On the occasion of the opening of the hebrew University 15 страница

‘That really sounds most mysterious. The strangest thing about it is that apparently even this mighty force of the patient’s conscience does not reach his consciousness.’6

Yes, we are only beginning to appreciate the significance of all these important circumstances. That is why my description was bound to turn out so obscure. But now I can proceed. We describe all the forces that oppose the work of recovery as the patient’s ‘resistances’. The gain from illness is one such resistance. The ‘unconscious sense of guilt’ represents the super-ego’s resistance; it is the most powerful factor, and the one most dreaded by us. We meet with still other resistances during the treatment. If the ego during the early period has set up a repression out of fear, then the fear still persists and manifests itself as a resistance if the ego approaches the repressed material. And finally, as you can imagine, there are likely to be difficulties if an instinctual process which has been going along a particular path for whole decades is suddenly expected to take a new path that has just been made open for it. That might be called the id’s resistance. The struggle against all these resistances is our main work during an analytic treatment; the task of making interpretations is nothing compared to it. But as a result of this struggle and of the overcoming of the resistances, the patient’s ego is so much altered and strengthened that we can look forward calmly to his future behaviour when the treatment is over. On the other hand, you can understand now why we need such long treatments. The length of the path of development and the wealth of the material are not the decisive factors. It is more a question of whether the path is clear. An army can be held up for weeks on a stretch of country which in peace time an express train crosses in a couple of hours - if the army has to overcome the enemy’s resistance there. Such battles call for time in mental life too. I am unfortunately obliged to tell you that every effort to hasten analytic treatment appreciably has hitherto failed. The best way of shortening it seems to be to carry it out according to the rules.

‘If I ever felt any desire to poach on your preserves and try my hand at analysing someone else, what you tell me about the resistances would have cured me of it. But how about the special personal influence that you yourself have after all admitted? Does not that come into action against the resistances?’

It is a good thing you have asked me about that. This personal influence is our most powerful dynamic weapon. It is the new element which we introduce into the situation and by means of which we make it fluid. The intellectual content of our explanations cannot do it, for the patient, who shares all the prejudices of the world around him, need believe us as little as our scientific critics do. The neurotic sets to work because he has faith in the analyst, and he believes him because he acquires a special emotional attitude towards the figure of the analyst. Children, too, only believe people they are attached to. I have already told you what use we make of this particularly large ‘suggestive’ influence. Not for suppressing the symptoms - this distinguishes the analytic method from other psychotherapeutic procedures - but as a motive force to induce the patient to overcome his resistances.

‘Well, and if that succeeds, does not everything then go smoothly?’

Yes, it ought to. But there turns out to be an unexpected complication. It was perhaps the greatest of the analyst’s surprises to find that the emotional relation which the patient adopts towards him is of a quite peculiar nature. The very first doctor who attempted an analysis - it was not myself - came up against this phenomenon and did not know what to make of it. For this emotional relation is, to put it plainly, in the nature of falling in love. Strange, is it not? Especially when you take into account that the analyst does nothing to provoke it but on the contrary rather keeps at a distance from the patient, speaking humanly, and surrounds himself with some degree of reserve - when you learn besides that this odd love-relationship disregards anything else that is really propitious and every variation in personal attraction, age, sex or class. This love is of a positively compulsive kind. Not that that characteristic need be absent from spontaneous falling in love. As you know, the contrary is often the case. But in the analytic situation it makes its appearance with complete regularity without there being any rational explanation for it. One would have thought that the patient’s relation to the analyst called for no more than a certain amount of respect, trust, gratitude and human sympathy. Instead, there is this falling in love, which itself gives the impression of being a pathological phenomenon.

‘I should have thought all the same that it would be favourable for your analytic purposes. If someone is in love, he is amenable, and he will do anything in the world for the sake of the other person.’

