Letter to Georg fuchs 13 страница

But it is far from being the case that his ego is content to play the part of passively and obediently bringing us the material we require and of believing and accepting our translation of it. A number of other things happen, a few of which we might have foreseen but others of which are bound to surprise us. The most remarkable thing is this. The patient is not satisfied with regarding the analyst in the light of reality as a helper and adviser who, moreover, is remunerated for the trouble he takes and who would himself be content with some such role as that of a guide on a difficult mountain climb. On the contrary, the patient sees in him the return, the reincarnation, of some important figure out of his childhood or past, and consequently transfers on to him feelings and reactions which undoubtedly applied to this prototype. This fact of transference soon proves to be a factor of undreamt-of importance, on the one hand an instrument of irreplaceable value and on the other hand a source of serious dangers. This transference is ambivalent: it comprises positive (affectionate) as well as negative (hostile) attitudes towards the analyst, who as a rule is put in the place of one or other of the patient’s parents, his father or mother. So long as it is positive it serves us admirably. It alters the whole analytic situation; it pushes to one side the patient’s rational aim of becoming healthy and free from his ailments. Instead of it there emerges the aim of pleasing the analyst and of winning his applause and love. It becomes the true motive force of the patient’s collaboration; his weak ego becomes strong; under its influence he achieves things that would ordinarily be beyond his power; he leaves off his symptoms and seems apparently to have recovered - merely for the sake of the analyst. The analyst may shamefacedly admit to himself that he set out on a difficult undertaking without any suspicion of the extraordinary powers that would be at his command.

Moreover, the relation of transference brings with it two further advantages. If the patient puts the analyst in the place of his father (or mother), he is also giving him the power which his super-ego exercises over his ego, since his parents were, as we know, the origin of his super-ego. The new super-ego now has an opportunity for a sort of after-education of the neurotic; it can correct mistakes for which his parents were responsible in educating him. But at this point a warning must be given against misusing this new influence. However much the analyst may be tempted to become a teacher, model and ideal for other people and to create men in his own image, he should not forget that that is not his task in the analytic relationship, and indeed that he will be disloyal to his task if he allows himself to be led on by his inclinations. If he does, he will only be repeating a mistake of the parents who crushed their child’s independence by their influence, and he will only be replacing the patient’s earlier dependence by a new one. In all his attempts at improving and educating the patient the analyst should respect his individuality. The amount of influence which he may legitimately allow himself will be determined by the degree of developmental inhibition present in the patient. Some neurotics have remained so infantile that in analysis too they can only be treated as children.

Another advantage of transference, too, is that in it the patient produces before us with plastic clarity an important part of his life-story, of which he would otherwise have probably given us only an insufficient account. He acts it before us, as it were, instead of reporting it to us.6

And now for the other side of the situation. Since the transference reproduces the patient’s relation with his parents, it takes over the ambivalence of that relation as well. It almost inevitably happens that one day his positive attitude towards the analyst changes over into the negative, hostile one. This too is as a rule a repetition of the past. His obedience to his father (if it is his father that is in question), his courting of his father’s favour, had its roots in an erotic wish directed towards him. Some time or other that demand will press its way forward in the transference as well and insist on being satisfied. In the analytic situation it can only meet with frustration. Real sexual relations between patients and analysts are out of the question, and even the subtler methods of satisfaction, such as the giving of preference, intimacy and so on, are only sparingly granted by the analyst. A rejection of this kind is taken as the occasion for the change-over; probably things happened in the same way in the patient’s childhood.

The therapeutic successes that occurred under the sway of the positive transference are open to the suspicion of being of a suggestive nature. If the negative transference gains the upper hand, they are blown away like chaff before the wind. We observe with horror that all our trouble and labour hitherto have been in vain. Indeed, what we might have regarded as a permanent intellectual gain by the patient, his understanding of psycho-analysis and his reliance on its efficacy, suddenly vanish. He behaves like a child who has no power of judgement of his own but blindly believes anyone whom he loves and no one who is a stranger to him. The danger of these states of transference evidently lies in the patient’s misunderstanding their nature and taking them for fresh real experiences instead of reflections of the past. If he (or she) becomes aware of the strong erotic desire that lies concealed behind the positive transference, he believes that he has fallen passionately in love; if the transference changes over, then he feels insulted and neglected, he hates the analyst as his enemy and is ready to abandon the analysis. In both these extreme cases he has forgotten the pact that he made at the beginning of the treatment and has become useless for continuing the common work. It is the analyst’s task constantly to tear the patient out of his menacing illusion and to show him again and again that what he takes to be new real life is a reflection of the past. And lest he should fall into a state in which he is inaccessible to all evidence, the analyst takes care that neither the love nor the hostility reach an extreme height. This is effected by preparing him in good time for these possibilities and by not overlooking the first signs of them. Careful handling of the transference on these lines is as a rule richly rewarded. If we succeed, as we usually can, in enlightening the patient on the true nature of the phenomena of transference, we shall have struck a powerful weapon out of the hand of his resistance and shall have converted dangers into gains. For a patient never forgets again what he has experienced in the form of transference; it carries a greater force of conviction than anything he can acquire in other ways.

