Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XIX

Children of Different Ordinal Positions
George Edington & Bradford Wilson

Most clinicians recognize the relevance of being a firstborn or only child. Unfortunately, the significance of other ordinal positions in child development continues to be ignored. Examining birth order (as it is often called) offers the clinician a wide field for observation, for theory building, and for research. One's birth order makes for enduring attitudes about one's place in the scheme of things. Just as the mother and father are the first woman and man that the child knows, siblings are the child's first experience of competition, cooperation, mutual dependence, and mutual defiance of authority. The child's rivalrous tendencies can be modified by his recognition of siblings as a source of affection and support.
     A proliferation of research into ordinal position over the past decade has been confined mainly to comparisons of "firstborn" versus "later-born" populations. Results are often ambiguous since "firstborn" constitutes a homogeneous, easily defined group, whereas "later-born" may refer to anything from the younger member in a twosibling family to any child in a series of eight. The reader is referred to Sutton-Smith and Rosenberg's superb review and evaluation of this formidable body of data." They conclude that research findings on the younger of two brothers and the younger of two sisters are the most consistent. The few clinical studies in this area are represented by the pioneering work of Koch, Toman and a handful of others.
     The present authors have long collected data from clinical practice, comparing them with data from others in the field. We believe that most patients can be better understood if their ordinal position and its various ramifications are given appropriate weight within their clinical profile. Twinship is the only major sibling constellation not included in this study since its complexity and scope do not lend themselves to abbreviation.
     Koch devised a simple code to designate children in two-sibling configurations. The first letter of the code indicates the sex of the sibling in question; the number indicates whether the child is first- or second-born; and the second letter indicates the sex of the other siblings. Thus:
          F-1-F Firstborn girl with a younger sister.
          F-2-F Second-born girl with an older sister.
          F-I-M Firstborn girl with a younger brother.
          F-2-M Second-born girl with an older brother.
          M-1-F Firstborn boy with a younger sister.
          M-2-F Second-born boy with an older sister.
          M-1-M Firstborn boy with a younger brother.
          M-2-M Second-born boy with an older brother.
     Only children are commonly referred to as singletons. By extention, Koch's code can be used for other configurations. A firstborn may be designated as F-1 or M-1 without reference to other siblings. In larger constellations, however, the code would become unwieldly; the present authors have not attempted to use it for other than the above categories.
     The dynamics of two-sib combinations are often sufficient to explain behavior within larger sibling constellations. Thus, let us consider a patient who is the younger of two boys born three years apart. This pair was followed eight years later by two other siblings. In such an instance, the major dynamic constellation is more likely to be that of "younger of two brothers" (M-2-M in Koch's terminology) rather than "second-born of four." The rule of thumb here is that an age-gap of six or more years demarcates a new sibship.
     The observations noted here are based partly (although not entirely) on adult clinical populations, although most research on birth order comes from nonclinical groups (such as Koch's work with six-year-old school children). Our overall data constitutes an amalgam of observations drawn from a number of sources in addition to our own.

Firstborn: Only Child
Note that "firstborn oldest" and "firstborn only" child (or singleton) are distinct categories-but with much in common. The only child is often born of a mother who had difficulty conceiving, or could not afford more than one child, or did not want any children, but "got caught." The parents of these children are frequently older than those of most firstborns (often being aged thirty and beyond) at the time of the child's birth, so that the usual give-and-take between young parents and their children may well be lacking.
     During an only child's formative years, sibling rivalry in the usual sense rarely exists unless the nurturant household includes cousins or other contemporaries. This child is, however, confronted with formidable competition in the persons of the parents. Each of them is experienced as a rival for the other parent's attention and affection. In such a situation the child feels outclassed and outweighed by giants. If by chance the child is left alone to be raised with one parent, there may be no competition at all. But the guilt engendered by an unconscious "triumph" over the absent parent (and undiluted by sharing with siblings) can become acute.
     Only children have a difficult time learning how to compete and how to share. Characteristically, they remain diplomatically aloof from both modalities: partnerships present extraordinary problems for them, and in emotionally competitive situations they abdicate, covertly manipulate, or else show ill-concealed vindictiveness and overdomination. We find the adult singleton to be the most intensely jealous of all ordinal positions and the most prone to act it out.
     Never having had to share parental praise with other siblings, such individuals are inclined toward narcissism and egocentricity. On the other hand, not having others with whom to share blame renders them both perfectionistic and highly vulnerable to criticism. Extremely orderly and tidy in their habits, their living and work areas are usually immaculate and well-organized, with chores done punctually and conscientiously. As Sutton-Smith and Rosenberg" observe, this group is chiefly responsible for the traditional view that "the early born are especially eminent."
     Having only one child to center their concern upon-a single link with posterity-the parents of singletons are, quite often, unintentionally overintrusive, and this is especially true of the longawaited child of older parents. Arriving as many as ten or fifteen years late (possibly after one or more miscarriages), this particular singleton is most likely of all ordinal positions to be "killed with kindness"--i.e., parental smothering and intrusiveness.
     Sutton-Smith and Rosenberg" observe that mothers seem to favor the only boys more than the only girls, and they describe the boys as more "feminine" and the girls more "masculine" than their peers, adding that this leads to "a greater tendency toward sex deviations consonant with these tendencies." They note that as adults the only girls are more aggressive and less anxious than the only boys. Unless raised to be pathologically dependent on one or both parents, these girls are apt to develop self-sufficiency at a very early age and to delight in acquiring new and varied skills throughout life.
     Another special category of singleton is the youngest child who is separated from older siblings by ten years or more, and thus grows up, as it were, with several "parents." If the siblings are adolescent, they may abhor the newborn infant for giving public evidence of parental fornication.
These difficulties are further compounded when the child arrives as an unwelcome surprise to parents unprepared for late-in-life offspring. Such a child is apt to develop depressed and confused responses to the mixed messages arriving from the environment. He may develop a life-style dedicated to pleasing everyone and not being a burden or a disgrace. These children early learn to keep thoughts and feelings to themselves and to avoid taking sides. While presenting a friendly and socially outgoing facade, they are inwardly quite withdrawn.
     Because all firstborns are privy to "adult" information, singletons are almost invariably more comfortable with adults or much older children than with peers. They also display an exaggerated sense of responsibility and a well-developed, premature self-sufficiency. At the same time, they may feel needlessly isolated and lonely. We believe that frequent overnight (or longer) visits between the only child and contemporaries can help to remedy the disadvantages of this ordinal position.

