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Articles- Part XXXI
ON BEGINNING THE TREATMENT
(FURTHER RECOMMENDATIONS ON THE TECHNIQUE
OF PSYCHO-ANALYSIS I)
Sigmund Freud (1913)
ANYONE who hopes to learn the noble game of chess from books will soon discover that only the openings and end-games admit of an exhaustive systematic presentation and that the infinite variety of moves which develop after the opening defy any such description. This gap in instruction can only be filled by a diligent study of games fought out by masters. The rules which can be laid down for the practice of psycho-analytic treatment are subject to similar limitations.
In what follows I shall endeavour to collect together for the use of practising analysts some of the rules for the beginning of the treatment. Among them there are some which may seem to be petty details, as, indeed, they are. Their justification is that they are simply rules of the game which acquire their importance from their relation to the general plan of the game. I think I am well-advised, however, to call these rules `recommendations' and not to claim any unconditional acceptance for them. The extraordinary diversity of the psychical constellations concerned, the plasticity of all mental processes and the wealth of determining factors oppose any mechanization of the technique; and they bring it about that a course of action that is as a rule justified may at times prove ineffective, whilst one that is usually mistaken may once in a while lead to the desired end. These circumstances, however, do not prevent us from laying down a procedure for the physician which is effective on the average.
Some years ago I set out the most important indications for selecting patients and I shall therefore not repeat them here. They have in the meantime been approved by other psychoanalysts. But I may add that since then I have made it my habit, when I know little about a patient, only to take him on at first provisionally, for a period of one to two weeks. If one breaks off within this period one spares the patient the distressing impression of an attempted cure having failed. One has only been undertaking a `sounding' in order to get to know the case and to decide whether it is a suitable one for psychoanalysis. No other kind of preliminary examination but this procedure is at our disposal; the most lengthy discussions and questionings in ordinary consultations would offer no substitute. This preliminary experiment, however, is itself the beginning of a psycho-analysis and must conform to its rules. There may perhaps be this distinction made, that in it one lets the patient do nearly all the talking and explains nothing more than what is absolutely necessary to get him to go on with what he is saying.
There are also diagnostic reasons for beginning the treatment with a trial period of this sort lasting for one or two weeks. Often enough, when one sees a neurosis with hysterical or obsessional symptoms, which is not excessively marked and has not been in existence for long--just the type of case, that is, that one would regard as suitable for treatment--one has to reckon with the possibility that it may be a preliminary stage of what is known as dementia praecox ('schizophrenia', in Bleuler's terminology; `paraphrenia', as I have proposed to call it'), and that sooner or later it will show a well-marked picture of that affection. I do not agree that it is always possible to make the distinction so easily. I am aware that there are psychiatrists who hesitate less often in their differential diagnosis, but I have become convinced that just as often they make mistakes. To make a mistake, moreover, is of far greater moment for the psycho-analyst than it is for the clinical psychiatrist, as he is called. For the latter is not attempting to do anything that will be of use, whichever kind of case it may be. He merely runs the risk of making a theoretical mistake, and his diagnosis is of no more than academic interest. Where the psycho-analyst is concerned, however, if the case is unfavourable he has committed a practical error; he has been responsible for wasted expenditure and has discredited his method of treatment. He cannot fulfil his promise of cure if the patient is suffering, not from hysteria or obsessional neurosis, but from paraphrenia, and he therefore has particularly strong motives for avoiding mistakes in diagnosis. In an experimental treatment of a few weeks he will often observe suspicious signs which may determine him not to pursue the attempt any further. Unfortunately, I cannot assert that an attempt of this kind always enables us to arrive at a certain decision; it is only one wise precaution the more.
Lengthy preliminary discussions before the beginning of the analytic treatment, previous treatment by another method and also previous acquaintance between the analyst and the patient who is to be analysed, have special disadvantageous consequences for which one must be prepared. They result in the patient's meeting the doctor with a transference attitude which is already established and which the analyst must first slowly uncover instead of having the opportunity to observe the growth and development of the transference from the outset. In this way the patient gains a temporary start upon us which we do not willingly grant him in the treatment.
One must mistrust all prospective patients who want to make a delay before beginning their treatment. Experience shows that when the time agreed upon has arrived they fail to put in an appearance, even though the motive for the delay--i.e. their rationalization of their intention--seems to the uninitiated to be above suspicion.
Special difficulties arise when the analyst and his new patient or their families are on terms of friendship or have social ties with one another. The psycho-analyst who is asked to undertake the treatment of the wife or child of a friend must be prepared for it to cost him that friendship, no matter what the outcome of the treatment may be: nevertheless he must make the sacrifice if he cannot find a trustworthy substitute.
Both lay public and analysts--still ready to confuse psychoanalysis with treatment by suggestion--are inclined to attribute great importance to the expectations which the patient brings to the new treatment. They often believe in the case of one patient that he will not give much trouble, because he has great confidence in psycho-analysis and is fully convinced of its truth and efficacy; whereas in the case of another, they think that he will undoubtedly prove more difficult, because he has a sceptical outlook and will not believe anything until he has experienced its successful results on his own person. Actually, however, this attitude on the part of the patient has very little importance. His initial trust or distrust is almost negligible compared with the internal resistances which hold the neurosis firmly in place. It is true that the patient's happy trustfulness makes our earliest relationship with him a very pleasant one; we are grateful to him for that, but we warn him that his favourable prepossession will be shattered by the first difficulty that arises in the analysis. To the sceptic we say that the analysis requires no faith, that he may be as critical and suspicious as he pleases and that we do not regard his attitude as the effect of his judgement at all, for he is not in a position to form a reliable judgement on these matters; his distrust is only a symptom like his other symptoms and it will not be an interference, provided he conscientiously carries out what the rule of the treatment requires of him.
No one who is familiar with the nature of neurosis will be astonished to hear that even a man who is very well able to carry out an analysis on other people can behave like any other mortal and be capable of producing the most intense resistances as soon as he himself becomes the object of analytic investigation. When this happens we are once again reminded of the dimension of depth in the mind, and it does not surprise us to find that the neurosis has its roots in psychical strata to which an intellectual knowledge of analysis has not penetrated.
Points of importance at the beginning of the analysis are arrangements about time and money.
In regard to time, I adhere strictly to the principle of leasing a definite hour. Each patient is allotted a particular hour of my available working day; it belongs to him and he is liable for it, even if he does not make use of it. This arrangement, which is taken as a matter of course for teachers of music or languages in good society, may perhaps seem too rigorous in a doctor, or even unworthy of his profession. There will be an inclination to point to the many accidents which may prevent the patient from attending every day at the same hour and it will be expected that some allowance shall be made for the numerous intercurrent ailments which may occur in the course of a longish analytic treatment. But my answer is: no other way is practicable. Under a less stringent regime the `occasional' non-attendances increase so greatly that the doctor finds his material existence threatened; whereas when the arrangement is adhered to, it turns out that accidental hindrances do not occur at all and intercurrent illnesses only very seldom. The analyst is hardly ever put in the position of enjoying a leisure hour which he is paid for and would be ashamed of; and he can continue his work without interruptions, and is spared the distressing and bewildering experience of finding that a break for which he cannot blame himself is always bound to happen just when the work promises to be especially important and rich in content. Nothing brings home to one so strongly the significance of the psychogenic factor in the daily life of men, the frequency of malingering and the non-existence of chance, as a few years' practice of psycho-analysis on the strict principle of leasing by the hour. In cases of undoubted organic illnesses, which, after all, cannot be excluded by the patient's having a psychical interest in attending, I break off the treatment, consider myself entitled to dispose elsewhere of the hour which becomes free, and take the patient back again as soon as he has recovered and I have another hour vacant.
I work with my patients every day except on Sundays and public holidays--that is, as a rule, six days a week. For slight cases or the continuation of a treatment which is already well advanced, three days a week will be enough. Any restrictions of time beyond this bring no advantage either to the analyst or the patient; and at the beginning of an analysis they are quite out of the question. Even short interruptions have a slightly obscuring effect on the work. We used to speak jokingly of the `Monday crust' when we began work again after the rest on Sunday. When the hours of work are less frequent, there is a risk of not being able to keep pace with the patient's real life and of the treatment losing contact with the present and being forced into by-paths. Occasionally, too, one comes across patients to whom one must give more than the average time of one hour a day, because the best part of an hour is gone before they begin to open up and to become communicative at all.
An unwelcome question which the patient asks the analyst at the outset is: `How long will the treatment take? How much time will you need to relieve me of my trouble?' If one has proposed a trial treatment of a few weeks one can avoid giving a direct answer to this question by promising to make a more reliable pronouncement at the end of the trial period. Our answer is like the answer given by the Philosopher to the Wayfarer in Aesop's fable. When the Wayfarer asked how long a journey lay ahead, the Philosopher merely answered `Walk!' and afterwards explained his apparently unhelpful reply on the ground that he must know the length of the Wayfarer's stride before he could tell how long his journey would take.' This expedient helps one over the first difficulties; but the comparison is not a good one, for the neurotic can easily alter his pace and may at times make only very slow progress. In point of fact, the question as to the probable duration of a treatment is almost unanswerable.
