressions of sexual life are characterized by an increased pertinacity or susceptibility to fixation in persons who are later to become neurotics or perverts. For the same premature sexual manifestations, when they occur in other persons, fail to make so deep an impression; they do not tend in a compulsive manner towards repetition nor do they lay down the path to be taken by the sexual instinct for a whole lifetime. Part of the explanation of this pertinacity of early impressions may perhaps lie in another psychical factor which we must not overlook in the causation of the neuroses, namely the preponderance attaching in mental life to memory-traces in comparison with recent impressions. This factor is clearly dependent on intellectual education and increases in proportion to the degree of individual culture. The savage has been described in contrast as ‘das unglückselige Kind des Augenblickes’ [‘The hapless child of the moment.’].¹ In consequence of the inverse relation holding between civilization and the free development of sexuality, of which the consequences can be followed far into the structure of our existences, the course taken by the sexual life of a child is just as unimportant for later life where the cultural or social level is relatively low as it is important where that level is relatively high.

FIXATION The ground prepared by the psychical factors which have just been enumerated

affords a favourable basis for such stimulations of infantile sexuality as are experienced accidentally. The latter (first and foremost, seduction by other children or by adults) provide the material which, with the help of the former, can become fixated as a permanent disorder. A good proportion of the deviations from normal sexual life which are later observed both in neurotics and in perverts are thus established from the very first by the impressions of childhood - a period which is regarded as being devoid of sexuality. The causation is shared between a compliant constitution, precocity, the characteristic of increased pertinacity of early impressions and the chance stimulation of the sexual instinct by extraneous influences.

The unsatisfactory conclusion, however, that emerges from these investigations of the disturbances of sexual life is that we know far too little of the biological processes constituting the essence of sexuality to be able to construct from our fragmentary information a theory adequate to the understanding alike of normal and of pathological conditions.

¹ Increase in pertinacity may also possibly be the effect of an especially intense somatic manifestation of sexuality in early years.

FREUD’S PSYCHO-ANALYTIC PROCEDURE (1904)

The particular psychotherapeutic procedure which Freud practises and describes as ‘psycho-analysis’ is an outgrowth of what was known as the ‘cathartic’ method and was discussed by him in collaboration with Josef Breuer in their Studies on Hysteria (1895). This cathartic therapy was a discovery of Breuer’s, and was first used by him some ten years earlier in the successful treatment of a hysterical woman patient, in the course of which he obtained an insight into the pathogenesis of her symptoms. As the result of a personal suggestion from Breuer, Freud revived this procedure and tested it on a considerable number of patients.

The cathartic method of treatment presupposed that the patient could be hypnotized, and was based on the widening of consciousness that occurs under hypnosis. Its aim was the removal of the pathological symptoms, and it achieved this by inducing the patient to return to the psychical state in which the symptom had appeared for the first time. When this was done, there emerged in the hypnotized patient’s mind memories, thoughts and impulses which had previously dropped out of his consciousness; and, as soon as he had related these to the physician, to the accompaniment of intense expressions of emotion, the symptom was overcome and its return prevented. This experience, which could be regularly repeated, was taken by the authors in their joint paper to signify that the symptom takes the place of suppressed processes which have not reached consciousness, that is, that it represents a transformation (‘conversion’) of these processes. They explained the therapeutic effectiveness of their treatment as due to the discharge of what had previously been, as it were, ‘strangulated’ affect attaching to the suppressed mental acts (‘abreaction’). But in practice the simple schematic outline of the therapeutic operation was almost always complicated by the circumstance that it was not a single (‘traumatic’) impression, but in most cases a series of impressions - not easily scanned - which had participated in the creation of the symptom.

The main characteristic of the cathartic method, in contrast to all other methods used in psychotherapy, consists in the fact that its therapeutic efficacy does not lie in The expectation is rather that the symptoms will disappear automatically as soon as the operation, based on certain hypotheses concerning the psychical mechanism, succeeds in diverting the course of mental processes from their previous channel, which found an outlet in the formation of the symptom.

