Студопедия

КАТЕГОРИИ:


Архитектура-(3434)Астрономия-(809)Биология-(7483)Биотехнологии-(1457)Военное дело-(14632)Высокие технологии-(1363)География-(913)Геология-(1438)Государство-(451)Демография-(1065)Дом-(47672)Журналистика и СМИ-(912)Изобретательство-(14524)Иностранные языки-(4268)Информатика-(17799)Искусство-(1338)История-(13644)Компьютеры-(11121)Косметика-(55)Кулинария-(373)Культура-(8427)Лингвистика-(374)Литература-(1642)Маркетинг-(23702)Математика-(16968)Машиностроение-(1700)Медицина-(12668)Менеджмент-(24684)Механика-(15423)Науковедение-(506)Образование-(11852)Охрана труда-(3308)Педагогика-(5571)Полиграфия-(1312)Политика-(7869)Право-(5454)Приборостроение-(1369)Программирование-(2801)Производство-(97182)Промышленность-(8706)Психология-(18388)Религия-(3217)Связь-(10668)Сельское хозяйство-(299)Социология-(6455)Спорт-(42831)Строительство-(4793)Торговля-(5050)Транспорт-(2929)Туризм-(1568)Физика-(3942)Философия-(17015)Финансы-(26596)Химия-(22929)Экология-(12095)Экономика-(9961)Электроника-(8441)Электротехника-(4623)Энергетика-(12629)Юриспруденция-(1492)Ядерная техника-(1748)

Letter to Georg fuchs 16 страница




 

I now pass on to my second example, which raises the same problem. An unmarried woman, no longer young, had been cut off from life since puberty by an inability to walk, owing to severe pains in the legs. Her condition was obviously of a hysterical nature, and it had defied many kinds of treatment. An analysis lasting three-quarters of a year removed the trouble and restored to the patient, an excellent and worthy person, her right to a share in life. In the years following her recovery she was consistently unfortunate. There were disasters in her family, and financial losses, and, as she grew older, she saw every hope of happiness in love and marriage vanish. But the one-time invalid stood up to all this valiantly and was a support to her family in difficult times. I cannot remember whether it was twelve or fourteen years after the end of her analysis that, owing to profuse haemorrhages, she was obliged to undergo a gynaecological examination. A myoma was found, which made a complete hysterectomy advisable. From the time of this operation, the woman became ill once more. She fell in love with her surgeon, wallowed in masochistic phantasies about the fearful changes in her inside - phantasies with which she concealed her romance - and proved inaccessible to a further attempt at analysis. She remained abnormal to the end of her life. The successful analytic treatment took place so long ago that we cannot expect too much from it; it was in the earliest years of my work as an analyst. No doubt the patient’s second illness may have sprung from the same source as her first one which had been successfully overcome: it may have been a different manifestation of the same repressed impulses, which the analysis had only incompletely resolved. But I am inclined to think that, were it not for the new trauma, there would have been no fresh outbreak of neurosis.

 

These two examples, which have been purposely selected from a large number of similar ones, will suffice to start a discussion of the topics we are considering. The sceptical, the optimistic and the ambitious will take quite different views of them. The first will say that it is now proved that even a successful analytic treatment does not protect the patient, who at the time has been cured, from falling ill later on of another neurosis - for, indeed, of a neurosis derived from the same instinctual root - that is to say, from a recurrence of his old trouble. The others will consider that this is not proved. They will object that the two examples date from the early days of analysis, twenty and thirty years ago, respectively; and that since then we have acquired deeper insight and wider knowledge, and that our technique has changed in accordance with our new discoveries. To-day, they will say, we may demand and expect that an analytic cure shall prove permanent, or at least that if a patient falls ill again, his new illness shall not turn out to be a revival of his earlier instinctual disturbance, manifesting itself in new forms. Our experience, they will maintain, does not oblige us to restrict so materially the demands that can be made upon our therapeutic method.