Firstborn: The Oldest Child
What was said about the singleton can also hold true for the oldest child. A singleton's birth can result from parental efforts to "prove" sex-role adequacy, "cement" a failing marriage, etc. The oldest child, on the other hand, is most often born at a time when parental attraction and compatibility are at their height. Whatever problems bedevil inexperienced parents, their firstborn receives considerable and lifelong attention. His or her status as the family prince or princess entails assets which are legendary: primogeniture (real or implicit), parental support in every endeavor, inclusion in adult counsels, respect (often grudging) from sibs, and a continuing sense of intrinsic worthwhileness. In a poor family where "hand-me-downs" are worn, the oldest child gets the most new clothes. The larger the age gap between the oldest and the nextin-line, the more singleton characteristics will predominate.
     The liabilities, however, are considerable, and poignant. Oldest children are the frightened pioneer offspring of novice and anxious parents. Proud of their rove as strawbosses and parental message bearers, they pay a price in overseriousness. Dignified and sober, they are under a tacit injunction to "grow up"--"you're older, you ought to know better" is never said to the youngest child.
These children usually grow up feeling that ethers depend on them and they mustn't betray that trust. This is particularly true of a firstborn girl in a large family, who functions as surrogate mother for her younger sibs. In poor or motherless families she is likely to become the housewife, cook, and keeper-of-accounts as well. With or without siblings, she seems to grow up with a single motto-"it's all up to me"-and she devotes her life to setting the world straight, never doubting that she alone knows what ails it.
     In large families (especially in poor neighborhoods) the oldest boy may assume the role of family protector, obliged to defend his siblings even against heavy odds. He grows up serious and filled with a sense of responsibility toward others.
     Koch finds firstborns in general to be especiially high in curiosity, planfulness, competitiveness, and most self-confident in academics. She notes, surprisingly enough, that firstborn male children show the highest verbal skills of any ordinal position--even firstborn girls. This may be due, she hypothesizes, to the fact that "they are very active and get around more on their own." and that mothers show firstborn boys special devotion. The resulting extra verbal stimulation then leads to accelerated language development. In adulthood we find them relatively lacking in originality, and their creativity tends toward synthesizing the traditional. Konig points out that firstborns are par excellence the defenders of tradition, laws, and the continuity of customs.
     As regards this conforming tendency, Smith and Goodchilds find that they rank relatively low on self-confidence and in creative problem solving, where they function better when supported by membership in groups. Social anxiety and ambivalence seem to be lifelong characteristics of this ordinal position.
     Above all, these firstborn oldest children need to have areas in which they are free to be a child. Otherwise they grow up robbed of a certain playfulness permitted to others. For them, life is all too apt to be "real and earnest" at the expense of the carefree romping of later-horn children. As for their exaggerated strivings for primacy, Forer suggests that they need to learn how to avoid biting off more than they can chew, and adds that this holds particularly true for oldest girls.

The Middle Child
Alfred Adler first pointed to the middle child's difficulties, especially in a three-sibling family. With neither the status of the oldest child, nor the maternal deference of the youngest, he or she can feel left out. Not every middle child, however, fits this pattern, and it cannot be laid down as a general rule.
     In a multi-sib family, any one of the children may feel left out and feel like a fifth wheel in an already completed family (such as the "traditional" father, mother, son, and daughter). Any child resulting from an unwanted pregnancy may be made to feel superfluous to family happiness. However, we discuss these phenomena under the rubric of the "middle child" because it is the middle child who most often responds in these ways to these stresses.
     Siblings have a way of staking out territories with firm, tacitly agreed-upon boundaries. Thus one child may become "the musician," another "the athlete," and so forth; or, pejoratively, "the black sheep," "the dumbell," etc. While two or more siblings may share a talent or interest in common, characterological roles tend to be more exclusive-only one child gets dubbed "the trustworthy one," another "the scatterbrain," etc.
     Such sobriquets tend to be polar and to cluster at either end of a sibling array. The middle child, often passed over, feels left out. For example, if the oldest child is the conformist and the youngest the rebel, the middle child, sizing up the liabilities inherent in both roles, can refuse to play the game altogether. And if this child reaches similar conclusions about other domestic interactions, he or she may end up feeling superfluous, devoid of any meaningful family role.
     Caught in such a dilemma, the middle child often abandons the family arena and turns to peers for affirmation, preferring to "run with the pack" at school or in the larger world while being enigmatic and "out of it" at home. For these children what the "gang" thinks takes priority long before the usual preteen and adolescent phases when greater peer-group concerns normally develop.
     Like the singleton, he or she early acquires self-sufficiency and independence from family ties, but with sophisticated peer-group skills which the former usually lack. A liability of this birth order, however, can be a lifelong feeling that the doors of intimate trust and confidentiality are pretty much closed; the middle child knows and understands many other people but feels truly known and/or understood by very few. In our opinion, much needless isolation and loneliness can be forestalled by helping the middle child to carve out a valid and significant niche within the family at as early an age as possible.

The Youngest Child
Considered the most pampered, this "baby of the family" is heir to many hidden liabilities. While the firstborn oldest child must by definition suffer "replacement" by younger siblings who make successive claims for parental attention, the youngest child comes into a world where everybody else "was there first" and seems to have been born knowing how to tie shoelaces and a host of other prestigeous, praiseworthy skills. More often than not, older sibs show off their skills at the younger's expense, thus confirming the latter's fantasy that "the big people" never had to learn all the things at which this child feels so woefully inept.
     As a result, youngest children see two options: either to become adept at getting other people to do things for them, at the expense of developing a number of independent skills, or to become a dedicated "do-it-yourselfer" who refuses to be taught by anyone and feels compelled to "invent the wheel." Hobbies, and even vocational skills, are often learned in secret, by privately experimenting and covertly reading textbooks.
     Although often retaining carefree attitudes toward the more "serious" aspects of existence, the youngest child may nevertheless carry a perpetual sense of unimportance and "failure"; the world always seems to say "not yet; there is still one more hurdle." Whereas the oldest child is usually acclaimed for everything from teething to being awarded a Ph.D., the youngest child's identical landmarks are apt to be "old hat" when his turn comes around.
     Ambivalent about yearned-for acceptance, the youngest child may abandon projects in midstream, unconsciously fearing retaliation by the "big people" for daring to aspire to their rank, or by other "little people" for betraying their camaraderie as outcasts and no-accounts. Or "big people" may be courted in order to counterreject them--the youngest often abandons his membership in clubs, professional organizations, and other groups without warning or without apparent reason.
The youngest nevertheless has a lifelong yen to make a contribution, to be needed and listened to. Forer finds that youngest children are particularly vulnerable to the loss of a parent in early childhood, and populations of hospitalized schizophrenics and alcoholics show a significant preponderance of this group.
     Finally, an unfortunate but inescapable fact about the youngest child is that, of all ordinal positions, he is the most likely to have been sired by a man other than the mother's legitimate spouse. In such cases, the presence of guilt. resentment, overprotectiveness, or rejection, etc., on the part of one or both parents (not to mention siblings who are quick to respond to parental cues) exerts a profound influence upon the subsequent development of this child. In any event, the question needs to be asked: "Why was this child the last?" Just as the firstborn is usually a "love child," the last born is often an "accident," or a last-ditch effort to preserve parental eroticism, or (in poor families) "another mouth to feed"; "the last straw," or whatever. Much of the proverbial "spoiling" of this child may represent a compassionate reaction formation to parental consternation.
In child rearing it is important for the youngest child that genuine accomplishments receive the same parental affirmation as those of elder siblings: otherwise adulthood is likely to remain a mirage -always beckoning and forever out of reach,

Older of Two Boys (M-1-M )
This particular firstborn is prone to acquire the role of "heavy" quite early in life as he assumes the multiple burdens of trail blazer, role model. and stand-in for paterfamilias-both for his sibling and his mother. He tends to shoulder all responsibilities conscientiously, stoically, and unquestioningly. Careful to maintain his "princely" status, he is perpetually alert to maintain his defenses and to avoid the unconventional. According to Forer, he absorbs parental values at an early age and proceeds to apply them rigorously both to himself and to others. Afraid of parental disappointment or of ridicule by his brother (or worse, by his brother's cronies), his fears are confided only to his closest (and usually only) friend.
     Toman reports that the older of two boys gets along well with other males and makes friends with both males and females who themselves have older brothers. He delights in exerting self-control, planning ahead in practical matters, and keeping his house (financial and otherwise) in order. Toman adds that this boy deals with male authority by either identifying with it or subverting it via subtle invasion or erosion of the authority's prerogatives.
     Koch and Sutton-Smith and Rosenberg describe his childhood behavior as anxiously rivalrous over the mother's attention, quarrelsome, teasing, insistent on his rights, and of all ordinal positions the slowest to recover after upsets. These characteristics tend to become modified after about age ten.
     Forer points out that he needs to develop more patience and playfulness. Care should be taken during his growing-up years not to saddle him with so much work and so little play as to make him the proverbial "dull boy." He is usually less serious or more playful if one or both of his parents were younger children, even more so if one or both of his parents were firstborn oldest or singletons.

