PARAPRAXES 31 страница

We notice, then, that the patient, who ought to want nothing else but to find a way out of his distressing conflict, develops a special interest in the person of the doctor. Everything connected with the doctor seems to be more important to him than his own affairs and to be diverting him from his illness. For a time, accordingly, relations with him become very agreeable; he is particularly obliging, tries wherever possible to show his gratitude, reveals refinements and merits in his nature which we should not, perhaps, have expected to find in him. The doctor, too, thereupon forms a favourable opinion of the patient and appreciates the good fortune which has enabled him to give his assistance to such a particularly valuable personality. If the doctor has an opportunity of talking to the patient’s relatives, he learns to his satisfaction that the liking is a mutual one. The patient never tires in his home of praising the doctor and of extolling ever new qualities in him. ‘He’s enthusiastic about you,’ say his relatives, ‘he trusts you blindly; everything you say is like a revelation to him.’ Here and there someone in this chorus has sharper eyes and says: ‘It’s becoming a bore, the way he talks of nothing else but you and has your name on his lips all the time.’

Let us hope that the doctor is modest enough to attribute his patient’s high opinion of him to the hopes he can rouse in him and to the widening of his intellectual horizon by the surprising and liberating enlightenment that the treatment brings with it. Under these conditions the analysis makes fine progress too. The patient understands what is interpreted to him and becomes engrossed in the tasks set him by the treatment; the material of memories and associations floods in I upon him in plenty, the certainty and appositeness of his interpretations are a surprise to the doctor, and the latter can only take note with satisfaction that here is a patient who readily accepts all the psychological novelties which are apt to provoke the most bitter contradiction among healthy people in the outside world. Moreover the cordial relations that prevail during the work of analysis are accompanied by an objective improvement, which is recognized on all sides, in the patient’s illness.

But such fine weather cannot last for ever. One day it clouds over. Difficulties arise in the treatment; the patient declares that nothing more occurs to him. He gives the clearest impression of his interest being no longer in the work and of his cheerfully disregarding the instructions given him to say everything that comes into his head and not to give way to any critical obstacle to doing so. He behaves as though he were outside the treatment and as though he had not made this agreement with the doctor. He is evidently occupied with something, but intends to keep it to himself. This is a situation that is dangerous for the treatment. We are unmistakably confronted by a formidable resistance. But what has happened to account for it?

If we are able once more to clarify the position, we find that the cause of the disturbance is that the patient has transferred on to the doctor intense feelings of affection which are justified neither by the doctor’s behaviour nor by the situation that has developed during the treatment. The form in which this affection is expressed and what its aims are depend of course on the personal relation between the two people involved. If those concerned are a young girl and a youngish man, we shall get the impression of a normal case of falling in love; we shall find it understandable that a girl should fall in love with a man with whom she can be much alone and talk of intimate things and who has the advantage of having met her as a helpful superior; and we shall probably overlook the fact that what we should expect from a neurotic girl would rather be an impediment in her capacity for love. The further the personal relations between doctor and patient diverge from this supposed case, the more we shall be surprised to find nevertheless the same emotional relationship constantly recurring. It may still pass muster if a woman who is unhappy in her marriage appears to be seized with a serious passion for a doctor who is still unattached, if she is ready to seek a divorce in order to be his or if, where there are social obstacles, she even expresses no hesitation about entering into a secret liaison with him. Such things come about even outside psycho-analysis. But in these circumstances we are astonished to hear declarations by married women and girls which bear witness to a quite particular attitude to the therapeutic problem: they had always known, they say, that they could only be cured by love, and before the treatment began they had expected that through this relation they would at last be granted what life had hitherto withheld from them; it had only been in this hope that they had taken so much trouble over the treatment and overcome all the difficulties in communicating their thoughts - and we on our part can add: and had so easily understood what is otherwise so hard to believe. But an admission of this sort surprises us: it throws all our calculations to the winds. Can it be that we have left the most important item out of our account?

And indeed, the greater our experience the less we are able to resist making this correction, though having to do so puts our scientific pretensions to shame. On the first few occasions one might perhaps think that the analytic treatment had come up against a disturbance due to a chance event - an event, that is, not intended and not provoked by it. But when a similar affectionate attachment by the patient to the doctor is repeated regularly in every new case, when it comes to light again and again, under the most unfavourable conditions and where there are positively grotesque incongruities, even in elderly women and in relation to grey-bearded men, even where, in our judgement, there is nothing of any kind to entice - then we must abandon the idea of a chance disturbance and recognize that we are dealing with a phenomenon which is intimately bound up with the nature of the illness itself.