 

My reason for choosing these two examples is, of course, precisely because they lie so far back in the past. It is obvious that the more recent the successful outcome of an analysis is, the less utilizable it is for our discussion, since we have no means of predicting what the later history of the recovery will be. The optimists’ expectations clearly presuppose a number of things which are not precisely self-evident. They assume, firstly, that there really is a possibility of disposing of an instinctual conflict (or, more correctly, a conflict between the ego and an instinct) definitively and for all time; secondly, that while we are treating someone for one instinctual conflict we can, as it were, inoculate him against the possibility of any other such conflicts; and thirdly, that we have the power, for purposes of prophylaxis, to stir up a pathogenic conflict of this sort which is not betraying itself at the time by any indications, and that it is wise to do so. I throw out these questions without proposing to answer them now. Perhaps it may not be possible at present to give any certain answer to them at all.

 

Some light may probably be thrown on them by theoretical considerations. But another point has already become clear: if we wish to fulfil the more exacting demands upon analytic therapy, our road will not lead us to, or by way of, a shortening of its duration.2 III

 

An analytic experience which now extends over several decades, and a change which has taken place in the nature and mode of my activity, encourage me to attempt to answer the questions before us. In earlier days I treated quite a large number of patients, who, as was natural, wanted to be dealt with as quickly as possible. Of late years I have been mainly engaged in training analyses; a relatively small number of severe cases of illness remained with me for continuous treatment, interrupted, however, by longer or shorter intervals. With them, the therapeutic aim was no longer the same. There was no question of shortening the treatment; the purpose was radically to exhaust the possibilities of illness in them and to bring about a deep-going alteration of their personality.

 

Of the three factors which we have recognized as being decisive for the success or otherwise of analytic treatment - the influence of traumas, the constitutional strength of the instincts and alterations of the ego - what concerns us here is only the second, the strength of the instincts. A moment’s reflection raises a doubt whether the restrictive use of the adjective ‘constitutional’ (or ‘congenital’) is essential. However true it may be that the constitutional factor is of decisive importance from the very beginning, it is nevertheless conceivable that a reinforcement of instinct coming later in life might produce the same effects. If so, we should have to modify our formula and say ‘the strength of the instincts at the time’ instead of ‘the constitutional strength of the instincts’. The first of our questions was: ‘Is it possible by means of analytic therapy to dispose of a conflict between an instinct and the ego, or of a pathogenic instinctual demand upon the ego, permanently and definitively?’ To avoid misunderstanding it is not unnecessary, perhaps, to explain more exactly what is meant by ‘permanently disposing of an instinctual demand’. Certainly not ‘causing the demand to disappear so that nothing more is ever heard from it again’. This is in general impossible, nor is it at all to be desired. No, we mean something else, something which may be roughly described as a ‘taming’ of the instinct. That is to say, the instinct is brought completely into the harmony of the ego, becomes accessible to all the influences of the other trends in the ego and no longer seeks to go its independent way to satisfaction. If we are asked by what methods and means this result is achieved, it is not easy to find an answer. We can only say: ‘So muss denn doch die Hexe dran!’ - the Witch Metapsychology. Without metapsychological speculation and theorizing - I had almost said ‘phantasying’ - we shall not get another step forward. Unfortunately, here as elsewhere, what our Witch reveals is neither very clear nor very detailed. We have only a single clue to start from - though it is a clue of the highest value - namely, the antithesis between the primary and the secondary processes; and to that antithesis I shall at this point turn.

 

If now we take up our first question once more, we find that our new line of approach inevitably leads us to a particular conclusion. The question was whether it is possible to dispose of an instinctual conflict permanently and definitively - i.e. to ‘tame’ an instinctual demand in that fashion. Formulated in these terms, the question makes no mention at all of the strength of the instinct; but it is precisely on this that the outcome depends. Let us start from the assumption that what analysis achieves for neurotics is nothing other than what normal people bring about for themselves without its help. Everyday experience, however, teaches us that in a normal person any solution of an instinctual conflict only holds good for a particular strength of instinct, or, more correctly, only for a particular relation between the strength of the instinct and the strength of the ego.¹ If the strength of the ego diminishes, whether through illness or exhaustion, or from some similar cause, all the instincts which have so far been successfully tamed may renew their demands and strive to obtain substitutive satisfactions in abnormal ways.² Irrefutable proof of this statement is supplied by our nightly dreams; they react to the sleeping attitude assumed by the ego with an awakening of instinctual demands.

