On the occasion of the opening of the hebrew University 16 страница

‘But there are instances that can be quoted as legal precedents against allowing lay analysis; I mean the prohibition against laymen practising hypnotism and the recently enacted prohibition against holding spiritualist seances or founding spiritualist societies.’

I cannot say that I am an admirer of these measures. The second one is a quite undisguised encroachment of police supervision to the detriment of intellectual freedom. I am beyond suspicion of having much belief in what are known as ‘occult phenomena’ or of feeling any desire that they should be recognized. But prohibitions like these will not stifle people’s interest in that supposedly mysterious world. They may on the contrary have done much harm and have closed the door to an impartial curiosity which might have arrived at a judgement that would have set us free from these harassing possibilities. But once again this only applies to Austria. In other countries ‘para-psychical’ researches are not met by any legal obstacles. The case of hypnotism is somewhat different from that of analysis. Hypnotism is the evoking of an abnormal mental state and is used by laymen to-day only for the purpose of public shows. If hypnotic therapy had maintained its very promising beginnings, a position would have been arrived at similar to that of analysis. And incidentally the history of hypnotism provides a precedent for that of analysis in another direction. When I was a young lecturer in neuropathology, the doctors inveighed passionately against hypnotism, declared that it was a swindle, a deception of the Devil’s and a highly dangerous procedure. To-day they have monopolized this same hypnotism and they make use of it unhesitatingly as a method of examination; for some nerve specialists it is still their chief therapeutic instrument.

But I have already told you that I have no intention of making proposals which are based on the decision as to whether legal control or letting things go is to be preferred in the matter of analysis. I know this is a question of principle on the reply to which the inclinations of persons in authority will probably have more influence than arguments. I have already set out what seems to me to speak in favour of a policy of laissez faire. If the other decision is taken - for a policy of active intervention - then it seems to me that in any case a lame and unjust measure of ruthlessly forbidding analysis by non-doctors will be an insufficient outcome. More will have to be considered in that case: the conditions will have to be laid down under which the practice of analysis shall be permitted to all those who seek to make use of it, an authority will have to be set up from whom one can learn what analysis is and what sort of preparation is needed for it, and the possibilities for instruction in analysis will have to be encouraged. We must therefore either leave things alone or establish order and clarity; we must not rush into a complicated situation with a single isolated prohibition derived mechanically from a regulation that has become inadequate.

VII

‘Yes, but the doctors! the doctors! I cannot induce you to go into the real subject of our conversations. You still keep on evading me. It is a question of whether we should not give doctors the exclusive right of practising analysis - for all I care, after they have fulfilled certain conditions. The majority of doctors are certainly not quacks in analysis as you have represented them. You say yourself that the great majority of your pupils and followers are doctors. It has come to my ears that they are far from sharing your point of view on the question of lay analysis. I may no doubt assume that your pupils agree with your demands for sufficient preparation and so on; and yet these pupils think it consistent to close the practice of analysis to laymen. Is that so? and if so, how do you explain it?’

I see you are well informed. Yes, it is so. Not all, it is true, but a good proportion of my medical colleagues do not agree with me over this, and are in favour of doctors having an exclusive right to the analytic treatment of neurotics. This will show you that differences of opinion are allowed even in our camp. The side I take is well known and the contradiction on the subject of lay analysis does not interfere with our good understanding. How can I explain the attitude of these pupils of mine to you? I do not know for certain; I think it must be the power of professional feeling. The course of their development has been different from mine, they still feel uncomfortable in their isolation from their colleagues, they would like to be accepted by the ‘profession’ as having plenary rights, and are prepared, in exchange for that tolerance, to make a sacrifice at a point whose vital importance is not obvious to them. Perhaps it may be otherwise; to impute motives of competition to them would be not only to accuse them of base sentiments but also to attribute a strange shortsightedness to them. They are always ready to introduce other doctors into analysis, and from a material point of view it must be a matter of indifference to them whether they have to share the available patients with medical colleagues or with laymen. But something different probably plays a part. These pupils of mine may be influenced by certain factors which guarantee a doctor an undoubted advantage over a layman in analytic practice.

‘Guarantee him an advantage? There we have it. So you are admitting the advantage at last? This should settle the question.’

The admission is not hard for me to make. It may show you that I am not so passionately prejudiced as you suppose. I have put off mentioning these things because their discussion will once again make theoretical considerations necessary.

‘What are you thinking of now?’