Yes. It is favourable to start with. But when this falling in love has grown deeper, its whole nature comes to light, much of which is incompatible with the task of analysis. The patient’s love is not satisfied with being obedient; it grows exacting, calls for affectionate and sensual satisfactions, it demands exclusiveness, it develops jealousy, and it shows more and more clearly its reverse side, its readiness to become hostile and revengeful if it cannot obtain its ends. At the same time, like all falling in love, it drives away all other mental material; it extinguishes interest in the treatment and in recovery - in short, there can be no doubt that it has taken the place of the neurosis and that our work has had the result of driving out one form of illness with another.

‘That does sound hopeless! What can be done about it? The analysis would have to be given up. But if, as you say, the same thing happens in every case, it would be impossible to carry through any analyses at all.’

We will begin by using the situation in order to learn something from it. What we learn may then perhaps help us to master it. Is it not an extremely noteworthy fact that we succeed in transforming every neurosis, whatever its content, into a condition of pathological love?

Our conviction that a portion of erotic life that has been abnormally employed lies at the basis of neuroses must be unshakeably strengthened by this experience. With this discovery we are once more on a firm footing and can venture to make this love itself the object of analysis. And we can make another observation. Analytic love is not manifested in every case as clearly and blatantly as I have tried to depict it. Why not? We can soon see. In proportion as the purely sensual and the hostile sides of his love try to show themselves, the patient’s opposition to them is aroused. He struggles against them and tries to repress them before our very eyes. And now we understand what is happening. The patient is repeating in the form of falling in love with the analyst mental experiences which he has already been through once before; he has transferred on to the analyst mental attitudes that were lying ready in him and were intimately connected with his neurosis. He is also repeating before our eyes his old defensive actions; he would like best to repeat in his relation to the analyst all the history of that forgotten period of his life. So what he is showing us is the kernel of his intimate life history: he is reproducing it tangibly, as though it were actually happening, instead of remembering it. In this way the riddle of the transference-love is solved and the analysis can proceed on its way - with the help of the new situation which had seemed such a menace to it.

‘That is very cunning. And is the patient so easy to convince that he is not in love but only obliged to stage a revival of an old piece!’

Everything now depends on that. And the whole skill in handling the ‘transference’ is devoted to bringing it about. As you see, the requirements of analytic technique reach their maximum at this point. Here the gravest mistakes can be made or the greatest successes be registered. It would be folly to attempt to evade the difficulties by suppressing or neglecting the transference; whatever else had been done in the treatment, it would not deserve the name of an analysis. To send the patient away as soon as the inconveniences of his transference neurosis make their appearance would be no more sensible, and would moreover be cowardly. It would be as though one had conjured up spirits and run away from them as soon as they appeared. Sometimes, it is true, nothing else is possible. There are cases in which one cannot master the unleashed transference and the analysis has to be broken of; but one must at least have struggled with the evil spirits to the best of one’s strength. To yield to the demands of the transference, to fulfil the patient’s wishes for affectionate and sensual satisfaction, is not only justly forbidden by moral considerations but is also completely ineffective as a technical method for attaining the purpose of the analysis. A neurotic cannot be cured by being enabled to reproduce uncorrected an unconscious stereotype plate that is ready to hand in him. If one engages in compromises with him by offering him partial satisfactions in exchange for his further collaboration in the analysis, one must beware of falling into the ridiculous situation of the cleric who was supposed to convert a sick insurance agent. The sick man remained unconverted but the cleric took his leave insured. The only possible way out of the transference situation is to trace it back to the patient’s past, as he really experienced it or as he pictured it through the wish-fulfilling activity of his imagination. And this demands from the analyst much skill, patience, calm and self-abnegation.

‘And where do you suppose the neurotic experienced the prototype of his transference-love?’

In his childhood: as a rule in his relation with one of his parents. You will remember what importance we had to attribute to these earliest emotional ties. So here the circle closes.0

‘Have you finished at last? I am feeling just a little bewildered with all I have heard from you. Only tell me one thing more: how and where can one learn what is necessary for practising analysis?’