 

¹ Or, to be perfectly accurate, where that relation falls within certain limits.

² Here we have a justification of the claim to aetiological importance of such non-specific factors as overwork, shock, etc. These factors have always been assured of general recognition, but have had to be pushed into the background precisely by psycho-analysis. It is impossible to define health except in metapsychological terms: i.e. by reference to the dynamic relations between the agencies of the mental apparatus which have been recognized - or (if that is preferred) inferred or conjectured - by us.

 

The material on the other side is equally unambiguous. Twice in the course of individual development certain instincts are considerably reinforced: at puberty, and, in women, at the menopause. We are not in the least surprised if a person who was not neurotic before becomes so at these times. When his instincts were not so strong, he succeeded in taming them; but when they are reinforced he can no longer do so. The repressions behave like dams against the pressure of water. The same effects which are produced by these two physiological reinforcements of instinct, may be brought about in an irregular fashion by accidental causes at any other period of life. Such reinforcements may be set up by fresh traumas, enforced frustrations, or the collateral influence of instincts upon one another. The result is always the same, and it underlines the irresistible power of the quantitative factor in the causation of illness.

 

I feel as though I ought to be ashamed of so much ponderous exposition, seeing that everything I have said has long been familiar and self-evident. It is a fact that we have always behaved as if we knew all this; but, for the most part, our theoretical concepts have neglected to attach the same importance to the economic line of approach as they have to the dynamic and topographical ones. My excuse is therefore that I am drawing attention to this neglect.

 

Before we decide on an answer to this question, however, we must consider an objection whose force lies in the fact that we are probably predisposed in its favour. Our arguments, it will be said, are all deduced from the processes which take place spontaneously between the ego and the instincts, and they presuppose that analytic therapy can accomplish nothing which does not, under favourable and normal conditions, occur of itself. But is this really so? Is it not precisely the claim of our theory that analysis produces a state which never does arise spontaneously in the ego and that this newly created state constitutes the essential difference between a person who has been analysed and a person who has not? Let us bear in mind what this claim is based on. All repressions take place in early childhood; they are primitive defensive measures taken by the immature, feeble ego. In later years no fresh repressions are carried out; but the old ones persist, and their services continue to be made use of by the ego for mastering the instincts. New conflicts are disposed of by what we call ‘after-repression’. We may apply to these infantile repressions our general statement that repressions depend absolutely and entirely on the relative strength of the forces involved and that they cannot hold out against an increase in the strength of the instincts. Analysis, however, enables the ego, which has attained greater maturity and strength, to undertake a revision of these old repressions; a few are demolished, while others are recognized but constructed afresh out of more solid material. These new dams are of quite a different degree of firmness from the earlier ones; we may be confident that they will not give way so easily before a rising flood of instinctual strength. Thus the real achievement of analytic therapy would be the subsequent correction of the original process of repression, a correction which puts an end to the dominance of the quantitative factor.

 

Thus far our theory, which we cannot give up except under irresistible compulsion. And what does our experience have to say to this? Perhaps our experience is not yet wide enough for us to come to a settled conclusion. It confirms our expectations often enough, but not always. One has an impression that one ought not to be surprised if it should turn out in the end that the difference between a person who has not been analysed and the behaviour of a person after he has been analysed is not so thorough-going as we aim at making it and as we expect and maintain it to be. If this is so, it would mean that analysis sometimes

succeeds in eliminating the influence of an increase in instinct, but not invariably, or that the effect of analysis is limited to increasing the power of resistance of the inhibitions, so that they are equal to much greater demands than before the analysis or if no analysis had taken place. I really cannot commit myself to a decision on this point, nor do I know whether a decision is possible at the present time.

