Analytical Therapy YOU know our subject for today. You asked me why we do not make use of direct suggestion in psychoanalytic therapy, when we admit that our influence depends substantially upon transference, i.e., suggestion, for you have come to doubt whether or not we can answer for the objectivity of our psychological discoveries in the face of such a predominance of suggestion. I promised to give you a comprehensive answer. Direct suggestion is suggestion directed against the expression of the symptoms, a struggle between your authority and the motives of the disease. You pay no attention during this process to the motives, but only demand of the patient that he suppress their expression in symptoms. So it makes no difference in principle whether you hypnotize the patient or not. Bernheim, with his usual perspicacity, asserted that suggestion is the essential phenomenon underlying hypnotism, that hypnotism itself is already a result of suggestion, is a suggested condition. Bernheim was especially fond of practising suggestion upon a person in the waking state, and could achieve the same results as with suggestion under hypnosis. What shall I deal with first, the evidence of experience or theoretic considerations? Let us begin with our experiences. I was a pupil of Bernheim's, whom I sought out in Nancy in 1889, and whose book on suggestion I translated into German. For years I practised hypnotic treatment, at first by means of prohibitory suggestions alone, and later by this method in combination with investigation of the patient after the manner of Breuer. So I can speak from experience about the results of hypnotic or suggestive therapy. If we judge Bernheim's method according to the old doctor's So much for experience. It shows us that in renouncing direct suggestion we have given up nothing that is not replaceable. In the light of the knowledge we have gained from psychoanalysis we can describe the difference between hypnotic and psychoanalytic suggestion as follows: Hypnotic therapy seeks to hide something in psychic life, and to gloss it over; analytic therapy seeks to lay it bare and to remove it. The first method works cosmetically, the other surgically. The first uses suggestion in order to prevent the appearance of the symptoms, it strengthens suppression, but leaves unchanged all other processes that have led to symptom development. Analytic therapy attacks the illness closer to its sources, namely in the conflicts out of which the symptoms have emerged, it makes use of suggestion to change the solution of these conflicts. Hypnotic therapy leaves the patient inactive and unchanged, and therefore without resistance to every new occasion for disease. Analytic treatment places upon the physician, as well as upon the patient, a difficult responsibility; the inner resistance of the patient must be abolished. The psychic life of the patient is permanently changed by overcoming these resistances, it is lifted upon a higher plane of development and remains protected against new possibilities of disease. The work of overcoming resistance is the fundamental task of the analytic cure. The patient, however, must take it on himself to accomplish this, while the physician, with the aid of suggestion, makes it possible for him to do so. The suggestion works in the nature of an education. We are therefore justified in saying that analytic treatment is a sort of after-education. I hope I have made it clear to you wherein our technique of using suggestion differs therapeutically from the only use possible in hypnotic therapy. With your knowledge of the relation between suggestion and transference you will readily understand the capriciousness of hypnotic therapy which attracted our attention, and you will see why, on the other hand, analytic suggestion can be relied upon to its limits. In hypnosis we depend on the condition of the patient's capacity for transference, yet we are unable to exert any influence on this capacity. The transference of the subject may be negative, or, as is most frequent, ambivalent; the patient may have protected himself against suggestion by very special adjustments, yet we are unable to learn anything concerning them. In psychoanalysis we work with the transference itself, we do away with the forces opposing it, prepare the instrument with which we are to work. So it becomes possible to derive entirely new uses from the power of suggestion; we are able to control it, the patient does not work himself into any state of mind he pleases, but in so far as we are able to influence him at all, we can guide the suggestion. Now you will say, regardless of whether we call the driving force of our analysis transference or suggestion, there is still the danger that through our influence on the patient the objective certainty of our discoveries becomes doubtful. That which becomes a benefit to therapy works harm to the investigation. This objection is most often raised against psychoanalysis, and it must be admitted that even if it does not hit the mark, it cannot be waved aside as stupid. But if it were justified, psychoanalysis would be nothing more than an extraordinarily well disguised and especially workable kind of treatment by suggestion, and we may lay little weight upon all its assertions concerning the influences of life, psychic dynamics, and the unconscious. This is in fact the opinion held by our opponents; we are supposed especially to have "balked into" the patients everything that supports the importance of sexual experiences, and often the experiences themselves, after the combinations themselves have grown up in our degenerate imaginations. We can refute these attacks most easily by calling on the evidence of experience rather than by resorting to theory. Anyone who has himself performed a psychoanalysis has been able to convince himself innumerable times that it is impossible thus to suggest Presumably the creation of the separate suggestions is counteracted, in the course of the cure, by our being continually forced to attack resistances which have the ability to change themselves into negative (hostile) transferences. Furthermore, let me call your attention to the fact that a large number of results of analysis, otherwise perhaps subject to the suspicion that they are products of suggestion, can be confirmed from other unquestionable We now want to complete our statement concerning the mechanism of healing, by including it within the formulae of the libido theory. The neurotic is incapable both of enjoyment and work; first, because his libido is not directed toward any real object, and second because he must use up a great deal of his former energy to keep his libido suppressed and to arm himself against its attacks. He would become well if there could be an end to the conflict between his ego and his libido, and if his ego could again have the libido at its disposal. The task of