Autobiographical note 91 страница

7 (b) It seems to me that there is a widespread and erroneous impression among my colleagues that this technique of searching for the origins of an illness and removing its manifestations by that means is an easy one which can be practised off-hand, as it were. I conclude this from the fact that not one of all the people who have shown an interest in my therapy and passed definite judgements upon it has ever asked me how I actually go about it. There can be only one reason for this: that they think there is nothing to enquire about, that the thing is perfectly self-evident. Again, I am now and then astonished to hear that in this or that department of a hospital a young assistant has received an order from his chief to undertake a ‘psycho-analysis’ of a hysterical patient. I am sure he would not be allowed to examine an extirpated tumour unless he had convinced his chiefs that he was conversant with histological technique. Similarly, reports reach my ears that this or that colleague has arranged appointments with a patient in order to undertake a mental treatment of the case, though I am certain he knows nothing of the technique of any such therapy. His expectation must be therefore that the patient will make him a present of his secrets, or perhaps that he is looking for salvation in some sort of confession or confidence. I should not be surprised if a patient were injured rather than benefited by being treated in such a fashion. For it is not so easy to play upon the instrument of the mind. I am reminded on such occasions of the words of a world-famous neurotic - though it is true that he was never treated by a physician but existed only in a poet’s imagination - Hamlet, Prince of Denmark. The King has ordered two courtiers, Rosenkranz and Guildenstern, to follow him, to question him and drag the secret of his depression out of him. He wards them off. Then some recorders are brought on the stage and Hamlet, taking one of them, begs one of his tormentors to play upon it, telling him that it is as easy as lying. The courtier excuses himself, for he knows no touch of the instrument, and when he cannot be persuaded to try it, Hamlet finally breaks out with these words: ‘Why, look you now, how unworthy a thing you make of me! You would play upon me;... you would pluck out the heart of my mystery; you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice, in this little organ; yet you cannot make it speak. ‘Sblood, do you think I am easier to be played on than a pipe? Call me what instrument you will, though you can fret me, you cannot play upon me.’ (Act III, Scene 2.)

8 (c) From certain of my remarks you will have gathered that there are many characteristics in the analytic method which prevent it from being an ideal form of therapy. Tuto, cito, jucunde: investigation and probing do not indicate speedy results, and the resistance I have mentioned would prepare you to expect unpleasantness of various kinds. Psycho-analytic treatment certainly makes great demands upon the patient as well as upon the physician. From the patient it requires perfect sincerity - a sacrifice in itself; it absorbs time and is therefore also costly; for the physician it is no less time-absorbing, and the technique which he must study and practise is fairly laborious. I consider it quite justifiable to resort to more convenient methods of treatment as long as there is any prospect of achieving anything by their means. That, after all, is the only point at issue. If the more difficult and lengthy method accomplishes considerably more than the short and easy one, then, in spite of everything, the use of the former is justified. Only consider, Gentlemen, how much more inconvenient and costly is the Finsen therapy of lupus than the method of cauterizing and scraping previously employed; and yet the use of the former signifies a great advance, for it performs a radical cure. Although I do not wish to carry this comparison to extremes, the psycho-analytic method may claim a similar privilege. Actually, I have been able to elaborate and to test my therapeutic method only on severe, indeed on the severest cases; at first my material consisted entirely of patients who had tried everything else without success, and had spent long years in sanatoria. I have scarcely been able to bring together sufficient material to enable me to say how my method works with those slighter, episodic cases which we see recovering under all kinds of influences and even spontaneously. Psycho-analytic therapy was created through and for the treatment of patients permanently unfit for existence, and its triumph has been that it has made a satisfactorily large number of these permanently fit for existence. In the face of such an achievement all the effort expended seems trivial. We cannot conceal from ourselves what, as physicians, we are in the habit of denying to our patients, namely, that a severe neurosis is no less serious for the sufferer than any cachexia or any of the dreaded major diseases.

