PARAPRAXES 17 страница

PART III GENERAL THEORY OF THE NEUROSES

(1917)

LECTURE XVI PSYCHO-ANALYSIS AND PSYCHIATRY

LADIES AND GENTLEMEN, - I am delighted to see you again, at the beginning of a new academic year, for a resumption of our discussions. Last year I spoke to you of the way in which psycho-analysis deals with parapraxes and dreams. This year I should like to introduce you to an understanding of the phenomena of neurosis, which, as you will soon learn, have a great deal in common with both of the others. But I must warn you in advance that I shall not be able to offer you the same position in relation to me this year as I did last year. At that time I set great store on never taking a step without remaining in agreement with your judgement; I discussed a great deal with you and gave way to your objections - in fact I recognized you and your ‘common sense’ as a deciding factor. But this is no longer possible and for a simple reason. Parapraxes and dreams were not unfamiliar to you as phenomena; we might say that you had as much experience or could easily obtain as much experience of them as I had. The region of the phenomena of neurosis is, however, strange to you; in so far as you are not doctors yourselves, you have no other access to them than through what I have to tell you; and of what help is the best judgement if it is not accompanied by familiarity with the material that is to be judged?

But you must not take this warning of mine to mean that I propose to give you dogmatic lectures and to insist on your unqualified belief. Such a misunderstanding would do me a grave injustice. I do not wish to arouse conviction; I wish to stimulate thought and to upset prejudices. If as a result of lack of knowledge of the material you are not in a position to form a judgement, you should neither believe nor reject. You should listen and allow what I tell you to work on you. It is not so easy to arrive at convictions, or, if they are reached easily, they soon turn out to be worthless and incapable of resistance. The only person who has a right to a conviction is someone who, like me, has worked for many years at the same material and who, in doing so, has himself had the same new and surprising experiences. What is the good, then, in the sphere of the intellect, of these sudden convictions, these lightning-like conversions, these instantaneous rejections? Is it not clear that the ‘coup de foudre’, love at first sight, is derived from quite another sphere, from that of the emotions? We do not even require of our patients that they should bring a conviction of the truth of psycho-analysis into the treatment or be adherents of it. Such an attitude often raises our suspicions. The attitude that we find the most desirable in them is a benevolent scepticism. So you too should endeavour to allow the psycho-analytic view to grow up quietly in you alongside of the popular or psychiatric one, till opportunities arise for the two to influence each other, to compete with each other and to unite in leading to a conclusion.

On the other hand, you should not for a moment suppose that what I put before you as the psycho-analytic view is a speculative system. It is on the contrary empirical - either a direct expression of observations or the outcome of a process of working them over. Whether this working-over has been carried out in an adequate and justifiable manner will appear in the course of the further advance of the science, and indeed I may assert without boasting, after a lapse of nearly twenty-five years, and having reached a fairly advanced age, that these observations are the result of particularly hard, concentrated and deep going work. I have often had an impression that our opponents were unwilling to take any account of this origin of our theses, as though they thought what was in question were merely subjectively determined notions to which someone else might oppose others of his own choice. This behaviour of our opponents is not entirely intelligible to me. It may perhaps be due to the fact that, as a doctor, one usually makes so little contact with neurotic patients and pays so little attention to what they say that one cannot imagine the possibility that anything valuable could be derived from their communications - the possibility, that is, of carrying out any thorough observations upon them. I take this opportunity of assuring you that in the course of these lectures I shall indulge in very little controversy, especially with individuals. I have never been able to convince myself of the truth of the maxim that strife is the father of all things. I believe it is derived from the Greek sophists and is at fault, like them, through overvaluing dialectics. It seems to me, on the contrary, that what is known as scientific controversy is on the whole quite unproductive, apart from the fact that it is almost always conducted on highly personal lines. Up to a few years ago I was able to boast that I had only once engaged in a regular scientific dispute - with one single worker (Löwenfeld of Munich). It ended in our becoming friends and we have remained so to this day. But I did not repeat the experiment for a long time, as I did not feel sure that the outcome would be the same.