This new fact, which we thus recognize so unwillingly, is known by us as transference. We mean a transference of feelings on to the person of the doctor, since we do not believe that the situation in the treatment could justify the development of such feelings. We suspect, on the contrary, that the whole readiness for these feelings is derived from elsewhere, that they were already prepared in the patient and, upon the opportunity offered by the analytic treatment, are transferred on to the person of the doctor. Transference can appear as a passionate demand for love or in more moderate forms; in place of a wish to be loved, a wish can emerge between a girl and an old man to be received as a favourite daughter; the libidinal desire can be toned down into a proposal for an inseparable, but ideally non-sensual, friendship. Some women succeed in sublimating the transference and in moulding it till it achieves a kind of viability; others must express it in its crude, original, and for the most part, impossible form. But at bottom it is always the same, and never allows its origin from the same source to be mistaken.

Before we enquire where we are to find a place for this new fact, I will complete my description of it. What happens with male patients? There at least one might hope to escape the troublesome interference caused by difference of sex and by sexual attraction. Our answer, however, must be much the same as in the case of women. There is the same attachment to the doctor, the same overvaluation of his qualities, the same absorption in his interests, the same jealousy of everyone close to him in real life. The sublimated forms of transference are more frequent between one man and another and straightforward sexual demands are rarer, in proportion as manifest homosexuality is unusual as compared with the other ways in which these instinctual components are employed. With his male patients, again, more often than with women, the doctor comes across a form of expression of the transference which seems at first sight to contradict all our previous descriptions - a hostile or negative transference.

5 I must begin by making it clear that a transference is present in the patient from the beginning of the treatment and for a while is the most powerful motive in its advance. We see no trace of it and need not bother about it so long as it operates in favour of the joint work of analysis. If it then changes into a resistance, we must turn our attention to it and we recognize that it alters its relation to the treatment under two different and contrary conditions: firstly, if as an affectionate trend it has become so powerful, and betrays signs of its origin in a sexual need so clearly, that it inevitably provokes an internal opposition to itself, and, secondly, if it consists of hostile instead of affectionate impulses. The hostile feelings make their appearance as a rule later than the affectionate ones and behind them; their simultaneous presence gives a good picture of the emotional ambivalence which is dominant in the majority of our intimate relations with other people. The hostile feelings are as much an indication of an emotional tie as the affectionate ones, in the same way as defiance signifies dependence as much as obedience does, though with a ‘minus’ instead of a ‘plus’ sign before it. We can be in no doubt that the hostile feelings towards the doctor deserve to be called a ‘transference’, since the situation in the treatment quite certainly offers no adequate grounds for their origin; this necessary view of the negative transference assures us, therefore, that we have not gone wrong in our judgement of the positive or affectionate one.

Where the transference arises, what difficulties it raises for us, how we overcome them and what advantages we eventually derive from it - these are questions to be dealt with in a technical guide to analysis, and I shall only touch on them lightly to-day. It is out of the question for us to yield to the patient’s demands deriving from the transference; it would be absurd for us to reject them in an unfriendly, still more in an indignant, manner. We overcome the transference by pointing out to the patient that his feelings do not arise from the present situation and do not apply to the person of the doctor, but that they are repeating something that happened to him earlier. In this way we oblige him to transform his repetition into a memory. By that means the transference, which, whether affectionate or hostile, seemed in every case to constitute the greatest threat to the treatment, becomes its best tool, by whose help the most secret compartments of mental life can be opened.

But I should like to say a few words to you to relieve you of your surprise at the emergence of this unexpected phenomenon. We must not forget that the patient’s illness, which we have undertaken to analyse, is not something which has been rounded off and become rigid but that it is still growing and developing like a living organism. The beginning of the treatment does not put an end to this development; when, however, the treatment has obtained mastery over the patient, what happens is that the whole of his illness’s new production is concentrated upon a single point - his relation to the doctor. Thus the transference may be compared to the cambium layer in a tree between the wood and the bark, from which the new formation of tissue and the increase in the girth of the trunk derive. When the transference has risen to this significance, work upon the patient’s memories retreats far into the background. Thereafter it is not incorrect to say that we are no longer concerned with the patient’s earlier illness but with a newly created and transformed neurosis which has taken the former’s place. We have followed this new edition of the old disorder from its start, we have observed its origin and growth, and we are especially well able to find our way about in it since, as its object, we are situated at its very centre. All the patient’s symptoms have abandoned their original meaning and have take on a new sense which lies in a relation to the transference; or only such symptoms have persisted as are capable of undergoing such a transformation. But the mastering of this new, artificial neurosis coincides with getting rid of the illness which was originally brought to the treatment - with the accomplishment of our therapeutic task. A person who has become normal and free from the operation of repressed instinctual impulse in his relation to the doctor will remain so in his own life after the doctor has once more withdrawn from it.

