Recommendations to physicians practising psycho-analysis 3 страница

A particularly large number of patients object to being asked to lie down, while the doctor sits out of sight behind them. They ask to be allowed to go through the treatment in some other position, for the most part because they are anxious not to be deprived of a view of the doctor. Permission is regularly refused, but one cannot prevent them from contriving to say a few sentences before the beginning of the actual ‘session’ or after one has signified that it is finished and they have got up from the sofa. In this way they divide the treatment in their own view into an official portion, in which they mostly behave in a very inhibited manner, and an informal ‘friendly’ portion, in which they speak really freely and say all sorts of things which they themselves do not regard as being part of the treatment. The doctor does not accept this division for long. He takes note of what is said before or after the session and he brings it forward at the first opportunity, thus pulling down the partition which the patient has tried to erect. This partition, once again, will have been put together from the material of a transference-resistance.

So long as the patient’s communications and ideas run on without any obstruction, the theme of transference should be left untouched. One must wait until the transference, which is the most delicate of all procedures, has become a resistance.

The next question with which we are faced raises a matter of principle. It is this: When are we to begin making our communications to the patient? When is the moment for disclosing to him the hidden meaning of the ideas that occur to him, and for initiating him into the postulates and technical procedures of analysis?

The answer to this can only be: Not until an effective transference has been established in the patient, a proper rapport with him. It remains the first aim of the treatment to attach him to it and to the person of the doctor. To ensure this, nothing need be done but to give him time. If one exhibits a serious interest in him, carefully clears away the resistances that crop up at the beginning and avoids making certain mistakes, he will of himself form such an attachment and link the doctor up with one of the imagos of the people by whom he was accustomed to be treated with affection. It is certainly possible to forfeit this first success if from the start one takes up any standpoint other than one of sympathetic understanding, such as a moralizing one, or if one behaves like a representative or contending party - of the other member of a married couple, for instance.

This answer of course involves a condemnation of any line of behaviour which would lead us to give the patient a translation of his symptoms as soon as we have guessed it ourselves, or would even lead us to regard it as a special triumph to fling these ‘solutions’ in his face at the first interview. It is not difficult for a skilled analyst to read the patient’s secret wishes plainly between the lines of his complaints and the story of his illness; but what a measure of self-complacency and thoughtlessness must be possessed by anyone who can, on the shortest acquaintance, inform a stranger who is entirely ignorant of all the tenets of analysis that he is attached to his mother by incestuous ties, that he harbours wishes for the death of his wife whom he appears to love, that he conceals an intention of betraying his superior, and so on! I have heard that there are analysts who plume themselves upon these kinds of lightning diagnoses and ‘express’ treatments, but I must warn everyone against following such examples. Behaviour of this sort will completely discredit oneself and the treatment in the patient’s eyes and will arouse the most violent opposition in him, whether one’s guess has been true or not; indeed, the truer the guess the more violent will be the resistance. As a rule the therapeutic effect will be nil; but the deterring of the patient from analysis will be final. Even in the later stages of analysis one must be careful not to give a patient the solution of a symptom or the translation of a wish until he is already so close to it that he has only one short step more to make in order to get hold of the explanation for himself. In former years I often had occasion to find that the premature communication of a solution brought the treatment to an untimely end, on account not only of the resistances which it thus suddenly awakened but also of the relief which the solution brought with it.

But at this point an objection will be raised. Is it, then, our task to lengthen the treatment and not, rather, to bring it to an end as rapidly as possible? Are not the patient’s ailments due to his lack of knowledge and understanding and is it not a duty to enlighten him as soon as possible - that is, as soon as the doctor himself knows the explanations? The answer to this question calls for a short digression on the meaning of knowledge and the mechanism of cure in analysis.

3 It is true that in the earliest days of analytic technique we took an intellectualist view of the situation. We set a high value on the patient’s knowledge of what he had forgotten, and in this we made hardly any distinction between our knowledge of it and his. We thought it a special piece of good luck if we were able to obtain information about the forgotten childhood trauma from other sources - for instance, from parents or nurses or the seducer himself - as in some cases it was possible to do; and we hastened to convey the information and the proofs of its correctness to the patient, in the certain expectation of thus bringing the neurosis and the treatment to a rapid end. It was a severe disappointment when the expected success was not forthcoming. How could it be that the patient, who now knew about his traumatic experience, nevertheless still behaved as if he knew no more about it than before? Indeed, telling and describing his repressed trauma to him did not even result in any recollection of it coming into his mind.

