On transformations of instinct as exemplified in anal erotism 3 страница

In actual fact, indeed, the neurotic patient presents us with a torn mind, divided by resistances. As we analyse it and remove the resistances, it grows together; the great unity which we call his ego fits into itself all the instinctual impulses which before had been split off and held apart from it. The psycho-synthesis is thus achieved during analytic treatment without our intervention, automatically and inevitably. We have created the conditions for it by breaking up the symptoms into their elements and by removing the resistances. It is not true that something in the patient has been divided into its components and is now quietly waiting for us to put it somehow together again.

Developments in our therapy, therefore, will no doubt proceed along other lines; first and foremost, along the one which Ferenczi, in his paper ‘Technical Difficulties in an Analysis of Hysteria’ (1919), has lately termed ‘activity’ on the part of the analyst.

¹ After all, something very similar occurs in chemical analysis. Simultaneously with the isolation of the various elements induced by the chemist, syntheses which are no part of his intention come about, owing to the liberation of the elective affinities of the substances concerned.

Let us at once agree upon what we mean by this activity. We have defined our therapeutic task as consisting of two things: making conscious the repressed material and uncovering the resistances. In that we are active enough, to be sure. But are we to leave it to the patient to deal alone with the resistances we have pointed out to him? Can we give him no other help in this besides the stimulus he gets from the transference? Does it not seem natural that we should help him in another way as well, by putting him into the mental situation most favourable to the solution of the conflict which is our aim? After all, what he can achieve depends, too, on a combination of external circumstances. Should we hesitate to alter this combination by intervening in a suitable manner? I think activity of such a kind on the part of the analysing physician is unobjectionable and entirely justified.

You will observe that this opens up a new field of analytic technique the working over of which will require close application and which will lead to quite definite rules of procedure. I shall not attempt to-day to introduce you to this new technique, which is still in the course of being evolved, but will content myself with enunciating a fundamental principle which will probably dominate our work in this field. It runs as follows: Analytic treatment should be carried through, as far as is possible, under privation - in a state of abstinence.

How far it is possible to show that I am right in this must be left to a more detailed discussion. By abstinence, however, is not to be understood doing without any and every satisfaction - that would of course not be practicable; nor do we mean what it popularly connotes, refraining from sexual intercourse; it means something else which has far more to do with the dynamics of falling ill and recovering.2

You will remember that it was a frustration that made the patient ill, and that his symptoms serve him as substitutive satisfactions. It is possible to observe during the treatment that every improvement in his condition reduces the rate at which he recovers and diminishes the instinctual force impelling him towards recovery. But this instinctual force is indispensible; reduction of it endangers our aim - the patient’s restoration to health. What, then, is the conclusion that forces itself inevitably upon us? Cruel though it may sound, we must see to it that the patient’s suffering, to a degree that is in some way or other effective, does not come to an end prematurely. If, owing to the symptoms having been taken apart and having lost their value, his suffering becomes mitigated, we must reinstate it elsewhere in the form of some appreciable privation; otherwise we run the danger of never achieving any improvements except quite insignificant and transitory ones.

As far as I can see, the danger threatens from two directions in especial. On the one hand, when the illness has been broken down by the analysis, the patient makes the most assiduous efforts to create for himself in place of his symptoms new substitutive satisfactions, which now lack the feature of suffering. He makes use of the enormous capacity for displacement possessed by the now partly liberated libido, in order to cathect with libido and promote to the position of substitutive satisfactions the most diverse kinds of activities, preferences and habits, not excluding some that have been his already. He continually finds new distractions of this kind, into which the energy necessary to carrying on the treatment escapes, and he knows how to keep them secret for a time. It is the analyst’s task to detect these divergent paths and to require him every time to abandon them, however harmless the activity which leads to satisfaction may be in itself. The half-recovered patient may also enter on less harmless paths - as when, for instance, if he is a man, he seeks prematurely to attach himself to a woman. It may be observed, incidentally, that unhappy marriage and physical infirmity are the two things that most often supersede a neurosis. They satisfy in particular the sense of guilt (need for punishment) which makes many patients cling so fast to their neuroses. By a foolish choice in marriage they punish themselves; they regard a long organic illness as a punishment by fate and thereafter often cease to keep up their neurosis.