The transference possesses this extraordinary, and for the treatment, positively central, importance in hysteria, anxiety hysteria and obsessional neurosis, which are for that reason rightly classed together as ‘transference neuroses’. No one who has taken in a full impression of the fact of transference from his analytic work will any longer doubt the nature of the suppressed impulses that obtain expression in the symptoms of these neuroses, and will call for no more powerful evidence of their libidinal character. It may be said that our conviction of the significance of symptoms as substitutive satisfactions of the libido only received its final confirmation after the enlistment of the transference.

There is every reason now for us to improve our earlier dynamic account of the therapeutic process and to bring it into harmony with our new realization. If the patient is to fight his way through the normal conflict with the resistances which we have uncovered for him in the analysis, he is in need of a powerful stimulus which will influence the decision in the sense which we desire, leading to recovery. Otherwise it might happen that he would choose in favour of repeating the earlier outcome and would allow what had been brought up into consciousness to slip back again into repression. At this point what turns the scale in his struggle is not his intellectual insight which is neither strong enough nor free enough for such an achievement - but simply and solely his relation to the doctor. In so far as his transference bears a ‘plus’ sign, it clothes the doctor with authority and is transformed into belief in his communications and explanations. In the absence of such a transference, or if it is a negative one, the patient would never even give a hearing to the doctor and his arguments. In this his belief is repeating the story of its own development; it is a derivative of love and, to start with, needed no arguments. Only later did he allow them enough room to submit them to examination, provided they were brought forward by someone he loved. Without such supports arguments carried no weight, and in most people’s lives they never do. Thus in general a man is only accessible from the intellectual side too, in so far as he is capable of a libidinal cathexis of objects; and we have good reason to recognize and to dread in the amount of his narcissism a barrier against the possibility of being influenced by even the best analytic technique.

A capacity for directing libidinal object-cathexes on to people must of course be attributed to every normal person. The tendency to transference of the neurotics I have spoken of is only an extraordinary increase of this universal characteristic. It would indeed be very strange if a human trait so widespread and so important had never been noticed or appreciated. And in fact it has been. Bernheim, with an unerring eye based his theory of hypnotic phenomena on the thesis that everyone is in some way ‘suggestible’. His suggestibility was nothing other than the tendency to transference, somewhat too narrowly conceived, so that it did not include negative transference. But Bernheim was never able to say what suggestion actually was and how it came about. For him it was a fundamental fact on whose origin he could throw no light. He did not know that his ‘suggestibilité' depended on sexuality, on the activity of the libido. And it must dawn on us that in our technique we have abandoned hypnosis only to rediscover suggestion in the shape of transference.

But here I will pause, and let you have a word; for I see an objection boiling up in you so fiercely that it would make you incapable of listening if it were not put into words: ‘Ah! so you’ve admitted it at last! You work with the help of suggestion, just like the hypnotists! That is what we’ve thought for a long time. But, if so, why the roundabout road by way of memories of the past, discovering the unconscious, interpreting and translating back distortions - this immense expenditure of labour, time and money - when the one effective thing is after all only suggestion? Why do you not make direct suggestion against the symptoms, as the others do - the honest hypnotists? Moreover, if you try to excuse yourself for your long detour on the ground that you have made a number of important psychological discoveries which are hidden by direct suggestion - what about the certainty of these discoveries now? Are not they a result of suggestion too, of unintentional suggestion? Is it not possible that you are forcing on the patient what you want and what seems to you correct, in this field as well?’

What you are throwing up at me in this is uncommonly interesting and must be answered. But I cannot do so to-day: we have not the time. Till our next meeting, then. I will answer you, you will see. But to-day I must finish what I have begun. I promised to make you understand by the help of the fact of transference why our therapeutic efforts have no success with the narcissistic neuroses.

I can do so in a few words, and you will see how simply the riddle can be solved and how well everything fits together. Observation shows that sufferers from narcissistic neuroses have no capacity for transference or only insufficient residues of it. They reject the doctor, not with hostility but with indifference. For that reason they cannot be influenced by him either; what he says leaves them cold, makes no impression on them; consequently the mechanism of cure which we carry through with other people - the revival of the pathogenic conflict and the overcoming of the resistance due to repression - cannot be operated with them. They remain as they are. Often they have already undertaken attempts at recovery on their own account which have led to pathological results. We cannot alter this in any way.

