Recommendations to physicians practising psycho-analysis 2 страница

No one who is familiar with the nature of neurosis will be astonished to hear that even a man who is very well able to carry out an analysis on other people can behave like any other mortal and be capable of producing the most intense resistances as soon as he himself becomes the object of analytic investigation. When this happens we are once again reminded of the dimension of depth in the mind, and it does not surprise us to find that the neurosis has its roots in psychical strata to which an intellectual knowledge of analysis has not penetrated.

0 Points of importance at the beginning of the analysis are arrangements about time and money.

In regard to time, I adhere strictly to the principle of leasing a definite hour. Each patient is allotted a particular hour of my available working day; it belongs to him and he is liable for it, even if he does not make use of it. This arrangement, which is taken as a matter of course for teachers of music or languages in good society, may perhaps seem too rigorous in a doctor, or even unworthy of his profession. There will be an inclination to point to the many accidents which may prevent the patient from attending every day at the same hour and it will be expected that some allowance shall be made for the numerous intercurrent ailments which may occur in the course of a longish analytic treatment. But my answer is: no other way is practicable. Under a less stringent régime the ‘occasional’ non-attendances increase so greatly that the doctor finds his material existence threatened; whereas when the arrangement is adhered to, it turns out that accidental hindrances do not occur at all and intercurrent illnesses only very seldom. The analyst is hardly ever put in the position of enjoying a leisure hour which he is paid for and would be ashamed of; and he can continue his work without interruptions, and is spared the distressing and bewildering experience of finding that a break for which he cannot blame himself is always bound to happen just when the work promises to be especially important and rich in content. Nothing brings home to one so strongly the significance of the psychogenic factor in the daily life of men, the frequency of malingering and the non-existent of chance, as a few years’ practice of psycho-analysis on the strict principle of leasing by the hour. In cases of undoubted organic illnesses, which, after all, cannot be excluded by the patient’s having a psychical interest in attending, I break off the treatment, consider myself entitled to dispose elsewhere of the hour which becomes free, and take the patient back again as soon as he has recovered and I have another hour vacant.

I work with my patients every day except on Sundays and public holidays - that is, as a rule, six days a week. For slight cases or the continuation of a treatment which is already well advanced, three days a week will be enough. Any restrictions of time beyond this bring no advantage either to the doctor or the patient; and at the beginning of an analysis they are quite out of the question. Even short interruptions have a slightly, obscuring effect on the work. We used to speak jokingly of the ‘Monday crust’ when we began work again after the rest on Sunday. When the hours of work are less frequent, there is a risk of not being able to keep pace with the patient’s real life and of the treatment losing contact with the present and being forced into by-paths. Occasionally, too, one comes across patients to whom one must give more than the average time of one hour a day, because the best part of an hour is gone before they begin to open up and to become communicative at all.

An unwelcome question which the patient asks the doctor at the outset is: ‘How long will the treatment take? How much time will you need to relieve me of my trouble?’ If one has proposed a trial treatment of a few weeks one can avoid giving a direct answer to this question by promising to make a more reliable pronouncement at the end of the trial period. Our answer is like the answer given by the Philosopher to the Wayfarer in Aesop’s fable. When the Wayfarer asked how long a journey lay ahead, the Philosopher merely answered ‘Walk!’ and afterwards explained his apparently unhelpful reply on the ground that he must know the length of the Wayfarer’s stride before he could tell how long his journey would take. This expedient helps one over the first difficulties; but the comparison is not a good one, for the neurotic can easily alter his pace and may at times make only very slow progress. In point of fact, the question as to the probable duration of a treatment is almost unanswerable.

As the combined result of lack of insight on the part of patients and disingenuousness on the part of doctors, analysis finds itself expected to fulfil the most boundless demands, and that in the shortest time. Let me, as an example, give some details from a letter which I received a few days ago from a lady in Russia. She is 53 years old, her illness began twenty-three years ago and for the last ten years she has no longer been able to do any continuous work. ‘Treatment in a number of institutions for nervous cases’ have not succeeded in making an ‘active life’ possible for her. She hopes to be completely cured by psycho-analysis, which she has read about, but her illness has already cost her family so much money that she cannot manage to come to Vienna for longer than six weeks or two months. Another added difficulty is that she wishes from the very start to ‘explain’ herself in writing only, since any discussion of her complexes would cause an explosion of feeling in her or ‘render her temporarily unable to speak’. - No one would expect a man to lift a heavy table with two fingers as if it were a light stool, or to build a large house in the time it would take to put up a wooden hut; but as soon as it becomes a question of the neuroses - which do not seem so far to have found a proper place in human thought - even intelligent people forget that a necessary proportion must be observed between time, work and success. This, incidentally, is an understandable result of the deep ignorance which prevails about the aetiology of the neuroses. Thanks to this ignorance, neurosis is looked or as a kind of ‘maiden from afar’. ‘None knew whence she came’; so they expected that one day she would vanish.