In one particular case the mother of a hysterical girl had confided to me the homosexual experience which had greatly contributed to the fixation of the girl’s attacks. The mother had herself surprised the scene; but the patient had completely forgotten it, though it had occurred when she was already approaching puberty. I was now able to make a most instructive observation. Every time I repeated her mother’s story to the girl she reacted with a hysterical attack, and after this she forgot the story once more. There is no doubt that the patient was expressing a violent resistance against the knowledge that was being forced upon her. Finally she simulated feeble-mindedness and a complete loss of memory in order to protect herself against what I had told her. After this, there was no choice but to cease attributing to the fact of knowing, in itself, the importance that had previously been given to it and to place the emphasis on the resistances which had in the past brought about the state of not knowing and which were still ready to defend that state. Conscious knowledge, even if it was not subsequently driven out again, was powerless against those resistances.

The strange behaviour of patients, in being able to combine a conscious knowing with not knowing, remains inexplicable by what is called normal psychology. But to psycho-analysis, which recognizes the existence of the unconscious, it presents no difficulty. The phenomenon we have described, moreover, provides some of the best support for a view which approaches mental processes from the angle of topographical differentiation. The patients now know of the repressed experience in their conscious thought, but this thought lacks any connection with the place where the repressed recollection is in some way or other contained. No change is possible until the conscious thought-process has penetrated to that place and has overcome the resistances of repression there. It is just as though a decree were promulgated by the Ministry of Justice to the effect that juvenile delinquencies should be dealt with in a certain lenient manner. As long as this decree has not come to the knowledge of the local magistrates, or in the event of their not intending to obey it but preferring to administer justice by their own lights, no change can occur in the treatment of particular youthful delinquents. For the sake of complete accuracy, however, it should be added that the communication of repressed material to the patient’s consciousness is nevertheless not without effect. It does not produce the hoped-for result of putting an end to the symptoms; but it has other consequences. At first it arouses resistances, but then, when these have been overcome, it sets up a process of thought in the course of which the expected influencing of the unconscious recollection eventually takes place.

It is now time for us to take a survey of the play of forces which is set in motion by the treatment. The primary motive force in the therapy is the patient’s suffering and the wish to be cured that arises from it. The strength of this motive force is subtracted from by various factors - which are not discovered till the analysis is in progress - above all, by what we have called the ‘secondary gain from illness’; but it must be maintained till the end of the treatment. Every improvement effects a diminution of it. By itself, however, this motive force is not sufficient to get rid of the illness. Two things are lacking in it for this: it does not know what paths to follow to reach this end; and it does not possess the necessary quota of energy with which to oppose the resistances. The analytic treatment helps to remedy both these deficiencies. It supplies the amounts of energy that are needed for overcoming the resistances by making mobile the energies which lie ready for the transference; and, by giving the patient information at the right time, it shows him the paths along which he should direct those energies. Often enough the transference is able to remove the symptoms of the disease by itself, but only for a while - only for as long as it itself lasts. In this case the treatment is a treatment by suggestion, and not a psycho-analysis at all. It only deserves the latter name if the intensity of the transference has been utilized for the overcoming of resistances. Only then has being ill become impossible, even when the transference has once more been dissolved, which is its destined end.

In the course of the treatment yet another helpful factor is aroused. This is the patient’s intellectual interest and understanding. But this alone hardly comes into consideration in comparison with the other forces that are engaged in the struggle; for it is always in danger of losing its value, as a result of the clouding of judgement that arises from the resistances. Thus the new sources of strength for which the patient is indebted to his analyst are reducible to transference and instruction (through the communications made to him). The patient, however, only makes use of the instruction in so far as he is induced to do so by the transference; and it is for this reason that our first communication should be withheld until a strong transference has been established. And this, we may add, holds good of every subsequent communication. In each case we must wait until the disturbance of the transference by the successive emergence of transference-resistances has been removed.