There are at the moment two Institutes at which instruction in psycho-analysis is given. The first has been founded in Berlin by Dr. Max Eitingon, who is a member of the Society there. The second is maintained by the Vienna Psycho-Analytical Society at its own expense and at considerable sacrifice. The part played by the authorities is at present limited to the many difficulties which they put in the way of the young undertaking. A third training Institute is at this moment being opened in London by the Society there, under the direction of Dr. Ernest Jones. At these Institutes the candidates themselves are taken into analysis, receive theoretical instruction by lectures on all the subjects that are important for them, and enjoy the supervision of older and more experienced analysts when they are allowed to make their first trials with comparatively slight cases. A period of some two years is calculated for this training. Even after this period, of course, the candidate is only a beginner and not yet a master. What is still needed must be acquired by practice and by an exchange of ideas in the psycho-analytical societies in which young and old members meet together. Preparation for analytic activity is by no means so easy and simple. The work is hard, the responsibility great. But anyone who has passed through such a course of instruction, who has been analysed himself, who has mastered what can be taught to-day of the psychology of the unconscious, who is at home in the science of sexual life, who has learnt the delicate technique of psycho-analysis, the art of interpretation, of fighting resistances and of handling the transference - anyone who has accomplished all this is no longer a layman in the field of psycho-analysis. He is capable of undertaking the treatment of neurotic disorders, and will be able in time to achieve in that field whatever can be required from this form of therapy.

VI

‘You have expended a great deal of effort on showing me what psycho-analysis is and what sort of knowledge is needed in order to practise it with some prospect of success. Very well. Listening to you can have done me no harm. But I do not know what influence on my judgement you expect your explanations to have. I see before me a case which has nothing unusual about it. The neuroses are a particular kind of illness and analysis is a particular method of treating them - a specialized branch of medicine. It is the rule in other cases as well for a doctor who has chosen a special branch of medicine not to be satisfied with the education that is confirmed by his diploma: particularly if he intends to set up in a fairly large town, such as can alone offer a livelihood to specialists. Anyone who wants to be a surgeon tries to work for a few years at a surgical clinic, and similarly with oculists, laryngologists and so on - to say nothing of psychiatrists, who are perhaps never able to get away from a state institution or a sanatorium. And the same will happen in the case of psycho-analysts: anyone who decides in favour of this new specialized branch of medicine will, when his studies are completed, take on the two years’ training you spoke of in a training institute, if it really requires so much time. He will realize afterwards, too, that it is to his advantage to keep up his contact with his colleagues in a psycho-analytical society, and everything will go along swimmingly. I cannot see where there is a place in this for the question of lay analysis.’

A doctor who does what you have promised on his behalf will be welcome to all of us. Four-fifths of those whom I recognize as my pupils are in any case doctors. But allow me to point out to you how the relations of doctors to analysis have really developed and how they will probably continue to develop. Doctors have no historical claim to the sole possession of analysis. On the contrary, until recently they have met it with everything possible that could damage it, from the shallowest ridicule to the gravest calumny. You will justly reply that that belongs to the past and need not affect the future. I agree, but I fear the future will be different from what you have foretold.

Permit me to give the word ‘quack’ the meaning it ought to have instead of the legal one. According to the law a quack is anyone who treats patients without possessing a state diploma to prove he is a doctor. I should prefer another definition: a quack is anyone who undertakes a treatment without possessing the knowledge and capacities necessary for it. Taking my stand on this definition, I venture to assert that - not only in European countries - doctors form a preponderating contingent of quacks in analysis. They very frequently practise analytic treatment without having learnt it and without understanding it.

It is no use your objecting that that is unconscientious and that you cannot believe doctors capable of it; that after all a doctor knows that a medical diploma is not a letter of marque and that a patient is not an outlaw; and that one must always grant to a doctor that he is acting in good faith even if he may perhaps be in error.

The facts remain; we will hope that they can be accounted for as you think. I will try to explain to you how it becomes possible for a doctor to act in connection with psycho-analysis in a manner which he would carefully avoid in every other field.