Doctors lend support to these fond hopes. Even the informed among them often fail to estimate properly the severity of nervous disorders. A friend and colleague of mine, to whose great credit I account it that after several decades of scientific work on other principles he became converted to the merits of psycho-analysis, once wrote to me: ‘What we need is a short, convenient, out-patient treatment for obsessional neurosis.’ I could not supply him with it and felt ashamed; so I tried to excuse myself with the remark that specialists in internal diseases, too, would probably be very glad of a treatment for tuberculosis or carcinoma which combined these advantages.

To speak more plainly, psycho-analysis is always a matter of long periods of time, of half a year or whole years - of longer periods than the patient expects. It is therefore our duty to tell the patient this before he finally decides upon the treatment. I consider it altogether more honourable, and also more expedient, to draw his attention - without trying to frighten him off, but at the very beginning - to the difficulties and sacrifices which analytic treatment involves, and in this way to deprive him of any right to say later on that he has been inveigled into a treatment whose extent and implications he did not realize. A patient who lets himself be dissuaded by this information would in any case have shown himself unsuitable later on. It is a good thing to institute a selection of this kind before the beginning of the treatment. With the progress of understanding among patients the number of those who successfully meet this first test increases.

I do not bind patients to continue the treatment for a certain length of time; I allow each one to break off whenever he likes. But I do not hide it from him that if the treatment is stopped after only a small amount of work has been done it will not be successful and may easily, like an unfinished operation, leave him in an unsatisfactory state. In the early years of my psycho-analytic practice I used to have the greatest difficulty in prevailing on my patients to continue their analysis. This difficulty has long since been shifted, and I now have to take the greatest pains to induce them to give it up.

To shorten analytic treatment is a justifiable wish, and its fulfilment, as we shall learn, is being attempted along various lines. Unfortunately, it is opposed by a very important factor, namely, the slowness with which deep-going changes in the mind are accomplished - in the last resort, no doubt, the ‘timelessness’ of our unconscious processes. When patients are faced with the difficulty of the great expenditure of time required for analysis they not infrequently manage to propose a way out of it. They divide up their ailments and describe some as unbearable, and others as secondary, and then say: ‘If only you will relieve me from this one (for instance, a headache or a particular fear) I can deal with the other one on my own in my ordinary life.’ In doing this, however, they over-estimate the selective power of analysis. The analyst is certainly able to do a great deal, but he cannot determine beforehand exactly what results he will effect. He sets in motion a process, that of the resolving of existing repressions. He can supervise this process, further it, remove obstacles in its way, and he can undoubtedly vitiate much of it. But on the whole, once begun, it goes its own way and does not allow either the direction it takes or the order in which it picks up its points to be prescribed for it. The analyst’s power over the symptoms of the disease may thus be compared to male sexual potency. A man can, it is true, beget a whole child, but even the strongest man cannot create in the female organism a head alone or an arm or a leg; he cannot even prescribe the child’s sex. He, too, only sets in motion a highly complicated process, determined by events in the remote past, which ends with the severance of the child from its mother. A neurosis as well has the character of an organism. Its component manifestations are not independent of one another; they condition one another and give one another mutual support. A person suffers from one neurosis only, never from several which have accidentally met together in a single individual. The patient freed, according to his wish, from his one unendurable symptom might easily find that a symptom which had previously been negligible had now increased and grown unendurable. The analyst who wishes the treatment to owe its success as little as possible to its elements of suggestion (i.e. to the transference) will do well to refrain from making use of even the trace of selective influence upon the results of the therapy which may perhaps be open to him. The patients who are bound to be most welcome to him are those who ask him to give them complete health, in so far as that is attainable, and who place as much time at his disposal as is necessary for the process of recovery. Such favourable conditions as these are, of course, to be looked for in only a few cases.