We think it most undesirable if the patient acts outside the transference instead of remembering. The ideal conduct for our purposes would be that he should behave as normally as possible outside the treatment and express his abnormal reactions only in the transference.

The method by which we strengthen the weakened ego has as a starting-point an extending of its self-knowledge. That is not, of course, the whole story but it is a first step. The loss of such knowledge signifies for the ego a surrender of power and influence; it is the first tangible sign that it is being hemmed in and hampered by the demands of the id and the super-ego. Accordingly, the first part of the help we have to offer is intellectual work on our side and encouragement to the patient to collaborate in it. This first kind of activity, as we know, is intended to pave the way to another, more difficult, task. We shall not lose sight of the dynamic element in this task, even during its preliminary stage. We gather the material for our work from a variety of sources - from what is conveyed to us by the information given us by the patient and by his free associations, from what he shows us in his transferences, from what we arrive at by interpreting his dreams and from what he betrays by his slips or parapraxes. All this material helps us to make constructions about what happened to him and has been forgotten as well as about what is happening in him now without his understanding it. But in all this we never fail to make a strict distinction between our knowledge and his knowledge. We avoid telling him at once things that we have often discovered at an early stage, and we avoid telling him the whole of what we think we have discovered. We reflect carefully over when we shall impart the knowledge of one of our constructions to him and we wait for what seems to us the suitable moment - which it is not always easy to decide. As a rule we put off telling him of a construction or explanation till he himself has so nearly arrived at it that only a single step remains to be taken, though that step is in fact the decisive synthesis. If we proceeded in another way and overwhelmed him with our interpretations before he was prepared for them, our information would either produce no effect or it would provoke a violent outbreak of resistance which would make the progress of our work more difficult or might even threaten to stop it altogether. But if we have prepared everything properly, it often happens that the patient will at once confirm our construction and himself recollect the internal or external event which he had forgotten. The more exactly the construction coincides with the details of what has been forgotten the easier will it be for him to assent. On that particular matter our knowledge will then have become his knowledge as well.

With the mention of resistance we have reached the second and more important part of our task. We have already learnt that the ego protects itself against the invasion of undesired elements from the unconscious and repressed id by means of anticathexes, which must remain intact if it is to function normally. The more hard-pressed the ego feels, the more convulsively it clings (as though in a fright) to these anticathexes, in order to protect what remains of itself from further irruptions. But this defensive purpose does not by any means accord with the aims of our treatment. What we desire, on the contrary, is that the ego, emboldened by the certainty of our help, shall dare to take the offensive in order to reconquer what has been lost. And it is here that we become aware of the strength of these anticathexes in the form of resistances to our work. The ego draws back in alarm from such undertakings, which seem dangerous and threaten unpleasure; it must be constantly encouraged and soothed if it is not to fail us. This resistance, which persists throughout the whole treatment and is renewed at every fresh piece of work, is known, not quite correctly, as the resistance due to repression. We shall find that it is not the only one that faces us. It is interesting to notice that in this situation the party-divisions are to some extent reversed: for the ego struggles against our instigation, while the unconscious, which is ordinarily our opponent, comes to our help, since it has a natural ‘upward drive’ and desires nothing better than to press forward across its settled frontiers into the ego and so to consciousness. The struggle which develops, if we gain our end and can induce the ego to overcome its resistances, is carried through under our direction and with our assistance. Its outcome is a matter of indifference: whether it results in the ego accepting, after a fresh examination, an instinctual demand which it has hitherto rejected, or whether it dismisses it once more, this time for good and all. In either case a permanent danger has been disposed of, the compass of the ego has been extended and a wasteful expenditure of energy has been made unnecessary.

