On the occasion of the opening of the hebrew University 17 страница

‘Aha! a new kind of Salvation Army!’

Why not? Our imagination always follows patterns. The stream of eager learners who will then flow to Europe will be obliged to pass Vienna by, for here the development of analysis may have succumbed to a premature trauma of prohibition. You smile? I am not saying this as a bribe for your support. Not in the least. I know you do not believe me; nor can I guarantee that it will happen. But one thing I do know. It is by no means so important what decision you give on the question of lay analysis. It may have a local effect. But the things that really matter - the possibilities in psycho-analysis for internal development - can never be affected by regulations and prohibitions.

POSTSCRIPT

(1927)

The immediate occasion of my writing the small volume which was the starting-point of the present discussion was a charge of quackery brought against a non-medical member of our Society, Dr. Theodor Reik, in the Vienna Courts. It is generally known, I think, that after all the preliminary proceedings had been completed and a number of expert opinions had been received, the charge was dropped. I do not believe that this was a result of my book. No doubt the prosecution’s case was too weak, and the person who brought the charge as an aggrieved party proved an untrustworthy witness. So that the quashing of the proceedings against Dr. Reik is probably not to be regarded as a considered judgement of the Vienna Courts on the general question of lay analysis. When I drew the figure of the ‘Impartial Person’ who was my interlocutor in my tract, I had before my mind one of our high officials. This was a man with a friendly attitude and a mind of unusual integrity, to whom I had myself talked about Reik’s case and for whom I had, at his request, written a confidential opinion on the subject. I knew I had not succeeded in converting him to my views, and that was why I made my dialogue with the Impartial Person end without agreement too.

Nor did I expect that I should succeed in bringing about unanimity in the attitude of analysts themselves towards the problem of lay analysis. Anyone who compares the views expressed by the Hungarian Society in this discussion with those of the New York group will perhaps conclude that my book has produced no effect whatever and that everyone persists in his former opinion. But I do not believe this either. I think that many of my colleagues have modified their extreme parti pris and that the majority have accepted my view that the problem of lay analysis ought not to be decided along the lines of traditional usage but that it arises from a novel situation and therefore demands a fresh judgement.

Again, the turn which I gave to the whole discussion seems to have met with approval. My main thesis was that the important question is not whether an analyst possesses a medical diploma but whether he has had the special training necessary for the practice of analysis. This served as the starting-point for a discussion, which was eagerly embarked upon, as to what is the training most suitable for an analyst. My own view was and still remains that it is not the training prescribed by the University for future doctors. What is known as medical education appears to me to be an arduous and circuitous way of approaching the profession of analysis. No doubt it offers an analyst much that is indispensable to him. But it burdens him with too much else of which he can never make use, and there is a danger of its diverting his interest and his whole mode of thought from the understanding of psychical phenomena. A scheme of training for analysts has still to be created. It must include elements from the mental sciences, from psychology, the history of civilization and sociology, as well as from anatomy, biology and the study of evolution. There is so much to be taught in all this that it is justifiable to omit from the curriculum anything which has no direct bearing on the practice of analysis and only serves indirectly (like any other study) as a training for the intellect and for the powers of observation. It is easy to meet this suggestion by objecting that analytic colleges of this kind do not exist and that I am merely setting up an ideal. An ideal, no doubt. But an ideal which can and must be realized. And in our training institutes, in spite of all their youthful insufficiencies, that realization has already begun.

It will not have escaped my readers that in what I have said I have assumed as axiomatic something that is still violently disputed in the discussion. I have assumed, that is to say, that psycho-analysis is not a specialized branch of medicine. I cannot see how it is possible to dispute this. Psycho-analysis is a part of psychology; not of medical psychology in the old sense, not of the psychology of morbid processes, but simply of psychology. It is certainly not the whole of psychology, but its sub-structure and perhaps even its entire foundation. The possibility of its application to medical purposes must not lead us astray. Electricity and radiology also have their medical application, but the science to which they both belong is none the less physics. Nor can their situation be affected by historical arguments. The whole theory of electricity had its origin in an observation of a nerve-muscle preparation; yet no one would dream to-day of regarding it as a part of physiology. It is argued that psycho-analysis was after all discovered by a physician in the course of his efforts to assist his patients. But that is clearly neither here nor there. Moreover, the historical argument is double-edged. We might pursue the story and recall the unfriendliness and indeed the animosity with which the medical profession treated analysis from the very first. That would seem to imply that it can have no claims over analysis to-day. And though I do not accept that implication, I still feel some doubts as to whether the present wooing of psycho-analysis by the doctors is based, from the point of view of the libido theory, upon the first or upon the second of Abraham’s sub-stages - whether they wish to take possession of their object for the purpose of destroying or of preserving it.