4 The next point that must be decided at the beginning of the treatment is the one of money, of the doctor’s fee. An analyst does not dispute that money is to be regarded in the first instance as a medium for self-preservation and for obtaining power; but he maintains that, besides this, powerful sexual factors are involved in the value set upon it. He can point out the money matters are treated by civilized people in the same way as sexual matters - with the same inconsistency, prudishness and hypocrisy. The analyst is therefore determined from the first not to fall in with this attitude, but, in his dealings with his patients, to treat of money matters with the same matter-of-course frankness to which he wishes to educate them in things relating to sexual life. He shows them that he himself has cast off false shame on these topics, by voluntarily telling them the price at which he values his time. Ordinary good sense cautions him, furthermore, not to allow large sums of money to accumulate, but to ask for payment at fairly short regular intervals - monthly, perhaps. (It is a familiar fact that the value of the treatment is not enhanced in the patient’s eyes if a very low fee is asked.) This is, of course, not the usual practice of nerve specialists or other physicians in our European society. But the psycho-analyst may put himself in the position of a surgeon, who is frank and expensive because he has at his disposal methods of treatment which can be of use. It seems to me more respectable and ethically less objectionable to acknowledge one’s actual claims and needs rather than, as is still the practice among physicians, to act the part of the disinterested philanthropist - a position which one is not, in fact, able to fill, with the result that one is secretly aggrieved, or complains aloud, at the lack of consideration and the desire for exploitation evinced by one’s patients. In fixing his fee the analyst must also allow for the fact that, hard as he may work, he can never earn as much as other medical specialists.

For the same reason he should also refrain from giving treatment free, and make no exceptions to this in favour of his colleagues or their families. This last recommendation will seem to offend against professional amenities. It must be remembered, however, that a gratuitous treatment means much more to a psycho-analyst than to any other medical man; it means the sacrifice of a considerable portion - an eighth or a seventh part, perhaps - of the working time available to him for earning his living, over a period of many months. A second free treatment carried on at the same time would already deprive him of a quarter or a third of his earning capacity, and this would be comparable to the damage inflicted by a severe accident.

The question then arises whether the advantage gained by the patient would not to some extent counterbalance the sacrifice made by the physician. I may venture to form a judgement about this, since for ten years or so I set aside one hour a day, and sometimes two, for gratuitous treatments, because I wanted, in order to find my way about in the neuroses, to work in the face of as little resistance as possible. The advantages I sought by this means were not forthcoming. Free treatment enormously increases some of a neurotic’s resistances - in young women, for instance, the temptation which is inherent in their transference-relation, and in young men, their opposition to an obligation to feel grateful, an opposition which arises from their father-complex and which presents one of the most troublesome hindrances to the acceptance of medical help. The absence of the regulating effect offered by the payment of a fee to the doctor makes itself very painfully felt; the whole relationship is removed from the real world, and the patient is deprived of a strong motive for endeavouring to bring the treatment to an end.

One may be very far from the ascetic view of money as a curse and yet regret that analytic therapy is almost inaccessible to poor people, both for external and internal reasons. Little can be done to remedy this. Perhaps there is truth in the widespread belief that those who are forced by necessity to a life of hard toil are less easily overtaken by neurosis. But on the other hand experience shows without a doubt that when once a poor man has produced a neurosis it is only with difficulty that he lets it be taken from him. It renders him too good a service in the struggle for existence; the secondary gain from illness which it brings him is much too important. He now claims by right of his neurosis the pity which the world has refused to his material distress, and he can now absolve himself from the obligation of combating his poverty by working. Anyone therefore who tries to deal with the neurosis of a poor person by psychotherapy usually discovers that what is here required of him is a practical therapy of a very different kind - the kind which, according to our local tradition, used to be dispensed by the Emperor Joseph II. Naturally, one does occasionally come across deserving people who are helpless from no fault of their own, in whom unpaid treatment does not meet with any of the obstacles that I have mentioned and in whom it leads to excellent results.

As far as the middle classes are concerned, the expense involved in psycho-analysis is excessive only in appearance. Quite apart from the fact that no comparison is possible between restored health and efficiency on the one hand and a moderate financial outlay on the other, when we add up the unceasing costs of nursing-homes and medical treatment and contrast them with the increase of efficiency and earning capacity which results from a successfully completed analysis, we are entitled to say that the patients have made a good bargain. Nothing in life is so expensive as illness - and stupidity.