As the combined result of lack of insight on the part of patients and disingenuousness on the part of analysts, analysis finds itself expected to fulfil the most boundless demands, and that in the shortest time. Let me, as an example, give some details from a letter which I received a few days ago from a lady in Russia. She is 53 years old, her illness began twenty-three years ago and for the last ten years she has no longer been able to do any continuous work. `Treatment in a number of institutions for nervous cases' have not succeeded in making an `active life' possible for her. She hopes to be completely cured by psycho-analysis, which she has read about, but her illness has already cost her family so much money that she cannot manage to come to Vienna for longer than six weeks or two months. Another added difficulty is that she wishes from the very start to `explain' herself in writing only, since any discussion of her complexes would cause an explosion of feeling in her or `render her temporarily unable to speak'.--No one would expect a man to lift a heavy table with two fingers as if it were a light stool, or to build a large house in the time it would take to put up a wooden hut; but as soon as it becomes a question of the neuroses--which do not seem so far to have found a proper place in human thought--even intelligent people forget that a necessary proportion must be observed between time, work and success. This, incidentally, is an understandable result of the deep ignorance which prevails about the aetiology of the neuroses. Thanks to this ignorance, neurosis is looked on as a kind of `maiden from afar' 'None knew whence she came'; so they expected that one day she would vanish.
Analysts lend support to these fond hopes. Even the informed among them often fail to estimate properly the severity of nervous disorders. A friend and colleague of mine, to whose great credit I account it that after several decades of scientific work on other principles he became converted to the merits of psycho-analysis, once wrote to me: `What we need is a short, convenient, out-patient treatment for obsessional neurosis.' I could not supply him with it and felt ashamed; so I tried to excuse myself with the remark that specialists in internal diseases, too, would probably be very glad of a treatment for tuberculosis or carcinoma which combined these advantages.
To speak more plainly, psycho-analysis is always a matter of long periods of time, of half a year or whole years--of longer periods than the patient expects. It is therefore our duty to tell the patient this before he finally decides upon the treatment. I consider it altogether more honourable, and also more expedient, to draw his attention--without trying to frighten him off, but at the very beginning--to the difficulties and sacrifices which analytic treatment involves, and in this way to deprive him of any right to say later on that he has been inveigled into a treatment whose extent and implications he did not realize. A patient who lets himself be dissuaded by this information would in any case have shown himself unsuitable later on. It is a good thing to institute a selection of this kind before the beginning of the treatment. With the progress of understanding among patients the number of those who successfully meet this first test increases.
I do not bind patients to continue the treatment for a certain length of time; I allow each one to break off whenever he likes. But I do not hide it from him that if the treatment is stopped after only a small amount of work has been done it will not be successful and may easily, like an unfinished operation, leave him in an unsatisfactory state. In the early years of my psycho-analytic practice I used to have the greatest difficulty in prevailing on my patients to continue their analysis. This difficulty has long since been shifted, and I now have to take the greatest pains to induce them to give it up.
To shorten analytic treatment is a justifiable wish, and its fulfilment, as we shall learn, is being attempted along various lines. Unfortunately, it is opposed by a very important factor, namely, the slowness with which deep-going changes in the mind are accomplished--in the last resort, no doubt, the `timelessness' of our unconscious processes. When patients are faced with the difficulty of the great expenditure of time required for analysis they not infrequently manage to propose a way out of it. They divide up their ailments and describe some as unbearable, and others as secondary, and then say: `If only you will relieve me from this one (for instance, a headache or a particular fear) I can deal with the other one on my own in my ordinary life.' In doing this, however, they over-estimate the selective power of analysis. The analyst is certainly able to do a great deal, but he cannot determine beforehand exactly what results he will effect. He sets in motion a process, that of the resolving of existing repressions. He can supervise this process, further it, remove obstacles in its way, and he can undoubtedly vitiate much of it. But on the whole, once begun, it goes its own way and does not allow either the direction it takes or the order in which it picks up its points to be prescribed for it. The analyst's power over the symptoms of the disease may thus be compared to male sexual potency. A man can, it is true, beget a whole child, but even the strongest man cannot create in the female organism a head alone or an arm or a leg; he cannot even prescribe the child's sex. He, too, only sets in motion a highly complicated process, determined by events in the remote past, which ends with the severance of the child from its mother. A neurosis as well has the character of an organism. Its component manifestations are not independent of one another; they condition one another and give one another mutual support. A person suffers from one neurosis only, never from several which have accidentally met together in a single individual. The patient freed, according to his wish, from his one unendurable symptom might easily find that a symptom which had previously been negligible had now increased and grown unendurable. The analyst who wishes the treatment to owe its success as little as possible to its elements of suggestion (i.e. to the transference) will do well to refrain from making use of even the trace of selective influence upon the results of the therapy which may perhaps be open to him. The patients who are bound to be most welcome to him are those who ask him to give them complete health, in so far as that is attainable, and who place as much time at his disposal as is necessary for the process of recovery. Such favourable conditions as these are, of course, to be looked for in only a few cases.
The next point that must be decided at the beginning of the treatment is the one of money, of the analyst's fee. An analyst does not dispute that money is to be regarded in the first instance as a medium for self-preservation and for obtaining power; but he maintains that, besides this, powerful sexual factors are involved in the value set upon it. He can point out that money matters are treated by civilized people in the same way as sexual matters--with the same inconsistency, prudishness and hypocrisy. The analyst is therefore determined from the first not to fall in with this attitude, but, in his dealings with his patients, to treat of money matters with the same matter-ofcourse frankness to which he wishes to educate them in things relating to sexual life. He shows them that he himself has cast off false shame on these topics, by voluntarily telling them the price at which he values his time. Ordinary good sense cautions him, furthermore, not to allow large sums of money to accumulate, but to ask for payment at fairly short regular intervals--monthly, perhaps. (It is a familiar fact that the value of the treatment is not enhanced in the patient's eyes if a very low fee is asked.) This is, of course, not the usual practice of nerve specialists or other physicians in our European society. But the psycho-analyst may put himself in the position of a surgeon, who is frank and expensive because he has at his disposal methods of treatment which can be of use. It seems to me more respectable and ethically less objectionable to acknowledge one's actual claims and needs rather than, as is still the practice among physicians, to act the part of the disinterested philanthropist--a position which one is not, in fact, able to fill, with the result that one is secretly aggrieved, or complains aloud, at the lack of consideration and the desire for exploitation evinced by one's patients. In fixing his fee the analyst must also allow for the fact that, hard as he may work, he can never earn as much as other medical specialists.
For the same reason he should also refrain from giving treatment free, and make no exceptions to this in favour of his colleagues or their families. This last recommendation will seem to offend against professional amenities. It must be remembered, however, that a gratuitous treatment means much more to a psycho-analyst than to any other medical man; it means the sacrifice of a considerable portion--an eighth or a seventh part, perhaps--of the working time available to him for earning his living, over a period of many months. A second free treatment carried on at the same time would already deprive him of a quarter or a third of his earning capacity, and this would be comparable to the damage inflicted by a severe accident.
The question then arises whether the advantage gained by the patient would not to some extent counterbalance the sacrifice made by the physician. I may venture to form a judgement about this, since for ten years or so I set aside one hour a day, and sometimes two, for gratuitous treatments, because I wanted, in order to find my way about in the neuroses, to work in the face of as little resistance as possible. The advantages I sought by this means were not forthcoming. Free treatment enormously increases some of a neurotic's resistances--in young women, for instance, the temptation which is inherent in their transference-relation, and in young men, their opposition to an obligation to feel grateful, an opposition which arises from their father-complex and which presents one of the most troublesome hindrances to the acceptance of medical help. The absence of the regulating effect offered by the payment of a fee to the analyst makes itself very painfully felt; the whole relationship is removed from the real world, and the patient is deprived of a strong motive for endeavouring to bring the treatment to an end.
One may be very far from the ascetic view of money as a curse and yet regret that analytic therapy is almost inaccessible to poor people, both for external and internal reasons. Little can be done to remedy this. Perhaps there is truth in the widespread belief that those who are forced by necessity to a life of hard toil are less easily overtaken by neurosis. But on the other hand experience shows without a doubt that when once a poor man has produced a neurosis it is only with difficulty that he lets it be taken from him. It renders him too good a service in the struggle for existence; the secondary gain from illness which it brings him is much too important. He now claims by right of his neurosis the pity which the world has refused to his material distress, and he can now absolve himself from the obligation of combating his poverty by working. Anyone therefore who tries to deal with the neurosis of a poor person by psychotherapy usually discovers that what is here required of him is a practical therapy of a very different kind--the kind which, according to our local tradition, used to be dispensed by the Emperor Joseph II. Naturally, one does occasionally come across deserving people who are helpless from no fault of their own, in whom unpaid treatment does not meet with any of the obstacles that I have mentioned and in whom it leads to excellent results.