The first consideration is that in his medical school a doctor receives a training which is more or less the opposite of what he would need as a preparation for psycho-analysis. His attention has been directed to objectively ascertainable facts of anatomy, physics and chemistry, on the correct appreciation and suitable influencing of which the success of medical treatment depends. The problem of life is brought into his field of vision so far as it has hitherto been explained to us by the play of forces which can also be observed in inanimate nature. His interest is not aroused in the mental side of vital phenomena; medicine is not concerned with the study of the higher intellectual functions, which lies in the sphere of another faculty. Only psychiatry is supposed to deal with the disturbances of mental functions; but we know in what manner and with what aims it does so. It looks for the somatic determinants of mental disorders and treats them like other causes of illness.

Psychiatry is right to do so and medical education is clearly excellent. If it is described as one-sided, one must first discover the standpoint from which one is making that characteristic into a reproach. In itself every science is one-sided. It must be so, since it restricts itself to particular subjects, points of view and methods. It is a piece of nonsense in which I would take no part to play off one science against another. After all, physics does not diminish the value of chemistry; it cannot take its place but on the other hand cannot be replaced by it. Psycho-analysis is certainly quite particularly one-sided, as being the science of the mental unconscious. We must not therefore dispute to the medical sciences their right to be one-sided.

We shall only find the standpoint we are in search of if we turn from scientific medicine to practical therapeutics. A sick person is a complicated organism. He may remind us that even the mental phenomena which are so hard to grasp should not be effaced from the picture of life. Neurotics, indeed, are an undesired complication, an embarrassment as much to therapeutics as to jurisprudencc and to military service. But they exist and are a particular concern of medicine. Medical education, however, does nothing, literally nothing, towards their understanding and treatment. In view of the intimate connection between the things that we distinguish as physical and mental, we may look forward to a day when paths of knowledge and, let us hope, of influence will be opened up, leading from organic biology and chemistry to the field of neurotic phenomena. That day still seems a distant one, and for the present these illnesses are inaccessible to us from the direction of medicine.

It would be tolerable if medical education merely failed to give doctors any orientation in the field of the neuroses. But it does more: it gives them a false and detrimental attitude. Doctors whose interest has not been aroused in the psychical factors of life are all too ready to form a low estimate of them and to ridicule them as unscientific. For that reason they are unable to take anything really seriously which has to do with them and do not recognize the obligations which derive from them. They therefore fall into the layman’s lack of respect for psychological research and make their own task easy for themselves. - No doubt neurotics have to be treated, since they are sick people and come to the doctor; and one must always be ready to experiment with something new. But why burden oneself with a tedious preparation? We shall manage all right; who can tell if what they teach in the analytic institutes is any good? - The less such doctors understand about the matter, the more venturesome they become. Only a man who really knows is modest, for he knows how insufficient his knowledge is.

The comparison which you brought up to pacify me, between specialization in analysis and in other branches of medicine, is thus not applicable. For surgery, ophthalmology, and so on, the medical school itself offers an opportunity for further education. The analytic training institutes are few in number, young in years, and without authority. The medical schools have not recognized them and take no notice of them. The young doctor, who has had to take so much on trust from his teachers that he has had little occasion for educating his judgement, will gladly seize an occasion for playing the part of a critic for once in a field in which there is as yet no recognized authority.