7 Before I wind up these remarks on beginning analytic treatment, I must say a word about a certain ceremonial which concerns the position in which the treatment is carried out. I hold to the plan of getting the patient to lie on a sofa while I sit behind him out of his sight. This arrangement has a historical basis; it is the remnant of the hypnotic method out of which psycho-analysis was evolved. But it deserves to be maintained for many reasons. The first is a personal motive, but one which others may share with me. I cannot put up with being stared at by other people for eight hours a day (or more). Since, while I am listening to the patient, I, too, give myself over to the current of my unconscious thoughts, I do not wish my expressions of face to give the patient material for interpretations or to influence him in what he tells me. The patient usually regards being made to adopt this position as a hardship and rebels against it, especially if the instinct for looking (scopophilia) plays an important part in his neurosis. I insist on this procedure, however, for its purpose and result are to prevent the transference from mingling with the patient’s associations imperceptibly, to isolate the transference and to allow it to come forward in due course sharply defined as a resistance. I know that many analysts work in a different way, but I do not know whether this deviation is due more to a craving for doing things differently or to some advantage which they find they gain by it.

The conditions of treatment having been regulated in this manner, the question arises at what point and with what material is the treatment to begin?

What the material is with which one starts the treatment is on the whole a matter of indifference - whether it is the patient’s life-history or the history of his illness or his recollections of childhood. But in any case the patient must be left to do the talking and must be free to choose at what point he shall begin. We therefore say to him: ‘Before I can say anything to you I must know a great deal about you; please tell me what you know about yourself.’

The only exception to this is in regard to the fundamental rule of psycho-analytic technique which the patient has to observe. This must be imparted to him at the very beginning: ‘One more thing before you start. What you tell me must differ in one respect from an ordinary conversation. Ordinarily you rightly try to keep a connecting thread running through your remarks and you exclude any intrusive ideas that may occur to you and any side-issues, so as not to wander too far from the point. But in this case you must proceed differently. You will notice that as you relate things various thoughts will occur to you which you would like to put aside on the ground of certain criticisms and objections. You will be tempted to say to yourself that this or that is irrelevant here, or is quite up important, or nonsensical, so that there is no need to say it. You must never give in to these criticisms, but must say it in spite of them - indeed, you must say it precisely because you feel an aversion to doing so. Later on you will find out and learn to understand the reason for this injunction, which is really the only one you have to follow. So say whatever goes through your mind. Act as though, for instance, you were a traveller sitting next to the window of a railway carriage and describing to someone inside the carriage the changing views which you see outside. Finally, never forget that you have promised to be absolutely honest, and never leave anything out because, for some reason or other, it is unpleasant to tell it.’¹

¹ Much might be said about our experiences with the fundamental rule of psycho-analysis. One occasionally comes across people who behave as if they had made this rule for themselves. Others offend against it from the very beginning. It is indispensable, and also advantageous, to lay down the rule in the first stages of the treatment. Later, under the dominance of the resistances, obedience to it weakens, and there comes a time in every analysis when the patient disregards it. We must remember from our own self-analysis how irresistible the temptation is to yield to these pretexts put forward by critical judgement for rejecting certain ideas. How small is the effect of such agreements as one makes with the patient in laying down the fundamental rule is regularly demonstrated when something intimate about a third person comes up in his mind for the first time. He knows that he is supposed to say everything, but he turns discretion about other people into a new obstacle! ‘Must I really say everything? I thought that only applied to things that concern myself.’ It is naturally impossible to carry out analysis if the patient’s relations with other people and his thoughts about them are excluded. Pour faire une omelette il faut casser des oeufs. An honourable man readily forgets such of the private affairs of strangers as do not seem to him important to know. Nor can an exception be made in the case of names. Otherwise the patient’s narratives became a little shadowy, like the scenes in Goethe’s play Die natürliche Tochter [The Natural Daughter], and do not lodge in the doctor’s memory. Moreover, the names that are withheld screen the approach to all sorts of important connections. But one may perhaps allow names to be left on one side until the patient has become more familiar with the doctor and the procedure of analysis. It is very remarkable how the whole task becomes impossible if a reservation is allowed at any single place. But we have only to reflect what would happen if the right of asylum existed at any one point in a town; how long would it be before all the riff-raff of the town had collected there? I once treated a high official who was bound by his oath of office not to communicate certain things because they were state secrets, and the analysis came to grief as a consequence of this restriction. Psycho-analytic treatment must have no regard for any consideration, because the neurosis and its resistances are themselves without any such regard.

Patients who date their illness from a particular moment usually concentrate upon its precipitating cause. Others, who themselves recognize the connection between their neurosis and their childhood, often begin with an account of their whole life-history. A systematic narrative should never be expected and nothing should be done to encourage it. Every detail of the story will have to be told afresh later on, and it is only with these repetitions that additional material will appear which will supply the important connections that are unknown to the patient.

