Recommendations to physicians practising psycho-analysis 1 страница

(1912)

The technical rules which I am putting forward here have been arrived at from my own experience in the course of many years after unfortunate results had led me to abandon other methods. It will easily be seen that they (or at least many of them) may be summed up in a single precept. My hope is that observance of them will spare physicians practising analysis much unnecessary effort and guard them against some oversights. I must however make it clear that what I am asserting is that this technique is the only one suited to my individuality; I do not venture to deny that a physician quite differently constituted might find himself driven to adopt a different attitude to his patients and to the task before him.

(a) The first problem confronting an analyst who is treating more than one patient in the day will seem to him the hardest. It is the task of keeping in mind all the innumerable names, dates, detailed memories and pathological products which each patient communicates in the course of months and years of treatment, and of not confusing them with similar material produced by other patients under treatment simultaneously or previously. If one is required to analyse six, eight, or even more patients daily, the feat of memory involved in achieving this will provoke incredulity, astonishment or even commiseration in uninformed observers. Curiosity will in any case be felt about the technique which makes it possible to master such an abundance of material, and the expectation will be that some special expedients are required for the purpose.

The technique, however, is a very simple one. As we shall see, it rejects the use of any special expedient (even that of taking notes). It consists simply in not directing one’s notice to anything in particular and in maintaining the same ‘evenly-suspended attention’ (as I have called it) in the face of all that one hears. In this way we spare ourselves a strain on our attention which could not in any case be kept up for several hours daily, and we avoid a danger which is inseparable from the exercise of deliberate attention. For as soon as anyone deliberately concentrates his attention to a certain degree, he begins to select from the material before him; one point will be fixed in his mind with particular clearness and some other will be correspondingly disregarded, and in making this selection he will be following his expectations or inclinations. This, however, is precisely what must not be done. In making the selection, if he follows his expectations he is in danger of never finding anything but what he already knows; and if he follows his inclinations he will certainly falsify what he may perceive. It must not be forgotten that the things one hears are for the most part things whose meaning is only recognized later on.

It will be seen that the rule of giving equal notice to everything is the necessary counterpart to the demand made on the patient that he should communicate everything that occurs to him without criticism or selection. If the doctor behaves otherwise, he is throwing away most of the advantage which results from the patient’s obeying the ‘fundamental rule of psycho- analysis’. The rule for the doctor may be expressed: ‘He should withhold all conscious influences from his capacity to attend, and give himself over completely to his "unconscious memory".’ Or, to put it purely in terms of technique: ‘He should simply listen, and not bother about whether he is keeping anything in mind.’

What is achieved in this manner will be sufficient for all requirements during the treatment. Those elements of the material which already form a connected context will be at the doctor’s conscious disposal; the rest, as yet unconnected and in chaotic disorder, seems at first to be submerged, but rises readily into recollection as soon as the patient brings up something new to which it can be related and by which it can be continued. The undeserved compliment of having ‘a remarkably good memory’ which the patient pays one when one reproduces some detail after a year and a day can then be accepted with a smile, whereas a conscious determination to recollect the point would probably have resulted in failure. Mistakes in this process of remembering occur only at times and places at which one is disturbed by some personal consideration (see below) - that is, when one has fallen seriously below the standard of an ideal analyst. Confusion with material brought up by other patients occurs very rarely. Where there is a dispute with the patient as to whether or how he has said some particular thing, the doctor is usually in the right.¹

¹ A patient will often assert that he has already told the doctor something on a previous occasion, while the doctor can assure him with a quiet feeling of superiority that it has come up now for the first time. It then turns out that the patient had previously had the intention of saying it, but had been prevented from performing his intention by a resistance which was still present. His recollection of his intention is indistinguishable to him from a recollection of its performance.

9 (b) I cannot advise the taking of full notes, the keeping of a shorthand record, etc., during analytic sessions. Apart from the unfavourable impression which this makes on some patients, the same considerations as have been advanced with regard to attention apply here too. A detrimental selection from the material will necessarily be made as one writes the notes or shorthand, and part of one’s own mental activity is tied up in this way, which would be better employed in interpreting what one has heard. No objection can be raised to making exceptions to this rule in the case of dates, the text of dreams, or particular noteworthy events which can easily be detached from their context and are suitable for independent use as instances. But I am not in the habit of doing this either. As regards instances, I write them down from memory in the evening after work is over; as regards texts of dreams to which I attach importance, I get the patient to repeat them to me after he has related them so that I can fix them in my mind.