therapy, therefore, consists of freeing the libido from its present bonds, which have estranged it from the ego, and furthermore to bring it once more into the service of the ego. Where is the libido of the neurotics? It is easy to find; it is bound to the symptoms which at that time furnish it with the only available substitute satisfaction. We have to become master of the symptoms, and abolish them, which is of course exactly what the patient asks us to do. To abolish the symptoms it becomes necessary to go back to their origin, to renew the conflict out of which they emerged, but this time with the help of motive forces that were originally not available, to guide it toward a new solution. This revision of the process of suppression can be accomplished only in part by following the traces in memory of the occurrences which led to the suppression. The decisive part of the cure is accomplished by means of the relationship to the physician, the transference, by means of which new editions of the old conflict are created. Under this situation the patient would like to behave as he had behaved originally, but by summoning all his available psychic power we compel him to reach a different decision. Transference, then, becomes the battlefield on which all the contending forces are to meet. The full strength of the libido, as well as the entire resistance against it, is concentrated in this relationship to the physician; so it is inevitable that the symptoms of the libido should be laid bare. In place of his original disturbance the patient manifests the artificially constructed disturbance of transference; in place of heterogeneous unreal objects for the libido you now have only the person of the physician, a single object, which, however, is also fantastic. The new struggle over this object is, however, raised to the highest psychic level with the aid of the physician's suggestions, and proceeds as a normal psychic conflict. By avoiding a new suppression the estrangement between the ego and the libido comes to an end, the psychic unity of the personality is restored. When the libido again becomes detached from the temporary object of the physician it cannot return to its former objects, but is now at the disposal of the ego. The forces we have overcome in the task of therapy are on the one hand the aversion of the ego for certain directions of the libido, which had expressed itself as a tendency to suppression, and on the other hand the tenacity of the libido, which is loathe to leave an object which it has once occupied. Accordingly the work of therapy falls into two phases: first, all the libido is forced from the symptoms into the transference, and concentrated there; secondly, the struggle over this new object is carried on and the libido set free. The decisive change for the better in this renewed conflict is the throwing out of the suppression, so that the libido cannot this time again escape the ego by fleeing into the unconscious. This is accomplished by the change in the ego under the influence of the physician's suggestion. In the course of the work of interpretation, which translates unconscious into conscious, the ego grows at the expense of the unconscious; it learns forgiveness toward the libido, and becomes inclined to permit some sort of satisfaction for it. The ego's timidity in the face of the demands of the libido is now lessened by the prospect of occupying some of the libido through sublimation. The more the processes of the treatment correspond to this theoretic description the greater will be the success of psychoanalytic therapy. It is limited by the lack of mobility of the libido, which can stand in the way of releasing its objects, and by the obstinate narcism which will not permit the object-transference to effect more than just so It is to be remembered that we cannot reach a direct conclusion as to the disposition of the libido during the disease from the distributions of the libido which are effected during and because of the treatment. Assuming that we have succeeded in curing the case by means of the creation and destruction of a strong father-transference to the physician, it would be wrong to conclude that the patient had previously suffered from a similar and unconscious attachment of his libido to his father. The father-transference is merely the battlefield upon which we were able to overcome the libido; the patient's libido had been concentrated here from its other positions. The battlefield need not necessarily have coincided with the most important fortresses of the enemy. Defense of the hostile capital need not take place before its very gates. Not until we have again destroyed the transference can we begin to reconstruct the distribution of the libido that existed during the illness. From the standpoint of the libido theory we might say a last word in regard to the dream. The dreams of neurotics, as well as their errors and haphazard thoughts, help us in finding the meaning of the symptoms and in discovering the disposition of the libido. In the form of the wish fulfillment they show us what wish impulses have been suppressed, and to what objects the libido, withdrawn from the ego, has been attached. That is why interpretation of dreams plays a large role in psychoanalytic treatment, and is in many cases, for a long time, the most important means with which we work. We already know that the condition of sleep itself carries with it a certain abatement of suppressions. Because of this lessening of the pressure upon it, it becomes possible for the suppressed impulse to create in the dream a much clearer expression than the symptom can furnish during the day. So dream-study is the easiest approach to a knowledge of the libidinous suppressed unconscious which has been withdrawn from the ego. Dreams of neurotics differ in no essential point from the dreams of normal persons; you might even say they cannot be The difference between nervous health and neurosis is entirely a practical one which is determined by the available capacity for enjoyment and accomplishment retained by the individual. It varies presumably with the relative proportion of the energy totals which have remained free and those which have been bound by suppressions, and is quantitative rather than qualitative. I do not have to remind you that this conception is the theoretical basis for the certainty that neuroses can be cured, despite their foundation in constitutional disposition. This is accordingly what we may make out of the identity between the dreams of the healthy and those of the neurotic for the definition of health. As regards the dream itself, we must note further that we cannot separate it from its relation to neurotic symptoms. We must recognize that it is not completely defined as a translation of thoughts into an archaic form of expression, that is, we must assume it discloses a disposition of libido and of object-occupations