First there is the question of diagnosis. When one takes into analysis a patient suffering from what are described as nervous disorders, one wishes beforehand to be certain - so far, of course, as certainty can be attained - that he is suited for this kind of treatment, that one can help him, that is to say, by this method. That, however, is only the case if he really has a neurosis.

‘I should have thought that would be recognizable from the phenomena, the symptoms, of which he complains.’

This is where a fresh complication arises. It cannot always be recognized with complete certainty. The patient may exhibit the external picture of a neurosis, and yet it may be something else - the beginning of an incurable mental disease or the preliminary of a destructive process in the brain. The distinction - the differential diagnosis - is not always easy and cannot be made immediately in every phase. The responsibility for such a decision can of course only be undertaken by a doctor. As I have said, it is not always easy for him. The illness may have an innocent appearance for a considerable time, till in the end it after all displays its evil character. Indeed, it is one of the regular fears of neurotics that they may become insane. However, if a doctor has been mistaken for a time over a case of this sort or has been in uncertainty about it, no harm has been caused and nothing unnecessary has been done. Nor indeed would the analytic treatment of this case have done any harm, though it would have been exposed as an unnecessary waste. And moreover there would certainly be enough people who would blame the analysis for the unfortunate outcome. Unjustly, no doubt, but such occasions ought to be avoided.

‘But that sounds hopeless. It strikes at the roots of everything you have told me about the nature and origin of a neurosis.’ 2

Not at all. It merely confirms once again the fact that neurotics are a nuisance and an embarrassment for all concerned - including the analysts. But perhaps I shall clear up your confusion if I state my new information in more correct terms. It would probably be more correct to say of the cases we are now dealing with that they have readily developed a neurosis, but that it is not psychogenic but somatogenic - that its causes are not mental but physical. Do you understand?

‘Oh, yes, I understand. But I cannot bring it into harmony with the other side, the psychological one.’

That can be managed, though, if one bears in mind the complexities of living substance. In what did we find the essence of a neurosis? In the fact that the ego, the higher organization of the mental apparatus (elevated through the influence of the external world), is not able to fulfil its function of mediating between the id and reality, that in its feebleness it draws back from some instinctual portions of the id and, to make up for this, has to put up with the consequences of its renunciation in the form of restrictions, symptoms and unsuccessful reaction-formations.

A feebleness of the ego of this sort is to be found in all of us in childhood; and that is why the experiences of the earliest years of childhood are of such great importance for later life. Under the extraordinary burden of this period of childhood we have in a few years to cover the enormous developmental distance between stone-age primitive men and the participants in contemporary civilization, and, at the same time and in particular, we have to fend off the instinctual impulses of the early sexual period - under this burden, then, our ego takes refuge in repression and lays itself open to a childhood neurosis, the precipitate of which it carries with it into maturity as a disposition to a later nervous illness. Everything now depends on how the growing organism is treated by fate. If life becomes too hard, if the gulf between instinctual claims and the demands of reality becomes too great, the ego may fail in its efforts to reconcile the two, and the more readily, the more it is inhibited by the disposition carried over by it from infancy. The process of repression is then repeated, the instincts tear themselves away from the ego’s domination, find their substitutive satisfactions along the paths of regression, and the poor ego has become helplessly neurotic.

Only let us hold fast to this: the nodal point and pivot of the whole situation is the relative strength of the ego organization. We shall then find it easy to complete our aetiological survey. As what may be called the normal causes of neurotic illness we already know the feebleness of the childhood ego, the task of dealing with the early sexual impulses and the effects of the more or less chance experiences of childhood. Is it not possible, however, that yet other factors play a part, derived from the time before the beginning of the child’s life? For instance, an innate strength and unruliness of the instinctual life in the id, which from the outset sets the ego tasks too hard for it? Or a special developmental feebleness of the ego due to unknown reasons? Such factors must of course acquire an aetiological importance, in some cases a transcendent one. We have invariably to reckon with the instinctual strength of the id; if it has developed to excess, the prospects of our therapy are poor. We still know too little of the causes of a developmental inhibition of the ego. These then would be the cases of neurosis with an essentially constitutional basis. Without some such constitutional, congenital favouring factors a neurosis can, no doubt, scarcely come about.