The changes which Freud introduced in Breuer’s cathartic method of treatment were at first changes in technique; these, however, led to new findings and have finally necessitated a different though not contradictory conception of the therapeutic process.

The cathartic method had already renounced suggestion; Freud went a step further and gave up hypnosis as well. At the present time he treats his patients as follows. Without exerting my other kind of influence, he invites them to lie down in a comfortable attitude on a sofa, while he himself sits on a chair behind them outside their field of vision. He does not even ask them to close their eyes, and avoids touching them in any way, as well as any other procedure which might be reminiscent of hypnosis. The session thus proceeds like a conversation between two people equally awake, but one of whom is spared every muscular exertion and every distracting sensory impression which might divert his attention from his own mental activity.

Since, as we all know, it depends upon the choice of the patient whether he can be hypnotized or not, no matter what the skill of the physician may be, and since a large number of neurotic patients cannot be hypnotized by any means whatever, it followed that with the abandonment of hypnosis the applicability of the treatment was assured to an unlimited number of patients. On the other hand, the widening of consciousness, which had supplied the physician with precisely the psychical material of memories and images by the help of which the transformation of the symptoms and the liberation of the affects was accomplished, was now missing. Unless a substitute could be produced for this missing element, any therapeutic effect was out of the question.

Freud found such a substitute - and a completely satisfactory one - in the ‘associations’ of his patients; that is, in the involuntary thoughts (most frequently regarded as disturbing elements and therefore ordinarily pushed aside) which so often break across the continuity of a consecutive narrative.

In order to secure these ideas and associations he asks the patient to ‘let himself go’ in what he says, ‘as you would do in a conversation in which you were rambling on quite disconnectedly and at random’. Before he asks them for a detailed account of their case history he insists that they must include in it whatever comes into their heads, even if they think it unimportant or irrelevant or nonsensical; he lays special stress on their not omitting any thought or idea from their story because to relate it would be embarrassing or distressing to them. In the course of collecting this material of otherwise neglected ideas Freud made the observations which became the determining factor of his entire theory. Gaps appear in the patient’s memory even while he narrates his case: actual occurrences are forgotten, the chronological order is confused, or causal connections are broken, with unintelligible results. No neurotic case history is without amnesia of some kind or other. If the patient is urged to fill these gaps in his memory by an increased application of attention, it is noticed that all the ideas which occur to him are pushed back by every possible critical expedient, until at last he feels positive discomfort when the memory really returns. From this experience Freud concludes that the amnesias are the result of a process which he calls ‘repression’ and the motive for which he finds in feelings of unpleasure. The psychical forces which have brought about this repression can also be detected, according to him, in the ‘resistance’ which operates against the recovery of the lost memories.

The factor of resistance has become one of the corner-stones of his theory. The ideas which are normally pushed aside on every sort of excuse - such as those mentioned above - are regarded by him as derivatives of the repressed psychical phenomena (thoughts and impulses), distorted owing to the resistance against their reproduction. Ideas which are normally pushed aside on every sort of excuse - such as those mentioned above - are regarded by him as derivatives of the repressed psychical phenomena (thoughts and impulses), distorted owing to the resistance against their reproduction.

The greater the resistance, the greater is the distortion. The value of these unintentional thoughts for the purposes of therapeutic technique lies in this relation of theirs to the repressed psychical material. If one possesses a procedure which makes it possible to arrive at the repressed material from the associations, at the distorted material from the distortions, then what was formerly unconscious in mental life can be made accessible to consciousness even without hypnosis.

Freud has developed on this basis an art of interpretation which takes on the task of, as it were, extracting the pure metal of the repressed thoughts from the ore of the unintentional ideas. This work of interpretation is applied not only to the patient’s ideas but also to his dreams, which open up the most direct approach to a knowledge of the unconscious, to his unintentional as well as to his purposeless actions (symptomatic acts) and to the blunders he makes in everyday life (slips of the tongue, bungled actions, and so on). The details of this technique of interpretation or translation have not yet been published by Freud. According to indications he has given, they comprise a number of rules, reached empirically, of how the unconscious material may be reconstructed from the associations, directions on how to know what it means when the patient’s ideas cease to flow, and experiences of the most important typical resistances that arise in the course of such treatments. A bulky volume called The Interpretation of Dreams, published by Freud in 1900, may be regarded as the forerunner of an initiation into his technique.