(c) Taking notes during the session with the patient might be justified by an intention of publishing a scientific study of the case. On general grounds this can scarcely be denied. Nevertheless it must be borne in mind that exact reports of analytic case histories are of less value than might be expected. Strictly speaking, they only possess the ostensible exactness of which ‘modern’ psychiatry affords us some striking examples. They are, as a rule, fatiguing to the reader and yet do not succeed in being a substitute for his actual presence at an analysis. Experience invariably shows that if readers are willing to believe an analyst they will have confidence in any slight revision to which he has submitted his material; if, on the other hand, they are unwilling to take analysis and the analyst seriously, they will pay no attention to accurate verbatim records of the treatment either. This is not the way, it seems, to remedy the lack of convincing evidence to be found in psycho-analytic reports.

(d) One of the claims of psycho-analysis to distinction is, no doubt, that in its execution research and treatment coincide; nevertheless, after a certain point, the technique required for the one opposes that required for the other. It is not a good thing to work on a case scientifically while treatment is still proceeding - to piece together its structure, to try to foretell its further progress, and to get a picture from time to time of the current state of affairs, as scientific interest would demand. Cases which are devoted from the first to scientific purposes and are treated accordingly suffer in their outcome; while the most successful cases are those in which one proceeds, as it were, without any purpose in view, allows oneself to be taken by surprise by any new turn in them, and always meets them with an open mind, free from any presuppositions. The correct behaviour for an analyst lies in swinging over according to need from the one mental attitude to the other, in avoiding speculation or brooding over cases while they are in analysis, and in submitting the material obtained to a synthetic process of thought only after the analysis is concluded. The distinction between the two attitudes would be meaningless if we already possessed all the knowledge (or at least the essential knowledge) about the psychology of the unconscious and about the structure of the neuroses that we can obtain from psycho-analytic work. At present we are still far from that goal and we ought not to cut ourselves off from the possibility of testing what we have already learnt and of extending our knowledge further.

0 (e) I cannot advise my colleagues too urgently to model themselves during psycho-analytic treatment on the surgeon, who puts aside all his feelings, even his human sympathy, and concentrates his mental forces on the simple aim of performing the operation as skilfully as possible. Under present-day conditions the feeling that is most dangerous to a psycho-analyst is the therapeutic ambition to achieve by this novel and much disputed method something that will produce a convincing effect upon other people. This will not only put him into a state of mind which is unfavourable for his work, but will make him helpless against certain resistances of the patient, whose recovery, as we know, primarily depends on the interplay of forces in him. The justification for requiring this emotional coldness in the analyst is that it creates the most advantageous conditions for both parties: for the doctor a desirable protection for his own emotional life and for the patient the largest amount of help that we can give him to-day. A surgeon of earlier times took as his motto the words: ‘Je le pansai, Dieu le guérit.’¹ The analyst should be content with something similar.

(f) It is easy to see upon what aim the different rules I have brought forward converge. They are all intended to create for the doctor a counterpart to the ‘fundamental rule of psycho-analysis’ which is laid down for the patient. Just as the patient must relate everything that his self-observation can detect, and keep back all the logical and affective objections that seek to induce him to make a selection from among them, so the doctor must put himself in a position to make use of everything he is told for the purposes of interpretation and of recognizing the concealed unconscious material without substituting a censorship of his own for the selection that the patient has forgone. To put it in a formula: he must turn his own unconscious like a receptive organ towards the transmitting unconscious of the patient. He must adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone. Just as the receiver converts back into sound waves the electric oscillations in the telephone line which were set up by sound waves, so the doctor’s unconscious is able, from the derivatives of the unconscious which are communicated to him, to reconstruct that unconscious, which has determined the patient’s free associations.

¹ [‘I dressed his wounds, God cured him.’]1

But if the doctor is to be in a position to use his unconscious in this way as an instrument in the analysis, he must himself fulfil one psychological condition to a high degree. He may not tolerate any resistances in himself which hold back from his consciousness what has been perceived by his unconscious; otherwise he would introduce into the analysis a new species of selection and distortion which would be far more detrimental than that resulting from concentration of conscious attention. It is not enough for this that he himself should be an approximately normal person. It may be insisted, rather, that he should have undergone a psycho-analytic purification and have become aware of those complexes of his own which would be apt to interfere with his grasp of what the patient tells him. There can be no reasonable doubt about the disqualifying effect of such defects in the doctor; every unresolved repression in him constitutes what has been aptly described by Stekel as a ‘blind spot’ in his analytic perception.