The overcoming of resistances is the part of our work that requires the most time and the greatest trouble. It is worth while, however, for it brings about an advantageous alteration of the ego which will be maintained independently of the outcome of the transference and will hold good in life. We have also worked simultaneously at getting rid of the alteration of the ego which had been brought about under the influence of the unconscious; for whenever we have been able to detect any of its derivatives in the ego we have pointed out their illegitimate origin and have instigated the ego to reject them. It will be remembered that it was one of the necessary preconditions of our pact of assistance that any such alteration of the ego due to the intrusion of unconscious elements should not have gone beyond a certain amount.

The further our work proceeds and the more deeply our insight penetrates into the mental life of neurotics, the more clearly two new factors force themselves on our notice, which demand the closest attention as sources of resistance. Both of them are completely unknown to the patient, neither of them could be taken into account when our pact was made; nor do they arise from the patient’s ego. They may both be embraced under the single name of ‘need to he ill or to suffer’, but they have different origins though in other respects they are of a kindred nature. The first of these two factors is the sense of guilt or consciousness of guilt, as it is called, though the patient does not feel it and is not aware of it. It is evidently the portion of the resistance contributed by a super-ego that has become particularly severe and cruel. The patient must not become well but must remain ill, for he deserves no better. This resistance does not actually interfere with our intellectual work, but it makes it inoperative; indeed, it often allows us to remove one form of neurotic suffering, but is ready at once to replace it by another, or perhaps by some somatic illness. The sense of guilt also explains the cure or improvement of severe neuroses which we occasionally observe after real misfortunes: all that matters is that the patient should be miserable - in what way is of no consequence. The uncomplaining resignation with which such people often put up with their hard fate is most remarkable, but also revealing. In warding off this resistance we are obliged to restrict ourselves to making it conscious and attempting to bring about the slow demolition of the hostile super-ego.

It is less easy to demonstrate the existence of another resistance, our means of combating which are specially inadequate. There are some neurotics in whom, to judge by all their reactions, the instinct of self-preservation has actually been reversed. They seem to aim at nothing other than self-injury and self-destruction. It is possible too that the people who in fact do in the end commit suicide belong to this group. It is to be assumed that in such people far-reaching defusions of instinct have taken place, as a result of which there has been a liberation of excessive quantities of the destructive instinct directed inwards. Patients of this kind are not able to tolerate recovery through our treatment and fight against it with all their strength. But we must confess that this is a case which we have not yet succeeded in completely explaining.

Let us once more glance over the situation which we have reached in our attempt at bringing help to the patient’s neurotic ego. That ego is no longer able to fulfil the task set it by the external world (including human society). Not all of its experiences are at its disposal, a large proportion of its store of memories have escaped it. Its activity is inhibited by strict prohibitions from the super-ego, its energy is consumed in vain attempts at fending off the demands of the id. Beyond this, as a result of continuous irruptions by the id, its organization is impaired, it is no longer capable of any proper synthesis, it is torn by mutually opposed urges, by unsettled conflicts and by unsolved doubts. To start with, we get the patient’s thus weakened ego to take part in the purely intellectual work of interpretation, which aims at provisionally filling the gaps in his mental assets, and to transfer to us the authority of his super-ego; we encourage it to take up the struggle over each individual demand made by the id and to conquer the resistances which arise in connection with it. At the same time we restore order in the ego by detecting the material and urges which have forced their way in from the unconscious, and expose them to criticism by tracing them back to their origin. We serve the patient in various functions, as an authority and a substitute for his parents, as a teacher and educator; and we have done the best for him if, as analysts, we raise the mental processes in his ego to a normal level, transform what has become unconscious and repressed into preconscious material and thus return it once more to the possession of his ego. On the patient’s side a few rational factors work in our favour, such as the need for recovery which has its motive in his sufferings, and the intellectual interest that we may awaken in him in the theories and revelations of psycho-analysis; but of far greater force is the positive transference with which he meets us. Fighting against us, on the other hand, are the negative transference, the ego’s resistance due to repression (that is, its unpleasure at having to lay itself open to the hard work imposed on it), the sense of guilt arising from its relation to the super-ego and the need to be ill due to deep-going changes in the economics of his instincts. The share taken by the last two factors decides whether the case is to be regarded as slight or severe. Apart from these, a few other factors may be discerned as having a favourable or unfavourable bearing. A certain psychical inertia, a sluggishness of the libido, which is unwilling to abandon its fixations cannot be welcome to us; the patient’s capacity for sublimating his instincts plays a large part and so does his capacity for rising above the crude life of the instincts; so, too, does the relative power of his intellectual functions.