REMEMBERING, REPEATING AND WORKING-THROUGH (FURTHER RECOMMENDATIONS ON THE TECHNIQUE OF PSYCHO-ANALYSIS II) (1914)

It seems to me not unnecessary to keep on reminding students of the far-reaching changes which psycho-analytic technique has undergone since its first beginnings. In its first phase - that of Breuer’s catharsis - it consisted in bringing directly into focus the moment at which the symptom was formed, and in persistently endeavouring to reproduce the mental processes involved in that situation, in order to direct their discharge along the path of conscious activity. Remembering and abreacting, with the help of the hypnotic state, were what was at that time aimed at. Next, where hypnosis had been given up, the task became one of discovering from the patient’s free associations what he failed to remember. The resistance was to be circumvented by the work of interpretation and by making its results known to the patient. The situations which had given rise to the formation of the symptom and the other situations which lay behind the moment at which the illness broke out retained their place as the focus of interest; but the element of abreaction receded into the background and seemed to be replaced by the expenditure of work which the patient had to make in being obliged to overcome his criticism of his free associations, in accordance with the fundamental rule of psycho-analysis. Finally, there was evolved the consistent technique used to-day, in which the analyst gives up the attempt to bring a particular moment or problem into focus. He contents himself with studying whatever is present for the time being on the surface of the patient’s mind, and he employs the art of interpretation mainly for the purpose of recognizing the resistances which appear there, and making them conscious to the patient. From this there results a new sort of division of labour: the doctor uncovers the resistances which are unknown to the patient; when these have been got the better of, the patient often relates the forgotten situations and connections without any difficulty. The aim of these different techniques has, of course, remained the same. Descriptively speaking, it is to fill in gaps in memory; dynamically speaking, it is to overcome resistances due to repression.

We must still be grateful to the old hypnotic technique for having brought before us single psychical processes of analysis in an isolated or schematic form. Only this could have given us the courage ourselves to create more complicated situations in the analytic treatment and to keep them clear before us.

In these hypnotic treatments the process of remembering took a very simple form. The patient put himself back into an earlier situation, which he seemed never to confuse with the present one, and gave an account of the mental processes belonging to it, in so far as they had remained normal; he then added to this whatever was able to emerge as a result of transforming the processes that had at the time been unconscious into conscious ones.

At this point I will interpolate a few remarks which every analyst has found confirmed in his observations. Forgetting impressions, scenes or experiences nearly always reduces itself to shutting them off. When the patient talks about these ‘forgotten’ things he seldom fails to add: ‘As a matter of fact I’ve always known it; only I’ve never thought of it.’ He often expresses disappointment at the fact that not enough things come into his head that he can call ‘forgotten’ - that he has never thought of since they happened. Nevertheless, even this desire is fulfilled, especially in the case of conversion hysterias. ‘Forgetting’ becomes still further restricted when we assess at their true value the screen memories which are so generally present. In some cases I have had an impression that the familiar childhood amnesia, which is theoretically so important to us, is completely counterbalanced by screen memories. Not only some but all of what is essential from childhood has been retained in these memories. It is simply a question of knowing how to extract it out of them by analysis. They represent the forgotten years of childhood as adequately as the manifest content of a dream represents the dream-thoughts.

The other group of psychical processes - phantasies, processes of reference, emotional impulses, thought-connections - which, as purely internal acts, can be contrasted with impressions and experiences, must, in their relation to forgetting and remembering, be considered separately. In these processes it particularly often happens that something is ‘remembered’ which could never have been ‘forgotten’ because it was never at any time noticed - was never conscious. As regards the course taken by psychical events it seems to make no difference whatever whether such a ‘thought-connection’ was conscious and then forgotten or whether it never managed to become conscious at all. The conviction which the patient obtains in the course of his analysis is quite independent of this kind of memory.

In the many different forms of obsessional neurosis in particular, forgetting is mostly restricted to dissolving thought-connections, failing to draw the right conclusions and isolating memories.

There is one special class of experiences of the utmost importance for which no memory can as a rule be recovered. These are experiences which occurred in very early childhood and were not understood at the time but which were subsequently understood and interpreted. One gains a knowledge of them through dreams and one is obliged to believe in them on the most compelling evidence provided by the fabric of the neurosis. Moreover, we can ascertain for ourselves that the patient, after his resistances have been overcome, no longer invokes the absence of any memory of them (any sense of familiarity with them) as a ground for refusing to accept them. This matter, however, calls for so much critical caution and introduces so much that is novel and startling that I shall reserve it for a separate discussion in connection with suitable material.