9 (d) The conditions under which this method is indicated, or contra-indicated, can scarcely be definitely laid down as yet, because of the many practical limitations to which my activities have been subjected. Nevertheless, I will attempt to discuss a few of them here:

(1) One should look beyond the patient’s illness and form an estimate of his whole personality; those patients who do not possess a reasonable degree of education and a fairly reliable character should be refused. It must not be forgotten that there are healthy people as well as unhealthy ones who are good for nothing in life, and that there is a temptation to ascribe to their illness everything that incapacitates them, if they show any sign of neurosis. In my opinion a neurosis is by no means a stamp of degeneracy, though it may often enough be found in one person along with the signs of degeneracy. Now analytic psychotherapy is not a process suited to the treatment of neuropathic degeneracy; on the contrary, degeneracy is a barrier to its effectiveness. Nor is the method applicable to people who are not driven to seek treatment by their own sufferings, but who submit to it only because they are forced to by the authority of relatives. The qualification which is the determining factor of fitness for psycho-analytic treatment - that is, whether the patient is educable - must be discussed further from another standpoint.

(2) To be quite safe, one should limit one’s choice of patients to those who possess a normal mental condition, since in the psycho-analytic method this is used as a foothold from which to obtain control of the morbid manifestations. Psychoses, states of confusion and deeply-rooted (I might say toxic) depression are therefore not suitable for psycho-analysis; at least not for the method as it has been practised up to the present. I do not regard it as by any means impossible that by suitable changes in the method we may succeed in overcoming this contraindication - and so be able to initiate a psychotherapy of the psychoses.

(3) The age of patients has this much importance in determining their fitness for psycho-analytic treatment, that, on the one hand, near or above the age of fifty the elasticity of the mental processes, on which the treatment depends, is as a rule lacking - old people are no longer educable - and, on the other hand, the mass of material to be dealt with would prolong the duration of the treatment indefinitely. In the other direction the age limit can be determined only individually; youthful persons under the age of adolescence are often exceedingly amenable to influence.

(4) Psycho-analysis should not be attempted when the speedy removal of dangerous symptoms is required, as, for example, in a case of hysterical anorexia.0 By this time you will have formed an impression that the field of analytic psychotherapy is a very narrow one, since you have in fact heard nothing from me except indications that point against it. There remain, however, cases and types of disease enough on which this therapy may be tested - as, for instance, all chronic forms of hysteria with residual manifestations, the broad field of obsessive conditions, aboulias, and the like.

It is gratifying that precisely the most valuable and most highly developed persons are best suited for this procedure; and one may also safely claim that in cases where analytic psychotherapy has been able to achieve but little, any other therapy would certainly not have been able to effect anything at all.

(e) You will no doubt wish to enquire about the possibility of doing harm by undertaking a psycho-analysis. In reply to this I may say that if you are willing to judge impartially, if you will consider this procedure in the same spirit of critical fairness that you show to our other therapeutic methods, you will have to agree with me that no injury to the patient is to be feared when the treatment is conducted with comprehension. Anyone who is accustomed, like the lay public, to blame the treatment for whatever happens during an illness will doubtless judge differently. It is not so very long since the same prejudice was directed against our hydropathic establishments. Many patients who were advised to go into an establishment of that kind hesitated because they had known someone who had entered the place as a nervous invalid and had become insane there. As you may guess, these were cases of early general paralysis that could still in their first stage be sent to a hydropathic establishment; once there, they had run their inevitable course until manifest mental disorder supervened: but the public blamed the water for this disastrous change. When it is a matter of new kinds of therapeutic treatment even physicians are not always free from such errors of judgement. I recall once making an attempt at psychotherapy with a woman who had passed the greater part of her life in a state alternating between mania and melancholia. I took on the case at the close of a period of melancholia and for two weeks things seemed to go smoothly; in the third week we were already at the beginning of the next attack of mania. This was undoubtedly a spontaneous transformation of the clinical picture, since in two weeks analytic psychotherapy cannot accomplish anything. And yet the eminent physician (now deceased) who saw the case with me could not refrain from the remark that psychotherapy was probably to blame for this ‘relapse’. I am quite convinced that in other circumstances he would have shown a more critical judgement.