Some years ago I gave as an answer to the question of how one can become an analyst: ‘By analysing one’s own dreams.’ This preparation is no doubt enough for many people, but not for everyone who wishes to learn analysis. Nor can everyone succeed in interpreting his own dreams without outside help. I count it as one of the many merits of the Zurich school of analysis that they have laid increased emphasis on this requirement, and have embodied it in the demand that everyone who wishes to carry out analyses on other people shall first himself undergo an analysis by someone with expert knowledge. Anyone who takes up the work seriously should choose this course, which offers more than one advantage; the sacrifice involved in laying oneself open to another person without being driven to it by illness is amply rewarded. Not only is one’s aim of learning to know what is hidden in one’s own mind far more rapidly attained and with less expense of affect, but impressions and convictions will be gained in relation to oneself which will be sought in vain from studying books and attending lectures. And lastly, we must not under-estimate the advantage to be derived from the lasting mental contact that is as a rule established between the student and his guide.

An analysis such as this of someone who is practically healthy will, as may be imagined, remain incomplete. Anyone who can appreciate the high value of the self-knowledge and increase in self-control thus acquired will, when it is over, continue the analytic examination of his personality in the form of a self-analysis, and be content to realize that, within himself as well as in the external world, he must always expect to find something new. But anyone who has scorned to take the precaution of being analysed himself will not merely be punished by being incapable of learning more than a certain amount from his patients, he will risk a more serious danger and one which may become a danger to others. He will easily fall into the temptation of projecting outwards some of the peculiarities of his own personality, which he has dimly perceived, into the field of science, as a theory having universal validity; he will bring the psycho-analytic method into discredit, and lead the inexperienced astray.

2 (g) I shall now add a few other rules, that will serve as a transition from the attitude of the doctor to the treatment of the patient.

Young and eager psycho-analysts will no doubt be tempted to bring their own individuality freely into the discussion, in order to carry the patient along with them and lift him over the barriers of his own narrow personality. It might be expected that it would be quite allowable and indeed useful, with a view to overcoming the patient’s existing resistances, for the doctor to afford him a glimpse of his own mental defects and conflicts and, by giving him intimate information about his own life, enable him to put himself on an equal footing. One confidence deserves another, and anyone who demands intimacy from someone else must be prepared to give it in return.

But in psycho-analytic relations things often happen differently from what the psychology of consciousness might lead us to expect. Experience does not speak in favour of an affective technique of this kind. Nor is it hard to see that it involves a departure from psycho-analytic principles and verges upon treatment by suggestion. It may induce the patient to bring forward sooner and with less difficulty things he already knows but would otherwise have kept back for a time through conventional resistances. But this technique achieves nothing towards the uncovering of what is unconscious to the patient. It makes him even more incapable of overcoming his deeper resistances, and in severer cases it invariably fails by encouraging the patient to be insatiable: he would like to reverse the situation, and finds the analysis of the doctor more interesting than his own. The resolution of the transference, too - one of the main tasks of the treatment - is made more difficult by an intimate attitude on the doctor’s part, so that any gain there may be at the beginning is more than outweighed at the end. I have no hesitation, therefore, in condemning this kind of technique as incorrect. The doctor should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him. In practice, it is true, there is nothing to be said against a psychotherapist combining a certain amount of analysis with some suggestive influence in order to achieve a perceptible result in a shorter time - as is necessary, for instance, in institutions. But one has a right to insist that he himself should be in no doubt about what he is doing and should know that his method is not that of true psycho-analysis.