There are other things too that favour his appearing as an analytic quack. If he tried to undertake eye-operations without sufficient preparation, the failure of his cataract extractions and iridectomies and the absence of patients would soon bring his hazardous enterprise to an end. The practice of analysis is comparatively safe for him. The public is spoilt by the average successful outcome of eye-operations and expects cure from the surgeon. But if a ‘nerve-specialist’ fails to restore his patients no one is surprised. People have not been spoilt by successes in the therapy of the neuroses; the nerve-specialist has at least ‘taken a lot of trouble with them’. Indeed, there is not much that can be done; nature must help, or time. With women there is first menstruation, then marriage, and later on the menopause. Finally death is a real help. Moreover, what the medical analyst has done with his neurotic patient is so inconspicuous that no reproach can attach to it. He has made use of no instruments or medicines; he has merely conversed with him and tried to talk him into or out of something. Surely that can do no harm, especially if he avoids touching on distressing or agitating subjects. The medical analyst, who has avoided any strict teaching, will, no doubt, not have omitted an attempt to improve analysis, to pull out its poison fangs and make it pleasant for the patient. And it will be wise for him to stop there; for if he really ventures to call up resistances and then does not know how to meet them, he may in true earnest make himself unpopular.

Honesty compels me to admit that the activity of an untrained analyst does less harm to his patients than that of an unskilled surgeon. The possible damage is limited to the patient having been led into useless expenditure and having his chances of recovery removed or diminished. Furthermore, the reputation of analytic therapy has been lowered. All this is most undesirable, but it bears no comparison with the dangers that threaten from the knife of a surgical quack. In my judgement, severe or permanent aggravations of a pathological condition are not to be feared even with an unskilled use of analysis. The unwelcome reactions cease after a while. Compared with the traumas of life which have provoked the illness, a little mishandling by the doctor is of no account. It is simply that the unsuitable attempt at a cure has done the patient no good.

‘I have listened to your account of the medical quack in analysis without interrupting you, though I formed an impression that you are dominated by a hostility against the medical profession to the historical explanation of which you yourself have pointed the way. But I will grant you one thing: if analyses are to be carried out, it should be by people who have been thoroughly trained for it. And do you not think that with time the doctors who turn to analysis will do everything to obtain that training?’

I fear not. So long as the attitude of the medical school to the analytic training institute remains unaltered, doctors will find the temptation to make things easier for themselves too great.

‘But you seem to be consistently evading any direct pronouncement on the question of lay analysis. What I guess now is that, because it is impossible to keep a check on doctors who want to analyse, you are proposing, out of revenge, as it were, to punish them by depriving them of their monopoly in analysis and by throwing open this medical activity to laymen as well.’

I cannot say whether you have guessed my motives correctly. Perhaps I shall be able later on to put evidence before you of a less partial attitude. But I lay stress on the demand that no one should practise analysis who has not acquired the right to do so by a particular training. Whether such a person is a doctor or not seems to me immaterial.6

‘Then what definite proposals have you to make?’

I have not got so far as that yet; and I cannot tell whether I shall get there at all. I should like to discuss another question with you, and first of all to touch on one special point. It is said that the authorities, at the instigation of the medical profession, want to forbid the practice of analysis by laymen altogether. Such a prohibition would also affect the non-medical members of the Psycho-Analytical Society, who have enjoyed an excellent training and have perfected themselves greatly by practice. If the prohibition were enacted, we should find ourselves in a position in which a number of people are prevented from carrying out an activity which one can safely feel convinced they can perform very well, while the same activity is opened to other people for whom there is no question of a similar guarantee. That is not precisely the sort of result to which legislation should lead. However, this special problem is neither very important nor difficult to solve. Only a handful of people are concerned, who cannot be seriously damaged. They will probably emigrate to Germany where no legislation will prevent them from finding recognition for their proficiency. If it is desired to spare them this and to mitigate the law’s severity, that can easily be done on the basis of some well-known precedents. Under the Austrian Monarchy it repeatedly happened that permission was given to notorious quacks, ad personam, to carry out medical activities in certain fields, because people were convinced of their real ability. Those concerned were for the most part peasant healers, and their recommendation seems regularly to have been made by one of the Archduchesses who were once so numerous; but it ought to be possible for it also to be done in the case of town-dwellers and on the basis of a different and merely expert guarantee. Such a prohibition would have more important effects on the Vienna analytic training institute, which would thenceforward be unable to accept any candidates for training from non-medical circles. Thus once again in our country a line of intellectual activity would be suppressed which is allowed to develop freely elsewhere. I am the last person to claim any competence in judging laws and regulations. But this much I can see: that to lay emphasis on our quackery law does not lead in the direction of the approach to conditions in Germany which is so much aimed at to-day, and that the application of that law to the case of psycho-analysis has something of an anachronism about it, since at the time of its enactment there was as yet no such thing as analysis and the peculiar nature of neurotic illnesses was not yet recognized.