 

There is, however, another angle from which we can approach this problem of the variability in the effect of analysis. We know that the first step towards attaining intellectual mastery of our environment is to discover generalizations, rules and laws which bring order into chaos. In doing this we simplify the world of phenomena; but we cannot avoid falsifying it, especially if we are dealing with processes of development and change. What we are concerned with is discerning a qualitative alteration, and as a rule in doing so we neglect, at any rate to begin with, a quantitative factor. In the real world, transitions and intermediate stages are far more common than sharply differentiated opposite states. In studying developments and changes we direct our attention solely to the outcome; we readily overlook the fact that such processes are usually more or less incomplete - that is to say, that they are in fact only partial alterations. A shrewd satirist of old Austria, Johann Nestroy, once said: ‘Every step forward is only half as big as it looks at first.’ It is tempting to attribute a quite general validity to this malicious dictum. There are nearly always residual phenomena, a partial hanging-back. When an open-handed Maecenas surprises us by some isolated trait of miserliness, or when a person who is consistently over-kind suddenly indulges in a hostile action, such ‘residual phenomena’ are invaluable for genetic research. They show us that these praiseworthy and precious qualities are based on compensation and overcompensation which, as was to have been expected, have not been absolutely and fully successful. Our first account of the development of the libido was that an original oral phase gave way to a sadistic-anal phase and that this was in turn succeeded by a phallic-genital one. Later research has not contradicted this view, but it has corrected it by adding that these replacements do not take place all of a sudden but gradually, so that portions of the earlier organization always persist alongside of the more recent one, and even in normal development the transformation is never complete and residues of earlier libidinal fixations may still be retained in the final configuration. The same thing is to be seen in quite other fields. Of all the erroneous and superstitious beliefs of mankind that have supposedly been surmounted there is not one whose residues do not live on among us to-day in the lower strata of civilized peoples or even in the highest strata of cultural society. What has once come to life clings tenaciously to its existence. One feels inclined to doubt sometimes whether the dragons of primaeval days are really extinct.

 

Applying these remarks to our present problem, I think that the answer to the question of how to explain the variable results of our analytic therapy might well be that we, too, in endeavouring to replace repressions that are insecure by reliable ego-syntonic controls, do not always achieve our aim to its full extent - that is, do not achieve it thoroughly enough. The transformation is achieved, but often only partially: portions of the old mechanisms remain untouched by the work of analysis. It is difficult to prove that this is really so; for we have no other way of judging what happens but by the outcome which we are trying to explain. Nevertheless, the impressions one receives during the work of analysis do not contradict this assumption; indeed, they seem rather to confirm it. But we must not take the clarity of our own insight as a measure of the conviction which we produce in the patient. His conviction may lack ‘depth’, as one might say; it is always a question of the quantitative factor, which is so easily overlooked. If this is the correct answer to our question, we may say that analysis, in claiming to cure neuroses by ensuring control over instinct, is always right in theory but not always right in practice. And this is because it does not always succeed in ensuring to a sufficient degree the foundations on which a control of instinct is based. The cause of such a partial failure is easily discovered. In the past, the quantitative factor of instinctual strength opposed the ego’s defensive efforts; for that reason we called in the work of analysis to help; and now that same factor sets a limit to the efficacy of this new effort. If the strength of the instinct is excessive, the mature ego, supported by analysis, fails in its task, just as the helpless ego failed formerly. Its control over instinct is improved, but it remains imperfect because the transformation in the defensive mechanism is only incomplete. There is nothing surprising in this, since the power of the instruments with which analysis operates is not unlimited but restricted, and the final upshot always depends on the relative strength of the psychical agencies which are struggling with one another.

 

No doubt it is desirable to shorten the duration of analytic treatment, but we can only achieve our therapeutic purpose by increasing the power of analysis to come to the assistance of the ego. Hypnotic influence seemed to be an excellent instrument for our purposes; but the reasons for our having to abandon it are well known. No substitute for hypnosis has yet been found. From this point of view we can understand how such a master of analysis as Ferenczi came to devote the last years of his life to therapeutic experiments, which, unhappily, proved to be vain.

7IV

 

The two further questions - whether, while we are treating one instinctual conflict, we can protect a patient from future conflicts, and whether it is feasible and expedient, for prophylactic purposes, to stir up a conflict which is not at the time manifest - must be treated together; for obviously the first task can only be carried out in so far as the second one is - that is, in so far as a possible future conflict is turned into an actual present one upon which influence is then brought to bear. This new way of stating the problem is at bottom only an extension of the earlier one. Whereas in the first instance we were considering how to guard against a return of the same conflict, we are now considering how to guard against its possible replacement by another conflict. This sounds a very ambitious proposal, but all we are trying to do is to make clear what limits are set to the efficacy of analytic therapy.