Now you will no doubt conclude that a rejection such as this of all written discussion argues a high degree of inaccessibility to objections, of obstinacy, or, to use the polite colloquial scientific term, of pig-headedness. I should like to say in reply that when once, after such hard work, one has arrived at a conviction, one has at the same time acquired a certain right to retain that conviction with some tenacity. I may also urge that in the course of my work I have modified my views on a few important points, changed them and replaced them by fresh ones - and in each case, of course, I have made this publicly known. And the outcome of this frankness? Some people have taken no notice whatever of myself - corrections and continue to this day to criticize me for hypotheses which have long ceased to have the same meaning for me. Others reproach me precisely for these changes and regard me as untrustworthy on their account. Of course! a person who has occasionally changed his opinions is deserving of no belief at all, since he has made it all too likely that his latest assertions may also be mistaken; but a person who has unflinchingly maintained what he once asserted, or who cannot be quickly enough persuaded to give it up, must naturally be pig-headed or stubborn! What can one do, in the face of these contradictory objections by the critics, but remain as one is and behave in accordance with one’s own judgement? I am resolved to do that, and I shall not be deterred from modifying or withdrawing any of my theories, as my advancing experience may require. In regard to fundamental discoveries I have hitherto found nothing to alter, and I hope this will remain true in the future.

9 I am to put before you, then, the psycho-analytic view of the phenomena of neurosis. In doing so, the best plan would seem to be to make a start in connection with the phenomena we have already dealt with, for the sake both of analogy and contrast; and I will begin with a symptomatic action which I have seen many people perform during my consulting hours. We analysts cannot do much for the people who come to us in our consulting-room to lay before us in a quarter of an hour the miseries of a long lifetime. Our deeper knowledge makes it difficult for us to give the kind of opinion another doctor would - ‘There’s nothing wrong with you’ - with the added advice: ‘You should arrange for a mild hydropathic treatment.’ One of my colleagues who was asked what he did with his consultation patients shrugged his shoulders and replied: ‘I fine them so-and-so many Kronen for a frivolous waste of time.’ So you will not be surprised to hear that even in the case of busy psycho-analysts their consulting hours are not apt to be very lively. I have had the ordinary door between my waiting-room and my consulting- and treatment-room doubled and given a baize lining. There can be no doubt about the purpose of this arrangement. Now it constantly happens that a person whom I have brought in from the waiting-room omits to shut the door behind him and almost always he leaves both doors open. As soon as I notice this I insist in a rather unfriendly tone on his or her going back and making good the omission even if the person concerned is a well-dressed gentleman or a fashionable lady. This makes an impression of uncalled-for pedantry. Occasionally, too, I have put myself in a foolish position by making this request when it has turned out to be a person who cannot touch a door-handle himself and is glad if someone with him spares him the necessity. But in the majority of cases I have been right; for anyone who behaves like this and leaves the door open between a doctor’s waiting-room and consulting-room is ill-mannered and deserves an unfriendly reception. But do not take sides over this till you have heard the sequel. For this carelessness on the part of the patient only occurs when he has been alone in the waiting-room and has therefore left an empty room behind him; it never happens if other people, strangers to him, have been waiting with him. In this latter case he knows quite well that it is in his interest not to be overheard while he is talking to the doctor, and he never fails to shut both the doors carefully.

Thus the patient’s omission is neither accidentally nor senselessly determined; and indeed it is not unimportant, for, as we shall see, it throws light on the newcomer’s attitude to the doctor. The patient is one of the great multitude who have a craving for mundane authority, who wish to be dazzled and intimidated. He may have enquired on the telephone as to the hour at which he could most easily get an appointment; he had formed a picture of a crowd of people seeking for help, like the crowd outside one of Julius Meinl’s branches. He now comes into an empty, and moreover extremely modestly furnished, waiting-room, and is shocked. He has to make the doctor pay for the superfluous respect which he had intended to offer him: so - he omits to shut the door between the waiting-room and the consulting-room. What he means to say to the doctor by his conduct is: ‘Ah, so there’s no one here and no one’s likely to come while I’m here.’ He would behave equally impolitely and disrespectfully during the consultation if his arrogance were not given a sharp reprimand at the very beginning.

The analysis of this small symptomatic action tells you no thing you did not know before: the thesis that it was not a matter of chance but had a motive, a sense and an intention, that it had a place in an assignable mental context and that it provided information, by a small indication, of a more important mental process. But, more than anything else, it tells you that the process thus indicated was unknown to the consciousness of the person who carried out the action, since none of the patients who left the two doors open would have been able to admit- that by this omission he wanted to give evidence of his contempt. Some of them would probably have been aware of a sense of disappointment when they entered the empty waiting room; but the connection between this impression and the symptomatic action which followed certainly remained unknown to their consciousness.