From these remarks on the technique of the psycho-analytic method the conclusion might be drawn that its inventor has given himself needless trouble and has made a mistake in abandoning the less complicated hypnotic mode of procedure. However, in the first place, the technique of psycho-analysis is much easier in practice, when once one has learnt it, than any description of it would indicate; and, secondly, there is no other way which leads to the desired goal, so that the hard road is still the shortest one to travel. The objection to hypnosis is that it conceals the resistance and for that reason has obstructed the physician’s insight into the play of psychical forces. Hypnosis does not do away with the resistance but only evades it and therefore yields only incomplete information and transitory therapeutic success.

The task which the psycho-analytic method seeks to perform may be formulated in different ways, which are, however, in their essence equivalent. It may, for instance, be stated thus: the task of the treatment is to remove the amnesias. When all gaps in memory have been filled in, all the enigmatic products of mental life elucidated, the continuance and even a renewal of the morbid condition are made impossible. Or the formula may be expressed in this fashion: all repressions must be undone. The mental condition is then the same as one in which all amnesias have been removed. Another formulation reaches further: the task consists in making the unconscious accessible to consciousness, which is done by overcoming the resistances. But it must be remembered that an ideal condition such as this is not present even in the normal, and further that it is only rarely possible to carry the treatment to a point approaching it. Just as health and sickness are not different from each other in essence but are only separated by a quantitative line of demarcation which can be determined in practice, so the aim of the treatment will never be anything else but the practical recovery of the patient, the restoration of his ability to lead an active life and of his capacity for enjoyment. In a treatment which is incomplete or in which success is not perfect, one may at any rate achieve a considerable improvement in the general mental condition, while the symptoms (though now of smaller importance to the patient) may continue to exist without stamping him as a sick man.

The therapeutic procedure remains the same, apart from insignificant modifications, for all the various clinical pictures that may be presented in hysteria, and all forms of obsessional neurosis. This does not imply, however, that it can have an unlimited application. The nature of the psycho-analytic method involves indications and contra-indications with respect to the person to be treated as well as with respect to the clinical picture. Chronic cases of psychoneuroses without any very violent or dangerous symptoms are the most favourable ones for psycho-analysis: thus in the first place every species of obsessional neurosis, obsessive thinking and acting, and cases of hysteria in which phobias and aboulias play the most important part; further, all somatic expressions of hysteria whenever they do not, as in anorexia, require the physician to attend promptly to the speedy removal of symptoms. In acute cases of hysteria it will be necessary to wait for a calmer stage; in all cases where nervous exhaustion dominates the clinical picture a treatment which in itself demands effort, brings only slow improvement and for a time cannot take the persistence of the symptoms into account, will have to be avoided.

Various qualifications are required of anyone who is to be beneficially affected by psycho-analysis. To begin with, he must be capable of a psychically normal condition; during periods of confusion or melancholic depression nothing can be accomplished even in cases of hysteria. Furthermore, a certain measure of natural intelligence and ethical development are to be required of him; if the physician has to deal with a worthless character, he soon loses the interest which makes it possible for him to enter profoundly into the patient’s mental life. Deep-rooted malformations of character, traits of an actually degenerate constitution, show themselves during treatment as sources of a resistance that can scarcely be overcome. In this respect the constitution of the patient sets a general limit to the curative effect of psychotherapy. If the patient’s age is in the neighbourhood of the fifties the conditions for psycho-analysis become unfavourable. The mass of psychical material is then no longer manageable; the time required for recovery is too long; and the ability to undo psychical processes begins to grow weaker.