But if the relative feebleness of the ego is the decisive factor for the genesis of a neurosis, it must also be possible for a later physical illness to produce a neurosis, provided that it can bring about an enfeeblement of the ego. And that, once again, is very frequently found. A physical disorder of this kind can affect the instinctual life in the id and increase the strength of the instincts beyond the limit up to which the ego is capable of coping with them. The normal model of such processes is perhaps the alteration in women caused by the disturbances of menstruation and the menopause. Or again, a general somatic illness, indeed an organic disease of the nervous central organ, may attack the nutritional conditions of the mental apparatus and compel it to reduce its functioning and to bring to a halt its more delicate workings, one of which is the maintenance of the ego organization. In all these cases approximately the same picture of neurosis emerges; neurosis always has the same psychological mechanism, but, as we see, a most varied and often very complex aetiology.

‘You please me better now. You have begun talking like a doctor at last. And now I expect you to admit that such a complicated medical affair as a neurosis can only be handled by a doctor.’

I fear you are overshooting the mark. What we have been discussing was a piece of pathology, what we are concerned with in analysis is a therapeutic procedure. I allow - no, I insist - that in every case which is under consideration for analysis the diagnosis shall be established first by a doctor. Far the greater number of neuroses which occupy us are fortunately of a psychogenic nature and give no grounds for pathological suspicions. Once the doctor has established this, he can confidently hand over the treatment to a lay analyst. In our analytical societies matters have always been arranged in that way. Thanks to the intimate contact between medical and non-medical members, mistakes such as might be feared have been as good as completely avoided. There is a further contingency, again, in which the analyst has to ask the doctor’s help. In the course of an analytic treatment, symptoms - most often physical symptoms - may appear about which one is doubtful whether they should be regarded as belonging to the neurosis or whether they should be related to an independent organic illness that has intervened. The decision on this point must once again be left to a doctor.

‘So that even during the course of an analysis a lay analyst cannot do without a doctor. A fresh argument against their fitness.’

No. No argument against lay analysts can be manufactured out of this possibility, for in such circumstances a medical analyst would not act differently.

‘I do not understand that.’

There is a technical rule that an analyst, if dubious symptoms like this emerge during the treatment, shall not submit them to his own judgement but shall get them reported upon by a doctor who is not connected with analysis - a consultant physician, perhaps - even if the analyst himself is a doctor and still well versed in his medical knowledge.

‘And why should a rule be made that seems to me so uncalled-for?’ 5

It is not uncalled-for; in fact there are several reasons for it. In the first place it is not a good plan for a combination of organic and psychical treatment to be carried out by one and the same person. Secondly the relation in the transference may make it inadvisable for the analyst to examine the patient physically. And thirdly the analyst has every reason for doubting whether he is unprejudiced, since his interests are directed so intensely to the psychical factors.

‘I now understand your attitude to lay analysis quite clearly. You are determined that there must be lay analysts. And since you cannot dispute their inadequacy for their task, you are scraping together everything you can to excuse them and make their existence easier. But I cannot in the least see why there should be lay analysts, who, after all, can only be therapists of the second class. I am ready, so far as I am concerned, to make an exception in the case of the few laymen who have already been trained as analysts; but no fresh ones should be created and the training institutes should be put under an obligation to take no more laymen into training.’

I am at one with you, if it can be shown that all the interests involved will be served by this restriction. You will agree that these interests are of three sorts: that of the patients, that of the doctors and - last not least - that of science, which indeed comprises the interests of all future patients. Shall we examine these three points together?

For the patient, then, it is a matter of indifference whether the analyst is a doctor or not, provided only that the danger of his condition being misunderstood is excluded by the necessary medical report before the treatment begins and on some possible occasions during the course of it. For him it is incomparably more important that the analyst should possess personal qualities that make him trustworthy, and that he should have acquired the knowledge and understanding as well as the experience which alone can make it possible for him to fulfil his task. It might be thought that it would damage an analyst’s authority if the patient knows that he is not a doctor and cannot in some situations do without a doctor’s support. We have, of course, never omitted to inform patients of their analyst’s qualification, and we have been able to convince ourselves that professional prejudices find no echo in them and that they are ready to accept a cure from whatever direction it is offered them - which, incidentally, the medical profession discovered long ago to its deep mortification. Nor are the lay analysts who practise analysis to-day any chance collection of riff-raff, but people of academic education, doctors of philosophy, educationalists, together with a few women of great experience in life and outstanding personality. The analysis, to which all the candidates in an analytic training institute have to submit, is at the same time the best means of forming an opinion of their personal aptitude for carrying out their exacting occupation.