As far as the middle classes are concerned, the expense involved in psycho-analysis is excessive only in appearance. Quite apart from the fact that no comparison is possible between restored health and efficiency on the one hand and a moderate financial outlay on the other, when we add up the unceasing costs of nursing-homes and medical treatment and contrast them with the increase of efficiency and earning capacity which results from a successfully completed analysis, we are entitled to say that the patients have made a good bargain. Nothing in life is so expensive as illness-and stupidity.
Before I wind up these remarks on beginning analytic treatment, I must say a word about a certain ceremonial which concerns the position in which the treatment is carried out. I hold to the plan of getting the patient to lie on a sofa while I sit behind him out of his sight. This arrangement has a historical basis; it is the remnant of the hypnotic method out of which psycho-analysis was evolved. But it deserves to be maintained for many reasons. The first is a personal motive, but one which others may share with me. I cannot put up with being stared at by other people for eight hours a day (or more). Since, while I am listening to the patient, I, too, give myself over to the current of my unconscious thoughts, I do not wish my expressions of face to give the patient material for interpretations or to influence him in what he tells me. The patient usually regards being made to adopt this position as a hardship and rebels against it, especially if the instinct for looking (scopophilia) plays an important part in his neurosis. I insist on this procedure, however, for its purpose and result are to prevent the transference from mingling with the patient's associations imperceptibly, to isolate the transference and to allow it to come forward in due course sharply defined as a resistance. I know that many analysts work in a different way, but I do not know whether this deviation is due more to a craving for doing things differently or to some advantage which they find they gain by it.
The conditions of treatment having been regulated in this manner, the question arises at what point and with what material is the treatment to begin? What the material is with which one starts the treatment is on the whole a matter of indifference--whether it is the patient's life-history or the history of his illness or his recollections of childhood. But in any case the patient must be left to do the talking and must be free to choose at what point he shall begin. We therefore say to him: `Before I can say anything to you I must know a great deal about you; please tell me what you know about yourself.'
The only exception to this is in regard to the fundamental rule of psycho-analytic technique which the patient has to observe. This must be imparted to him at the very beginning: `One more thing before you start. What you tell me must differ in one respect from an ordinary conversation. Ordinarily you rightly try to keep a connecting thread running through your remarks and you exclude any intrusive ideas that may occur to you and any side-issues, so as not to wander too far from the point. But in this case you must proceed differently. You will notice that as you relate things, various thoughts will occur to you which you would like to put aside on the ground of certain criticisms and objections. You will be tempted to say to yourself that this or that is irrelevant here, or is quite unimportant, or nonsensical, so that there is no need to say it. You must never give in to these criticisms, but must say it in spite of them--indeed, you must say it precisely because you feel an aversion to doing so. Later on you will find out and learn to understand the reason for this injunction, which is really the only one you have to follow. So say whatever goes through your mind. Act as though, for instance, you were a traveller sitting next to the window of a railway carriage and describing to someone inside the carriage the changing views which you see outside. Finally, never forget that you have promised to be absolutely honest, and never leave anything out because, for some reason or other, it is unpleasant to tell it."
Much might be said about our experiences with the fundamental rule of psycho-analysis. One occasionally comes across people who behave as if they had made this rule for themselves. Others offend against it from the very beginning. It is indispensable, and also advantageous, to lay down the rule in the first stages of the treatment. Later, under the dominance of the resistances, obedience to it weakens, and there comes a time in every analysis when the patient disregards it. We must remember from our own self-analysis how irresistible the temptation is to yield to these pretexts put forward by critical judgement for rejecting certain ideas. How small is the effect of such agreements as one makes with the patient in laying down the fundamental rule is regularly demonstrated when something intimate about a third person comes up in his mind for the first time. He knows that he is supposed to say everything, but he turns discretion about other people into a new obstacle. `Must I really say everything? I thought that only applied to things that concern myself.' It is naturally impossible to carry out analysis if the patient's relations with other people and his thoughts about them are excluded. Pour faire une omelette it faut casser des oeufs. An honourable man readily forgets such of the private affairs of strangers as do not seem to him important to know. Nor can an exception be made in the case of names. Otherwise the patient's narratives became a little shadowy, like the scenes in Goethe's play Die natiirliche Tochter [The Natural Daughter], and do not lodge in the analyst's memory. Moreover, the names that are withheld screen the approach to all sorts of important connections. But one may perhaps allow names to be left on one side until the patient has become more familiar with the analyst and the procedure of analysis. It is very remarkable how the whole task becomes impossible if a reservation is allowed at any single place. But we have only to reflect what would happen if the right of asylum existed at any one point in a town; how long would it be before all the riffraff of the town had collected there? I once treated a high official who was bound by his oath of office not to communicate certain things because they were state secrets, and the analysis came to grief as a consequence of this restriction. Psycho-analytic treatment must have no regard for any consideration, because the neurosis and its resistances are themselves without any such regard.
Patients who date their illness from a particular moment usually concentrate upon its precipitating cause. Others, who themselves recognize the connection between their neurosis and their childhood, often begin with an account of their whole life-history. A systematic narrative should never be expected and nothing should be done to encourage it. Every detail of the story will have to be told afresh later on, and it is only with these repetitions that additional material will appear which will supply the important connections that are unknown to the patient.
There are patients who from the very first hours carefully prepare what they are going to communicate, ostensibly so as to be sure of making better use of the time devoted to the treatment. What is thus disguising itself as eagerness is resistance. Any preparation of this sort should be disrecommended, for it is only employed to guard against unwelcome thoughts cropping up. However genuinely the patient may believe in his excellent intentions, the resistance will play its part in this deliberate method of preparation and will see to it that the most valuable material escapes communication. One will soon find that the patient devises yet other means by which what is required may be withheld from the treatment. He may talk over the treatment every day with some intimate friend, and bring into this discussion all the thoughts which should come forward in the presence of the analyst. The treatment thus has a leak which lets through precisely what is most valuable. When this happens, the patient must, without much delay, be advised to treat his analysis as a matter between himself and his analyst and to exclude everyone else from sharing in the knowledge of it, no matter how close to him they may be, or how inquisitive. In later stages of the treatment the patient is usually not subjected to temptations of this sort.
Certain patients want their treatment to be kept secret, often because they have kept their neurosis secret; and I put no obstacle in their way. That in consequence the world hears nothing of some of the most successful cures is, of course, a consideration that cannot be taken into account. It is obvious that a patient's decision in favour of secrecy already reveals a feature of his secret history.
In advising the patient at the beginning of the treatment to tell as few people as possible about it, we also protect him to some extent from the many hostile influences that will seek to entice him away from analysis. Such influences may be very mischievous at the outset of the treatment; later, they are usually immaterial, or even useful in bringing to the fore resistances which are trying to conceal themselves.
If during the course of the analysis the patient should temporarily need some other medical or specialist treatment, it is far wiser to call in a non-analytic colleague than to give this other treatment oneself. Combined treatments for neurotic disorders which have a powerful organic basis are nearly always impracticable. The patients withdraw their interest from analysis as soon as they are shown more than one path that promises to lead them to health. The best plan is to postpone the organic treatment until the psychical treatment is finished; if the former were tried first it would in most cases meet with no success.
To return to the beginning of the treatment. Patients are occasionally met with who start the treatment by assuring us that they cannot think of anything to say, although the whole field of their life-history and the story of their illness is open to them to choose from. Their request that we should tell them what to talk about must not be granted on this first occasion any more than on any later one. We must bear in mind what is involved here. A strong resistance has come to the front in order to defend the neurosis; we must take up the challenge then and there and come to grips with it. Energetic and repeated assurances to the patient that it is impossible for no ideas at all to occur to him at the beginning, and that what is in question is a resistance against the analysis, soon oblige him to make the expected admissions or to uncover a first piece of his complexes. It is a bad sign if he has to confess that while he was listening to the fundamental rule of analysis he made a mental reservation that he would nevertheless keep this or that to himself; it is not so serious if all he has to tell us is how mistrustful he is of analysis or the horrifying things he has heard about it. If he denies these and similar possibilities when they are put before him, he can be driven by our insistence to acknowledge that he has nevertheless overlooked certain thoughts which were occupying his mind. He had thought of the treatment itself, though nothing definite about it, or he had been occupied with the picture of the room in which he was, or he could not help thinking of the objects in the consulting room and of the fact that he was lying here on a sofa--all of which he has replaced by the word `nothing'. These indications are intelligible enough: everything connected with the present situation represents a transference to the analyst, which proves suitable to serve as a first resistance." We are thus obliged to begin by uncovering this transference; and a path from it will give rapid access to the patient's pathogenic material. Women who are prepared by events in their past history to be subjected to sexual aggression and men with over-strong repressed homosexuality are the most apt thus to withhold the ideas that occur to them at the outset of their analysis.