Beside this small analysis of a symptomatic action we will now place an observation on a patient. I choose this one because it is fresh in my memory, but also because it can be reported comparatively briefly A certain amount of detail is indispensable in any such account.1 A young officer, home on short leave, asked me to undertake the treatment of his mother-in-law, who, though in the happiest circumstances, was embittering her own life and the lives of her relatives through an absurd idea. In this way I made the acquaintance of a well-preserved lady of fifty-three, friendly and simple in her nature, who told me the following story without any reluctance. She lived in the country, most happily married, with her husband, who was at the head of a large factory. She could not give enough praise to her husband’s affectionate solicitude. It had been a love-match thirty years ago, and since then there had never been any trouble, discord or cause for jealousy. Her two children were happily married; her husband (and their father), out of a sense of duty, was not yet willing to retire. A year before, she had received an anonymous letter accusing her excellent husband of a love affair with a young girl; and the incredible - and to herself unintelligible - result was that she immediately believed it, and since then her happiness had been destroyed. The course of events, in greater detail, was something like this. She had a housemaid with whom she used, perhaps too often, to have intimate talks. This girl pursued another one with a positively malicious hostility because she had done so much better for herself in life, though she was of no higher origin. Instead of going into service, this other girl had managed to get a commercial training, had entered the factory and, as a result of shortness of personnel, owing to members of the staff being called up for military service, she was promoted to a good position. She now lived in the factory itself, had social relations with all the gentlemen and was actually addressed as ’Fräulein’. The girl who had made less of a success in life was of course ready to repeat all kinds of bad things of her former schoolmate. One day our lady had a conversation with the housemaid about a gentleman who had been staying with them, who was well known not to be living with his wife but to be having an affair with another woman. She did not know how it happened, but she suddenly said: ‘The most dreadful thing that could happen to me would be if I were to learn that my dear husband was having an affair too.’ The next day she received an anonymous letter by post which, as though by magic, gave her this very information, written in a disguised hand. She decided, probably rightly, that the letter was the work of the malicious housemaid, since it specified as her husband’s mistress the girl whom the servant pursued with her hatred. But although she at once saw through the intrigue and had seen enough instances where she lived of how little credence such cowardly denunciations deserved, what happened was that the letter instantly prostrated her. She became terribly excited, sent for her husband at once and reproached him violently. Her husband laughed the accusation off and did the best possible thing. He brought in the family doctor (who was also the factory doctor) who made efforts to soothe the unfortunate lady. The further conduct of both of them was also entirely sensible. The housemaid was dismissed, but the alleged rival was not. Since then the patient had repeatedly been pacified to the point of no longer believing the content of the anonymous letter, but never thoroughly and never for long. It was enough for her to hear the young lady’s name mentioned or to meet her in the street and a fresh attack of distrust, pain and reproaches would burst out in her.

This, then, is the case history of this excellent woman. Not much psychiatric experience was needed to understand that, in contrast to other neurotics, she was giving too mild an account of her case - that she was, as we say, - dissimulating and that she)lad never really got over her belief in the accusation contained in the anonymous letter.

What attitude, then, will a psychiatrist adopt in a case of illness like this? We know already how he would behave to the symptomatic action of the patient who fails to shut the consulting-room door. He pronounces it to be a chance event of no psychological interest with which he has no further concern. But this procedure cannot be carried over to the illness of the jealous woman. The symptomatic action seems to be a matter of indifference; but the symptom forces itself on our attention as a matter of importance. It is accompanied by intense subjective suffering and, as an objective fact, it threatens the communal life of a family; it is thus an undeniable subject of psychiatric interest. The psychiatrist will start by endeavouring to characterize the symptom by some essential feature. The idea with which the woman torments herself cannot in itself be called absurd; it does, indeed, happen that elderly gentlemen have love affairs with young girls. But there is something else about it which is absurd and hard to understand. The patient had no other reason at all for believing that her affectionate and loyal husband belonged to this otherwise not so rare class of husbands except what was asserted in the anonymous letter. She knew that this document had no evidential value and she was able to give a satisfying explanation of its origin. She ought therefore to have been able to tell herself that she had no ground whatever for her jealousy, and she did tell herself so. But in spite of this she suffered as much as if she regarded this jealousy as completely justified. Ideas of this kind, which are inaccessible to logical arguments based on reality, are by general agreement described as delusions. The good lady, then, was suffering from delusions of jealousy. This is no doubt the essential feature of this case of illness.