1 Under the new technique very little, and often nothing, is left of this delightfully smooth course of events. There are some cases which behave like those under the hypnotic technique up to a point and only later cease to do so; but others behave differently from the beginning. If we confine ourselves to this second type in order to bring out the difference, we may say that the patient does not remember anything of what he has forgotten and repressed, but acts it out. He reproduces it not as a memory but as an action; he repeats it, without, of course, knowing that he is repeating it.

For instance, the patient does not say that he remembers that he used to be defiant and critical towards his parents’ authority; instead, he behaves in that way to the doctor. He does not remember how he came to a helpless and hopeless deadlock in his infantile sexual researches; but he produces a mass of confused dreams and associations, complains that he cannot succeed in anything and asserts that he is fated never to carry through what he undertakes. He does not remember having been intensely ashamed of certain sexual activities and afraid of their being found out; but he makes it clear that he is ashamed of the treatment on which he is now embarked and tries to keep it secret from everybody. And so on.

Above all, the patient will begin his treatment with a repetition of this kind. When one has announced the fundamental rule of psycho-analysis to a patient with an eventful life-history and a long story of illness and has then asked him to say what occurs to his mind, one expects him to pour out a flood of information; but often the first thing that happens is that he has nothing to say. He is silent and declares that nothing occurs to him. This, of course, is merely a repetition of a homosexual attitude which comes to the fore as a resistance against remembering anything. As long as the patient is in the treatment he cannot escape from this compulsion to repeat; and in the end we understand that this is his way of remembering.

What interests us most of all is naturally the relation of this compulsion to repeat to the transference and to resistance. We soon perceive that the transference is itself only a piece of repetition, and that the repetition is a transference of the forgotten past not only on to the doctor but also on to all the other aspects of the current situation. We must be prepared to find, therefore, that the patient yields to the compulsion to repeat, which now replaces the impulsion to remember, not only in his personal attitude to his doctor but also in every other activity and relationship which may occupy his life at the time - if, for instance, he falls in love or undertakes a task or starts an enterprise during the treatment. The part played by resistance, too, is easily recognized. The greater the resistance, the more extensively will acting out (repetition) replace remembering. For the ideal remembering of what has been forgotten which occurs in hypnosis corresponds to a state in which resistance has been put completely on one side. If the patient starts his treatment under the auspices of a mild and unpronounced positive transference it makes it possible at first for him to unearth his memories just as he would under hypnosis, and during this time his pathological symptoms themselves are quiescent. But if, as the analysis proceeds, the transference becomes hostile or unduly intense and therefore in need of repression, remembering at once gives way to acting out. From then onwards the resistances determine the sequence of the material which is to be repeated. The patient brings out of the armoury of the past the weapons with which he defends himself against the progress of the treatment - weapons which we must wrest from him one by one.

We have learnt that the patient repeats instead of remembering, and repeats under the conditions of resistance. We may now ask what it is that he in fact repeats or acts out. The answer is that he repeats everything that has already made its way from the sources of the repressed into his manifest personality - his inhibitions and unserviceable attitudes and his pathological character-traits. He also repeats all his symptoms in the course of the treatment. And now we can see that in drawing attention to the compulsion to repeat we have acquired no new fact but only a more comprehensive view. We have only made it clear to ourselves that the patient’s state of being ill cannot cease with the beginning of his analysis, and that we must treat his illness, not as an event of the past, but as a present-day force. This state of illness is brought, piece by piece, within the field and range of operation of the treatment, and while the patient experiences it as something real and contemporary, we have to do our therapeutic work on it, which consists in a large measure in tracing it back to the past.

Remembering, as it was induced in hypnosis, could not but give the impression of an experiment carried out in the laboratory. Repeating, as it is induced in analytic treatment according to the newer technique, on the other hand, implies conjuring up a piece of real life; and for that reason it cannot always be harmless and unobjectionable. This consideration opens up the whole problem of what is so often unavoidable - ‘deterioration during treatment’.