I should like to consider the historical argument a moment longer. Since it is with me personally that we are concerned, I can throw a little light, for anyone who may be interested, on my own motives. After forty-one years of medical activity, my self-knowledge tells me that I have never really been a doctor in the proper sense. I became a doctor through being compelled to deviate from my original purpose; and the triumph of my life lies in my having, after a long and roundabout journey, found my way back to my earliest path. I have no knowledge of having had any craving in my early childhood to help suffering humanity. My innate sadistic disposition was not a very strong one, so that I had no need to develop this one of its derivatives. Nor did I ever play the ‘doctor game’; my infantile curiosity evidently chose other paths. In my youth I felt an overpowering need to understand something of the riddles of the world in which we live and perhaps even to contribute something to their solution. The most hopeful means of achieving this end seemed to be to enrol myself in the medical faculty; but even after that I experimented - unsuccessfully - with zoology and chemistry, till at last, under the influence of Brücke, who carried more weight with me than any one else in my whole life, I settled down to physiology, though in those days it was too narrowly restricted to histology. By that time I had already passed all my medical examinations; but I took no interest in anything to do with medicine till the teacher whom I so deeply respected warned me that in view of my impoverished material circumstances I could not possibly take up a theoretical career. Thus I passed from the histology of the nervous system to neuropathology and then, prompted by fresh influences, I began to be concerned with the neuroses. I scarcely think, however, that my lack of a genuine medical temperament has done much damage to my patients. For it is not greatly to the advantage of patients if their doctor’s therapeutic interest has too marked an emotional emphasis. They are best helped if he carries out his task coolly and keeping as closely as possible to the rules.

No doubt what I have just said throws little light on the problem of lay analysis; it was only intended to exhibit my personal credentials as being myself a supporter of the inherent value of psycho-analysis and of its independence of its application to medicine. But it will be objected at this point that whether psycho-analysis, regarded as a science, is a subdivision of medicine or of psychology is a purely academic question and of no practical interest. The real point at issue, it will be said, is a different one, namely the application of analysis to the treatment of patients; in so far as it claims to do this it must be content, the argument will run, to be accepted as a specialized branch of medicine, like radiology, for instance, and to submit to the rules laid down for all therapeutic methods. I recognize that that is so; I admit it. I only want to feel assured that the therapy will not destroy the science. Unluckily analogies never carry one more than a certain distance; a point is soon reached at which the subjects of the comparison take divergent paths. The case of analysis differs from that of radiology. A physicist does not require to have a patient in order to study the laws that govern X-rays. But the only subject-matter of psycho-analysis is the mental processes of human beings and it is only in human beings that it can be studied. For reasons which can easily be understood, neurotic human beings offer far more instructive and accessible material than normal ones, and to withhold that material from anyone who wishes to study and apply analysis is to dock him of a good half of his training possibilities. I have, of course, no intention of asking that the interests of neurotic patients should be sacrificed to those of instruction and scientific research. The aim of my small volume on the question of lay analysis was precisely to show that, if certain precautions are observed, the two interests can quite easily be brought into harmony and that the interests of medicine, as rightly understood, will not be the last to profit by such a solution.

I myself brought forward all the necessary precautions and I can safely say that the discussion added nothing on this point. But I should like to remark that the emphasis was often placed in a manner which did not do justice to the facts. What was said about the difficulties of differential diagnosis and the uncertainty in many cases in deciding about somatic symptoms - situations, that is, in which medical knowledge and medical intervention are necessary - this is all of it perfectly true. Nevertheless, the number of cases in which doubts of this kind never arise at all and in which a doctor is not required is surely incomparably greater. These cases may be quite uninteresting scientifically, but they play an important enough part in life to justify the activity of lay analysts, who are perfectly competent to deal with them. Some time ago I analysed a colleague who gave evidence of a particularly strong dislike of the idea of anyone being allowed to engage in a medical activity who was not himself a medical man. I was in a position to say to him: ‘We have now been working for more than three months. At what point in our analysis have I had occasion to make use of my medical knowledge?’ He admitted that I had had no such occasion.