Younger of Two Boys (M-2-M)
This child usually grows up blissfully unaware of the buffering role of his sober elder brother. More gregarious and extroverted than his sibling, he fails to see what all the fuss is about. To his thinking, most things work themselves out eventually, so let others do the worrying at which they seem to be so proficient.
     The youngest child syndrome is ameliorated for the younger of two boys by the fact that he has a single sib and may receive a greater share of parental affirmation than the youngest in a larger family. The smaller the age gap, the more likely he is to be both playmate and pal to his elder brother-provided that one of them being dubbed "Mother's Boy" and the other one "Father's Boy" does not engender a special rivalry. If that does occur, the ensuing competitiveness between samesex siblings is usually far more bitter than that between parentally polarized boy and girl sibs.
     This boy, generally easygoing and with a sunny disposition, is least likely of all ordinals to generate incapacitating psychiatric syndromes. He is often fonder of his brother than his brother is of him, unaware that in his own upbringing his parents relaxed many anxieties and strictures which had adversely affected the psychic economy of his elder sib. The younger of two boys' chief asset is his firm belief that the world stands ready to offer advice and help whenever needed. He does have a distinct disadvantage in the form of a certain reluctance to maintain a minority opinion against great odds, or to enter uncharted territory.
     According to Toman he is a "capricious and willful" iconoclast who depends on (and feels lost without) icons to react against. Irregular in his goal orientation, he either concentrates intensely or else dawdles and procrastinates-half hoping, half expecting that a magic rescuer will (as usual) relieve him of any onerous tasks. Inclined to live in the moment, he spends lavishly, disregarding the future. Childhood toys are likely to be soon lost, broken, or discarded. He often responds well to opportunities, but is not inclined to create them. Much depends upon his moods, which are in turn a function of the amount of seconding which he receives from his environment. Others (even his elders) can easily evoke his empathy and understanding.
     In Toman's view this boy gets along best with boys who have younger brothers, girls with younger siblings, and with singletons. Generally anti authoritarian, he prefers as allies an elite group or at best a benign, paternalistic authority. During childhood he often presents attention-seeking behavior problems.
     Sutton-Smith and Rosenberg find that as a preadolescent he is apt to display "a surge of emotional dependence and submissiveness." Of all ordinal positions he is likely to be lowest in conformity and affiliation, and highest in "masculinity" and athleticism. Koch describes him as having "more readiness to anger" than boys in other ordinal positions. When the age gap is small he plays "follow the leader" to his older brother in social situations. She notes, however, that with a wider age gap he shows more aggressiveness, curiosity, originality, enthusiasm and planfulness, and is apt to be socially expansive and bouyant. Meanwhile, he recovers more readily than his brother from emotional upsets. Forer feels that this boy needs to develop more confidence and initiative, to strike a better balance between work and play activities, and to develop more verbal skills.

Older Boy with Younger Sister (M-1-F )
When a firstborn child gets to be three years old or more, the birth of a younger sibling may take on increasingly traumatic aspects. In a way, the parents "can't win"-if the secondborn is of the same sex as the firstborn, the (mute) complaint is "Why? Wasn't I a good enough boy (or girl)? Why did they want a second one?" And if the later-born is of the opposite sex, the complaint becomes "Wasn't my sex good enough? Why did they have to invite this kind of creature into the family?"
     In the case of the older boy with a younger sister, the loss of maternal attentiveness constitutes a serious hurdle, and if he is aged four or older (a time when he is involved in ambivalent struggles with his father), any pronounced paternal involvement with the newborn girl can be devastating. Most commonly the boy clings tenaciously to his prior status of crown prince-a role which the younger sister (if not the parents) usually accepts completely. The sister, however, may be treated with lofty disdain (as adults, these males can go through forty or fifty psychotherapy sessions before mentioning that they grew up with a younger sister).
     Koch characterizes this child as highly jealous but otherwise aggressive, self-confident, curious, and planful. Toman finds him a pacifist and reluctant to take risks--usually not "one of the boys" (although his relations with males are cordial enough) and often on the lookout for good father figures; "He wants his peace and his fun. That's what life is for." In fights among other boys "he is for mediation and reason, even if it earns him the reputation of a coward." Sutton-Smith and Rosenberg remark that his "maleness is more in his posture than his competence."" Like the younger brother with an elder sister, he tends to ensconce himself in emotionally disbursed relationships to male peers en masse, with no male confidants whatever. Relations with females are distantly cordial although marked by an almost compulsive and obligatory seductiveness. As adults, Wilson finds older boys with younger sisters to be conventional and all-around good guys, while close associates frequently observe that even after many years of acquaintanceship, they really don't know him very well.
     When the age gap is smaller (three years or less) this boy is apt to be close and protective toward his younger sister, resulting in an overtoleration of mistreatment by female peers. Nevertheless, a certain emotional distance and detachment characterizes his relationships to most people. Overt intensity seems to frighten him, threatening to open up a Pandora's box of undealt with hostility and/or ambivalence, and he rarely has any confidential friends of either sex.

Younger Boy with Older Sister (M-2-F )
Owing to the absentee role of fathers in Western culture, this boy often feels that his behavior is constantly being monitored by his older sister and his mother. By the time his father returns home from work, he feels that the damage has been done. He has either been bossed or wheedled into so many tiny concessions and thwartings of selfassertion that he can no longer remember exactly what they were about and he is likely to wind up being a "rebel without a cause." He often finds himself feeling resentful, angry, and rebellious without quite knowing why. Emotional detachment and rather ineffectual nay-saying may persist well into adolescence when the companionship and support of male peers finally exerts a calming and steadying effect.
     He can achieve a kind of detente with peers of both sexes, but feels that his personal freedom is left on the doorstep when he enters the family circle. Rarely able to articulate this deeply felt problem, he usually finds himself unable to appeal to his father for sorely needed male support and thus runs the risk of estrangement. Consequently the all-important father-son relationship is seldom openly confidential, but is marked by quiet, nonverbal rapport.
     Koch notes that in childhood the younger boy with an older sister tends to be withdrawn and depressive ("sissyish, hostile and not very friendly") and not a joiner of peer groups. She finds him passive; low in ambition and initiative. Sutton-Smith and Rosenberg see him as exhibitionistic, selfish, uncooperative with peers, and given to teasing. At the same time they see his high self-esteem as possibly explaining his apparently scant need for peer affirmation. According to them, of all male ordinal positions, he ranks highest on measures of "femininity." Toman finds him to be "low on insight," hypothesizing that, owing to the attentions of his women folk, he never had a need to develop it. Toman adds that this ordinal tends to marry a woman whose sole career "is the background management of his interests and welfare," adding that he is apt to be unpopular with male peers, "who resent his taking help and support for granted and leaving them to clean up after him." Most researchers find him highly quarrelsome at all ages, and the authors note that he is prone to violent temper tantrums during adolescence and early adulthood. This seems particularly true when the division of labor between mother and father is blurred--i.e., when the mother seems to cut a more vibrant professional figure in the world such that the father's prestige appears dim by comparison. Given a weak or incapacitated (but not physically absent) father, this boy can get into serious emotional difficulties. This ordinal prefers environments that are gregarious but not intimate. As an adult he will most often enter a field which is (so far as possible) closed to women.
     The best way for parents to avoid the pitfalls of this ordinal position is to initiate clearcut agreements regarding his territorial rights. There must be a firm guarantee that in such areas the mother and sister will respect his boundaries. The father can help by making special "unsmothering" efforts toward a personal level of rigorously private confidentiality that under no circumstances should be shared with the mother or sister without the boy's prior permission. For the younger boy with an older sister, no greater crime exists than for one fellow to betray another's confidences.