 

However much our therapeutic ambition may be tempted to undertake such tasks, experience flatly rejects the notion. If an instinctual conflict is not a currently active one, is not manifesting itself, we cannot influence it even by analysis. The warning that we should let sleeping dogs lie, which we have so often heard in connection with our efforts to explore the psychical underworld, is peculiarly inapposite when applied to the conditions of mental life. For if the instincts are causing disturbances, it is a proof that the dogs are not sleeping; and if they seem really to be sleeping, it is not in our power to awaken them. This last statement, however, does not seem to be quite accurate and calls for a more detailed discussion. Let us consider what means we have at our disposal for turning an instinctual conflict which is at the moment latent into one which is currently active. Obviously there are only two things that we can do. We can bring about situations in which the conflict does become currently active, or we can content ourselves with discussing it in the analysis and pointing out the possibility of its arising. The first of these two alternatives can be carried out in two ways: in reality, or in the transference - in either case by exposing the patient to a certain amount of real suffering through frustration and the damming up of libido. Now it is true that we already make use of a technique of this kind in our ordinary analytic procedure. What would otherwise be the meaning of the rule that analysis must be carried out ‘in a state of frustration’? But this is a technique which we use in treating a conflict which is already currently active. We seek to bring this conflict to a head, to develop it to its highest pitch, in order to increase the instinctual force available for its solution. Analytic experience has taught us that the better is always the enemy of the good and that in every phase of the patient’s recovery we have to fight against his inertia, which is ready to be content with an incomplete solution.

 

If, however, what we are aiming at is a prophylactic treatment of instinctual conflicts that are not currently active but merely potential, it will not be enough to regulate sufferings which are already present in the patient and which he cannot avoid. We should have to make up our minds to provoke fresh sufferings in him; and this we have hitherto quite rightly left to fate. We should receive admonitions from all sides against the presumption of vying with fate in subjecting poor human creatures to such cruel experiments. And what sort of experiments would they be? Could we, for purposes of prophylaxis, take the responsibility of destroying a satisfactory marriage, or causing a patient to give up a post upon which his livelihood depends? Fortunately, we never find ourselves in the position of having to consider whether such interventions in the patient’s real life are justified; we do not possess the plenary powers which they would necessitate, and the subject of our therapeutic experiment would certainly refuse to co-operate in it. In practice, then, such a procedure is virtually excluded; but there are, besides, theoretical objections to it. For the work of analysis proceeds best if the patient’s pathogenic experiences belong to the past, so that his ego can stand at a distance from them. In states of acute crisis analysis is to all intents and purposes unusable. The ego’s whole interest is taken up by the painful reality and it withholds itself from analysis, which is attempting to go below the surface and uncover the influences of the past. To create a fresh conflict would thus only be to make the work of analysis longer and more difficult.

 

It will be objected that these remarks are quite unnecessary. Nobody thinks of purposely conjuring up new situations of suffering in order to make it possible for a latent instinctual conflict to be treated. This would not be much to boast of as a prophylactic achievement. We know, for instance, that a patient who has recovered from scarlet fever is immune to a return of the same illness; yet it never occurs to a doctor to take a healthy person who may possibly fall ill of scarlet fever and infect him with scarlet fever in order to make him immune to it. The protective measure must not produce the same situation of danger as is produced by the illness itself, but only something very much slighter, as is the case with vaccination against small-pox and many other similar procedures. In analytic prophylaxis against instinctual conflicts, therefore, the only methods which come into consideration are the other two which we have mentioned: the artificial production of new conflicts in the transference (conflicts which, after all, lack the character of reality), and the arousing of such conflicts in the patient’s imagination by talking to him about them and making him familiar with their possibility.