1 (f) Finally, Gentlemen, I must confess that it is hardly fair to take up your attention for so long on the subject of psycho-analytic therapy without telling you in what this treatment consists and on what it is based. Still, as I am forced to be brief, I can only hint at this: This therapy, then, is based on the recognition that unconscious ideas - or better, the unconsciousness of certain mental processes - are the direct cause of the morbid symptoms. We share this opinion with the French school (Janet) who, by the way, owing to excessive schematization, refer the cause of hysterical symptoms to an unconscious idée fixe. Now please do not be afraid that this is going to land us in the depths of philosophical obscurities. Our unconscious is not quite the same thing as that of philosophers and, moreover, the majority of philosophers will hear nothing of ‘unconscious mental processes’. If, however, you will look at the matter from our point of view, you will understand that the transformation of this unconscious material in the mind of the patient into conscious material must have the result of correcting his deviation from normality and of lifting the compulsion to which his mind has been subjected. For conscious will-power governs only conscious mental processes, and every mental compulsion is rooted in the unconscious. Nor need you ever fear that the patient will be harmed by the shock accompanying the introduction of the unconscious into consciousness, for you can convince yourselves theoretically that the somatic and emotional effect of an impulse that has become conscious can never be so powerful as that of an unconscious one. It is only by the application of our highest mental functions, which are bound up with consciousness, that we can control all our impulses.

There is, however, another angle from which you may seek to understand the psycho-analytic method. The uncovering and translating of the unconscious occurs in the face of a continuous resistance on the part of the patient. The process of bringing this unconscious material to light is associated with unpleasure, and because of this the patient rejects it again and again. It is for you then to interpose in this conflict in the patient’s mental life. If you succeed in persuading him to accept, by virtue of a better understanding, something that up to now, in consequence of this automatic regulation by unpleasure, he has rejected (repressed), you will have accomplished something towards his education. For it is education even to induce someone who dislikes getting up early to do so all the same. Psycho-analytic treatment may in general be conceived of as such a re-education in overcoming internal resistances. Re-education of this kind is, however, in no respect more necessary to nervous patients than in regard to the mental element in their sexual life. For nowhere else have civilization and education done so much harm as in this field, and this is the point, as experience will show you, at which to look for those aetiologies of the neuroses that are amenable to influence; for the other aetiological factor, the constitutional component, consists of something fixed and unalterable. And from this it follows that one important qualification is required of the physician in this work: not only must his own character be irreproachable - ‘As to morals, that goes without saying’, as the hero of Vischer’s novel Auch Einer was in the habit of declaring - but he must also have overcome in his own mind that mixture of prurience and prudery with which, unfortunately, so many people habitually consider sexual problems.

At this juncture another remark is perhaps not out of place. I know that the emphasis which I lay upon the part played by sexuality in creating the psychoneuroses has become generally known. But I know, too, that qualifications and exact particularization are of little use with the general public; there is very little room in the memory of the multitude; it only retains the bare gist of any thesis and fabricates an extreme version which is easy to remember. It may be, too, that some physicians vaguely apprehend the content of my doctrine to be that I regard sexual privation as the ultimate cause of the neuroses. In the conditions of life in modern society there is certainly no lack of sexual privation. On this basis, would it not be simpler to aim directly at recovery by recommending sexual activity as a therapeutic measure, instead of pursuing the circuitous and laborious path of mental treatment?(I know of nothing which could impel me to suppress such an inference if it were justified. The real state of things, however, is otherwise. Sexual need and privation are merely one factor at work in the mechanism of neurosis; if there were no others the result would be dissipation, not disease. The other, no less essential, factor, which is all too readily forgotten, is the neurotic’s aversion from sexuality, his incapacity for loving, that feature of the mind which I have called ‘repression’. Not until there is a conflict between the two tendencies does nervous illness break out, and therefore to advise sexual activity in the psychoneuroses can only very rarely be described as good advice.

Let me end upon this defensive note. And let us hope that your interest in psychotherapy, when freed from every hostile prejudice, may lend us support in our endeavour to achieve success in treating even severe cases of psychoneurosis.3

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