Older Girl with Younger Brother (F-1-M )
This girl, like the older girl with a younger sister, may act out an oedipal fantasy about being the mother in the family (i.e., her father's wife) and copes with her resentment toward her newborn rival by becoming his nursemaid, thus turning her jealousy into a compensatory "overprotective" maternalism.
     From mediating between her younger brother and the outside world it is but a short step to being a go-between and peacemaker in other family relationships-for example, bickering parents or other relatives. Her first motto is "It's all up to me." While she may disdain her male contemporaries, she is apt to be more secure in male company, regarding other girls with suspicion and distrust. As Toman puts it, she tends to patronize males while still being nurturant and helpful toward their goals.
     Accustomed from early childhood to taking charge of things, she often acts "bossy" toward males without realizing it, but is generally adept at smoothing ruffled feathers and making necessary conciliatory gestures. In situations involving competition with other females, she prefers to behave as though they do not exist-much to their chagrin.
     Koch found that in childhood this girl is friendly with her teachers, socially expansive, and noted for leadership. The authors' clinical observation is that the older girl with a younger brother often seems to have brought herself up; she can astonish her parents with an organization and precision not learned by precept or example.
     According to Sutton-Smith and Rosenberg she ranked high on conformity and emotional dependency. As she grows older, Sutton-Smith, Roberts, and Rosenberg assert that she is likely to become "the most submissive, most dependent, most anxious, but also the most competitive of the female groups studied."
     It appears that when the age gap is three years or more, this ordinal maintains her ascendancy by polishing her verbal and intellectual skills. She does this in an effort to maintain her father's respect and interest. As was noted earlier, her brother then tends to stake out nonverbal territories, putting him at a serious disadvantage, both socially and personally. The authors consider adult older sisters with younger brothers to be the most predictable of ordinal positions, displaying most of the following characteristics:
1. She does not particularly like children. While not rejecting her own children, she is apt to be more maternal as a teacher, child psychologist, etc., to other people's children.
2. She is usually a career woman. However, she may regard her marriage and homemaking activities as her "career." Her second motto is "I'm from Missouri, show me." She takes nothing on faith, and demands proof. In therapy, she is affable and acts promptly on insights but makes it almost a point of honor never to acknowledge the therapist's contribution to her life.
3. Her genuine love for her parents is tempered by a keen awareness of their shortcomings so that her attitude toward them can be one of almost loving contempt implemented more by filial obligation than by genuine concern.
4. In her personal life the older sister with younger brother shows an underlying disdain for emotionalism. She tends to become attached to men who are intellectual, professional, who "believe in" solving every problem rationally, but who are inept socially--almost as though she seeks a man who will not compete with her in poise and social expertise.
     Collaborative childhood undertakings carried out in the company of male and female peers with minimal adult supervision can go a long way toward correcting the imbalances that have been outlined.

Older Girl with One Younger Sister (F-1-F )
This child is more likely than her male counterpart (older boy with younger brother) to be nursemaid for the younger sibling at an extremely early age, perhaps because the transition from playing mommy to a doll to that of parenting a younger sibling is easy to make. Unaware of the pitfalls in such a role, parents may place a heavy burden of responsibility on this elder daughter. Such a policy fails to take into account the fact that the two children are siblings, and most important, that this little mother is herself a child, and entitled to the prerogatives of a bona fide childhood. Relinquishing these prerogatives plays into the little girl's desire to be a woman like her mother and makes it difficult for her to come to terms with the resentment and anger that such a heavy sacrifice entails.
     Toman finds her responsible, competent, often bossy, highly competitive with other females, conscientious, and inclined toward self-righteousness. He observes that while she relates best to younger sisters of sisters, both boys and girls may feel intimidated by her-which she doesn't seem to mind at all. Koch notes that her childhood playmates are largely female and that in family terms she tends to see herself as being closer to her father, and her sister as closer to the mother. Toman likewise sees her as being strongly attached to her father, in competition with her mother; as father's helpmate or second-in-command. Sutton-Smith et al. find her "the most independent of all girls at all ages."
     Where a narrow (one- to three-year) age gap exists, she may treat the younger sister more like a twin and they may become inseparable-confidantes, the proverbial "sister act." If the age gap is four years or more, rivalry usually takes over and this girl then regards her sister as the recipient of numberless parental favors, as being "spoiled" and unfairly indulged. In this case she can be the most bitterly hostile toward her sibling of all ordinal positions.
     As with other two-sib configurations, when the special advantages of each birth order are openly spelled out to the child and consistently adhered to, many of these problems are avoidable. In the meantime it is best if the caretaking duties of this elder sister are held to a realistic minimum.

Younger Girl with an Older Sister (F-2-F )
Like the younger girl with older brother and the younger boy with older sister, this girl is relatively rare in adult clinical caseloads. An examination of her childhood personality profile may help to explain why she so rarely seeks (needs?) psychotherapy.
     While Koch finds the younger girl with an older sister quite dependent on adult attention (especially the mother's) and having difficulty making final decisions, she is also described as being less moody, less fearful of physical activities, and less vacillating than other children. Apparently the wider the sibling age gap the better her social adjustment and the more self-confident, cheerful, and less moody she is apt to be. SuttonSmith et al. find her conforming and affiliative, high in emotional dependency, and low in competitiveness. At the same time, they find her the "most feminine and least masculine of the two child female sibling statuses." As with the younger of two boys, Koch notes that with a narrow age gap, this ordinal girl tends to be a hanger-on in social groups chosen by her elder sister.
     The relatively few younger girls with older sisters whom the authors have encountered clinically are gregarious, energetic, confident, ebullient (bordering on silliness), and breathtakingly verbose. The social chatterbox and single swinger is most apt to be such an ordinal.
     Her rarity among patient populations may be due either to a highly successful social repertoire which serves to assuage and distract her from deeper internal concerns, or to the sense of total erasure which could result from a too serious defeat at the hands of a competitively successful older sister.
     A problem met with in all two-sister families is that one parent may have wanted a boy and demands that one of the girls either fulfill this role or else do eternal penance for having failed to do so.
     Forer feels that a younger girl with an older sister needs much reassurance as an adolescent and young adult, and that it is "important for her to develop her own interests and abilities rather than compete with the sister on the sister's terms."