On the basis of our clinical impressions we maintained that these patients’ object-cathexes must have been given up and that their object-libido must have been transformed into ego-libido. Through this characteristic we distinguished them from the first group of neurotics (sufferers from hysteria, anxiety-hysteria and obsessional neurosis). This suspicion is now confirmed by their behaviour in our attempts at therapy. They manifest no transference and for that reason are inaccessible to our efforts and cannot be cured by us.

LECTURE XXVIII ANALYTIC THERAPY

LADIES AND GENTLEMEN, - You know what we are going to talk about to-day. You asked me why we do not make use of direct suggestion in psycho-analytic therapy, when we admit that our influence rests essentially on transference - that is, on suggestion; and you added a doubt whether, in view of this predominance of suggestion, we are still able to claim that our psychological discoveries are objective. I promised I would give you a detailed reply.

Direct suggestion is suggestion aimed against the manifestation of the symptoms; it is a struggle between your authority and the motives for the illness. In this you do not concern yourself with these motives; you merely request the patient to suppress their manifestation in symptoms. It makes no difference of principle whether you put the patient under hypnosis or not. Once again Bernheim, with his characteristic perspicacity, maintained that suggestion was the essential element in the phenomena of hypnotism, that hypnosis itself was already a result of suggestion, a suggested state; and he preferred to practise suggestion in a waking state, which can achieve the same effects as suggestion under hypnosis.

Which would you rather hear first on this question - what experience tells us or theoretical considerations?1 Let us begin with the former. I was a pupil of Bernheim’s, whom I visited at Nancy in 1889 and whose book on suggestion I translated into German. I practised hypnotic treatment for many years, at first by prohibitory suggestion and later in combination with Breuer’s method of questioning the patient. I can therefore speak of the results of hypnotic or suggestive therapy on the basis of a wide experience. If, in the words of the old medical aphorism, an ideal therapy should be rapid, reliable and not disagreeable for the patient, Bernheim’s method fulfilled at least two of these requirements. It could be carried through much quicker - or, rather, infinitely quicker - than analytic treatment and it caused the patient neither trouble nor unpleasantness. For the doctor it became, in the long run, monotonous: in each case, in the same way, with the same ceremonial, forbidding the most variegated symptoms to exist, without being able to learn anything of their sense and meaning. It was hackwork and not a scientific activity, and it recalled magic, incantations and hocus-pocus. That could not weigh, however, against the patient’s interest. But the third quality was lacking: the procedure was not reliable in any respect. It could be used with one patient, but not with another; it achieved a great deal with one and very little with another, and one never knew why. Worse than the capriciousness of the procedure was the lack of permanence in its successes. If, after a short time, one had news of the patient once more, the old ailment was back again or its place had been taken by a new one. One might hypnotize him again. But in the background there was the warning given by experienced workers against robbing the patient of his self-reliance by frequently repeated hypnosis and so making him an addict to this kind of therapy as though it were a narcotic. Admittedly sometimes things went entirely as one would wish: after a few efforts, success was complete and permanent. But the conditions determining such a favourable outcome remained unknown. On one occasion a severe condition in a woman, which I had entirely got rid of by a short hypnotic treatment, returned unchanged after the patient had, through no action on my part, got annoyed with me; after a reconciliation, I removed the trouble again and far more thoroughly; yet it returned once more after she had fallen foul of me a second time. On another occasion a woman patient, whom I had repeatedly helped out of neurotic states by hypnosis, suddenly, during the treatment of a specially obstinate situation, threw her arms round my neck. After this one could scarcely avoid, whether one wanted to or not, investigating the question of the nature and origin of one’s authority in suggestive treatment.

2 So much for experiences. They show us that in renouncing direct suggestion we are not giving up anything of irreplaceable value. Now let us add a few reflections to this. The practice of hypnotic therapy makes very small demands on either the patient or the doctor. It agrees most beautifully with the estimate in which neuroses are still held by the majority of doctors. The doctor says to the neurotic patient: ‘There’s nothing wrong with you, it’s only a question of nerves; so I can blow away your trouble in two or three minutes with just a few words.’ But our views on the laws of energy are offended by the notion of its being possible to move a great weight by a tiny application of force, attacking it directly, without the outside help of any appropriate appliances. In so far as the conditions are comparable, experience shows that this feat is not successfully accomplished in the case of the neuroses either. But I am aware that this argument is not unimpeachable. There is such a thing as a ‘trigger-action’.