3 (h) Another temptation arises out of the educative activity which, in psycho-analytic treatment, devolves on the doctor without any deliberate intention on his part. When the developmental inhibitions are resolved, it happens of itself that the doctor finds himself in a position to indicate new aims for the trends that have been liberated. It is then no more than a natural ambition if he endeavours to make something specially excellent of a person whom he has been at such pains to free from his neurosis and if he prescribes high aims for his wishes. But here again the doctor should hold himself in check, and take the patient’s capacities rather than his own desires as guide. Not every neurotic has a high talent for sublimation; one can assume of many of them that they would not have fallen ill at all if they had possessed the art of sublimating their instincts. If we press them unduly towards sublimation and cut them off from the most accessible and convenient instinctual satisfactions, we shall usually make life even harder for them than they feel it in any case. As a doctor, one must above all be tolerant to the weakness of a patient, and must be content if one has won back some degree of capacity for work and enjoyment for a person even of only moderate worth. Educative ambition is of as little use as therapeutic ambition. It must further be borne in mind that many people fall ill precisely from an attempt to sublimate their instincts beyond the degree permitted by their organization and that in those who have a capacity for sublimation the process usually takes place of itself as soon as their inhibitions have been overcome by analysis. In my opinion, therefore, efforts invariably to make use of the analytic treatment to bring about sublimation of instinct are, though no doubt always laudable, far from being in every case advisable.

4 (i) To what extent should the patient’s intellectual co-operation be sought for in the treatment? It is difficult to say anything of general applicability on this point: the patient’s personality is the determining factor. But in any case caution and self-restraint must be observed in this connection. It is wrong to set a patient tasks, such as collecting his memories or thinking over some particular period of his life. On the contrary, he has to learn above all - what never comes easily to anyone - that mental activities such as thinking something over or concentrating the attention solve none of the riddles of a neurosis; that can only be done by patiently obeying the psycho-analytic rule, which enjoins the exclusion of all criticism of the unconscious or of its derivatives. One must be especially unyielding about obedience to that rule with patients who practise the art of sheering off into intellectual discussion during their treatment, who speculate a great deal and often very wisely about their condition and in that way avoid doing anything to overcome it. For this reason I dislike making use of analytic writings as an assistance to my patients; I require them to learn by personal experience, and I assure them that they will acquire wider and more valuable knowledge than the whole literature of psycho-analysis could teach them. I recognize, however, that under institutional conditions it may be of great advantage to employ reading as a preparation for patients in analysis and as a means of creating an atmosphere of influence.

I must give a most earnest warning against any attempt to gain the confidence or support of parents or relatives by giving them psycho-analytic books to read, whether of an introductory or an advanced kind. This well-meant step usually has the effect of bringing on prematurely the natural opposition of the relatives to the treatment - an opposition which is bound to appear sooner or later - so that the treatment is never ever begun.

Let me express a hope that the increasing experience of psycho-analysts will soon lead to agreement on questions of technique and on the most effective method of treating neurotic patients. As regards the treatment of their relatives I must confess myself utterly at a loss, and I have in general little faith in any individual treatment of them.

ON BEGINNING THE TREATMENT (further recommendations on the technique of psycho-analysis I) (1913)

Anyone who hopes to learn the noble game of chess from book will soon discover that only the openings and end-games admit of an exhaustive systematic presentation and that the infinite variety of moves which develop after the opening defy any such description. This gap in instruction can only be filled by a diligent study of games fought out by masters. The rules which can be laid down for the practice of psycho-analytic treatment are subject to similar limitations.

In what follows I shall endeavour to collect together for the use of practising analysts some of the rules for the beginning of the treatment. Among them there are some which may seem to be petty details, as, indeed, they are. Their justification is that they are simply rules of the game which acquire their importance from their relation to the general plan of the game. I think I am well-advised, however, to call these rules ‘recommendations’ and not to claim any unconditional acceptance for them. The extraordinary diversity of the psychical constellations concerned, the plasticity of all mental processes and the wealth of determining factors oppose any mechanization of the technique; and they bring it about that a course of action that is as a rule justified may at times prove ineffective, whilst one that is usually mistaken may once in a while lead to the desired end. These circumstances, however, do not prevent us from laying down a procedure for the physician which is effective on the average.

Some years ago I set out the most important indications for selecting patients¹ and I shall therefore not repeat them here. They have in the meantime been approved by other psycho-analysts. But I may add that since then I have made it my habit, when I know little about a patient, only to take him on at first provisionally, for a period of one to two weeks. If one breaks off within this period one spares the patient the distressing impression of an attempted cure having failed. One has only been undertaking a ‘sounding’ in order to get to know the case and to decide whether it is a suitable one for psycho-analysis. No other kind of preliminary examination but this procedure is at our disposal; the most lengthy discussions and questionings in ordinary consultations would offer no substitute. This preliminary experiment, however, is itself the beginning of a psycho-analysis and must conform to its rules. There may perhaps be this distinction made, that in it one lets the patient do nearly all the talking and explains nothing more than what is absolutely necessary to get him to go on with what he is saying.