Younger Sister with an Older Brother (F-2-M )
In a study of thirty-five therapist caseloads, the oldest sister of three or more siblings is the least likely ordinal position to seek psychotherapeutic help. But this ordinal girl was the next rarest. Clinical experience with her older brother has convinced the authors that this girl frequently suffers serious and subtle childhood damage, the nature of which her older brother (who scarcely acknowledges her existence) is unable to elucidate. Combining limited clinical findings with extraclinical sources, one may hypothesize that her development proceeds as follows.
Her feelings toward the older brother (and males in general) seem marked by a lifelong ambivalence. She oscillates between anguished yearnings for his love and support accompanied by a sense of resentment and despair at feeling patronized, rejected, or totally ignored by the family "prince." At the same time she feels that her parents compare her unfavorably with her brother. A wish to be her brother's devoted sychophant wars with an equally strong impulse to compete with and defeat her lofty competitor. Her adult romantic relations with men seem to be governed by an unconscious paradox: "I want a strong, self-assertive, masculine man who will do exactly as I tell him to."
     Sexual experiments between siblings are by no means rare. However, they can be traumatic for the younger sister with an older brother. She feels "used" by the older brother rather than loved, affirmed, or physically and emotionally appreciated by him. He, meanwhile, represses, denies, or dismisses such contacts as being mutually inconsequential. When the age gap is small, however, this pair can also be genuinely close.
     Kammeyer and Sutton-Smith and Rosenberg" comment upon her "masculine" qualities, which are more pronounced than for girls in any other ordinal position; she is most often involved in entrepreneurial activities and in college is apt to be "overrepresented among physical education majors." Rather than being "masculine" in the traditional sense, she plays down her vulnerability so as to avoid possible vanquishment either by males or by more dominant females. Toman says that she collaborates well with males in work situations, but that other females, without knowing why, do not trust her. He further confirms that with a wide sibling age gap she often feels that she runs a poor second to her brother and dreads anything resembling failure in the eyes of the world.
     Koch, adds that with the wider age gap, the juvenile young sister with an older brother shows decreased cheerfulness, self-confidence, finality of decision making, and speed of recovery from emotional upsets: she is also less friendly toward adults. She displays an increased tendancy to alibi, to be critical, to hid for adult attention, and to be readily upset by defeats. Otherwise Koch describes her as dynamic, highly observant, and tenacious, although with a "tendency to procrastinate."
     Sutton-Smith et al. find her to be low on affiliation and conformity, more emotionally independent than other girls, and "least powerful vis-a-vis siblings . . . a surprisingly unmitigated record of the older male sibling's influence on the younger girl." Toman notes that she doesn't seem to seek friendship with females and Koch reports that at the six-year-old level this ordinal girl is apt to display "tomboyish" qualities. Moreover, compared to other girls she is apt to be more quarrelsome, tenacious, resourceful, selfish, competitive, and confident as well as enthusiastic, popular, and "high on leadership." Koch further points to her "greater expressed desire to become the opposite-sex sibling than any [other] group." More than any ordinal position (with the single exception of the younger boy with an older sister), from birth onward this child needs a great deal of love and affirmation from her same-sex parent (or parental surrogates).

While the ramifications of birth order are manifold, appreciating the significance of ordinal position provides information crucial to understanding a given child. Knowing parental (and even grandparental) ordinal positions can widen the scope of that understanding. An older sister may see her own daughter as the embodiment of her younger sister and "transfer" onto the child her resentment of that sister's presumed privileges. Singleton parents become upset when their own children squabble, while parents who come from large families consider sibling quarrels to be run-of-the-mill. Finally, an eldest brother may resent his own children because they, like his siblings, compete for his wife's ("mother's") love and attention. As we have pointed out, these matters are not cutand-dried, but are complicated by many modifying factors. Considerably more clinical investigation is called for in this largely neglected area, since the surface has hardly been scratched.

1. ADLER, A., Understanding Human Nature, Premier Books (Fawcett Publications), New York, 1959.
2. FORER, L. B., Birth Order and Life Roles, Charles C Thomas, Springfield, Ill., 1969.
3. KAMMEYER, K., "Birth Order and the Feminine Sex Role among College Women," American Sociological Review, 31:508-515, 1966.
4. KOCH, H. L., "Some Emotional Attitudes of the Young Child in Relation to Characteristics of His Sibling," Child Development, 27:393-426, 1956.
5. ----------,"Childrens' Work Attitudes and Sibling Characteristics," Child Development, 27:289-310, 1956.
6. ----------, Some Personality Correlates of Sex, Sibling Position, and Sex of Sibling among Five- and Six-Year-Old Children, Genetic Psychology Monographs, vol. 52, pp. 3-50, 1955.
7. ----------, "The Relation of Certain Family Constellation Characteristics and the Attitudes of Children towards Adults," Child Development, 26:13-40, 1955.
8. ----------, "The Relation of `Primary Mental Abilities' in Five- and Six-Year-Olds to Sex of Child and Characteristics of His Sibling," Child Development, 25:209-223, 1954.
9. KONIG, K., Brothers and Sisters, St. George Books, Blauvelt, N.Y., 1973.
10. SMITH, E. E., and GOODCHILDS, J. D., "Some Personality and Behavioral Factors Related to Birth Order," Journal of Applied Psychology, 47:300-303, 1963.
11. SUTTON-SMITH, B., and ROSENBERG, B. G., The Sibling, Holt, Rinehart and Winston, New York, 1970.
12. SUTTON-SMITH, B., ROBERTS, J. M., and ROSENBERG, B. G., "Sibling Association and Role Involvement," Merrill-Palmer Quarterly, 10:25-38, 1964.
13. TOMAN, W., Family Constellation, 2nd ed., Springer, New York, 1969.
14. WILSON, B., "A Clinical Portrait of M-1-F, the Elder Brother with One Younger Sibling, a Sister," unpublished manuscript, 1966.
15. ----------, "The Personality of M-1-F as Seen in An Out-Patient Population: A Pilot Study," unpublished manuscript, 1968.

Analytic Therapy
Sigmund Freud, Introductory Lectures on Psychoanalysis- Lecture 28