The patient's first symptoms or chance actions, like his first resistance, may possess a special interest and may betray a complex which governs his neurosis. A clever young philosopher with exquisite aesthetic sensibilities will hasten to put the creases of his trousers straight before lying down for his first hour; he is revealing himself as a former coprophilic of the highest refinement--which was to be expected from the later aesthete. A young girl will at the same juncture hurriedly pull the hem of her skirt over her exposed ankles; in doing this she is giving away the gist of what her analysis will uncover later: her narcissistic pride in her physical beauty and her inclinations to exhibitionism.
A particularly large number of patients object to being asked to lie down, while the analyst sits out of sight behind them. They ask to be allowed to go through the treatment in some other position, for the most part because they are anxious not to be deprived of a view of the analyst. Permission is regularly refused, but one cannot prevent them from contriving to say a few sentences before the beginning of the actual `session' or after one has signified that it is finished and they have got up from the sofa. In this way they divide the treatment in their own view into an official portion, in which they mostly behave in a very inhibited manner, and an informal `friendly' portion, in which they speak really freely and say all sorts of things which they themselves do not regard as being part of the treatment. The analyst does not accept this division for long. He takes note of what is said before or after the session and he brings it forward at the first opportunity, thus pulling down the partition which the patient has tried to erect. This partition, once again, will have been put together from the material of a transference-resistance.
So long as the patient's communications and ideas run on without any obstruction, the theme of transference should be left untouched. One must wait until the transference, which is the most delicate of all procedures, has become a resistance.
The next question with which we are faced raises a matter of principle. It is this: When are we to begin making our communications to the patient? When is the moment for disclosing to him the hidden meaning of the ideas that occur to him, and for initiating him into the postulates and technical procedures of analysis?
The answer to this can only be: Not until an effective transference has been established in the patient, a proper rapport with him. It remains the first aim of the treatment to attach him to it and to the person of the analyst. To ensure this, nothing need be done but to give him time. If one exhibits a serious interest in him, carefully clears away the resistances that crop up at the beginning and avoids making certain mistakes, he will of himself form such an attachment and link the analyst up with one of the imagos of the people by whom he was accustomed to be treated with affection. It is certainly possible to forfeit this first success if from the start one takes up any standpoint other than one of sympathetic understanding, such as a moralizing one, or if one behaves like a representative or advocate of some contending party--of the other member of a married couple, for instance.
This answer of course involves a condemnation of any line of behaviour which would lead us to give the patient a translation of his symptoms as soon as we have guessed it ourselves, or would even lead us to regard it as a special triumph to fling these `solutions' in his face at the first interview. It is not difficult for a skilled analyst to read the patient's secret wishes plainly between the lines of his complaints and the story of his illness; but what a measure of self-complacency and thoughtlessness must be possessed by anyone who can, on the shortest acquaintance, inform a stranger who is entirely ignorant of all the tenets of analysis that he is attached to his mother by incestuous ties, that he harbours wishes for the death of his wife whom he appears to love, that he conceals an intention of betraying his superior, and so on ! I have heard that there are analysts who plume themselves upon these kinds of lightning diagnoses and `express' treatments, but I must warn everyone against following such examples. Behaviour of this sort will completely discredit oneself and the treatment in the patient's eyes and will arouse the most violent opposition in him, whether one's guess has been true or not; indeed, the truer the guess the more violent will be the resistance. As a rule the therapeutic effect will be nil; but the deterring of the patient from analysis will be final. Even in the later stages of analysis one must be careful not to give a patient the solution of a symptom or the translation of a wish until he is already so close to it that he has only one short step more to make in order to get hold of the explanation for himself. In former years I often had occasion to find that the premature communication of a solution brought the treatment to an untimely end, on account not only of the resistances which it thus suddenly awakened but also of the relief which the solution brought with it.
But at this point an objection will be raised. Is it, then, our task to lengthen the treatment and not, rather, to bring it to an end as rapidly as possible? Are not the patient's ailments due to his lack of knowledge and understanding and is it not a duty to enlighten him as soon as possible--that is, as soon as the analyst himself knows the explanations? The answer to this question calls for a short digression on the meaning of knowledge and the mechanism of cure in analysis.
It is true that in the earliest days of analytic technique we took an intellectualist view of the situation. We set a high value on the patient's knowledge of what he had forgotten, and in this we made hardly any distinction between our knowledge of it and his. We thought it a special piece of good luck if we were able to obtain information about the forgotten childhood trauma from other sources--for instance, from parents or nurses or the seducer himself--as in some cases it was possible to do; and we hastened to convey the information and the proofs of its correctness to the patient, in the certain expectation of thus bringing the neurosis and the treatment to a rapid end. It was a severe disappointment when the expected success was not forthcoming. How could it be that the patient, who now knew about his traumatic experience, nevertheless still behaved as if he knew no more about it than before? Indeed, telling and describing his repressed trauma to him did not even result in any recollection of it coming into his mind.
In one particular case the mother of a hysterical girl had confided to me the homosexual experience which had greatly contributed to the fixation of the girl's attacks. The mother had herself surprised the scene; but the patient had completely forgotten it, though it had occurred when she was already approaching puberty. I was now able to make a most instructive observation. Every time I repeated her mother's story to the girl she reacted with a hysterical attack, and after this she forgot the story once more. There is no doubt that the patient was expressing a violent resistance against the knowledge that was being forced upon her. Finally she simulated feeble-mindedness and a complete loss of memory in order to protect herself against what I had told her. After this, there was no choice but to cease attributing to the fact of knowing, in itself, the importance that had previously been given to it and to place the emphasis on the resistances which had in the past brought about the state of not knowing and which were still ready to defend that state. Conscious knowledge, even if it was not subsequently driven out again, was powerless against those resistances.
The strange behaviour of patients, in being able to combine a conscious knowing with not knowing, remains inexplicable by what is called normal psychology. But to psycho-analysis, which recognizes the existence of the unconscious, it presents no difficulty. The phenomenon we have described, moreover, provides some of the best support for a view which approaches mental processes from the angle of topographical differentiation. The patients now know of the repressed experience in their conscious thought, but this thought lacks any connection with the place where the repressed recollection is in some way or other contained. No change is possible until the conscious thought-process has penetrated to that place and has overcome the resistances of repression there. It is just as though a decree were promulgated by the Ministry of Justice to the effect that juvenile delinquencies should be dealt with in a certain lenient manner. As long as this decree has not come to the knowledge of the local magistrates, or in the event of their not intending to obey it but preferring to administer justice by their own lights, no change can occur in the treatment of particular youthful delinquents. For the sake of complete accuracy, however, it should be added that the communication of repressed material to the patient's consciousness is nevertheless not without effect. It does not produce the hoped-for result of putting an end to the symptoms; but it has other consequences. At first it arouses resistances, but then, when these have been overcome, it sets up a process of thought in the course of which the expected influencing of the unconscious recollection eventually takes place.
It is now time for us to take a survey of the play of forces which is set in motion by the treatment. The primary motive force in the therapy is the patient's suffering and the wish to be cured that arises from it. The strength of this motive force is subtracted from by various factors--which are not discovered till the analysis is in progress--above all, by what we have called the `secondary gain from illness'; but it must be maintained till the end of the treatment. Every improvement effects a diminution of it. By itself, however, this motive force is not sufficient to get rid of the illness. Two things are lacking in it for this: it does not know what paths to follow to reach this end; and it does not possess the necessary quota of energy with which to oppose the resistances. The analytic treatment helps to remedy both these deficiencies. It supplies the amounts of energy that are needed for overcoming the resistances by making mobile the energies which lie ready for the transference; and, by giving the patient information at the right time, it shows him the paths along which he should direct those energies. Often enough the transference is able to remove the symptoms of the disease by itself, but only for a while--only for as long as it itself lasts. In this case the treatment is a treatment by suggestion, and not a psycho-analysis at all. It only deserves the latter name if the intensity of the transference has been utilized for the overcoming of resistances. Only then has being ill become impossible, even when the transference has once more been dissolved, which is its destined end.
In the course of the treatment yet another helpful factor is aroused. This is the patient's intellectual interest and understanding. But this alone hardly comes into consideration in comparison with the other forces that are engaged in the struggle; for it is always in danger of losing its value, as a result of the clouding of judgement that arises from the resistances. Thus the new sources of strength for which the patient is indebted to his analyst are reducible to transference and instruction (through the communications made to him). The patient, however, only makes use of the instruction in so far as he is induced to do so by the transference; and it is for this reason that our first communication should be withheld until a strong transference has been established. And this, we may add, holds good of every subsequent communication. In each case we must wait until the disturbance of the transference by the successive emergence of transference-resistances has been removed.