which have actually taken place. We have about come to the end. Perhaps you are disappointed that I have dealt only with theory in this chapter on psychoanalytic therapy, and have said nothing concerning the conditions under which the cure is undertaken, or of the successes which it achieves. But I shall omit both. I shall omit the first because I had intended no practical training in the practice of psychoanalysis, and I shall neglect the second for numerous reasons. At the beginning of our talks I emphasized the fact that under favorable circumstances we attain results which can be favorably compared with the happiest achievements in the field of internal therapy, and, I may add, these results could not have been otherwise achieved. If I were to say more I might be suspected of wishing to drown the voices of disparagement, which have become so loud, by advertising our claims. We psychoanalysts have repeatedly been threatened by our medical colleagues, even in open congresses, that the eyes of the suffering public must be opened to the worthlessness of this method of treatment by a statistical collection of analytic failures and injuries. But such a collection, aside from the biased, denunciatory character of its purpose, would hardly be able to give a correct picture of the therapeutic values of analysis. Analytic therapy is, as you know, still young; it took a long time to establish the technique, and this could be done only during the course of the work and under the influence of accumulating experience. As a result of the difficulties of instruction the physician who begins the practice of psychoanalysis is more dependent upon his capacity to develop on his own account than is the ordinary specialist, and the results he achieves in his first years can never be taken as indicative of the possibilities of analytic therapy. Many attempts at treatment failed in the early years of analysis because they were made on cases that were not at all suited to the procedure, and which today we exclude by our classification of symptoms. But this classification could be made only after practice. In the beginning we did not know that paranoia and dementia praecox are, in their fully developed phases, inaccessible, and we were justified in trying out our method on all kinds of conditions. Besides, the greatest number of failures in those first years were not due to the fault of the physician or because of unsuitable choice of subjects, but rather Instead of many cases, I shall tell you of just one in which, because of professional precautions, I was destined to play a In the years before the war, when the influx of patients from all parts made me independent of the favor or disfavor of my native city, I followed the rule of not treating anyone who was not sui juris, was not independent of all other persons in his essential relations of life. Every psychoanalyst cannot do this. You may conclude from my warning against the relatives of patients that for purposes of psychoanalysis we should take the patients away from their families, and should limit this therapy to the inmates of sanatoriums. I should not agree with This offers a sad outlook indeed for the effectiveness of psychoanalysis as a therapy, even if we can explain the great majority of our failures by putting the blame on such disturbing external factors! Friends of analysis have advised us to counterbalance such a collection of failures by means of a statistical compilation on our part of our successful cases. Yet I could not try myself to do this. I tried to explain that statistics would be worthless if the collected cases were not comparable, and in fact, the various neuroses which we have undertaken to treat could, as a matter of fact, hardly be compared on the same basis, since they differed in many fundamental respects. Besides, the period of time over which we could report was too short to permit us to judge the permanency of our cures, and concerning certain cases we could not have given any information whatever. They related to persons who had kept their ailments, as well as their treatment, secret, and whose cure must necessarily be kept secret as well. The strongest hindrance, however, lay in the knowledge that men behave most irrationally in matters of therapy, and that we have no prospect of attaining anything by an appeal to reason. A therapeutic novelty is received either with frenzied enthusiasm, as was the case when Koch first made public his tuberculin against tuberculosis, or it is treated with abysmal distrust, as was the really blessed vaccination of Jenner, which even today retains implacable opponents. There was a very obvious prejudice against psychoanalysis. When we had cured a very difficult case we would hear it said: "That is no proof, he would have become well by himself in all this time." Yet when a patient who had already gone through four cycles of depression and mania came into my care during a temporary cessation in the melancholia, and three weeks later found herself It may be possible that the prejudice against psychoanalysis is already on the wane. The continual spread of psychoanalytic doctrine, the increase of the number of physicians in many lands who treat analytically, seems to vouch for it. When I was a young physician I was caught in just such a storm of outraged feeling of the medical profession toward hypnosis, treatment by suggestion, which today is contrasted with psychoanalysis by "sober" men. Hypnotism did not, however, as a therapeutic agent, live up to its promises; we psychoanalysts may call ourselves its rightful heirs, and we have not forgotten the large amount of encouragement and theoretical explanation we owe to it. The injuries blamed upon psychoanalysis are limited essentially to temporary aggravation of the conflict when the analysis is clumsily handled, or when it is broken off unfinished. You have heard our justification for our form of treatment, and you can form your own opinion as to whether or not our endeavors are likely to lead to lasting injury. Misuse of psychoanalysis is possible in various ways; above all, transference is a dangerous remedy in the hands of an unconscientious physician. But no professional method of procedure is protected from misuse; a knife that is not sharp is of no use in effecting a cure. I have thus reached the end, ladies and gentlemen. It is more than the customary formal speech when I admit that I am myself keenly depressed over the many faults in the lectures I have just delivered. First of all, I am sorry that I have so often promised to return to a subject only slightly touched upon at the time, and then found that the context has not made it possible to keep my word. I have undertaken to inform you concerning an unfinished thing, still in the process of development, and my brief exposition itself was an incomplete thing. Often
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