In all such situations activity on the part of the physician must take the form of energetic opposition to premature substitutive satisfactions. It is easier for him, however, to prevent the second danger which jeopardizes the propelling force of the analysis, though it is not one to be under-estimated. The patient looks for his substitutive satisfactions above all in the treatment itself, in his transference-relationship with the physician; and he may even strive to compensate himself by this means for all the other privations laid upon him. Some concessions must of course be made to him, greater or less, according to the nature of the case and the patient’s individuality. But it is not good to let them become too great. Any analyst who out of the fullness of his heart, perhaps, and his readiness to help, extends to the patient all that one human being may hope to receive from another, commits the same economic error as that of which our non-analytic institutions for nervous patients are guilty. Their one aim is to make everything as pleasant as possible for the patient, so that he may feel well there and be glad to take refuge there again from the trials of life. In so doing they make no attempt to give him more strength for facing life and more capacity for carrying out his actual tasks in it. In analytic treatment all such spoiling must be avoided. As far as his relations with the physician are concerned, the patient must be left with unfulfilled wishes in abundance. It is expedient to deny him precisely those satisfactions which he desires most intensely and expresses most importunately.

I do not think I have exhausted the range of desirable activity on the part of the physician in saying that a condition of privation is to be kept up during the treatment. Activity in another direction during analytic treatment has already, as you will remember, been a point at issue between us and the Swiss school. We refused most emphatically to turn a patient who puts himself into our hands in search of help into our private property, to decide his fate for him, to force our own ideals upon him, and with the pride of a Creator to form him in our own image and see that it is good. I still adhere to this refusal, and I think that this is the proper place for the medical discretion which we have had to ignore in other connections. I have learnt by experience, too, that such a far-reaching activity towards patients is not in the least necessary for therapeutic purposes. For I have been able to help people with whom I had nothing in common - neither race, education, social position nor outlook upon life in general - without affecting their individuality. At the time of the controversy I have just spoken of, I had the impression, to be sure, that the objections of our spokesmen - I think it was Ernest Jones who took the chief part - were too harsh and uncompromising. We cannot avoid taking some patients for treatment who are so helpless and incapable of ordinary life that for them one has to combine analytic with educative influence; and even with the majority, occasions now and then arise in which the physician is bound to take up the position of teacher and mentor. But it must always be done with great caution, and the patient should be educated to liberate and fulfil his own nature, not to resemble ourselves.

Our honoured friend, J. J. Putnam, in the land of America which is now so hostile to us, must forgive us if we cannot accept his proposal either - namely that psycho-analysis should place itself in the service of a particular philosophical outlook on the world and should urge this upon the patient for the purpose of ennobling his mind. In my opinion, this is after all only to use violence, even though it is overlaid with the most honourable motives.

Lastly, another quite different kind of activity is necessitated by the gradually growing appreciation that the various forms of disease treated by us cannot all be dealt with by the same technique. It would be premature to discuss this in detail, but I can give two examples of the way in which a new kind of activity comes into question. Our technique grew up in the treatment of hysteria and is still directed principally to the cure of that affection. But the phobias have already made it necessary for us to go beyond our former limits. One can hardly master a phobia if one waits till the patient lets the analysis influence him to give it up. He will never in that case bring into the analysis the material indispensable for a convincing resolution of the phobia. One must proceed differently. Take the example of agoraphobia; there are two classes of it, one mild, the other severe. Patients belonging to the first class suffer from anxiety when they go into the street by themselves, but they have not yet given up going out alone on that account; the others protect themselves from the anxiety by altogether ceasing to go about alone. With these last one succeeds only when one can induce them by the influence of the analysis to behave like phobic patients of the first class - that is, to go into the street and to struggle with their anxiety while they make the attempt. One starts, therefore, by moderating the phobia so far; and it is only when that has been achieved at the physician’s demand that the associations and memories come into the patient’s mind which enable the phobia to be resolved.

In severe cases of obsessive acts a passive waiting attitude seems even less indicated. Indeed in general these cases incline to an ‘asymptotic’ process of recovery, an interminable protraction of the treatment. Their analysis is always in danger of bringing to light a great deal and changing nothing. I think there is little doubt that here the correct technique can only be to wait until the treatment itself has become a compulsion, and then with this counter-compulsion forcibly to suppress the compulsion of the disease. You will understand, however, that these two instances I have given you are only samples of the new developments towards which our therapy is tending.