REMEMBERING, REPEATING AND WORKING-THROUGH
(FURTHER RECOMMENDATIONS ON THE TECHNIQUE
OF PSYCHO-ANALYSIS II)
Sigmund Freud (1914)
IT seems to me not unnecessary to keep on reminding students of the far-reaching changes which psycho-analytic technique has undergone since its first beginnings. In its first phase-that of Breuer's catharsis---it consisted in bringing directly into focus the moment at which the symptom was formed, and in persistently endeavouring to reproduce the mental processes involved in that situation, in order to direct their discharge along the path of conscious activity. Remembering and abreacting, with the help of the hypnotic state, were what was at that time aimed at. Next, when hypnosis had been given up, the task became one of discovering from the patient's free associations what he failed to remember. The resistance was to be circumvented by the work of interpretation and by making its results known to the patient. The situations which had given rise to the formation of the symptom and the other situations which lay behind the moment at which the illness broke out retained their place as the focus of interest; but the element of abreaction receded into the background and seemed to be replaced by the expenditure of work which the patient had to make in being obliged to overcome his criticism of his free associations, in accordance with the fundamental rule of psycho-analysis. Finally, there was evolved the consistent technique used today, in which the analyst gives up the attempt to bring a particular moment or problem into focus. He contents himself with studying whatever is present for the time being on the surface of the patient's mind, and he employs the art of interpretation mainly for the purpose of recognizing the resistances which appear there, and making them conscious to the patient. From this there results a new sort of division of labour: the analyst uncovers the resistances which are unknown to the patient; when these have been got the better of, the patient often relates the forgotten situations and connections without any difficulty. The aim of these different techniques has, of course, remained the same. Descriptively speaking, it is to fill in gaps in memory; dynamically speaking, it is to overcome resistances due to repression.
We must still be grateful to the old hypnotic technique for having brought before us single psychical processes of analysis in an isolated or schematic form. Only this could have given us the courage ourselves to create more complicated situations in the analytic treatment and to keep them clear before us.
In these hypnotic treatments the process of remembering took a very simple form. The patient put himself back into an earlier situation, which he seemed never to confuse with the present one, and gave an account of the mental processes belonging to it, in so far as they had remained normal; he then added to this whatever was able to emerge as a result of transforming the processes that had at the time been unconscious into conscious ones.
At this point I will interpolate a few remarks which every analyst has found confirmed in his observations. Forgetting impressions, scenes or experiences nearly always reduces itself to shutting them off. When the patient talks about these `forgotten' things he seldom fails to add: `As a matter of fact I've always known it; only I've never thought of it.' He often expresses disappointment at the fact that not enough things come into his head that he can call 'forgotten'--that he has never thought of since they happened. Nevertheless, even this desire is fulfilled, especially in the case of conversion hysterias. `Forgetting' becomes still further restricted when we assess at their true value the screen memories which are so generally present. In some cases I have had an impression that the familiar childhood amnesia, which is theoretically so important to us, is completely counterbalanced by screen memories. Not only some but all of what is essential from childhood has been retained in these memories. It is simply a question of knowing how to extract it out of them by analysis. They represent the forgotten years of childhood as adequately as the manifest content of a dream represents the dream-thoughts.
The other group of psychical processes--phantasies, processes of reference, emotional impulses, thought-connections--which, as purely internal acts, can be contrasted with impressions and experiences, must, in their relation to forgetting and remembering, be considered separately. In these processes it particularly often happens that something is `remembered' which could never have been `forgotten' because it was never at any time noticed--was never conscious. As regards the course taken by psychical events it seems to make no difference whatever whether such a 'thought-connection' was conscious and then forgotten or whether it never managed to become conscious at all. The conviction which the patient obtains in the course of his analysis is quite independent of this kind of memory.
In the many different forms of obsessional neurosis in particular, forgetting is mostly restricted to dissolving thoughtconnections, failing to draw the right conclusions and isolating memories.
There is one special class of experiences of the utmost importance for which no memory can as a rule be recovered. These are experiences which occurred in very early childhood and were not understood at the time but which were subsequently understood and interpreted. One gains a knowledge of them through dreams and one is obliged to believe in them on the most compelling evidence provided by the fabric of the neurosis. Moreover, we can ascertain for ourselves that the patient, after his resistances have been overcome, no longer invokes the absence of any memory of them (any sense of familiarity with them) as a ground for refusing to accept them. This matter, however, calls for so much critical caution and introduces so much that is novel and startling that I shall reserve it for a separate discussion in connection with suitable material.
Under the new technique very little, and often nothing, is left of this delightfully smooth course of events. There are some cases which behave like those under the hypnotic technique up to a point and only later cease to do so; but others behave differently from the beginning. If we confine ourselves to this second type in order to bring out the difference, we may say that the patient does not remember anything of what he has forgotten and repressed, but acts it out. He reproduces it not as a memory but as an action; he repeats it, without, of course, knowing that he is repeating it.
For instance, the patient does not say that he remembers that he used to be defiant and critical towards his parents' authority; instead, he behaves in that way to the analyst. He does not remember how he came to a helpless and hopeless deadlock in his infantile sexual researches; but he produces a mass of confused dreams and associations, complains that he cannot succeed in anything and asserts that he is fated never to carry through what he undertakes. He does not remember having been intensely ashamed of certain sexual activities and afraid of their being found out; but he makes it clear that he is ashamed of the treatment on which he is now embarked and tries to keep it secret from everybody. And so on.
Above all, the patient will begin his treatment with a repetition of this kind. When one has announced the fundamental rule of psycho-analysis to a patient with an eventful life-history and a long story of illness and has then asked him to say what occurs to his mind, one expects him to pour out a flood of information; but often the first thing that happens is that he has nothing to say. He is silent and declares that nothing occurs to him. This, of course, is merely a repetition of a homosexual attitude which comes to the fore as a resistance against remembering anything. As long as the patient is in the treatment he cannot escape from this compulsion to repeat; and in the end we understand that this is his way of remembering.
What interests us most of all is naturally the relation of this compulsion to repeat to the transference and to resistance. We soon perceive that the transference is itself only a piece of repetition, and that the repetition is a transference of the forgotten past not only on to the analyst but also on to all the other aspects of the current situation. We must be prepared to find, therefore, that the patient yields to the compulsion to repeat, which now replaces the impulsion to remember, not only in his personal attitude to his analyst but also in every other activity and relationship which may occupy his life at the time--if, for instance, he falls in love or undertakes a task or starts an enterprise during the treatment. The part played by resistance, too, is easily recognized. The greater the resistance, the more extensively will acting out (repetition) replace remembering. For the ideal remembering of what has been forgotten which occurs in hypnosis corresponds to a state in which resistance has been put completely on one side. If the patient starts his treatment under the auspices of a mild and unpronounced positive transference it makes it possible at first for him to unearth his memories just as he would under hypnosis, and during this time his pathological symptoms themselves are quiescent. But if, as the analysis proceeds, the transference becomes hostile or unduly intense and therefore in need of repression, remembering at once gives way to acting out. From then onwards the resistances determine the sequence of the material which is to be repeated. The patient brings out of the armoury of the past the weapons with which he defends himself against the progress of the treatment--weapons which we must wrest from him one by one.
We have learnt that the patient repeats instead of remembering, and repeats under the conditions of resistance. We may now ask what it is that he in fact repeats or acts out. The answer is that he repeats everything that has already made its way from the sources of the repressed into his manifest personality--his inhibitions and unserviceable attitudes and his pathological character-traits. He also repeats all his symptoms in the course of the treatment. And now we can see that in drawing attention to the compulsion to repeat we have acquired no new fact but only a more comprehensive view. We have only made it clear to ourselves that the patient's state of being ill cannot cease with the beginning of his analysis, and that we must treat his illness, not as an event of the past, but as a present-day force. This state of illness is brought, piece by piece, within the field and range of operation of the treatment, and while the patient experiences it as something real and contemporary, we have to do our therapeutic work on it, which consists in a large measure in tracing it back to the past.
Remembering, as it was induced in hypnosis, could not but give the impression of an experiment carried out in the laboratory. Repeating, as it is induced in analytic treatment according to the newer technique, on the other hand, implies conjuring up a piece of real life; and for that reason it cannot always be harmless and unobjectionable. This consideration opens up the whole problem of what is so often unavoidable--'deterioration during treatment'.
First and foremost, the initiation of the treatment in itself brings about a change in the patient's conscious attitude to his illness. He has usually been content with lamenting it, despising it as nonsensical and under-estimating its importance; for the rest, he has extended to its manifestations the ostrich-like policy of repression which he adopted towards its origins. Thus it can happen that he does not properly know under what conditions his phobia breaks out or does not listen to the precise wording of his obsessional ideas or does not grasp the actual purpose of his obsessional impulse. The treatment, of course, is not helped by this. He must find the courage to direct his attention to the phenomena of his illness. His illness itself must no longer seem to him contemptible, but must become an enemy worthy of his mettle, a piece of his personality, which has solid ground for its existence and out of which things of value for his future life have to be derived. The way is thus paved from the beginning for a reconciliation with the repressed material which is coming to expression in his symptoms, while at the same time place is found for a certain tolerance for the state of being ill. If this new attitude towards the illness intensifies the conflicts and brings to the fore symptoms which till then had been indistinct, one can easily console the patient by pointing out that these are only necessary and temporary aggravations and that one cannot overcome an enemy who is absent or not within range. The resistance, however, may exploit the situation for its own ends and abuse the licence to be ill. It seems to say: `See what happens if I really give way to such things. Was I not right to consign them to repression?' Young and childish people in particular are inclined to make the necessity imposed by the treatment for paying attention to their illness a welcome excuse for luxuriating in their symptoms.