In spite of all these limitations, the number of persons suitable for psycho-analytic treatment is extraordinarily large and the extension which has come to our therapeutic powers from this method is, according to Freud, very considerable. Freud requires long periods, six months to three years, for an effective treatment; yet he informs us that up to the present, owing to various circumstances which can easily be guessed, he has for the most part been in a position to try his treatment only on very severe cases: patients have come to him after many years of illness, completely incapacitated for life, and, after being disappointed by all kinds of treatments, have had recourse as a last resort to a method which is novel and has been greeted with many doubts. In cases of less severe illness the duration of the treatment might well be much shorter, and very great advantage in the direction of future prevention might be achieved.

ON PSYCHOTHERAPY (1905)

Gentlemen, - Some eight years have passed since I had the opportunity, on the invitation of your much regretted chairman, Professor von Reder, of speaking here on the subject of hysteria. Shortly before that occasion I had published, in 1895, in collaboration with Dr. Josef Breuer, the Studies on Hysteria in which, on the basis of the new knowledge which we owe to his researches, an attempt was made to introduce a new method of treating the neuroses. I am glad to be able to say that the efforts we made in our Studies have met with success; the ideas expressed in them concerning the effects produced by psychical traumas owing to retention of affect, as well as the conception of hysterical symptoms as the results of an excitation transposed from the sphere of the mental to the physical - ideas for which we coined the terms ‘abreaction’ and ‘conversion’ - are to-day generally known and understood. There is, at least in German speaking countries, no presentation of hysteria to-day that does not take them to some extent into account, and we have no colleagues who do not, for a short distance at least, follow the road pointed out by us. And yet, while they were still new, these theorems and this terminology must have sounded not a little strange.

I cannot say the same of the therapeutic procedure which was introduced to our colleagues at the same time as our theory; it is still struggling for recognition. There may be special reasons for this. At that time the technique of the method was as yet undeveloped; it was impossible for me to give medical readers of the book the directions necessary to enable them to carry through the treatment completely. But causes of a general nature have certainly also played a part. To many physicians, even to-day, psychotherapy seems to be a product of modern mysticism and, compared with our physico-chemical remedies which are applied on the basis of physiological knowledge, appears positively unscientific and unworthy of the attention of a serious investigator. Allow me, therefore, to defend the cause of psychotherapy before you, and to point out to you what may be described as unjust or mistaken in this condemnation of it.

In the first place, let me remind you that psychotherapy is in no way a modern method of treatment. On the contrary, it is the most ancient form of therapy in medicine. In Löwenfeld’s instructive Lehrbuch der gesamten Psychotherapie many of the methods of primitive and ancient medical science are described. The majority of them must be classed under the head of psychotherapy; in order to effect a cure a condition of ‘expectation coloured by faith’ was induced in sick persons - a condition which answers a similar purpose for us to-day. Even since physicians have come upon other remedies, psychotherapeutic endeavours of one kind or another have never completely disappeared from medicine.

Secondly, let me draw your attention to the fact that we physicians cannot discard psychotherapy, if only because another person intimately concerned in the process of recovery - the patient - has no intention of discarding it. You will know of the increase in knowledge on this subject that we owe to the Nancy school, to Liébeault and Bernheim. A factor dependent on the psychical disposition of the patient contributes, without any intention on our part, to the effect of every therapeutic process initiated by a physician; most frequently it is favourable to recovery, but often it acts as an inhibition. We have learned to use the word ‘suggestion’ for this phenomenon, and Möbius has taught us that the unreliability which we deplore in so many of our therapeutic measures may be traced back to the disturbing influence of this very powerful factor. All physicians, therefore, yourselves included, are continually practising psychotherapy, even when you have no intention of doing so and are not aware of it; it is a disadvantage, however, to leave the mental factor in your treatment so completely in the patient’s hands. Thus it is impossible to keep a check on it, to administer it in doses or to intensify it. Is it not then a justifiable endeavour on the part of a physician to seek to obtain command of this factor, to use it with a purpose, and to direct and strengthen it? This and nothing else is what scientific psychotherapy proposes.