Again, I attach no great importance to the argument that a lay analyst, because he must be prepared to consult a doctor, will have no authority in the eyes of his patients and will be treated with no more respect than such people as bone-setters or masseurs. Once again, the analogy is an imperfect one - quite apart from the fact that what governs patients in their recognition of authority is usually their emotional transference and that the possession of a medical diploma does not impress them nearly so much as doctors believe. A professional lay analyst will have no difficulty in winning as much respect as is due to a secular pastoral worker. Indeed, the words, ‘secular pastoral worker’, might well serve as a general formula for describing the function which the analyst, whether he is a doctor or a layman, has to perform in his relation to the public. Our friends among the protestant clergy, and more recently among the catholic clergy as well, are often able to relieve their parishioners of the inhibitions of their daily life by confirming their faith - after having first offered them a little analytic information about the nature of their conflicts. Our opponents, the Adlerian ‘individual psychologists’, endeavour to produce a similar result in people who have become unstable and inefficient by arousing their interest in the social community after having first thrown some light upon a single corner of their mental life and shown them the part played in their illness by their egoistic and distrustful impulses. Both of these procedures, which derive their power from being based on analysis, have their place in psychotherapy. We who are analysts set before us as our aim the most complete and profoundest possible analysis of whoever may be our patient. We do not seek to bring him relief by receiving him into the catholic, protestant or socialist community. We seek rather to enrich him from his own internal sources, by putting at the disposal of his ego those energies which, owing to repression, are inaccessibly confined in his unconscious, as well as those which his ego is obliged to squander in the fruitless task of maintaining these repressions. Such activity as this is pastoral work in the best sense of the words. Have we set ourselves too high an aim? Are the majority of our patients worth the pains that this work requires of us? Would it not be more economical to prop up their weaknesses from without rather than to rebuild them from within? I cannot say; but there is something else that I do know. In psycho-analysis there has existed from the very first an inseparable bond between cure and research. Knowledge brought therapeutic success. It was impossible to treat a patient without learning something new; it was impossible to gain fresh insight without perceiving its beneficent results. Our analytic procedure is the only one in which this precious conjunction is assured. It is only by carrying on our analytic pastoral work that we can deepen our dawning comprehension of the human mind. This prospect of scientific gain has been the proudest and happiest feature of analytic work. Are we to sacrifice it for the sake of any considerations of a practical sort?

Some remarks that have been made in the course of this discussion have led me to suspect that, in spite of everything, my book on lay analysis has been misunderstood in one respect. The doctors have been defended against me, as though I had declared that they were in general incompetent to practise analysis and as though I had given it out as a password that medical reinforcements were to be rejected. That was not my intention. The idea probably arose from my having been led to declare in the course of my observations (which had a controversial end in view) that untrained medical analysts were even more dangerous than laymen. I might make my true opinion on this question clear by echoing a cynical remark about women that once appeared in Simplicissimus. One man was complaining to another about the weaknesses and troublesome nature of the fair sex. ‘All the same,’ replied his companion, ‘women are the best thing we have of the kind.’ I am bound to admit that, so long as schools such as we desire for the training of analysts are not yet in existence, people who have had a preliminary education in medicine are the best material for future analysts. We have a right to demand, however, that they should not mistake their preliminary education for a complete training, that they should overcome the one-sidedness that is fostered by instruction in medical schools and that they should resist the temptation to flirt with endocrinology and the autonomic nervous system, when what is needed is an apprehension of psychological facts with the help of a framework of psychological concepts. I also share the view that all those problems which relate to the connection between psychical phenomena and their organic, anatomical and chemical foundations can be approached only by those who have studied both, that is, by medical analysts. It should not be forgotten, however, that this is not the whole of psycho-analysis, and that for its other aspect we can never do without the co-operation of people who have had a preliminary education in the mental sciences. For practical reasons we have been in the habit - and this is true, incidentally, of our publications as well - of distinguishing between medical and applied analysis. But that is not a logical distinction. The true line of division is between scientific analysis and its applications alike in medical and in non-medical fields.

In these discussions the bluntest rejection of lay analysis has been expressed by our American colleagues. A few words to them in reply will, I think, not be out of place. I can scarcely be accused of making a misuse of analysis for controversial purposes if I express an opinion that their resistance is derived wholly from practical factors. They see how in their own country lay analysts put analysis to all kinds of mischievous and illegitimate purposes and in consequence cause injury both to their patients and to the good name of analysis. It is therefore not to be wondered at if in their indignation they give the widest possible berth to such unscrupulous mischief-makers and try to prevent any laymen from having a share in analysis. But these facts are already enough to diminish the significance of the American position; for the question of lay analysis must not be decided on practical considerations alone, and local conditions in America cannot be the sole determining influence on our views.