And now in conclusion I will cast a glance at a situation which belongs to the future - one that will seem fantastic to many of you, but which I think, nevertheless, deserves that we should be prepared for it in our minds. You know that our therapeutic activities are not very far-reaching. There are only a handful of us, and even by working very hard each one can devote himself in a year to only a small number of patients. Compared to the vast amount of neurotic misery which there is in the world, and perhaps need not be, the quantity we can do away with is almost negligible. Besides this, the necessities of our existence limit our work to the well-to-do classes, who are accustomed to choose their own physicians and whose choice is diverted away from psycho-analysis by all kinds of prejudices. At present we can do nothing for the wider social strata, who suffer extremely seriously from neuroses.

Now let us assume that by some kind of organization we succeeded in increasing our numbers to an extent sufficient for treating a considerable mass of the population. On the other hand, it is possible to foresee that at some time or other the conscience of society will awake and remind it that the poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery; and that the neuroses threaten public health no less than tuberculosis, and can be left as little as the latter to the impotent care of individual members of the community. When this happens, institutions or out-patient clinics will be started, to which analytically-trained physicians will be appointed, so that men who would otherwise give way to drink, women who have nearly succumbed under their burden of privations, children for whom there is no choice but between running wild or neurosis, may be made capable, by analysis, of resistance and of efficient work. Such treatments will be free. It may be a long time before the State comes to see these duties as urgent. Present conditions may delay its arrival even longer. Probably these institutions will first be started by private charity. Some time or other, however, it must come to this.

We shall then be faced by the task of adapting our technique to the new conditions. I have no doubt that the validity of our psychological assumptions will make its impression on the uneducated too, but we shall need to look for the simplest and most easily intelligible ways of expressing our theoretical doctrines. We shall probably discover that the poor are even less ready to part with their neuroses than the rich, because the hard life that awaits them if they recover offers them no attraction, and illness gives them one more claim to social help. Often, perhaps, we may only be able to achieve anything by combining mental assistance with some material support, in the manner of the Emperor Joseph. It is very probable, too, that the large-scale application of our therapy will compel us to alloy the pure gold of analysis freely with the copper of direct suggestion; and hypnotic influence, too, might find a place in it again, as it has in the treatment of war neuroses. But, whatever form this psychotherapy for the people may take, whatever the elements out of which it is compounded, its most effective and most important ingredients will assuredly remain those borrowed from strict and untendentious psycho-analysis.

ON THE TEACHING OF PSYCHO-ANALYSIS IN UNIVERSITIES (1919)

The question of the advisability of teaching psycho-analysis in Universities may be considered from two points of view: that of psycho-analysis and that of the University.

(1) The inclusion of psycho-analysis in the University curriculum would no doubt be regarded with satisfaction by every psycho-analyst. At the same time it is clear that the psycho-analyst can dispense entirely with the University without any loss to himself. For what he needs in the matter of theory can be obtained from the literature of the subject and, going more deeply, at the scientific meetings of the psycho-analytic societies as well as by personal contact with their more experienced members. As regards practical experience, apart from what he gains from his own personal analysis, he can acquire it by carrying out treatments, provided that he can get supervision and guidance from recognized psycho-analysts.

The fact that an organization of this kind exists is actually due to the exclusion of psycho-analysis from Universities. And it is therefore evident that these arrangements will continue to perform an effective function so long as this exclusion persists.

(2) So far as the Universities are concerned, the question depends on their deciding whether they are willing to attribute any value at all to psycho-analysis in the training of physicians and scientists. If so, the further problem remains of how it is to be incorporated into the regular educational framework.

The importance of psycho-analysis for the whole of medical and academic training is based on the following facts:

(a) This training has been quite rightly criticized during the last few decades for the one-sided way in which it directs the student into the fields of anatomy, physics and chemistry, while failing, on the other hand, to make plain to him the significance of mental factors in the different vital functions as well as in illnesses and their treatment. This short-coming in medical education makes itself felt later as a flagrant blind spot in the physician. This will not only show itself in his lack of interest in the most absorbing problems of human life, whether healthy or diseased, but will also render him unskilful in his treatment of patients, so that even quacks and ‘healers’ will have a greater effect on them than he does.9

This obvious deficiency led some time ago to the inclusion in the University curriculum of courses of lectures on medical psychology. But so long as these lectures were based on academic psychology or on experimental psychology (which deals only with questions of detail), they were unable to meet the requirements of the student’s training; nor could they bring him any nearer to the problems of life in general or to those of his profession. For these reasons the place occupied by this kind of medical psychology in the curriculum proved insecure.