Now as to the interest of the doctors. I cannot think that it would gain by the incorporation of psycho-analysis into medicine. The medical curriculum already lasts for five years and the final examinations extend well into a sixth year. Every few years fresh demands are made on the student, without the fulfilment of which his equipment for the future would have to be declared insufficient. Access to the medical profession is very difficult and its practice neither very satisfying nor very remunerative. If one supports what is certainly a fully justified demand that doctors should also be familiar with the mental side of illness, and if on that account one extends medical education to include some preparation for analysis, that implies a further increase in the curriculum and a corresponding prolongation of the period of study. I do not know whether the doctors will be pleased by this consequence of their claim upon analysis. But it can scarcely be escaped. And this at a period in which the conditions of material existence have so greatly deteriorated for the classes from which doctors are recruited, a period in which the younger generation sees itself compelled to make itself self-supporting as early in life as possible.

But perhaps you will choose not to burden medical studies with the preparation for analytic practice but think it more expedient for future analysts to take up their necessary training only after the end of their medical studies. You may say the loss of time involved in this is of no practical account, since after all a young man of less than thirty will never enjoy his patients’ confidence, which is a sine qua non of giving mental assistance. It might no doubt be said in reply that a newly-fledged physician for physical illnesses cannot count upon being treated by his patients with very great respect either, and that a young analyst might very well fill in his time by working in a psycho-analytic out-patient clinic under the supervision of experienced practitioners.

But what seems to me more important is that with this proposal of yours you are giving support to a waste of energy for which, in these difficult times, I can really find no economic justification. Analytic training, it is true, cuts across the field of medical education, but neither includes the other. If - which may sound fantastic to-day - one had to found a college of psycho-analysis, much would have to be taught in it which is also taught by the medical faculty: alongside of depth-psychology, which would always remain the principal subject, there would be an introduction to biology, as much as possible of the science of sexual life, and familiarity with the symptomatology of psychiatry. On the other hand, analytic instruction would include branches of knowledge which are remote from medicine and which the doctor does not come across in his practice: the history of civilization, mythology, the psychology of religion and the science of literature. Unless he is well at home in these subjects, an analyst can make nothing of a large amount of his material. By way of compensation, the great mass of what is taught in medical schools is of no use to him for his purposes. A knowledge of the anatomy of the tarsal bones, of the constitution of the carbohydrates, of the course of the cranial nerves, a grasp of all that medicine has brought to light on bacillary exciting causes of disease and the means of combating them, on serum reactions and on neoplasms - all of this knowledge, which is undoubtedly of the highest value in itself, is nevertheless of no consequence to him; it does not concern him; it neither helps him directly to understand a neurosis and to cure it nor does it contribute to a sharpening of those intellectual capacities on which his occupation makes the greatest demands. It cannot be objected that the case is much the same when a doctor takes up some other special branch of medicine - dentistry, for instance: in that case, too, he may not need some of what he has to pass examinations in, and he will have to learn much in addition, for which his schooling has not prepared him. But the two cases cannot be put on a par. In dentistry the great principles of pathology - the theories of inflammation, suppuration, necrosis, and of the metabolism of the bodily organs - still retain their importance. But the experience of an analyst lies in another world, with other phenomena and other laws. However much philosophy may ignore the gulf between the physical and the mental, it still exists for our immediate experience and still more for our practical endeavours.

It is unjust and inexpedient to try to compel a person who wants to set someone else free from the torment of a phobia or an obsession to take the roundabout road of the medical curriculum. Nor will such an endeavour have any success, unless it results in suppressing analysis entirely. Imagine a landscape in which two paths lead to a hilltop with a view - one short and straight, the other long, winding and circuitous. You try to stop up the short path by a prohibitory notice, perhaps because it passes by some flower-beds that you want to protect. The only chance you have of your prohibition being respected is if the short path is steep and difficult while the longer one leads gently up. If, however, that is not so, and the roundabout path is on the contrary the harder, you may imagine the use of your prohibition and the fate of your flower-beds! I fear you will succeed in compelling the laymen to study medicine just as little as I shall be able to induce doctors to learn analysis. For you know human nature as well as I do.

‘If you are right, that analytic treatment cannot be carried out without special training, but that the medical curriculum cannot bear the further burden of a preparation for it, and that medical knowledge is to a great extent unnecessary for an analyst, how shall we achieve the ideal physician who shall be equal to all the tasks of his calling?’