¹ ‘On Psychotherapy’ (1905a).8

There are also diagnostic reasons for beginning the treatment with a trial period of this sort lasting for one or two weeks. Often enough, when one sees a neurosis with hysterical or obsessional symptoms, which is not excessively marked and has not been in existence for long - just the type of case, that is, that one would regard as suitable for treatment - one has to, reckon with the possibility that it may be a preliminary stage of what is known as dementia praecox (‘schizophrenia’, in Bleuler’s terminology; ‘paraphrenia’, as I have proposed to call it), and that sooner or later it will show a well-marked picture of that affection. I do not agree that it is always possible to make the distinction so easily. I am aware that there are psychiatrists who hesitate less often in their differential diagnosis, but I have become convinced that just as often they make mistakes. To make a mistake, moreover, is of far greater moment for the psycho-analyst than it is for the clinical psychiatrist, as he is called. For the latter is not attempting to do anything that will be of use, whichever kind of case it may be. He merely runs the risk of making a theoretical mistake, and his diagnosis is of no more than academic interest. Where the psycho-analyst is concerned, however, if the case is unfavourable he has committed a practical error; he has been responsible for wasted expenditure and has discredited his method of treatment. He cannot fulfil his promise of cure if the patient is suffering, not from hysteria or obsessional neurosis, but from paraphrenia, and he therefore has particularly strong motives for avoiding mistakes in diagnosis. In an experimental treatment of a few weeks he will often observe suspicious signs which may determine him not to pursue the attempt any further. Unfortunately I cannot assert that an attempt of this kind always enables us to arrive at a certain decision; it is only one wise precaution the more.¹

¹ There is a great deal to be said about this uncertainty in diagnosis, about the prospects of success in analysing mild forms of paraphrenia and about the reasons for the similarity between the two disorders; but I cannot enlarge on these subjects in the present context. I should be glad to follow Jung in contrasting hysteria and obsessional neurosis as ‘transference neuroses’ with the paraphrenic affections as ‘introversion neuroses’, if it were not that such a usage would deprive the concept of ‘introversion’ (of the libido) of its sole legitimate meaning.

9 Lengthy preliminary discussions before the beginning of the analytic treatment, previous treatment by another method and also previous acquaintance between the doctor and the patient who is to be analysed, have special disadvantageous consequences for which one must be prepared. They result in the patient’s meeting the doctor with a transference attitude which is already established and which the doctor must first slowly uncover instead of having the opportunity to observe the growth and development of the transference from the outset. In this way the patient gains a temporary start upon us which we do not willingly grant him in the treatment.

One must mistrust all prospective patients who want to make a delay before beginning their treatment. Experience show that when the time agreed upon has arrived they fail to put in an appearance, even though the motive for the delay - i.e. their rationalization of their intention - seems to the uninitiated to be above suspicion.

Special difficulties arise when the analyst and his new patient or their families are on terms of friendship or have social ties with one another. The psycho-analyst who is asked to undertake the treatment of the wife or child of a friend must be prepared for it to cost him that friendship, no matter what the outcome of the treatment may be: nevertheless he must make the sacrifice if he cannot find a trustworthy substitute.

Both lay public and doctors - still ready to confuse psycho-analysis with treatment by suggestion - are inclined to attribute great importance to the expectations which the patient brings to the new treatment. They often believe in the case of one patient that he will not give much trouble, because he has great confidence in psycho-analysis and is fully convinced of its truth and efficacy; whereas in the case of another, they think that he will undoubtedly prove more difficult, because he has a sceptical outlook and will not believe anything until he has experienced its successful results on his own person. Actually, however, this attitude on the part of the patient has very little importance. His initial trust or distrust is almost negligible compared with the internal resistances which hold the neurosis firmly in place. It is true that the patient’s happy trustfulness makes our earliest relationship with him a very pleasant one; we are grateful to him for that, but we warn him that his favourable prepossession will be shattered by the first difficulty that arises in the analysis. To the sceptic we say that the analysis requires no faith, that he may be as critical and suspicious as he pleases and that we do not regard his attitude as the effect of his judgement at all, for he is not in a position to form a reliable judgement on these matters; his distrust is only a symptom like his other symptoms and it will not be an interference, provided he conscientiously carries out what the rule of the treatment requires of him.

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