There are patients who from the very first hours carefully prepare what they are going to communicate, ostensibly so as to be sure of making better use of the time devoted to the treatment. What is thus disguising itself as eagerness is resistance. Any preparation of this sort should be disrecommended, for it is only employed to guard against unwelcome thoughts cropping up.¹ However genuinely the patient may believe in his excellent intentions, the resistance will play its part in this deliberate method of preparation and will see to it that the most valuable material escapes communication. One will soon find that the patient devises yet other means by which what is required may be withheld from the treatment. He may talk over the treatment every day with some intimate friend, and bring into this discussion all the thoughts which should come forward in the presence of the doctor. The treatment thus has a leak which lets through precisely what is most valuable. When this happens, the patient must, without much delay, be advised to treat his analysis as a matter between himself and his doctor and to exclude everyone else from sharing in the knowledge of it, no matter how close to him they may be, or how inquisitive. In later stages of the treatment the patient is usually not subjected to temptations of this sort.

Certain patients want their treatment to be kept secret, often because they have kept their neurosis secret; and I put no obstacle in their way. That in consequence the world hears nothing of some of the most successful cures is, of course, a consideration that cannot be taken into account. It is obvious that a patient’s decision in favour of secrecy already reveals a feature of his secret history.

¹ Exceptions may be made only for such data as family relationships, times and places of residence, operations, and so on.

In advising the patient at the beginning of the treatment to tell as few people as possible about it, we also protect him to some extent from the many hostile influences that will seem to entice him away from analysis. Such influences may be very mischievous at the outset of the treatment; later, they are usually immaterial, or even useful in bringing to the fore resistances which are trying to conceal themselves.

If during the course of the analysis the patient should temporarily need some other medical or specialist treatment, it is far wiser to call in a non-analytic colleague than to give this other treatment oneself. Combined treatments for neurotic disorders which have a powerful organic basis are nearly always impracticable. The patients withdraw their interest from analysis as soon as they are shown more than one path that promises to lead them to health. The best plan is to postpone the organic treatment until the psychical treatment is finished; if the former were tried first it would in most cases meet with no success.

To return to the beginning of the treatment. Patients are occasionally met with who start the treatment by assuring us that they cannot think of anything to say, although the whole field of their life-history and the story of their illness is open to them to choose from. Their request that we should tell them what to talk about must not be granted on this first occasion any more than on any later one. We must bear in mind what is involved here. A strong resistance has come to the front in order to defend the neurosis; we must take up the challenge then and there and come to grips with it. Energetic and repeated assurances to the patient that it is impossible for no ideas at all to occur to him at the beginning, and that what is in question is a resistance against the analysis, soon oblige him to make the expected admissions or to uncover a first piece of his complexes. It is a bad sign if he has to confess that while he was listening to the fundamental rule of analysis he made a mental reservation that he would nevertheless keep this or that to himself; it is not so serious if all he has to tell us is how mistrustful he is of analysis or the horrifying things he has heard about it. If he denies these and similar possibilities when they are put before him, he can be driven by our insistence to acknowledge that he has nevertheless overlooked certain thoughts which were occupying his mind. He had thought of the treatment itself, though nothing definite about it, or he had been occupied with the picture of the room in which he was, or he could not help thinking of the objects in the consulting room and of the fact that he was lying here on a sofa - all of which he has replaced by the word ‘nothing’. These indications are intelligible enough: everything connected with the present situation represents a transference to the doctor, which proves suitable to serve as a first resistance. We are thus obliged to begin by uncovering this transference; and a path from it will give rapid access to the patient’s pathogenic material. Women who are prepared by events in their past history to be subjected to sexual aggression and men with over-strong repressed homosexuality are the most apt thus to withhold the ideas that occur to them at the outset of their analysis.

The patient’s first symptoms or chance actions, like his first resistance, may possess a special interest and may betray a complex which governs his neurosis. A clever young philosopher with exquisite aesthetic sensibilities will hasten to put the creases of his trousers straight before lying down for his first hour; he is revealing himself as a former coprophilic of the highest refinement - which was to be expected from the later aesthete. A young girl will at the same juncture hurriedly pull the hem of her skirt over her exposed ankles; in doing this she is giving away the gist of what her analysis will uncover later: her narcissistic pride in her physical beauty and her inclinations to exhibitionism.

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