A course of lectures on psycho-analysis, on the other hand, would certainly answer these requirements. Before coming to psycho-analysis proper, an introductory course would be needed, which would deal in detail with the relations between mental and physical life - the basis of all kinds of psychotherapy -, would describe the various kinds of suggestive procedures, and would finally show how psycho-analysis constitutes the outcome and culmination of all the earlier methods of mental treatment. Psycho-analysis, in fact, more than any other system, is fitted for teaching psychology to the medical student.

(b) Another of the functions of psycho-analysis should be to afford a preparation for the study of psychiatry. This, in its present shape, is exclusively descriptive in character; it merely teaches the student to recognize a series of pathological entities, enabling him to distinguish which are incurable and which are dangerous to the community. Its sole connection with the other branches of medical science lies in organic aetiology - that is, in its anatomical findings; but it offers not the slightest understanding of the facts observed. Such an understanding can be furnished only by a depth-psychology.

In America, according to the best of my information, it has already been recognized that psycho-analysts (the first attempt at a depth-psychology) has made successful inroads into this unexplored region of psychiatry. Many medical schools in that country, accordingly, have already organized courses of psycho-analysis as an introduction to psychiatry.

The teaching of psycho-analysis would have to proceed in two stages: an elementary course, designed for all medical students, and a course of specialized lectures for psychiatrists.

(c) In the investigation of mental processes and intellectual functions, psycho-analysis pursues a specific method of its own. The application of this method is by no means confined to the field of psychological disorders, but extends also to the solution of problems in art, philosophy and religion. In this direction it has already yielded several new points of view and thrown valuable light on such subjects as the history of literature, on mythology, on the history of civilizations and on the philosophy of religion. Thus the general psycho-analytic course should be thrown open to the students of these branches of learning as well. The fertilizing effects of psycho-analytic thought on these other disciplines would certainly contribute greatly towards forging a closer link, in the sense of a universitas literarum, between medical science and the branches of learning which lie within the sphere of philosophy and the arts.

To sum up, it may be asserted that a University stands only to gain by the inclusion in its curriculum of the teaching of psycho-analysis. That teaching, it is true, can only be given in a dogmatic and critical manner, by means of theoretical lectures; for these lectures will allow only a very restricted opportunity for carrying out experiments or for practical demonstrations. For the purposes of research, it should be sufficient for teachers of psycho-analysis to have access to an out-patient department for the supply of the necessary material in the form of ‘neurotic’ patients. For psycho-analytic psychiatry, a mental in-patient department would also have to be available.

Consideration, lastly, must be given to the objection that, along these lines, the medical student will never learn psycho-analysis proper. This is indeed true, if we have in mind the actual practice of psycho-analysis. But for the purposes we have in view it will be enough if he learns something about psycho-analysis and something from it. After all, University training does not equip the medical student to be a skilled surgeon; and no one who chooses surgery as a profession can avoid further training in the form of several years of work in a surgical department of a hospital.

‘A CHILD IS BEING BEATEN’

A CONTRIBUTION TO THE STUDY OF THE ORIGIN OF SEXUAL PERVERSIONS (1919)

It is surprising how often people who seek analytic treatment for hysteria or an obsessional neurosis confess to having indulged in the phantasy: ‘A child is being beaten.’ Very probably there are still more frequent instances of it among the far greater number of people who have not been obliged to come to analysis by manifest illness.

The phantasy has feelings of pleasure attached to it, and on their account the patient has reproduced it on innumerable occasions in the past or may even still be doing so. At the climax of the imaginary situation there is almost invariably a masturbatory satisfaction - carried out, that is to say, on the genitals. At first this takes place voluntarily, but later on it does so in spite of the patient’s efforts, and with the characteristics of an obsession.

It is only with hesitation that this phantasy is confessed to. Its first appearance is recollected with uncertainty. The analytic treatment of the topic is met by unmistakable resistance. Shame and a sense of guilt are perhaps more strongly excited in this connection than when similar accounts are given of memories of the beginning of sexual life. Eventually it becomes possible to establish that the first phantasies of the kind were entertained very early in life: certainly before school age, and not later than in the fifth or sixth year. When the child was at school and saw other children being beaten by the teacher, then, if the phantasies had become dormant, this experience called them up again, or, if they were still present, it reinforced them and noticeably modified their content. From that time forward it was ‘an indefinite number’ of children that were being beaten. The influence of the school was so clear that the patients concerned were at first tempted to trace back their beating-phantasies exclusively to these impressions of school life, which dated from later than their sixth year. But it was never possible for them to maintain that position; the phantasies had already been in existence before.