Further dangers arise from the fact that in the course of the treatment new and deeper-lying instinctual impulses, which had not hitherto made themselves felt, may come to be `repeated'. Finally, it is possible that the patient's actions outside the transference may do him temporary harm in his ordinary life, or even have been so chosen as permanently to invalidate his prospects of recovery.
The tactics to be adopted by the physician in this situation are easily justified. For him, remembering in the old manner--reproduction in the psychical field--is the aim to which he adheres, even though he knows that such an aim cannot be achieved in the new technique. He is prepared for a perpetual struggle with his patient to keep in the psychical sphere all the impulses which the patient would like to direct into the motor sphere; and he celebrates it as a triumph for the treatment if he can bring it about that something that the patient wishes to discharge in action is disposed of through the work of remembering. If the attachment through transference has grown into something at all serviceable, the treatment is able to prevent the patient from executing any of the more important repetitive actions and to utilize his intention to do so in statu nascendi as material for the therapeutic work. One best protects the patient from injuries brought about through carrying out one of his impulses by making him promise not to take any important decisions affecting his life during the time of his treatment--for instance, not to choose any profession or definitive love-object--but to postpone all such plans until after his recovery.
At the same time one willingly leaves untouched as much of the patient's personal freedom as is compatible with these restrictions, nor does one hinder him from carrying out unimportant intentions, even if they are foolish; one does not forget that it is in fact only through his own experience and mishaps that a person learns sense. There are also people whom one cannot restrain from plunging into some quite undesirable project during the treatment and who only afterwards become ready for, and accessible to, analysis. Occasionally, too, it is bound to happen that the untamed instincts assert themselves before there is time to put the reins of the transference on them, or that the bonds which attach the patient to the treatment are broken by him in a repetitive action. As an extreme example of this, I may cite the case of an elderly lady who had repeatedly fled from her house and her husband in a twilight state and gone no one knew where, without ever having become conscious of her motive for decamping in this way. She came to treatment with a marked affectionate transference which grew in intensity with uncanny rapidity in the first few days; by the end of the week she had decamped from me, too, before I had had time to say anything to her which might have prevented this repetition.
The main instrument, however, for curbing the patient's compulsion to repeat and for turning it into a motive for remembering lies in the handling of the transference. We render the compulsion harmless, and indeed useful, by giving it the right to assert itself in a definite field. We admit it into the transference as a playground in which it is allowed to expand in almost complete freedom and in which it is expected to display to us everything in the way of pathogenic instincts that is hidden in the patient's mind. Provided only that the patient shows compliance enough to respect the necessary conditions of the analysis, we regularly succeed in giving all the symptoms of the illness a new transference meaning and in replacing his ordinary neurosis by a 'transference-neurosis' of which he can be cured by the therapeutic work. The transference thus creates an intermediate region between illness and real life through which the transition from the one to the other is made. The new condition has taken over all the features of the illness; but it represents an artificial illness which is at every point accessible to our intervention. It is a piece of real experience, but one which has been made possible by especially favourable conditions, and it is of a provisional nature. From the repetitive reactions which are exhibited in the transference we are led along the familiar paths to the
awakening of the memories, which appear without difficulty, as it were, after the resistance has been overcome.
I might break off at this point but for the title of this paper, which obliges me to discuss a further point in analytic technique. The first step in overcoming the resistances is made, as we know, by the analyst's uncovering the resistance, which is never recognized by the patient, and acquainting him with it. Now it seems that beginners in analytic practice are inclined to look on this introductory step as constituting the whole of their work. I have often been asked to advise upon cases in which the analyst complained that he had pointed out his resistance to the patient and that nevertheless no change had set in; indeed, the resistance had become all the stronger, and the whole situation was more obscure than ever. The treatment seemed to make no headway. This gloomy foreboding always proved mistaken. The treatment was as a rule progressing most satisfactorily. The analyst had merely forgotten that giving the resistance a name could not result in its immediate cessation. One must allow the patient time to become more conversant with this resistance with which he has now become acquainted, to work through it, to overcome it, by continuing, in defiance of it, the analytic work according to the fundamental rule of analysis. Only when the resistance is at its height can the analyst, working in common with his patient, discover the repressed instinctual impulses which are feeding the resistance; and it is this kind of experience which convinces the patient of the existence and power of such impulses. The analyst has nothing else to do than to wait and let things take their course, a course which cannot be avoided nor always hastened. If he holds fast to this conviction he will often be spared the illusion of having failed when in fact he is conducting the treatment on the right lines.
This working-through of the resistances may in practice turn out to be an arduous task for the subject of the analysis and a trial of patience for the analyst. Nevertheless it is a part of the work which effects the greatest changes in the patient and which distinguishes analytic treatment from any kind of treatment by suggestion. From a theoretical point of view one may correlate it with the `abreacting' of the quotas of affect strangulated by repression-an abreaction without which hypnotic treatment remained ineffective.
OBSERVATIONS ON TRANSFERENCE-LOVE
(FURTHER RECOMMENDATIONS ON THE TECHNIQUE
OF PSYCHO-ANALYSIS III)
Sigmund Freud (1915)
EVERY beginner in psycho-analysis probably feels alarmed at first at the difficulties in store for him when he comes to interpret the patient's associations and to deal with the reproduction of the repressed. When the time comes, however, he soon learns to look upon these difficulties as insignificant, and instead becomes convinced that the only really serious difficulties he has to meet lie in the management of the transference.
Among the situations which arise in this connection I shall select one which is very sharply circumscribed; and I shall select it, partly because it occurs so often and is so important in its real aspects and partly because of its theoretical interest. What I have in mind is the case in which a woman patient shows by unmistakable indications, or openly declares, that she has fallen in love, as any other mortal woman might, with the therapist who is analysing her. This situation has its distressing and comical aspects, as well as its serious ones. It is also determined by so many and such complicated factors, it is so unavoidable and so difficult to clear up, that a discussion of it to meet a vital need of analytic technique has long been overdue. But since we who laugh at other people's failings are not always free from them ourselves, we have not so far been precisely in a hurry to fulfil this task. We are constantly coming up against the obligation to professional discretion--a discretion which cannot be dispensed with in real life, but which is of no service in our science. In so far as psycho-analytic publications are a part of real life, too, we have here an insoluble contradiction. I have recently disregarded this matter of discretion at one point, and shown how this same transference situation held back the development of psycho-analytic therapy during its first decade.
To a well-educated layman (for that is what the ideal civilized person is in regard to psycho-analysis) things that have to do with love are incommensurable with everything else; they are, as it were, written on a special page on which no other writing is tolerated. If a woman patient has fallen in love with her analyst it seems to such a layman that only two outcomes are possible. One, which happens comparatively rarely, is that all the circumstances allow of a permanent legal union between them; the other, which is more frequent, is that the analyst and the patient part and give up the work they have begun which was to have led to her recovery, as though it had been interrupted by some elemental phenomenon. There is, to be sure, a third conceivable outcome, which even seems compatible with a continuation of the treatment. This is that they should enter into a love-relationship which is illicit and which is not intended to last for ever. But such a course is made impossible by conventional morality and professional standards. Nevertheless, our layman will beg the analyst to reassure him as unambiguously as possible that this third alternative is excluded.
It is clear that a psycho-analyst must look at things from a different point of view. Let us take the case of the second outcome of the situation we are considering. After the patient has fallen in love with her analyst, they part; the treatment is given up. But soon the patient's condition necessitates her making a second attempt at analysis, with another analyst. The next thing that happens is that she feels she has fallen in love with this second analyst too; and if she breaks off with him and begins yet again, the same thing will happen with the third analyst, and so on. This phenomenon, which occurs without fail and which is, as we know, one of the foundations of the psycho-analytic theory, may be evaluated from two points of view, that of the therapist who is carrying out the analysis and that of the patient who is in need of it.
For the analyst the phenomenon signifies a valuable piece of enlightenment and a useful warning against any tendency to a counter-transference which may be present in his own mind.' He must recognize that the patient's falling in love is induced by the analytic situation and is not to be attributed to the charms of his own person; so that he has no grounds whatever for being proud of such a `conquest', as it would be called outside analysis. And it is always well to be reminded of this. For the patient, however, there are two alternatives: either she must relinquish psycho-analytic treatment or she must accept falling in love with her analyst as an inescapable fate.