After this first point has been established our psychiatric interest will become even livelier. If a delusion is not to be got rid of by a reference to reality, no doubt it did not originate from reality either. Where else did it originate? There are delusions of the most varied content: why in our case is the content of the delusion jealousy in particular? In what kind of people do delusions, and especially delusions of jealousy, come about? We should like to hear what the psychiatrist has to say about this; but at this point he leaves us in the lurch. He enters into only a single one of our enquiries. He will investigate the woman’s family history and will perhaps give us this reply: ‘Delusions come about in people in whose families similar and other psychical disorders have repeatedly occurred.’ In other words, if this woman developed a delusion she was predisposed to it by hereditary transmission. No doubt that is something; but is it all we want to know? Was this the only thing that contributed to the causation of the illness? Must we be content to suppose that it is a matter of indifference or caprice or is inexplicable whether a delusion of jealousy arises rather than any other sort? And ought we to understand the assertion of the predominance of the hereditary influence in a negative sense as well - that no matter what experiences this woman’s mind encountered she was destined some time or other to produce a delusion? You will want to know why it is that scientific psychiatry will give us no further information. But my reply to you is: ‘he is a rogue who gives more than he has.’ The psychiatrist knows no way of throwing more light on a case like this one. He must content himself with a diagnosis and a prognosis - uncertain in spite of a wealth of experience - of its future course.

But can psycho-analysis do more here? Yes, it actually can. I hope to be able to show you that, even in a case so hard of access as this, it can discover something which makes a first understanding possible. And to begin with I would draw your attention to the inconspicuous detail that the patient herself positively provoked the anonymous letter, which now gave support to her delusion, by informing the scheming housemaid on the previous day that it would cause her the greatest unhappiness if her husband had a love affair with a young girl. In this way she first put the notion of sending the anonymous Letter into the housemaid’s head. Thus the delusion acquires a certain independence of the letter; it had been present already in the patient as a fear - or was it as a wish? Let us now add to this the small further indications yielded by only two analytic sessions. The patient, indeed, behaved in a very unco-operative way when, after telling me her story, she was asked for her further thoughts, ideas and memories. She said that nothing occurred to her, that she had told me everything already, and after two sessions the experiment with me had in fact to be broken off because she announced that she already felt well and that she was sure the pathological idea would not come back. She only said this, of course, from resistance and from dread of the continuation of the analysis. Nevertheless, during these two sessions she let fall a few remarks which allowed of, and indeed necessitated, a particular interpretation; and this interpretation threw a clear light on the genesis of her delusion of jealousy. She herself was intensely in love with a young man, with the same son-in-law who had persuaded her to come to me as a patient. She herself knew nothing, or perhaps only a very little, of this love; in the family relationship that existed between them it was easy for this passionate liking to disguise itself as innocent affection. After all our experiences elsewhere, it is not hard for us to feel our way into the mental life of this upright wife and worthy mother, of the age of fifty-three. Being in love like this, a monstrous and impossible thing, could not become conscious; but it remained in existence and, even though it was unconscious, it exercised a severe pressure. Something had to become of it, some relief had to be looked for; and the easiest mitigation was offered, no doubt, by the mechanism of displacement which plays a part so regularly in the generating of delusional jealousy. If not only were she, the old woman, in love with a young man, but if also her old husband were having a love affair with a young girl, then her conscience would be relieved of the weight of her unfaithfulness. The phantasy of her husband’s unfaithfulness thus acted as a cooling compress on her burning wound. Her own love had not become conscious to her, but its mirror-reflection, which brought her such an advantage, now became conscious as an obsession and delusion. No arguments against it could, of course, have any effect, for they were only directed against the mirror-image and not against the original which gave the other its strength and which lay hidden, inviolable, in the unconscious.

Let us now bring together what this effort at a psycho-analysis, short and impeded as it was, has brought to light for an understanding of this case - assuming, of course, that our enquiries were correctly carried out, which I cannot here submit to your judgement. Firstly, the delusion has ceased to be absurd or unintelligible; it had a sense, it had good motives and it fitted into the context of an emotional experience of the patient’s. Secondly, the delusion was necessary, as a reaction to an unconscious mental process which we have inferred from other indications, and it was precisely to this connection that it owed its delusional character and its resistance to every logical and realistic attack. It itself was something desired, a kind of consolation. Thirdly, the fact that the delusion turned out to be precisely a jealous one and not one of another kind was unambiguously determined by the experience that lay behind the illness. You recall of course that, the day before, she had told the scheming maid that the most dreadful thing that could happen to her would be her husband’s unfaithfulness. Nor will you have overlooked the two important analogies between this case and the symptomatic action which we analysed - the explanation of its sense or intention and its relation to something unconscious that was involved in the situation.