Ladies & Gentleman, you know what we are going to talk about today. You asked me why we do not make use of direct suggestion in psycho-analytic therapy, when we admit that our influence rests essentially on transference--that is, on suggestion; and you added a doubt whether, in view of this predominance of suggestion, we are still able to claim that our psychological discoveries are objective. I promised I would give you a detailed reply.
     Direct suggestion is suggestion aimed against the manifestation of the symptoms; it is a struggle between your authority and the motives for the illness. In this you do not concern yourself with these motives; you merely request the patient to suppress their manifestation in symptoms. It makes no difference of principle whether you put the patient under hypnosis or not. Once again Bernheim, with his characteristic perspicacity, maintained that suggestion was the essential element in the phenomena of hypnotism, that hypnosis itself was already a result of suggestion, a suggested state; and he preferred to practise suggestion in a waking state, which can achieve the same effects as suggestion under hypnosis.
     Which would you rather hear first on this question--what experience tells us or theoretical considerations? Let us begin with the former. I was a pupil of Bernheim's, whom I visited at Nancy in 1889 and whose book on suggestion I translated into German. I practised hypnotic treatment for many years, at first by prohibitory suggestion and later in combination with Breuer's method of questioning the patient. I can therefore speak of the results of hypnotic or suggestive therapy on the basis of a wide experience. If, in the words of the old medical aphorism, an ideal therapy should be rapid, reliable and not disagreeable for the patient [`cito, tuto, jucunde'], Bernheim's method fulfilled at least two of these requirements. It could be carried through much quicker--or, rather, infinitely quicker--than analytic treatment and it caused the patient neither trouble nor unpleasantness. For the doctor it became, in the long run, monotonous: in each case, in the same way, with the same ceremonial, forbidding the most variegated symptoms to exist, without being able to learn anything of their sense and meaning. It was hackwork and not a scientific activity, and it recalled magic, incantations and hocus-pocus. That could not weigh, however, against the patient's interest. But the third quality was lacking: the procedure was not reliable in any respect. It could be used with one patient but not with another; it achieved a great deal with one and very little with another, and one never knew why. Worse than the capriciousness of the procedure was the lack of permanence in its successes. If, after a short time, one had news of the patient once more, the old ailment was back again or its place had been taken by a new one. One might hypnotize him again. But in the background there was the warning given by experienced workers against robbing the patient of his self-reliance by frequently repeated hypnosis and so making him an addict to this kind of therapy as though it were a narcotic. Admittedly sometimes things went entirely as one would wish: after a few efforts, success was complete and permanent. But the conditions determining such a favourable outcome remained unknown. On one occasion a severe condition in a woman, which I had entirely got rid of by a short hypnotic treatment, returned unchanged after the patient had, through no action on my part, got annoyed with me; after a reconciliation, I removed the trouble again and far more thoroughly; yet it returned once more after she had fallen foul of me a second time. On another occasion a woman patient, whom I had repeatedly helped out of neurotic states by hypnosis, suddenly, during the treatment of a specially obstinate situation, threw her arms round my neck. After this one could scarcely avoid, whether one wanted to or not, investigating the question of the nature and origin of one's authority in suggestive treatment.
      So much for experiences. They show us that in renouncing direct suggestion we are not giving up anything of irreplaceable value. Now let us add a few reflections to this. The practice of hypnotic therapy makes very small demands on either the patient or the doctor. It agrees most beautifully with the estimate in which neuroses are still held by the majority of doctors. The doctor says to the neurotic patient: `There's nothing wrong with you, it's only a question of nerves; so I can blow away your trouble in two or three minutes with just a few words.' But our views on the laws of energy are offended by the notion of its being possible to move a great weight by a tiny application of force, attacking it directly, without the outside help of any appropriate appliances. In so far as the conditions are comparable, experience shows that this feat is not successfully accomplished in the case of the neuroses either. But I am aware that this argument is not unimpeachable. There is such a thing as a 'trigger-action'.
     In the light of the knowledge we have gained from psychoanalysis we can describe the difference between hypnotic and psycho-analytic suggestion as follows. Hypnotic treatment seeks to cover up and gloss over something in mental life; analytic treatment seeks to expose and get rid of something. The former acts like a cosmetic, the latter like surgery. The former makes use of suggestion in order to forbid the symptoms; it strengthens the repressions, but, apart from that, leaves all the processes that have led to the formation of the symptoms unaltered. Analytic treatment makes its impact further back towards the roots, where the conflicts are which gave rise to the symptoms, and uses suggestion in order to alter the outcome of those conflicts. Hypnotic treatment leaves the patient inert and unchanged, and for that reason, too, equally unable to resist any fresh occasion for falling ill. An analytic treatment demands from both doctor and patient the accomplishment of serious work, which is employed in lifting internal resistances. Through the overcoming of these resistances the patient's mental life is permanently changed, is raised to a high level of development and remains protected against fresh possibilities of falling ill. This work of overcoming resistances is the essential function of analytic treatment; the patient has to accomplish it and the doctor makes this possible for him with the help of suggestion operating in an educative sense. For that reason psychoanalytic treatment has justly been described as a kind of after-education.
     I hope I have now made it clear to you in what way our method of employing suggestion therapeutically differs from the only method possible in hypnotic treatment. You will understand too, from the fact that suggestion can be traced back to transference, the capriciousness which struck us in hypnotic. therapy, while analytic treatment remains calculable within its limits. In using hypnosis we are dependent on the state of the patient's capacity for transference without being able to influence it itself. The transference of a person who is to be hypnotized may be negative or, as most frequently, ambivalent, or he may have protected himself against his transference by adopting special attitudes; of that we learn nothing. In psychoanalysis we act upon the transference itself, resolve what opposes it, adjust the instrument with which we wish to make our impact. Thus it becomes possible for us to derive an entirely fresh advantage from the power of suggestion; we get it into our hands. The patient does not suggest to himself whatever he pleases: we guide his suggestion so far as he is in any way accessible to its influence.
      But you will now tell me that, no matter whether we call the motive force of our analysis transference or suggestion, there is a risk that the influencing of our patient may make the objective certainty of our findings doubtful. What is advantageous to our therapy is damaging to our researches. This is the objection that is most often raised against psycho-analysis, and it must be admitted that, though it is groundless, it cannot be rejected as unreasonable. If it were justified, psycho-analysis would be nothing more than a particularly well-disguised and particularly effective form of suggestive treatment and we should have to attach little weight to all that it tells us about what influences our lives, the dynamics of the mind or the unconscious. That is what our opponents believe; and in especial they think that we have `talked' the patients into everything relating to the importance of sexual experiences--or even into those experiences themselves--after such notions have grown up in our own depraved imagination. These accusations are contradicted more easily by an appeal to experience than by the help of theory. Anyone who has himself carried out psycho-analyses will have been able to convince himself on countless occasions that it is impossible to make suggestions to a patient in that way. The doctor has no difficulty, of course, in making him a supporter of some particular theory and in thus making him share some possible error of his own. In this respect the patient is behaving like anyone else--like a pupil--but this only affects his intelligence, not his illness. After all, his conflicts will only be successfully solved and his resistances overcome if the anticipatory ideas he is given tally with what is real in him. Whatever in the doctor's conjectures is inaccurate drops out in the course of the analysis; it has to be withdrawn and replaced by something more correct. We endeavour by a careful technique to avoid the occurrence of premature successes due to suggestion; but no harm is done even if they do occur, for we are not satisfied by a first success. We do not regard an analysis as at an end until all the obscurities of the case are cleared up, the gaps in the patient's memory filled in, the precipitating causes of the repressions discovered. We look upon successes that set in too soon as obstacles rather than as a help to the work of analysis; and we put an end to such successes by constantly resolving the transference on which they are based. It is this last characteristic which is the fundamental distinction between analytic and purely suggestive therapy, and which frees the results of analysis from the suspicion of being successes due to suggestion. In every other kind of suggestive treatment the transference is carefully preserved and left untouched; in analysis it is itself subjected to treatment and is dissected in all the shapes in which it appears. At the end of an analytic treatment the transference must itself be cleared away; and if success is then obtained or continues, it rests, not on suggestion, but on the achievement by its means of an overcoming of internal resistances, on the internal change that has been brought about in the patient.