I have no doubt that the patient's relatives and friends will decide as emphatically for the first of these two alternatives as the analyst will for the second. But I think that here is a case in which the decision cannot be left to the tender--or rather, the egoistic and jealous--concern of her relatives. The welfare of the patient alone should be the touchstone; her relatives' love cannot cure her neurosis. The analyst need not push himself forward, but he may insist that he is indispensable for the achievement of certain ends. Any relative who adopts Tolstoy's attitude to this problem can remain in undisturbed possession of his wife or daughter; but he will have to try to put up with the fact that she, for her part, retains her neurosis and the interference with her capacity for love which it involves. The situation, after all, is similar to that in a gynaecological treatment. Moreover, the jealous father or husband is greatly mistaken if he thinks that the patient will escape falling in love with her analyst if he hands her over to some kind of treatment other than analysis for combating her neurosis. The difference, on the contrary, will only be that a love of this kind, which is bound to remain unexpressed and unanalysed, can never make the contribution to the patient's recovery which analysis would have extracted from it.
It has come to my knowledge that some therapists who practise analysis frequently prepare their patients for the emergence of the erotic transference or even urge them to `go ahead and fall in love with the analyst so that the treatment may make progress'. I can hardly imagine a more senseless proceeding. In doing so, an analyst robs the phenomenon of the element of spontaneity which is so convincing and lays up obstacles for himself in the future which are hard to overcome.
At a first glance it certainly does not look as if the patient's falling in love in the transference could result in any advantage to the treatment. No matter how amenable she has been up till then, she suddenly loses all understanding of the treatment and all interest in it, and will not speak or hear about anything but her love, which she demands to have returned. She gives up her symptoms or pays no attention to them; indeed, she declares that she is well. There is a complete change of scene; it is as though some piece of make-believe had been stopped by the sudden irruption of reality--as when, for instance, a cry of fire is raised during a theatrical performance. No analyst who experiences this for the first time will find it easy to retain his grasp on the analytic situation and to keep clear of the illusion that the treatment is really at an end.
A little reflection enables one to find one's bearings. First and foremost, one keeps in mind the suspicion that anything that interferes with the continuation of the treatment may be an expression of resistance. There can be no doubt that the outbreak of a passionate demand for love is largely the work of resistance. One will have long since noticed in the patient the signs of an affectionate transference, and one will have been able to feel certain that her docility, her acceptance of the analytic explanations, her remarkable comprehension and the high degree of intelligence she showed were to be attributed to this attitude towards her analyst. Now all this is swept away. She has become quite without insight and seems to be swallowed up in her love. Moreover, this change quite regularly occurs precisely at a point of time when one is having to try to bring her to admit or remember some particularly distressing and heavily repressed piece of her life-history. She has been in love, therefore, for a long time; but now the resistance is beginning to make use of her love in order to hinder the continuation of the treatment, to deflect all her interest from the work and to put the analyst in an awkward position.
If one looks into the situation more closely one recognizes the influence of motives which further complicate things--of which some are connected with , being in love and others are particular expressions of resistance. Of the first kind are the patient's endeavour to assure herself of her irresistibility, to destroy the analyst's authority by bringing him down to the level of a lover and to gain all the other promised advantages incidental to the satisfaction of love. As regards the resistance, we may suspect that on occasion it makes use of a declaration of love on the patient's part as a means of putting her analyst's severity to the test, so that, if he should show signs of compliance, he may expect to be taken to task for it. But above all, one gets an impression that the resistance is acting as an agent provocateur; it heightens the patient's state of being in love and exaggerates her readiness for sexual surrender in order to justify the workings of repression all the more emphatically, by pointing to the dangers of such licentiousness. All these accessory motives, which in simpler cases may not be present, have, as we know, been regarded by Adler as the essential part of the whole process?
But how is the analyst to behave in order not to come to grief over this situation, supposing he is convinced that the treatment should be carried on in spite of this erotic transference and should take it in its stride?
It would be easy for me to lay stress on the universally accepted standards of morality and to insist that the analyst must never under any circumstances accept or return the tender feelings that are offered him: that, instead, he must consider that the time has come for him to put before the woman who is in love with him the demands of social morality and the necessity for renunciation, and to succeed in making her give up her desires, and, having surmounted the animal side of her self, go on with the work of analysis.
I shall not, however, fulfil these expectations--neither the first nor the second of them. Not the first, because I am writing not for patients but for analysts who have serious difficulties to contend with, and also because in this instance I am . able to trace the moral prescription back to its source, namely to expediency. I am on this occasion in the happy position of being able to replace the moral embargo by considerations of analytic technique, without any alteration in the outcome.
Even more decidedly, however, do I decline to fulfil the second of the expectations I have mentioned. To urge the patient to suppress, renounce or sublimate her instincts the moment she has admitted her erotic transference would be, not an analytic way of dealing with them, but a senseless one. It would be just as though, after summoning up a spirit from the underworld by cunning spells, one were to send him down again without having asked him a single question. One would have brought the repressed into consciousness, only to repress it once more in a fright. Nor should we deceive ourselves about the success of any such proceeding. As we know, the passions are little affected by sublime speeches. The patient will feel only the humiliation, and she will not fail to take her revenge for it.
Just as little can I advocate a middle course, which would recommend itself to some people as being specially ingenious. This would consist in declaring that one returns the patient's fond feelings but at the same time in avoiding any physical implementation of this fondness until one is able to guide the relationship into calmer channels and raise it to a higher level. My objection to this expedient is that psycho-analytic treatment is founded on truthfulness. In this fact lies a great part of its educative effect and its ethical value. It is dangerous to depart from this foundation. Anyone who has become saturated in the analytic technique will no longer be able to make use of the lies and pretences which an analystnormally finds unavoidable; and if, with the best intentions, he does attempt to do so, he is very likely to betray himself. Since we demand strict truthfulness from our patients, we jeopardize our whole authority if we let ourselves be caught out by them in a departure from the truth. Besides, the experiment of letting oneself go a little way in tender feelings for the patient is not altogether without danger. Our control over ourselves is not so complete that we may not suddenly one day go further than we had intended. In my opinion, therefore, we ought not to give up the neutrality towards the patient, which we have acquired through keeping the counter-transference in check.
I have already let it be understood that analytic technique requires of the physician that he should deny to the patient who is craving for love the satisfaction she demands. The treatment must be carried out in abstinence. By this I do not mean physical abstinence alone, nor yet the deprivation of everything that the patient desires, for perhaps no sick person could tolerate this. Instead, I shall state it as a fundamental principle that the patient's need and longing should be allowed to persist in her, in order that they may serve as forces impelling her to do work and to make changes, and that we must beware of appeasing those forces by means of surrogates. And what we could offer would never be anything else than a surrogate, for the patient's condition is such that, until her repressions are removed, she is incapable of getting real satisfaction.
Let us admit that this fundamental principle of the treatment being carried out in abstinence extends far beyond the single case we are considering here, and that it needs to be thoroughly discussed in order that we may define the limits of its possible application. We will not enter into this now, however, but will keep as close as possible to the situation from which we started out. What would happen if the analyst were to behave differently and, supposing both parties were free, if he were to avail himself of that freedom in order to return the patient's love and to still her need for affection?
If he has been guided by the calculation that this compliance on his part will ensure his domination over his patient and thus enable him to influence her to perform the tasks required by the treatment, and in this way to liberate herself permanently from her neurosis--then experience would inevitably show him that his calculation was wrong. The patient would achieve her aim, but he would never achieve his. What would happen to the analyst and the patient would only be what happened, according to the amusing anecdote, to the pastor and the insurance agent. The insurance agent, a freethinker, lay at the point of death and his relatives insisted on bringing in a man of God to convert him before he died. The interview lasted so long that those who were waiting outside began to have hopes. At last the door of the sick-chamber opened. The free-thinker had not been converted; but the pastor went away insured.
If the patient's advances were returned it would be a great triumph for her, but a complete defeat for the treatment. She would have succeeded in what all patients strive for in analysis--she would have succeeded in acting out, in repeating in real life, what she ought only to have remembered, to have reproduced as psychical material and to have kept within the sphere of psychical events. In the further course of the loverelationship she would bring out all the inhibitions and pathological reactions of her erotic life, without there being any possibility of correcting them; and the distressing episode would end in remorse and a great strengthening of her propensity to repression. The love-relationship in fact destroys the patient's susceptibility to influence from analytic treatment. A combination of the two would be an impossibility.
It is, therefore, just as disastrous for the analysis if the patient's craving for love is gratified as if it is suppressed. The course the analyst must pursue is neither of these; it is one for which there is no model in real life. He must take care not to steer away from the transference-love, or to repulse it or to make it distasteful to the patient; but he must just as resolutely withhold any response to it. He must keep firm hold of the transference-love, but treat it as something unreal, as a situation which has to be gone through in the treatment and traced back to its unconscious origins and which must assist in bringing all that is most deeply hidden in the patient's erotic life into her consciousness and therefore under her control. The more plainly the analyst lets it be seen that he is proof against every temptation, the more readily will he be able to extract from the situation its analytic content. The patient, whose sexual repression is of course not yet removed but merely pushed into the background, will then feel safe enough to allow all her preconditions for loving, all the phantasies springing from her sexual desires, all the detailed characteristics of her state of being in love, to come to light; and from these she will herself open the way to the infantile roots of her love.