We shall not be disappointed, but, on the contrary, we shall find it entirely intelligible, if we reach the conclusion that the final outcome of the struggle we have engaged in depends on quantitative relations - on the quota of energy we are able to mobilize in the patient to our advantage as compared with the sum of energy of the powers working against us. Here once again God is on the side of the big battalions. It is true that we do not always succeed in winning, but at least we can usually recognize why we have not won. Those who have been following our discussion only out of therapeutic interest will perhaps turn away in contempt after this admission. But here we are concerned with therapy only in so far as it works by psychological means; and for the time being we have no other. The future may teach us to exercise a direct influence, by means of particular chemical substances, on the amounts of energy and their distribution in the mental apparatus. It may be that there are other still undreamt-of possibilities of therapy. But for the moment we have nothing better at our disposal than the technique of psycho-analysis, and for that reason, in spite of its limitations, it should not be despised.

2 CHAPTER VII AN EXAMPLE OF PSYCHO-ANALYTIC WORK

We have arrived at a general acquaintance with the psychical apparatus, with the parts, organs and agencies of which it is composed, with the forces which operate in it and with the functions allotted to its parts. The neuroses and psychoses are the states in which disturbances in the functioning of the apparatus come to expression. We have chosen the neuroses as the subjects of our study because they alone seem accessible to the psychological methods of our intervention. While we are trying to influence them, we collect observations which give us a picture of their origin and of the manner in which they arise.

I will state in advance one of our chief findings before proceeding with my description. The neuroses (unlike infectious diseases, for instance) have no specific determinants. It would be idle to seek in them for pathogenic excitants. They shade off by easy transitions into what is described as the normal; and, on the other hand, there is scarcely any state recognized as normal in which indications of neurotic traits could not be pointed out. Neurotics have approximately the same innate dispositions as other people, they have the same experiences and they have the same tasks to perform. Why is it, then, that they live so much worse and with so much greater difficulty and, in the process, suffer more feelings of unpleasure, anxiety and pain?

We need not be at a loss to find an answer to this question. Quantitative disharmonies are what must be held responsible for the inadequacy and sufferings of neurotics. The determining cause of all the forms taken by human mental life, is, indeed, to be sought in the reciprocal action between innate dispositions and accidental experiences. Now a particular instinct may be too strong or too weak innately, or a particular capacity may be stunted or insufficiently developed in life. On the other hand, external impressions and experiences may make demands of differing strength on different people; and what one person’s constitution can deal with may prove an unmanageable task for another’s. These quantitative differences will determine the variety of the results.

We shall very soon feel, however, that this explanation is unsatisfactory: it is too general, it explains too much. The aetiology put forward applies to every case of mental suffering, misery and disablement, but not every such state can be termed neurotic. The neuroses have specific characteristics, they are miseries of a particular kind. So we must after all expect to find particular causes for them. Or we may adopt the supposition that, among the tasks with which mental life has to deal, there are a few on which it can especially easily come to grief; so that the peculiarity of the phenomena of neurosis, which are often so very remarkable, would follow from this without our needing to withdraw our earlier assertions. If it remains true that the neuroses do not differ in any essential respect from the normal, their study promises to yield us valuable contributions to our knowledge of the normal. It may be that we shall thus discover the ‘weak points’ in a normal organization.

The supposition we have just made finds confirmation. Analytic experiences teach us that there is in fact one instinctual demand attempts to deal with which most easily fail or succeed imperfectly and that there is one period of life which comes in question exclusively or predominantly in connection with the generation of a neurosis. These two factors - the nature of the instinct and the period of life concerned - call for separate consideration, although they are closely enough connected.