     The acceptance of suggestions on individual points is no doubt discouraged by the fact that during the treatment we are struggling unceasingly against resistances which are able to transform themselves into negative (hostile) transferences. Nor must we fail to point out that a large number of the individual findings of analysis, which might otherwise be suspected of being products of suggestion, are confirmed from another and irreproachable source. Our guarantors in this case are the sufferers from dementia praecox and paranoia, who are of course far above any suspicion of being influenced by suggestion. The translations of symbols and the phantasies, which these patients produce for us and which in them have forced their way through into consciousness, coincide faithfully with the results of our investigations into the unconscious of transference neurotics and thus confirm the objective correctness of our interpretations, on which doubt is so often thrown. You will not, I think, be going astray if you trust analysis on these points.
      I will now complete my picture of the mechanism of cure by clothing it in the formulas of the libido theory. A neurotic is incapable of enjoyment and of efficiency--the former because his libido is not directed on to any real object and the latter because he is obliged to employ a great deal of his available energy on keeping his libido under repression and on warding off its assaults. He would become healthy if the conflict between his ego and his libido came to an end and if his ego had his libido again at its disposal. The therapeutic task consists, therefore, in freeing the libido from its present attachments, which are withdrawn from the ego, and in making it once more serviceable to the ego. Where, then, is the neurotic's libido situated? It is easily found: it is attached to the symptoms, which yield it the only substitutive satisfaction possible at the time. We must therefore make ourselves masters of the symptoms and resolve them--which is precisely the same thing that the patient requires of us. In order to resolve the symptoms, we must go back as far as their origin, we must renew the conflict from which they arose, and, with the help of motive forces which were not at the patient's disposal in the past, we must guide it to a different outcome. This revision of the process of repression can be accomplished only in part in connection with the memory traces of the processes which led to repression. The decisive part of the work is achieved by creating in the patient's relation to the doctor--in the 'transference'--new editions of the old conflicts; in these the patient would like to behave in the same way as he did in the past, while we, by summoning up every available mental force [in the patient], compel him to come to a fresh decision. Thus the transference becomes the battlefield on which all the mutually struggling forces should meet one another.
     All the libido, as well as everything opposing it, is made to converge solely on the relation with the doctor. In this process the symptoms are inevitably divested of libido. In place of the patient's true illness there appears the artificially constructed transference illness, in place of the various unreal objects of his libido there appears a single, and once more imaginary, object in the person of the doctor. But, by the help of the doctor's suggestion, the new struggle around this object is lifted to the highest psychical level: it takes place as a normal mental conflict. Since a fresh repression is avoided, the alienation between ego and libido is brought to an end and the subject's mental unity is restored. When the libido is released once more from its temporary object in the person of the doctor, it cannot return to its earlier objects, but is at the disposal of the ego. The forces against which we have been struggling during our work of therapy are, on the one hand, the ego's antipathy to certain trends of the libido--an antipathy expressed in a tendency to repression--and, on the other hand, the tenacity or adhesiveness of the libido, which dislikes leaving objects that it has once cathected.
     Thus our therapeutic work falls into two phases. In the first, all the libido is forced from the symptoms into the transference and concentrated there; in the second, the struggle is waged around this new object and the libido is liberated from it. The change which is decisive for a favourable outcome is the elimination of repression in this renewed conflict, so that the libido cannot withdraw once more from the ego by flight into the unconscious. This is made possible by the alteration of the ego which is accomplished under the influence of the doctor's suggestion. By means of the work of interpretation, which transforms what is unconscious into what is conscious, the ego is enlarged at the cost of this unconscious; by means of instruction, it is made conciliatory towards the libido and inclined to grant it some satisfaction, and its repugnance to the claims of the libido is diminished by the possibility of disposing of a portion of it by sublimation. The more closely events in the treatment coincide with this ideal description, the greater will be the success of the psycho-analytic therapy. It finds its limits in the lack of mobility of the libido, which may refuse to leave its objects, and the rigidity of narcissism, which will not allow transference on to objects to increase beyond certain bounds. Further light may perhaps be thrown on the dynamics of the process of cure if I say that we get hold of the whole of the libido which has been withdrawn from the dominance of the ego by attracting a portion of it on to ourselves by means of the transference.
     It will not be out of place to give a warning that we can draw no direct conclusion from the distribution of the libido during and resulting from the treatment as to how it was distributed during the illness. Suppose we succeeded in bringing a case to a favourable conclusion by setting up and then resolving a strong father-transference to the doctor. It would not be correct to conclude that the patient had suffered previously from a similar unconscious attachment of his libido to his father. His father-transference was merely the battlefield on which we gained control of his libido; the patient's libido was directed to it from other positions. A battlefield need not necessarily coincide with one of the enemy's key fortresses. The defence of a hostile capital need not take place just in front of its gates. Not until after the transference has once more been resolved can we reconstruct in our thoughts the distribution of libido which had prevailed during the illness.
      From the standpoint of the libido theory, too, we may say a last word on dreams. A neurotic's dreams help us, like his parapraxes and his free associations to them, to discover the sense of his symptoms and to reveal the way in which his libido is allocated. They show us, in the form of a wish-fulfilment, what wishful impulses have been subjected to repression and to what objects the libido withdrawn from the ego has become attached. For this reason the interpretation of dreams plays a large part in a psycho-analytic treatment, and in some cases it is over long periods the most important instrument of our work. We already know that the state of sleep in itself leads to a certain relaxation of the repressions. A repressed impulse, owing to this reduction in the pressure weighing down upon it, becomes able to express itself far more clearly in a dream than it can be allowed to be expressed by a symptom during the day. The study of dreams therefore becomes the most convenient means of access to a knowledge of the repressed unconscious, of which the libido withdrawn from the ego forms a part.
     But the dreams of neurotics do not differ in any important respect from those of normal people; it is possible, indeed, that they cannot be distinguished from them at all. It would be absurd to give an account of the dreams of neurotics which could not also apply to the dreams of normal people. We must therefore say that the difference between neurosis and health holds only during the day; it is not prolonged into dream-life. We are obliged to carry over to healthy people a number of hypotheses which arise in connection with neurotics as a result of the link between the latter's dreams and their symptoms. We cannot deny that healthy people as well possess in their mental life what alone makes possible the formation both of dreams and of symptoms, and we must conclude that they too have carried out repressions, that they expend a certain amount of energy in order to maintain them, that their unconscious system conceals repressed impulses which are still cathected with energy, and that a portion of their libido is withdrawn from their ego's disposal. Thus a healthy person, too, is virtually a neurotic; but dreams appear to be the only symptoms which he is capable of forming. It is true that if one subjects his waking life to a closer examination one discovers something that contradicts this appearance--namely that this ostensibly healthy life is interspersed with a great number of trivial and in practice unimportant symptoms.
     The distinction between nervous health and neurosis is thus reduced to a practical question and is decided by the outcome -- by whether the subject is left with a sufficient amount of capacity for enjoyment and of efficiency. It probably goes back to the relative sizes of the quota of energy that remains free and of that which is bound by repression, and is of a quantitative not of a qualitative nature. I need not tell you that this discovery is the theoretical justification for our conviction that neuroses are in principle curable in spite of their being based on constitutional disposition.
The identity of the dreams of healthy and neurotic people enables us to infer thus much in regard to defining the characteristics of health. But in regard to dreams themselves we can make a further inference: we must not detach them from their connection with neurotic symptoms, we must not suppose that their essential nature is exhausted by the formula that describes them as a translation of thoughts into an archaic form of expression, but we must suppose that they exhibit to us allocations of the libido and object-cathexes that are really present.
      We shall soon have reached the end. You are perhaps disappointed that on the topic of the psycho-analytic method of therapy I have only spoken to you about theory and not about the conditions which determine whether a treatment is to be undertaken or about the results it produces. I shall discuss neither: the former because it is not my intention to give you practical instructions on how to carry out a psycho-analysis, and the latter because several reasons deter me from it. At the beginning of our talks, I emphasized the fact that under favourable conditions we achieve successes which are second to none of the finest in the field of internal medicine; and I can now add something further--namely that they could not have been achieved by any other procedure. If I were to say more than this I should be suspected of trying to drown the loudly raised voices of depreciation by self-advertisement. The threat has repeatedly been made against psycho-analysts by our medical 'colleagues'--even at public congresses--that a collection of the failures and damaging results of analysis would be published which would open the suffering public's eyes to the worthlessness of this method of treatment. But, apart from the malicious, denunciatory character of such a measure, it would not even be calculated to make it possible to form a correct judgement of the therapeutic effectiveness of analysis. Analytic therapy, as you know, is in its youth; it has taken a long time to establish its technique, and that could only be done in the course of working and under the influence of increasing experience. In consequence of the difficulties in giving instruction, the doctor who is a beginner in psycho-analysis is thrown back to a greater extent than other specialists on his own capacity for further development, and the results of his first years will never make it possible to judge the efficacy of analytic therapy.