And, in the third place, Gentlemen, I would remind you of the well-established fact that certain diseases, in particular the psychoneuroses, are far more readily accessible to mental influences than to any other form of medication. It is not a modern dictum but an old saying of physicians that these diseases are not cured by the drug but by the physician, that is, by the personality of the physician, inasmuch as through it he exerts a mental influence. I am well aware that you favour the view which Vischer, the professor of aesthetics, expressed so well in his parody of Faust:

Ich weiß, das Physikalische

Wirkt öfters aufs Moralische¹

But would it not be more to the point to say - and is it not more often the case - moral (that is, mental) means can influence a man’s moral side?

There are many ways and means of practising psychotherapy. All that lead to recovery are good. Our usual word of comfort, which we dispense so liberally to our patients - ‘You’ll soon be all right again’ -, corresponds to one of these psychotherapeutic methods; but now that we have deeper insight into the neuroses, we are no longer obliged to confine ourselves to the word of comfort. We have developed the technique of hypnotic suggestion, and psychotherapy by mental distraction, by exercise, and by eliciting suitable affects. I despise none of these methods and would use them all in appropriate circumstances. If I have actually come to confine myself to one form of treatment, to the method which Breuer called cathartic, but which I myself prefer to call ‘analytic’, it is because I have allowed myself to be influenced by purely subjective motives. Because of the part I have played in founding this therapy, I feel a personal obligation to devote myself to closer investigation of it and to the development of its technique. And I may say that the analytic method of psychotherapy is the one that penetrates most deeply and carries farthest, the one by means of which the most extensive transformations can be effected in patients. Putting aside for a moment the therapeutic point of view, I may also say of it that it is the most interesting method, the only one which informs us at all about the origin and inter-relation of morbid phenomena. Owing to the insight which we gain into mental illness by this method, it alone should be capable of leading us beyond its own limits and of pointing out the way to other forms of therapeutic influence.

¹ [I know that the physical

Often influences the moral.]6

Permit me now to correct a few mistakes that have been made in regard to this cathartic or analytic method of psychotherapy, and to give a few explanations on the subject.

(a) I have observed that this method is very often confused with hypnotic treatment by suggestion; I have noticed this because it happens comparatively often that colleagues who do not ordinarily confide their cases to me send me patients refractory patients, of course - with a request that I should hypnotize them. Now I have not used hypnosis for therapeutic purposes for some eight years (except for a few special experiments) so that I habitually send back these cases with the recommendation that anyone who relies upon hypnosis may employ it himself. There is, actually, the greatest possible antithesis between suggestive and analytic technique - the same antithesis which, in regard to the fine arts, the great Leonardo da Vinci summed up in the formulas: per via di porre and per via di levare. Painting, says Leonardo, works per via di porre, for it applies a substance - particles of colour - where there was no thing before, on the colourless canvas; sculpture, however, proceeds per via di levare, since it takes away from the block of stone all that hides the surface of the statue contained in it. In a similar way, the technique of suggestion aims at proceeding per via di porre; it is not concerned with the origin, strength and meaning of the morbid symptoms, but instead, it superimposes something - a suggestion - in the expectation that it will be strong enough to restrain the pathogenic idea from coming to expression. Analytic therapy, on the other hand, does not seek to add or to introduce anything new, but to take away something, to bring out something; and to this end concerns itself with the genesis of the morbid symptoms and the psychical context of the pathogenic idea which it seeks to remove. It is by the use of this mode of investigation that analytic therapy has increased our knowledge so notably. I gave up the suggestive technique, and with it hypnosis, so early in my practice because I despaired of making suggestion powerful and enduring enough to effect permanent cures. In every severe case I saw the suggestions which had been applied crumble away again; after which the disease or some substitute for it was back once more. Besides all this I have another reproach to make against this method, namely, that it conceals from us all insight into the play of mental forces; it does not permit us, for example, to recognize the resistance with which the patient clings to his disease and thus even fights against his own recovery; yet it is this phenomenon of resistance which alone makes it possible to understand his behaviour in daily life.

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