First and foremost, the initiation of the treatment in itself brings about a change in the patient’s conscious attitude to his illness. He has usually been content with lamenting it, despising it as nonsensical and under-estimating its importance; for the rest, he has extended to its manifestations the ostrich-like policy of repression which he adopted towards its origins. Thus it can happen that he does not properly know under what conditions his phobia breaks out or does not listen to the precise wording of his obsessional ideas or does not grasp the actual purpose of his obsessional impulse. The treatment, of course, is not helped by this. He must find the courage to direct his attention to the phenomena of his illness. His illness itself must no longer seem to him contemptible, but must become an enemy worthy of his mettle, a piece of his personality, which has solid ground for its existence and out of which things of value for his future life have to be derived. The way is thus paved from the beginning for a reconciliation with the repressed material which is coming to expression in his symptoms, while at the same time place is found for a certain tolerance for the state of being ill. If this new attitude towards the illness intensifies the conflicts and brings to the fore symptoms which till then had been indistinct, one can easily console the patient by pointing out that these are only necessary and temporary aggravations and that one cannot overcome an enemy who is absent or not within range. The resistance, however, may exploit the situation for its own ends and abuse the licence to be ill. It seems to say: ‘See what happens if I really give way to such things. Was I not right to consign them to repression?’ Young and childish people in particular are inclined to make the necessity imposed by the treatment for paying attention to their illness a welcome excuse for luxuriating in their symptoms.

Further dangers arise from the fact that in the course of the treatment new and deeper-lying instinctual impulses, which have not hitherto made themselves felt, may come to be ‘repeated’. Finally, it is possible that the patient’s actions outside the transference may do him temporary harm in his ordinary life, or even have been so chosen as permanently to invalidate his prospects of recovery.

The tactics to be adopted by the physician in this situation are easily justified. For him, remembering in the old manner - reproduction in the psychical field - is the aim to which he adheres, even though he knows that such an aim cannot be achieved in the new technique. He is prepared for a perpetual struggle with his patient to keep in the psychical sphere all the impulses which the patient would like to direct into the motor sphere; and he celebrates it as a triumph for the treatment if he can bring it about that something that the patient wishes to discharge in action is disposed of through the work of remembering. If the attachment through transference has grown into something at all serviceable, the treatment is able to prevent the patient from executing any of the more important repetitive actions and to utilize his intention to do so in statu nascendi as material for the therapeutic work. One best protects the patient from injuries brought about through carrying out one of his impulses by making him promise not to take any important decisions affecting his life during the time of his treatment - for instance, not to choose any profession or definitive love-object - but to postpone all such plans until after his recovery.

At the same time one willingly leaves untouched as much of the patient’s personal freedom as is compatible with these restrictions, nor does one hinder him from carrying out unimportant intentions, even if they are foolish; one does not forget that it is in fact only through his own experience and mishaps that a person learns sense. There are also people whom one cannot restrain from plunging into some quite undesirable project during the treatment and who only afterwards become ready for, and accessible to, analysis. Occasionally, too, it is bound to happen that the untamed instincts assert themselves before there is time to put the reins of the transference on them, or that the bonds which attach the patient to the treatment are broken by him in a repetitive action. As an extreme example of this, I may cite the case of an elderly lady who had repeatedly fled from her house and her husband in a twilight state and gone no one knew where, without ever having become conscious of her motive for decamping in this way. She came to treatment with a marked affectionate transference which grew in intensity with uncanny rapidity in the first few days; by the end of the week she had decamped from me, too, before I had had time to say anything to her which might have prevented this repetition.

The main instrument, however, for curbing the patient’s compulsion to repeat and for turning it into a motive for remembering lies in the handling of the transference. We render the compulsion harmless, and indeed useful, by giving it the right to assert itself in a definite field. We admit it into the transference as a playground in which it is allowed to expand in almost complete freedom and in which it is expected to display to us everything in the way of pathogenic instincts that is hidden in the patient’s mind. Provided only that the patient shows compliance enough to respect the necessary conditions of the analysis, we regularly succeed in giving all the symptoms of the illness a new transference meaning and in replacing his ordinary neurosis by a ‘transference-neurosis’ of which he can be cured by the therapeutic work. The transference thus creates an intermediate region between illness and real life through which the transition from the one to the other is made. The new condition has taken over all the features of the illness; but it represents an artificial illness which is at every point accessible to our intervention. It is a piece of real experience, but one which has been made possible by especially favourable conditions, and it is of a provisional nature. From the repetitive reactions which are exhibited in the transference we are led along the familiar paths to the awakening of the memories, which appear without difficulty, as it were, after the resistance has been overcome.

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