     Many attempts at treatment miscarried during the early period of analysis because they were undertaken in cases which were altogether unsuited to the procedure and which we should exclude today on the basis of our present view of the indications for treatment. But these indications, too, could only be arrived at by experiment. In those days we did not know a priori that paranoia and dementia praecox in strongly marked forms are inaccessible, and we had a right to make trial of the method on all kinds of disorders. But most of the failures of those early years were due not to the doctor's fault or an unsuitable choice of patients but to unfavourable external conditions. Here we have only dealt with internal resistances, those of the patient, which are inevitable and can be overcome. The external resistances which arise from the patient's circumstances, from his environment, are of small theoretical interest but of the greatest practical importance.
      Psycho-analytic treatment may be compared with a surgical operation and may similarly claim to be carried out under arrangements that will be the most favourable for its success. You know the precautionary measures adopted by a surgeon: a suitable room, good lighting, assistants, exclusion of the patient's relatives, and so on. Ask yourselves now how many of these operations would turn out successfully if they had to take place in the presence of all the members of the patient's family, who would stick their noses into the field of the operation and exclaim aloud at every incision. In psychoanalytic treatments the intervention of relatives is a positive danger and a danger one does not know how to meet. One is armed against the patient's internal resistances, which one knows are inevitable, but how can one ward off these external resistances? No kind of explanations make any impression on the patient's relatives; they cannot be induced to keep at a distance from the whole business, and one cannot make common cause with them because of the risk of losing the confidence of the patient, who quite rightly, moreover--expects the person in whom he has put his trust to take his side. No one who has any experience of the rifts which so often divide a family will, if he is an analyst, be surprised to find that the patient's closest relatives sometimes betray less interest in his recovering than in his remaining as he is. When, as so often, the neurosis is related to conflicts between members of a family, the healthy party will not hesitate long in choosing between his own interest and the sick party's recovery. It is not to be wondered at, indeed, if a husband looks with disfavour on a treatment in which, as he may rightly suspect, the whole catalogue of his sins will be brought to light. Nor do we wonder at it; but we cannot in that case blame ourselves if our efforts remain unsuccessful and the treatment is broken off prematurely because the husband's resistance is added to that of his sick wife. We had in fact undertaken something which in the prevailing circumstances was unrealizable.
     Instead of reporting a number of cases, I will tell you the story of a single one, in which, from considerations of medical discretion, I was condemned to play a long-suffering part. I undertook the analytic treatment--it was many years ago--of a girl who had for some time been unable, owing to anxiety, to go out in the street or to stay at home by herself. The patient slowly brought out an admission that her imagination had been seized by chance observations of the affectionate relations between her mother and a well-to-do friend of the family. But she was so clumsy--or so subtle--that she gave her mother a hint of what was being talked about in the analytic sessions. She brought this about by changing her behaviour towards her mother, by insisting on being protected by no one but her mother from her anxiety at being alone and by barring the door to her in her anxiety if she tried to leave the house. Her mother had herself been very neurotic in the past, but had been cured years before in a hydropathic establishment. Or rather, she had there made the acquaintance of the man with whom she was able to enter into a relation that was in every way satisfying to her. The girl's passionate demands took her aback, and she suddenly understood the meaning of her daughter's anxiety: the girl had made herself ill in order to keep her mother prisoner and to rob her of the freedom of movement that her relations with her lover required. The mother quickly made up her mind and brought the obnoxious treatment to an end. The girl was taken to a sanatorium for nervous diseases and was demonstrated for many years as `a poor victim of psycho-analysis'. All this time, too, I was pursued by the calumny of responsibility for the unhappy end of the treatment. I kept silence, for I thought I was bound by the duty of medical discretion. Long afterwards I learnt from one of my colleagues, who visited the sanatorium and had seen the agoraphobic girl there, that the liaison between her mother and the well-to-do friend of the family was common knowledge in the city and that it was probably connived at by the husband and father. Thus it was to this `secret' that the treatment had been sacrificed.
     In the years before the war, when arrivals from many foreign countries made me independent of the favour or disfavour of my own city, I followed a rule of not taking on a patient for treatment unless he was sui juris, not dependent on anyone else in the essential relations of his life. This is not possible, however, for every psycho-analyst. Perhaps you may conclude from my warning against relatives that patients designed for psychoanalysis should be removed from their families and that this kind of treatment should accordingly be restricted to inmates of hospitals for nervous diseases. I could not, however, follow you in that. It is much more advantageous for patients (in so far as they are not in a phase of severe exhaustion) to remain during the treatment in the conditions in which they have to struggle with the tasks that face them. But the patients' relatives ought not to cancel out this advantage by their conduct and should not offer any hostile opposition to the doctor's efforts. But how do you propose to influence in that direction factors like these which are inaccessible to us? And you will guess, of course, how much the prospects of a treatment are determined by the patient's social milieu and the cultural level of his family.
     This presents a gloomy prospect for the effectiveness of psycho-analysis as a therapy--does it not?--even though we are able to explain the great majority of our failures by attributing them to interfering external factors. Friends of analysis have advised us to meet the threatened publication of our failures with statistics of our successes drawn up by ourselves. I did not agree to this. I pointed out that statistics are worthless if the items assembled in them are too heterogeneous; and the cases of neurotic illness which we had taken into treatment were in fact incomparable in a great variety of respects. Moreover, the period of time that could be covered was too short to make it possible to judge the durability of the cures. And it was altogether impossible to report on many of the cases: they concerned people who had kept both their illness and its treatment secret, and their recovery had equally to be kept secret. But the strongest reason for holding back lay in the realization that in matters of therapy people behave highly irrationally, so that one has no prospect of accomplishing anything with them by rational means. A therapeutic novelty is either received with delirious enthusiasm--as, for instance, when Koch introduced his first tuberculin against tuberculosis to the public--or it is treated with abysmal distrust--like Jenner's vaccination, which was in fact a blessing and which even today has its irreconcilable opponents. There was obviously a prejudice against psycho-analysis. If one had cured a severe case, one might hear people say: `That proves nothing. He would have recovered on his own account by this time.' And when a woman patient, who had already passed through four cycles of depression and mania, came to be treated by me during an interval after an attack of melancholia and three weeks later started on a phase of mania, all the members of her family--and a high medical authority, too, who was called in for consultation--were convinced that the fresh attack could only be the result of my attempted analysis. Nothing can be done against prejudices. You can see it again today in the prejudices which each group of nations at war has developed against the other. The most sensible thing to do is to wait, and to leave such prejudices to the eroding effects of time. One day the same people begin to think about the same things in quite a different way from before; why they did not think so earlier remains a dark mystery.
It is possible that the prejudice against analytic treatment is already diminishing. The constant spread of analytic teachings, the increasing number of doctors practising analysis in a number of countries seems to vouch for this. When I was a young doctor, I found myself in a similar storm of indignation on the doctors' part against treatment by hypnotic suggestion, which is now held up in contrast to analysis by people of `moderate' views.' Hypnotism, however, has not fulfilled its original promise as a therapeutic agent. We psycho-analysts may claim to be its legitimate heirs and we do not forget how much encouragement and theoretical clarification we owe to it. The damaging results attributed to psycho-analysis are restricted essentially to passing manifestations of increased conflict if an analysis is clumsily carried out or if it is broken off in the middle. You have heard an account of what we do with our patients and can form your own judgement as to whether our efforts are calculated to lead to any lasting damage. Abuse of analysis is possible in various directions; in particular, the transference is a dangerous instrument in the hands of an unconscientious doctor. But no medical
instrument or procedure is guaranteed against abuse; if a knife does not cut, it cannot be used for healing either.
      I have finished, Ladies and Gentlemen. It is more than a conventional form of words if I admit that I myself am profoundly aware of the many defects in the lectures I have given you. I regret above all that I have so often promised to return later to a topic I have lightly touched on and have then found no opportunity of redeeming my promise. I undertook to give you an account of a subject which is still incomplete and in process of development, and my condensed summary has itself turned out to be an incomplete one. At some points I have set out the material on which to draw a conclusion and have then myself not drawn it. But I could not pretend to make you into experts; I have only tried to stimulate and enlighten you.