The resolution passed by our American colleagues against lay analysts, based as it essentially is upon practical reasons, appears to me nevertheless to be unpractical; for it cannot affect any of the factors which govern the situation. It is more or less equivalent to an attempt at repression. If it is impossible to prevent the lay analysts from pursuing their activities and if the public does not support the campaign against them, would it not be more expedient to recognize the fact of their existence by offering them opportunities for training? Might it not be possible in this way to gain some influence over them? And, if they were offered as an inducement the possibility of receiving the approval of the medical profession and of being invited to co-operate, might they not have some interest in raising their own ethical and intellectual level?

VIENNA, June 1927

PSYCHO-ANALYSIS (1926)

Since psycho-analysis was not mentioned in the eleventh edition of the Encyclopaedia Britannica, it is impossible to restrict this account to its advances since 1910. The more important and the more interesting portion of its history lies in the period before that date.

PREHISTORY

In the years 1880-2 a Viennese physician, Dr. Josef Breuer (1842-1925), discovered a new procedure by means of which he relieved a girl, who was suffering from severe hysteria, of her many and various symptoms. The idea occurred to him that the symptoms were connected with impressions which she had received during a period of agitation while she was nursing her sick father. He therefore induced her, while she was in a state of hypnotic somnambulism, to search for these connections in her memory and to live through the ‘pathogenic’ scenes once again without inhibiting the affects that arose in the process. He found that when she had done this the symptom in question disappeared for good.

This was at a date before the investigations of Charcot and Pierre Janet into the origin of hysterical symptoms, and Breuer’s discovery was thus entirely uninfluenced by them. But he did not pursue the matter any further at the time, and it was not until some ten years later that he took it up again in collaboration with Sigmund Freud. In 1895 they published a book, Studies on Hysteria, in which Breuer’s discoveries were described and an attempt was made to explain them by the theory of ‘catharsis’. According to that hypothesis, hysterical symptoms originate through the energy of a mental process being withheld from conscious influence and being diverted into bodily innervation (‘conversion’). A hysterical symptom would thus be a substitute for an omitted mental act and a reminiscence of the occasion which should have given rise to that act. And, on this view, recovery would be a result of the liberation of the affect that had gone astray and of its discharge along a normal path (‘abreaction’). Cathartic treatment gave excellent therapeutic results, but it was found that they were not permanent and that they were not independent of the personal relation between the patient and the physician. Freud, who later proceeded with these investigations by himself, made an alteration in their technique, by replacing hypnosis by the method of free association. He invented the term ‘psycho-analysis’, which in the course of time came to have two meanings: (1) a particular method of treating nervous disorders and (2) the science of unconscious mental processes, which has also been appropriately described as ‘depth-psychology’.

SUBJECT-MATTER OF PSYCHO-ANALYSIS

Psycho-analysis finds a constantly increasing amount of support as a therapeutic procedure, owing to the fact that it can do more for its patients than any other method of treatment. The principle field of its application is in the milder neuroses - hysteria, phobias and obsessional states; and in malformations of character and sexual inhibitions or abnormalities it can also bring about marked improvements or even recoveries. Its influence upon dementia praecox and paranoia is doubtful; on the other hand, in favourable circumstances it can cope with depressive states, even if they are of a severe type.

In every instance the treatment makes heavy claims upon both the physician and the patient: the former requires a special training and must devote a long period of time to exploring the mind of each patient, while the latter must make considerable sacrifices, both material and mental. Nevertheless, all the trouble involved is as a rule rewarded by the results. Psycho-analysis does not act as a convenient panacea (‘cito, tute, jucunde

’) for psychological disorders. On the contrary, its application has been instrumental in making clear for the first time the difficulties and limitations in the treatment of such affections. For the moment it is only in Berlin and Vienna that there are voluntary institutions which make psycho-analytic treatment accessible to the wage-earning classes.

The therapeutic influence of psycho-analysis depends on the replacement of unconscious mental acts by conscious ones and is effective within the limits of that factor. The replacement is effected by overcoming internal resistances in the patient’s mind. The future will probably attribute far greater importance to psycho-analysis as the science of the unconscious than as a therapeutic procedure.

Psycho-analysis, in its character of depth-psychology, considers mental life from three points of view: the dynamic, the economic and the topographical.