I cannot foresee the way out of these difficulties, nor is it my business to point it out. I see only two things, first that analysis is an embarrassment to you and that the best thing would be for it not to exist - though neurotics, no doubt, are an embarrassment too; and secondly, that the interests of everyone concerned would for the time being be met if the doctors could make up their minds to tolerate a class of therapists which would relieve them of the tedium of treating the enormously common psychogenic neuroses while remaining in constant touch with them to the benefit of the patients.

‘Is that your last word on the subject? or have you something more to say?’

Yes indeed. I wanted to bring up a third interest - the interest of science. What I have to say about that will concern you little; but, by comparison, it is of all the more importance to me.

For we do not consider it at all desirable for psycho-analysis to be swallowed up by medicine and to find its last resting-place in a text-book of psychiatry under the heading ‘Methods of Treatment’, alongside of procedures such as hypnotic suggestion, autosuggestion, and persuasion, which, born from our ignorance, have to thank the laziness and cowardice of mankind for their short-lived effects. It deserves a better fate and, it may be hoped, will meet with one. As a ‘depth-psychology’, a theory of the mental unconscious, it can become indispensable to all the sciences which are concerned with the evolution of human civilization and its major institutions such as art, religion and the social order. It has already, in my opinion, afforded these sciences considerable help in solving their problems. But these are only small contributions compared with what might be achieved if historians of civilization, psychologists of religion, philologists and so on would agree themselves to handle the new instrument of research which is at their service. The use of analysis for the treatment of the neuroses is only one of its applications; the future will perhaps show that it is not the most important one. In any case it would be wrong to sacrifice all the other applications to this single one, just because it touches on the circle of medical interests.

For here a further prospect stretches ahead, which cannot be encroached upon with impunity. If the representatives of the various mental sciences are to study psycho-analysis so as to be able to apply its methods and angles of approach to their own material, it will not be enough for them to stop short at the findings which are laid down in analytic literature. They must learn to understand analysis in the only way that is possible - by themselves undergoing an analysis. The neurotics who need analysis would thus be joined by a second class of persons, who accept analysis from intellectual motives, but who will no doubt also welcome the increase in their capacities which they will incidentally achieve. To carry out these analyses a number of analysts will be needed, for whom any medical knowledge will have particularly little importance. But these ‘teaching analysts’ - let us call them - will require to have had a particularly careful education. If this is not to be stunted, they must be given an opportunity of collecting experience from instructive and informative cases; and since healthy people who also lack the motive of curiosity do not present themselves for analysis, it is once more only upon neurotics that it will be possible for the teaching analysts - under careful supervision - to be educated for their subsequent non-medical activity. All this, however, requires a certain amount of freedom of movement, and is not compatible with petty restrictions.

Perhaps you do not believe in these purely theoretical interests of psycho-analysis or cannot allow them to affect the practical question of lay analysis. Then let me advise you that psycho-analysis has yet another sphere of application, which is outside the scope of the quackery law and to which the doctors will scarcely lay claim. Its application, I mean, to the bringing-up of children. If a child begins to show signs of an undesirable development, if it grows moody, refractory and inattentive, the paediatrician and even the school doctor can do nothing for it, even if the child produces clear neurotic symptoms, such as nervousness, loss of appetite, vomiting or insomnia. A treatment that combines analytic influence with educational measures, carried out by people who are not ashamed to concern themselves with the affairs in a child’s world, and who understand how to find their way into a child’s mental life, can bring about two things at once: the removal of the neurotic symptoms and the reversal of the change in character which had begun. Our recognition of the importance of these inconspicuous neuroses of children as laying down the disposition for serious illnesses in later life points to these child analyses as an excellent method of prophylaxis. Analysis undeniably still has its enemies. I do not know whether they have means at their command for stopping the activities of these educational analysts or analytic educationalists. I do not think it very likely; but one can never feel too secure.

Moreover, to return to our question of the analytic treatment of adult neurotics, even there we have not yet exhausted every line of approach. Our civilization imposes an almost intolerable pressure on us and it calls for a corrective. Is it too fantastic to expect that psycho-analysis in spite of its difficulties may be destined to the task of preparing mankind for such a corrective? Perhaps once more an American may hit on the idea of spending a little money to get the ‘social workers’ of his country trained analytically and to turn them into a band of helpers for combating the neuroses of civilization.

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