In the light of the knowledge we have gained from psycho-analysis we can describe the difference between hypnotic and psycho-analytic suggestion as follows. Hypnotic treatment seeks to cover up and gloss over something in mental life; analytic treatment seeks to expose and get rid of something. The former acts like a cosmetic, the latter like surgery. The former makes use of suggestion in order to forbid the symptoms; it strengthens the repressions, but, apart from that, leaves all the processes that have led to the formation of the symptoms unaltered. Analytic treatment makes its impact further back towards the roots, where the conflicts are which gave rise to the symptoms, and uses suggestion in order to alter the outcome of those conflicts. Hypnotic treatment leaves the patient inert and unchanged, and for that reason, too, equally unable to resist any fresh occasion for falling ill. An analytic treatment demands from both doctor and patient the accomplishment of serious work, which is employed in lifting internal resistances. Through the overcoming of these resistances the patient’s mental life is permanently changed, is raised to a high level of development and remains protected against fresh possibilities of falling ill. This work of overcoming resistances is the essential function of analytic treatment; the patient has to accomplish it and the doctor makes this possible for him with the help of suggestion operating in an educative sense. For that reason psycho-analytic treatment has justly been described as a kind of after-education.

I hope I have now made it clear to you in what way our method of employing suggestion therapeutically differs from the only method possible in hypnotic treatment. You will understand too, from the fact that suggestion can be traced back to transference, the capriciousness which struck us in hypnotic therapy, while analytic treatment remains calculable within its limits. In using hypnosis we are dependent on the state of the patient’s capacity for transference without being able to influence it itself. The transference of a person who is to be hypnotized may be negative or, as most frequently, ambivalent, or he may have protected himself against his transference by adopting special attitudes; of that we learn nothing. In psycho-analysis we act upon the transference itself, resolve what opposes it, adjust the instrument with which we wish to make our impact. Thus it becomes possible for us to derive an entirely fresh advantage from the power of suggestion; we get it into our hands. The patient does not suggest to himself whatever he pleases: we guide his suggestion so far as he is in any way accessible to its influence.

3 But you will now tell me that, no matter whether we call the motive force of our analysis transference or suggestion, there is a risk that the influencing of our patient may make the objective certainty of our findings doubtful. What is advantageous to our therapy is damaging to our researches. This is the objection that is most often raised against psycho-analysis, and it must be admitted that, though it is groundless, it cannot be rejected as unreasonable. If it were justified, psycho-analysis would be nothing more than a particularly well-disguised and particularly effective form of suggestive treatment and we should have to attach little weight to all that it tells us about what influences our lives, the dynamics of the mind or the unconscious. That is what our opponents believe; and in especial they think that we have ‘talked’ the patients into everything relating to the importance of sexual experiences - or even into those experiences themselves - after such notions have grown up in our own depraved imagination. These accusations are contradicted more easily by an appeal to experience than by the help of theory. Anyone who has himself carried out psycho-analyses will have been able to convince himself on countless occasions that it is impossible to make suggestions to a patient in that way. The doctor has no difficulty, of course, in making him a supporter of some particular theory and in thus making him share some possible error of his own. In this respect the patient is behaving like anyone else - like a pupil - but this only affects his intelligence, not his illness. After all, his conflicts will only be successfully solved and his resistances overcome if the anticipatory ideas he is given tally with what is real in him. Whatever in the doctor’s conjectures is inaccurate drops out in the course of the analysis; it has to be withdrawn and replaced by something more correct. We endeavour by a careful technique to avoid the occurrence of premature successes due to suggestion; but no harm is done even if they do occur, for we are not satisfied by a first success. We do not regard an analysis as at an end until all the obscurities of the case are cleared up, the gaps in the patient’s memory filled in, the precipitating causes of the repressions discovered. We look upon successes that set in too soon as obstacles rather than as a help to the work of analysis; and we put an end to such successes by constantly resolving the transference on which they are based. It is this last characteristic which is the fundamental distinction between analytic and purely suggestive therapy, and which frees the results of analysis from the suspicion of being successes due to suggestion. In every other kind of suggestive treatment the transference is carefully preserved and left untouched; in analysis it is itself subjected to treatment and is dissected in all the shapes in which it appears. At the end of an analytic treatment the transference must itself be cleared away; and if success is then obtained or continues, it rests, not on suggestion, but on the achievement by its means of an overcoming of internal resistances, on the internal change that has been brought about in the patient.

Дата добавления: 2014-12-23