From the first of these standpoints, the dynamic one, psycho-analysis derives all mental processes (apart from the reception of external stimuli) from the interplay of forces, which assist or inhibit one another, combine with one another, enter into compromises with one another, etc. All of these forces are originally in the nature of instincts; thus they have an organic origin. They are characterized by possessing an immense (somatic) store of power (‘the compulsion to repeat’); and they are represented mentally as images or ideas with an affective charge. In psycho-analysis, no less than in other sciences, the theory of the instincts is an obscure subject. An empirical analysis leads to the formulation of two groups of instincts: the so-called ‘ego-instincts’, which are directed towards self-preservation, and the ‘object-instincts’, which are concerned with relations to an external object. The social instincts are not regarded as elementary or irreducible. Theoretical speculation leads to the suspicion that there are two fundamental instincts which lie concealed behind the manifest ego-instincts and object-instincts: namely (a) Eros, the instinct which strives for ever closer union, and (b) the instinct of destruction, which leads towards the dissolution of what is living. In psycho-analysis the manifestation of the force of Eros is given the name ‘libido’.

From the economic standpoint psycho-analysis supposes that the mental representatives of the instincts have a charge (cathexis) of definite quantities of energy, and that it is the purpose of the mental apparatus to hinder any damming-up of these energies and to keep as low as possible the total amount of the excitations with which it is loaded. The course of mental processes is automatically regulated by the ‘

pleasure-unpleasure principle’; and unpleasure is thus in some way related to an increase of excitation and pleasure to a decrease. In the course of development the original pleasure principle undergoes a modification with reference to the external world, giving place to the ‘reality principle’, in accordance with which the mental apparatus learns to postpone the pleasure of satisfaction and to tolerate temporarily feelings of unpleasure.

Topographically, psycho-analysis regards the mental apparatus as a compound instrument, and endeavours to determine at what points in it the various mental processes take place. According to the most recent psycho-analytic views, the mental apparatus is composed of an ‘id’, which is the repository of the instinctual impulses, of an ‘ego’, which is the most superficial portion of the id and one which has been modified by the influence of the external world, and of a ‘super-ego’, which develops out of the id, dominates the ego and represents the inhibitions of instinct that are characteristic of man. The quality of consciousness, too, has a topographical reference; for processes in the id are entirely unconscious, while consciousness is the function of the ego’s outermost layer, which is concerned with the perception of the external world.

At this point two observations may be in place. It must not be supposed that these very general ideas are presuppositions upon which the work of psycho-analysis depends. On the contrary, they are its latest conclusions and are ‘open to revision’. Psycho-analysis is founded securely upon the observation of the facts of mental life; and for that very reason its theoretical superstructure is still incomplete and subject to constant alteration. Secondly, there is no reason for surprise that psycho-analysis, which was originally no more than an attempt at explaining pathological mental phenomena, should have developed into a psychology of normal mental life. The justification for this arose with the discovery that the dreams and mistakes of normal men have the same mechanism as neurotic symptoms.

The first task of psycho-analysis was the elucidation of nervous disorders. The analytic theory of the neuroses is based on three corner-stones: the recognition of (1) ‘repression’, of (2) the importance of the sexual instinct and of (3) ‘transference’.

(1) There is a force in the mind which exercises the functions of a censorship, and which excludes from consciousness and from any influence upon action all tendencies which displease it. Such tendencies are described as ‘repressed’. They remain unconscious; and if one attempts to bring them into the patient’s consciousness one provokes a ‘resistance’. These repressed instinctual impulses, however, have not always become powerless. In many cases they succeed in making their influence felt in the mind by circuitous paths, and the indirect or substitutive satisfactions of repressed impulses thus achieved are what constitute neurotic symptoms.

(2) For cultural reasons the most intense repression falls upon the sexual instincts; but it is precisely in connection with them that repression most easily miscarries, so that neurotic symptoms are found to be substitutive satisfactions of repressed sexuality. The belief that in man sexual life begins only at puberty is incorrect. On the contrary, signs of it can be detected from the beginning of extra-uterine existence; it reaches a first culminating point at or before the fifth year (‘early period’), after which it is inhibited or interrupted (‘latency period’) until the age of puberty, which is the second climax of its development. This diphasic onset of sexual development seems to be distinctive of the genus Homo. All experiences during the first period of childhood are of the greatest importance to the individual, and in combination with his inherited sexual constitution form the dispositions for the subsequent development of character and disease. It is wrong to make sexuality coincide with ‘genitality’. The sexual instincts pass through a complicated course of development, and it is only at the end of it that the ‘primacy of the genital zones’ is attained. Before this there are a number of ‘pregenital’ organizations of the libido - points at which it may become ‘fixated’ and to which, in the event of subsequent repression, it will return (‘regression’). The infantile fixations of the libido are what determine the form of any later neurosis. Thus the neuroses are to be regarded as inhibitions in the development of the libido. There are no specific causes of nervous disorders; the question whether a conflict finds a healthy solution or leads to a neurotic inhibition of function depends upon quantitative considerations.

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