I come now to a question the discussion of which seems to me more important. Is the practice of psycho-analysis a matter which should in general be subject to official interference, or would it be more expedient to leave it to follow its natural development? I shall certainly not come to any decision on this point here and now, but I shall take the liberty of putting the problem before you for your consideration. In our country from of old a positive furor prohibendi has been the rule, a tendency to keep people under tutelage, to interfere and to forbid, which, as we all know, has not borne particularly good fruit. In our new republican Austria, it seems, things have not yet changed very much. I fancy you will have an important word to say in deciding the case of psycho-analysis which we are now considering; I do not know whether you have the wish or the influence with which to oppose these bureaucratic tendencies. At all events, I shall not spare you my unauthoritative thoughts on the subject. In my opinion a superabundance of regulations and prohibitions injures the authority of the law. It can be observed that where only a few prohibitions exist they are carefully observed, but where one is accompanied by prohibitions at every step, one feels definitely tempted to disregard them. Moreover, it does not mean one is quite an anarchist if one is prepared to realize that laws and regulations cannot from their origin claim to possess the attribute of being sacred and untransgressable, that they are often inadequately framed and offend our sense of justice, or will do so after a time, and that, in view of the sluggishness of the authorities, there is often no other means of correcting such inexpedient laws than by boldly violating them. Furthermore, if one desires to maintain respect for laws and regulations it is advisable not to enact any where a watch cannot easily be kept on whether they are obeyed or transgressed. Much of what I have quoted above on the practice of analysis by doctors could be repeated here in regard to genuine analysis by laymen which the law is seeking to suppress. The course of an analysis is most inconspicuous, it employs neither medicines nor instruments and consists only in talking and an exchange of information; it will not be easy to prove that a layman is practising ‘analysis’, if he asserts that he is merely giving encouragement and explanations and trying to establish a healthy human influence on people who are in search of mental assistance. It would surely not be possible to forbid that merely because doctors sometimes do the same thing. In English-speaking countries the practices of Christian Science have become very widespread: a kind of dialectical denial of the evils in life, based on an appeal to the doctrines of the Christian religion. I do not hesitate to assert that that procedure represents a regrettable aberration of the human spirit; but who in America or England would dream of forbidding it and making it punishable? Are the authorities so certain of the right path to salvation that they venture to prevent each man from trying ‘to be saved after his own fashion’. And granted that many people if they are left to themselves run into danger and come to grief, would not the authorities do better carefully to mark the limits of the regions which are to be regarded as not to be trespassed upon, and for the rest, so far as possible, to allow human beings to be educated by experience and mutual influence? Psycho-analysis is something so new in the world, the mass of mankind is so little instructed about it, the attitude of official science to it is still so vacillating, that it seems to me over-hasty to intervene in its development with legislative regulations. Let us allow patients themselves to discover that it is damaging to them to look for mental assistance to people who have not learnt how to give it. If we explain this to them and warn them against it, we shall have spared ourselves the need to forbid it. On the main roads of Italy the pylons that carry high-tension cables bear the brief and impressive inscription: ‘Chi tocca, muore.’ This is perfectly calculated to regulate the behaviour of passers-by to any wires that may be hanging down. The corresponding German notices exhibit an unnecessary and offensive verbosity: ‘Das Berühren der Leitungsdrähte ist, weil lebensgefährlich, stregstens verboten.’ Why the prohibition? Anyone who holds his life dear will make the prohibition for himself; and anyone who wants to kill himself in that way will not ask for permission.

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