Naturally this does not answer all the questions that we might ask in connection with this case. On the contrary, the case bristles with further problems-some that have in general not yet become soluble and others which could not be solved owing to the particular circumstances being unfavourable. For instance, why did this lady who was happily married fall in love with her son-in-law? and why did the relief, which might have been possible in other ways, take the form of this mirror-image this projection of her state on to her husband? You must no: think it is otiose or frivolous to raise such questions. We already have some material at our disposal which might possibly serve to answer them. The lady was at a critical age, at which sexual needs in women suffer a sudden and undesired increase; that alone might account for the event. Or it may further have been that her excellent and faithful husband had for some years no longer enjoyed the sexual capacity which the well-preserved woman required for her satisfaction. Experience has shown us that it is precisely men in this position, whose faithfulness can consequently be taken for granted, who are distinguished by treating their wives with unusual tenderness, and by showing particular forbearance for their nervous troubles. Or, again, it may not be without significance that the object of this pathogenic love was precisely the young husband of one of her daughters. A powerful erotic tie with a daughter, which goes back in the last resort to the mother’s sexual constitution, often finds a way of persisting in a transformation of this sort. In this connection I may perhaps remind you that the relation between mother-in-law and son-in-law has been regarded from the earliest times of the human race as a particularly awkward one and that among primitive people it has given rise to very powerful taboo regulations and ‘avoidances’. The relation is frequently excessive by civilized standards both in a positive and negative direction. Which of these three factors became operative in our case, or whether two of them or perhaps all three came together, I cannot, it is true, tell you; but that is only because I was not permitted to continue the analysis of the case for more than two sessions.

6 I notice now, Gentlemen, that I have been talking to you about a number of things which you are not yet prepared to understand. I did so in order to carry out the comparison between psychiatry and psycho-analysis. But there is one thing that I can ask you now. Have you observed any sign of a contradiction between them? Psychiatry does not employ the technical methods of psycho-analysis; it omits to make any inferences from the content of the delusion, and, in pointing to heredity, it gives us a very general and remote aetiology instead of indicating first the more special and proximate causes. But is there a contradiction, an opposition in this? Is it not rather a case of one supplementing the other? Does the hereditary factor contradict the importance of experience? Do not the two things rather combine in the most effective manner? You will grant that there is nothing in the nature of psychiatric work which could be opposed to psycho-analytic research. What is opposed to psycho-analysis is not psychiatry but psychiatrists. Psycho-analysis is related to psychiatry approximately as histology is to anatomy: the one studies the external forms of the organs, the other studies their construction out of tissues and cells. It is not easy to imagine a contradiction between these two species of study, of which one is a continuation of the other. To-day, as you know, anatomy is regarded by us as the foundation of scientific medicine. But there was a time when it was as much forbidden to dissect the human cadaver in order to discover the internal structure of the body as it now seems to be to practise psycho-analysis in order to learn about the internal mechanism of the mind. It is to be expected that in the not too distant future it will be realized that a scientifically based psychiatry is not possible without a sound knowledge of the deeper-lying unconscious processes in mental life.

Perhaps, however, the much-abused psycho-analysis has friends among you who will be pleased if it can be justified from another direction - from the therapeutic side. As you know, our psychiatric therapy is not hitherto able to influence delusions. Is it possible, perhaps, that psycho-analysis can do so, thanks to its insight into the mechanism of these symptoms? No, Gentlemen, it cannot. It is as powerless (for the time being at least) against these ailments as any other form of therapy. We can understand, indeed, what has happened in the patient, but we have no means of making the patient himself understand it. You have heard how I was unable to pursue the analysis of this delusion beyond a first beginning. Will you be inclined to maintain on that account that an analysis of such cases is to be rejected because it is fruitless? I think not. We have a right, or rather a duty, to carry on our research without consideration of any immediate beneficial effect. In the end - we cannot tell where or when - every little fragment of knowledge will be transformed into power, and into therapeutic power as well. Even if psycho-analysis showed itself as unsuccessful in every other form of nervous and psychical disease as it does in delusions, it would still remain completely justified as an irreplaceable instrument of scientific research. It is true that in that case we should not be in a position to practise it. The human material on which we seek to learn, which lives, has its own will and needs its motives for co-operating in our work, would hold back from us. Let me therefore end my remarks to-day by informing you that there are extensive groups of nervous disorders in which the transformation of our better understanding into therapeutic power has actually taken place, and that in these illnesses, which are difficult of access by other means, we achieve, under favourable conditions, successes which are second to no others in the field of internal medicine.

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