We can speak with a fair degree of certainty about the part played by the period of life. It seems that neuroses are acquired only in early childhood (up to the age of six), even though their symptoms may not make their appearance till much later. The childhood neurosis may become manifest for a short time or may even be overlooked. In every case the later neurotic illness links up with the prelude in childhood. It is possible that what are known as traumatic neuroses (due to excessive fright or severe somatic shocks, such as railway collisions, burial under falls of earth, and so on) are an exception to this: their relations to determinants in childhood have hitherto eluded investigation. There is no difficulty in accounting for this aetiological preference for the first period of childhood. The neuroses are, as we know, disorders of the ego; and it is not to be wondered at if the ego, so long as it is feeble, immature and incapable of resistance, fails to deal with tasks which it could cope with later on with the utmost ease. In these circumstances instinctual demands from within, no less than excitations from the external world, operate as ‘traumas’, particularly if they are met half way by certain innate dispositions. The helpless ego fends them off by means of attempts at flight (repression), which later turn out to be inefficient and which involve permanent restrictions on further development. The damage inflicted on the ego by its first experiences gives us the appearance of being disproportionately great; but we have only to take as an analogy the differences in the results produced by the prick of a needle into a mass of cells in the act of cell-division (as in Roux’s experiments) and into the fully grown animal which eventually develops out of them. No human individual is spared such traumatic experiences; none escapes the repressions to which they give rise. These questionable reactions on the part of the ego may perhaps be indispensable for the attainment of another aim which is set for the same period of life: in the space of a few years the little primitive creature must turn into a civilized human being; he must pass through an immensely long stretch of human cultural development in an almost uncannily abbreviated form. This is made possible by hereditary disposition; but it can almost never be achieved without the additional help of upbringing, of parental influence, which, as a precursor of the super-ego, restricts the ego’s activity by prohibitions and punishments, and encourages or compels the setting-up of repressions. We must therefore not forget to include the influence of civilization among the determinants of neurosis. It is easy, as we can see, for a barbarian to be healthy; for a civilized man the task is hard. The desire for a powerful, uninhibited ego may seem to us intelligible; but, as we are taught by the times we live in, it is in the profoundest sense hostile to civilization. And since the demands of civilization are represented by family upbringing, we must bear in mind the part played by this biological characteristic of the human species - the prolonged period of its childhood dependence - in the aetiology of the neuroses.

As regards the other point - the specific instinctual factor - we come upon an interesting discrepancy between theory and experience. Theoretically there is no objection to supposing that any sort of instinctual demand might occasion the same repressions and their consequences; but our observation shows us invariably, so far as we can judge, that the excitations that play this pathogenic part arise from the component instincts of sexual life. The symptoms of neuroses are, it might be said, without exception either a substitutive satisfaction of some sexual urge or measures to prevent such a satisfaction; and as a rule they are compromises between the two, of the kind that come about in accordance with the laws operating between contraries in the unconscious. The gap in our theory cannot at present be filled; our decision is made more difficult by the fact that most of the urges of sexual life are not of a purely erotic nature but have arisen from alloys of the erotic instinct with portions of the destructive instinct. But it cannot be doubted that the instincts which manifest themselves physiologically as sexuality play a prominent, unexpectedly large part in the causation of the neuroses - whether it is an exclusive one remains to be decided. It must also be borne in mind that in the course of cultural development no other function has been so energetically and extensively repudiated as precisely the sexual one. Theory must rest satisfied with a few hints that betray a deeper connection: the fact that the first period of childhood, during which the ego begins to be differentiated from the id, is also the period of the early sexual efflorescence which is brought to an end by the period of latency; that it can hardly be a matter of chance that this momentous early period subsequently falls a victim to infantile amnesia; and lastly, that biological changes in sexual life (such as the function’s diphasic onset which we have already mentioned, the disappearance of the periodic character of sexual excitation and the transformation in the relation between female menstruation and male excitation) - that these innovations in sexuality must have been of high importance in the evolution of animals into man. It is left for the science of the future to bring these still isolated data together into a new understanding. It is not in psychology but in biology that there is a gap here. We shall not be wrong, perhaps, in saying that the weak point in the ego’s organization seems to lie in its attitude to the sexual function, as though the biological antithesis between self-preservation and the preservation of the species had found a psychological expression at that point.

Analytic experience has convinced us of the complete truth of the assertion so often to be heard that the child is psychologically father to the adult and that the events of his first years are of paramount importance for his whole later life. It will thus be of special interest to us if there is something that may be described as the central experience of this period of childhood. Our attention is first attracted by the effects of certain influences which do not apply to all children, though they are common enough - such as the sexual abuse of children by adults, their seduction by other children (brothers or sisters) slightly their seniors, and, what we should not expect, their being deeply stirred by seeing or hearing at first hand sexual behaviour between adults (their parents) mostly at a time at which one would not have thought they could either be interested in or understand any such impressions, or be capable of remembering them later. It is easy to confirm the extent to which such experiences arouse a child’s susceptibility and force his own sexual urges into certain channels from which they cannot afterwards depart. Since these impressions are subjected to repression either at once or as soon as they seek to return as memories, they constitute the determinant for the neurotic compulsion which will subsequently make it impossible for the ego to control the sexual function and will probably cause it to turn away from that function permanently. If this latter reaction occurs, the result will be a neurosis; if it is absent, a variety of perversions will develop, or the function, which is of immense importance not only for reproduction but also for the entire shaping of life, will become totally unmanageable.

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