 

I do not know whether we can assert that the first of these two milder procedures is altogether ruled out in analysis. No experiments have been particularly made in this direction. But difficulties at once suggest themselves, which do not throw a very promising light on such an undertaking. In the first place, the choice of such situations for the transference is very limited. The patients cannot themselves bring all their conflicts into the transference; nor is the analyst able to call out all their possible instinctual conflicts from the transference situation. He may make them jealous or cause them to experience disappointments in love; but no technical purpose is required to bring this about. Such things happen of themselves in any case in most analyses. In the second place, we must not overlook the fact that all measures of this sort would oblige the analyst to behave in an unfriendly way to the patient, and this would have a damaging effect upon the affectionate attitude - upon the positive transference - which is the strongest motive for the patient’s taking a share in the joint work of analysis. Thus we should on no account expect very much from this procedure.

 

This therefore leaves only the one method open to us - the one which was in all probability the only one originally contemplated. We tell the patient about the possibilities of other instinctual conflicts, and we arouse his expectation that such conflicts may occur in him. What we hope is that this information and this warning will have the effect of activating in him one of the conflicts we have indicated, in a modest degree and yet sufficiently for treatment. But this time experience speaks with no uncertain voice. The expected result does not come about. The patient hears our message, but there is no response. He may think to himself: ‘This is very interesting, but I feel no trace of it.’ We have increased his knowledge, but altered nothing else in him. The situation is much the same as when people read psycho-analytic writings. The reader is ‘stimulated’ only by those passages which he feels apply to himself - that is, which concern conflicts that are active in him at the time. Everything else leaves him cold. We can have analogous experiences, I think, when we give children sexual enlightenment. I am far from maintaining that this is a harmful or unnecessary thing to do, but it is clear that the prophylactic effect of this liberal measure has been greatly over-estimated. After such enlightenment, children know something they did not know before, but they make no use of the new knowledge that has been presented to them. We come to see that they are not even in so great a hurry to sacrifice for this new knowledge the sexual theories which might be described as a natural growth and which they have constructed in harmony with, and dependence on, their imperfect libidinal organization - theories about the part played by the stork, about the nature of sexual intercourse and about the way in which babies are made. For a long time after they have been given sexual enlightenment they behave like primitive races who have had Christianity thrust upon them and who continue to worship their old idols in secret.

0 V

 

We started from the question of how we can shorten the inconveniently long duration of analytic treatment, and, still with this question of time in mind, we went on to consider whether it is possible to achieve a permanent cure or even to prevent future illness by prophylactic treatment. In doing so, we found that the factors which were decisive for the success of our therapeutic efforts were the influence of traumatic aetiology, the relative strength of the instincts which have to be controlled, and something which we have called an alteration of the ego. Only the second of these factors has been discussed by us in any detail, and in connection with it we have had occasion to recognize the paramount importance of the quantitative factor and to stress the claim of the metapsychological line of approach to be taken into account in any attempt at explanation.

 

Concerning the third factor, the alteration of the ego, we have as yet said nothing. When we turn our attention to it, the first impression we receive is that there is much to ask and much to answer here, and that what we have to say about it will prove to be very inadequate. This first impression is confirmed when we go further into the problem. As is well known, the analytic situation consists in our allying ourselves with the ego of the person under treatment, in order to subdue portions of his id which are uncontrolled - that is to say to include them in the synthesis of his ego. The fact that a co-operation of this kind habitually fails in the case of psychotics affords us a first solid footing for our judgement. The ego, if we are to be able to make such a pact with it, must be a normal one. But a normal ego of this sort is, like normality in general, an ideal fiction. The abnormal ego, which is unserviceable for our purposes, is unfortunately no fiction. Every normal person, in fact, is only normal on the average. His ego approximates to that of the psychotic in some part or other and to a greater or lesser extent; and the degree of its remoteness from one end of the series and of its proximity to the other will furnish us with a provisional measure of what we have so indefinitely termed an ‘alteration of the ego’.




Поделиться с друзьями:


Дата добавления: 2014-12-23; Просмотров: 378; Нарушение авторских прав?; Мы поможем в написании вашей работы!


Нам важно ваше мнение! Был ли полезен опубликованный материал? Да | Нет



studopedia.su - Студопедия (2013 - 2024) год. Все материалы представленные на сайте исключительно с целью ознакомления читателями и не преследуют коммерческих целей или нарушение авторских прав! Последнее добавление




Генерация страницы за: 0.06 сек.