Though in the higher forms at school the children were no longer beaten, the influence of such occasions was replaced and more than replaced by the effects of reading, of which the importance was soon to be felt. In my patients’ milieu it was almost always the same books whose contents gave a new stimulus to the beating-phantasies: those accessible to young people, such as what was known as the ‘Bibliothèque rose’, Uncle Tom’s Cabin, etc. The child began to compete with these works of fiction by producing his own phantasies and by constructing a wealth of situations and institutions, in which children were beaten, or were punished and disciplined in some other way, because of their naughtiness and bad behaviour.

This phantasy - ‘a child is being beaten’ - was invariably cathected with a high degree of pleasure and had its issue in an act of pleasurable auto-erotic satisfaction. It might therefore be expected that the sight of another child being beaten at school would also be a source of similar enjoyment. But as a matter of fact this was never so. The experience of real scenes of beating at school produced in the child who witnessed them a peculiarly excited feeling which was probably of a mixed character and in which repugnance had a large share. In a few cases the real experience of the scenes of beating was felt to be intolerable. Moreover, it was always a condition of the more sophisticated phantasies of later years that the punishment should do the children no serious injury.

The question was bound to arise of what relation there might be between the importance of the beating-phantasies and the part that real corporal punishment might have played in the child’s bringing up at home. It was impossible, on account of the one-sidedness of the material, to confirm the first suspicion that the relation was an inverse one. The individuals from whom the data for these analyses were derived were very seldom beaten in their childhood, or were at all events not brought up by the help of the rod. Naturally, however, each of these children was bound to have become aware at one time or another of the superior physical strength of its parents or educators; the fact that in every nursery the children themselves at times come to blows requires no special emphasis.

As regards the early and simple phantasies which could not be obviously traced to the influence of school impressions or of scenes taken from books, further information would have been welcome. Who was the child that was being beaten? The one who was himself producing the phantasy or another? Was it always the same child or as often as not a different one? Who has it that was beating the child? A grown-up person? And if so, who? Or did the child imagine that he himself was beating another one? Nothing could be ascertained that threw any light upon all these questions - only the hesitant reply: ‘I know nothing more about it: a child is being beaten.’

Enquiries as to the sex of the child that was being beaten met with more success, but none the less brought no enlightenment. Sometimes the answer was: ‘Always boys’, or ‘Only girls’; more often it was: ‘I don’t know, or ‘It doesn’t matter which’. But the point to which the questions were directed, the discovery of some constant relation between the sex of the child producing the phantasy and that of the child that was being beaten, was never established. Now and again another characteristic detail of the content of the phantasy came to light: ‘A small child is being beaten on its naked bottom.’

In these circumstances it was impossible at first even to decide whether the pleasure attaching to the beating-phantasy was to be described as sadistic or masochistic.

II

A phantasy of this kind, arising, perhaps from accidental causes, in early childhood and retained for the purpose of auto-erotic satisfaction, can, in the light of our present knowledge, only be regarded as a primary trait of perversion. One of the components of the sexual function has, it seems, developed in advance of the rest, has made itself prematurely independent, has undergone fixation and in consequence been withdrawn from the later processes of development, and has in this way given evidence of a peculiar and abnormal constitution in the individual. We know that an infantile perversion of this sort need not persist for a whole lifetime; later on it can be subjected to repression, be replaced by a reaction-formation, or be transformed by sublimation. (It is possible that sublimation arises out of some special process which would be held back by repression.) But if these processes do not take place, then the perversion persists to maturity; and whenever we find a sexual aberration in adults - perversion, fetishism, inversion - we are justified in expecting that anamnestic investigation will reveal an event such as I have suggested, leading to a fixation in childhood. Indeed, long before the days of psycho-analysis, observers like Binet were able to trace the strange sexual aberrations of maturity back to similar impressions and to precisely the same period of childhood, namely, the fifth or sixth year. But at this point the enquiry was confronted with the limitations of our knowledge; for the impressions that brought about the fixation were without any traumatic force. They were for the most part commonplace and unexciting to other people. It was impossible to say why the sexual impulse had undergone fixation particularly upon them. It was possible, however, to look for their significance in the fact that they offered an occasion for fixation (even though it was an accidental one) to precisely that component which was prematurely developed and ready to press forward. We had in any case to be prepared to come to a provisional end somewhere or other in tracing back the train of causal connection; and the congenital constitution seemed exactly to correspond with what was required for a stopping-place of that kind.

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