There is, it is true, one class of women with whom this attempt to preserve the erotic transference for the purposes of analytic work without satisfying it will not succeed. These are women of elemental passionateness who tolerate no surrogates. They are children of nature who refuse to accept the psychical in place of the material, who, in the poet's words, are accessible only to `the logic of soup, with dumplings for arguments'. With such people one has the choice between returning their love or else bringing down upon oneself the full enmity of a woman scorned. In neither case can one safeguard the interests of the treatment. One has to withdraw, unsuccessful; and all one can do is to turn the problem over in one's mind of how it is that a capacity for neurosis is joined with such an intract able need for love.
Many analysts will no doubt be agreed on the method by which other women, who are less violent in their love, can be gradually made to adopt the analytic attitude. What we do, above all, is to stress to the patient the unmistakable element of resistance in this `love'. Genuine love, we say, would make her docile and intensify her readiness to solve the problems of her case, simply because the man she was in love with expected it of her. In such a case she would gladly choose the road to completion of the treatment, in order to acquire value in the analyst's eyes and to prepare herself for real life, where this feeling of love could find a proper place. Instead of this, we point out, she is showing a stubborn and rebellious spirit, she has thrown up all interest in her treatment, and clearly feels no respect for the analyst's well-founded convictions. She is thus bringing out a resistance under the guise of being in love with him; and in addition to this she has no compunction in placing him in a cleft stick. For if he refuses her love, as his duty and his understanding compel him to do, she can play the part of a woman scorned, and then withdraw from his therapeutic efforts out of revenge and resentment, exactly as she is now doing out of her ostensible love.
As a second argument against the genuineness of this love we advance the fact that it exhibits not a single new feature arising from the present situation, but is entirely composed of repetitions and copies of earlier reactions, including infantile ones. We undertake to prove this by a detailed analysis of the patient's behaviour in love.
If the necessary amount of patience is added to these arguments, it is usually possible to overcome the difficult situation and to continue the work with a love which has been moderated or transformed; the work then aims at uncovering the patient's infantile object-choice and the phantasies woven round it.
I should now like, however, to examine these arguments with a critical eye and to raise the question whether, in putting them forward to the patient, we are really telling the truth, or whether we are not resorting in our desperation to concealments and misrepresentations. In other words: can we truly say that the state of being in love which becomes manifest in analytic treatment is not a real one?
I think we have told the patient the truth, but not the whole truth regardless of the consequences. Of our two arguments the first is the stronger. The part played by resistance in transferencelove is unquestionable and very considerable. Nevertheless the resistance did not, after all, create this love; it finds it ready to hand, makes use of it and aggravates its manifestations. Nor is the genuineness of the phenomenon disproved by the resistance. The second argument is far weaker. It is true that the love consists of new editions of old traits and that it repeats infantile reactions. But this is the essential character of every state of being in love. There is no such state which does not reproduce infantile prototypes. It is precisely from this infantile determination that it receives its compulsive character, verging as it does on the pathological. Transference-love has perhaps a degree less of freedom than the love which appears in ordinary life and is called normal; it displays its dependence on the infantile pattern more clearly and is less adaptable and capable of modification; but that is all, and not what is essential.
By what other signs can the genuineness of a love be recognized? By its efficacy, its serviceability in achieving the aim of love? In this respect transference-love seems to be second to none; one has the impression that one could obtain anything from it.
Let us sum up, therefore. We have no right to dispute that the state of being in love which makes its appearance in the course of analytic treatment has the character of a `genuine' love. If it seems so lacking in normality, this is sufficiently explained by the fact that being in love in ordinary life, outside analysis, is also more similar to abnormal than to normal mental phenomena. Nevertheless, transference-love is characterized by certain features which ensure it a special position. In the first place, it is provoked by the analytic situation; secondly, it is greatly intensified by the resistance, which dominates the situation; and thirdly, it is lacking to a high
degree in a regard for reality, is less sensible, less concerned about consequences and more blind in its valuation of the loved person than we are prepared to admit in the case of normal love. We should not forget, however, that these departures from the norm constitute precisely what is essential about being in love.
As regards the analyst's line of action, it is the first of these three features of transference-love which is the decisive factor. He has evoked this love by instituting analytic treatment in order to cure the neurosis. For him, it is an unavoidable consequence of a medical situation, like the exposure of a patient's body or the imparting of a vital secret. It is therefore plain to him that he must not derive any personal advantage from it. The patient's willingness makes no difference; it merely throws the whole responsibility on the analyst himself. Indeed, as he must know, the patient had been prepared for no other mechanism of cure. After all the difficulties have been successfully overcome, she will often confess to having had an anticipatory phantasy at the time when she entered the treatment, to the effect that if she behaved well she would be rewarded at the end by the analyst's affection.
For the analyst, ethical motives unite with the technical ones to restrain him from giving the patient his love. The aim he has to keep in view is that this woman, whose capacity for love is impaired by infantile fixations, should gain free command over a function which is of such inestimable importance to her; that she should not, however, dissipate it in the treatment, but keep it ready for the time when, after her treatment, the demands of real life make themselves felt. He must not stage the scene of a dog-race in which the prize was to be a garland of sausages but which some humorist spoilt by throwing a single sausage on to the track. The result was, of course, that the dogs threw themselves upon it and forgot all about the race and about the garland that was luring them to victory in the far distance. I do not mean to say that it is always easy for the analyst to keep within the limits prescribed by ethics and technique. Those who are still youngish and not yet bound by strong ties may in particular find it a hard task. Sexual love is undoubtedly one of the chief things in life, and the union of mental and bodily satisfaction in the enjoyment of love is one of its culminating peaks. Apart from a few queer fanatics, all the world knows this and conducts its life accordingly; science alone is too delicate to admit it. Again, when a woman sues for love, to reject and refuse is a distressing part for a man to play; and, in spite of neurosis and resistance, there is an incomparable fascination in a woman of high principles who confesses her passion. It is not a patient's crudely sensual desires which constitute the temptation. These are more likely to repel, and it will call for all the analyst's tolerance if he is to regard them as a natural phenomenon. It is rather, perhaps, a woman's subtler and aim-inhibited wishes which bring with them the danger of making a man forget his technique and his medical task for the sake of a fine experience.
And yet it is quite out of the question for the analyst to give way. However highly he may prize love he must prize even more highly the opportunity for helping his patient over a decisive stage in her life. She has to learn from him to overcome the pleasure principle, to give up a satisfaction which lies to hand but is socially not acceptable, in favour of a more distant one, which is perhaps altogether uncertain, but which is both psychologically and socially unimpeachable. To achieve this overcoming, she has to be led through the primal period of her mental development and on that path she has to acquire the extra piece of mental freedom which distinguishes conscious mental activity--in the systematic sense--from unconscious.
The analytic psychotherapist thus has a threefold battle to wage--in his own mind against the forces which seek to drag him down from the analytic level; outside the analysis, against opponents who dispute the importance he attaches to the sexual instinctual forces and hinder him from making use of them in his scientific technique; and inside the analysis, against his patients, who at first behave like opponents but later on reveal the overvaluation of sexual life which dominates them, and who try to make him captive to their socially untamed passion.
The lay public, about whose attitude to psycho-analysis I spoke at the outset, will doubtless seize upon this discussion of transference-love as another opportunity for directing the attention of the world to the serious danger of this therapeutic method. The psycho-analyst knows that he is working with highly explosive forces and that he needs to proceed with as much caution and conscientiousness as a chemist. But when have chemists ever been forbidden, because of the danger, from handling explosive substances, which are indispensable, on account of their effects? It is remarkable that psycho-analysis has to win for itself afresh all the liberties which have long since been accorded to other medical activities. I am certainly not in favour of giving up the harmless methods of treatment. For many cases they are sufficient, and, when all is said, human society has no more use for the furor sanandil than for any other fanaticism. But to believe that the psychoneuroses are to be conquered by operating with harmless little remedies is grossly to under-estimate those disorders both as to their origin and their practical importance. No; in medical practice there will always be room for the 'ferrum' and the 'ignis' side by side with the `medicina' 1; and in the same way we shall never be able to do without a strictly regular, undiluted psycho-analysis which is not afraid to handle the most dangerous mental impulses and to obtain mastery over them for the benefit of the patient.
1 [An allusion to a saying attributed to Hippocrates: `Those diseases which medicines do not cure, iron (the knife?) cures; those which iron cannot cure, fire cures; and those which fire cannot cure are to be reckoned wholly incurable.' Aphorisms, VII, 87 (trans. 1849).]