Part 38

The disease of paranoia, a chronic form of systematic insanity, has a very uncertain position in the attempts at classification made by present-day psychiatry. There is no doubt, however, that it is closely related to dementia præcox; I have in fact proposed that they should both be included under the common designation of _paraphrenia_. The forms taken by paranoia are described according to the content of the delusion, e.g. delusions of grandeur, of persecution, of jealousy, of being loved (erotomania), etc. We do not expect attempts at explanation from psychiatry; as an example, an antiquated and not very fair example, I grant, I will tell you the attempt which was made to derive one of these symptoms from another, by means of a piece of intellectual rationalization: The patient who has a primary tendency to believe himself persecuted draws from this the conclusion that he must necessarily be a very important person and therefore develops a delusion of grandeur. According to our analytic conception, the delusion of grandeur is the direct consequence of the inflation of the Ego by the Libido withdrawn from the investment of objects, a secondary narcissism ensuing as a return of the original early infantile form. In the case of delusions of persecution, however, we observed things which led us to follow up a certain clue. In the first place we noticed that in the great majority of cases the persecuting person was of the same sex as the persecuted one; this was capable of a harmless explanation, it is true, but in certain cases which were closely studied it appeared that the person of the same sex who had been most beloved while the patient was normal became the persecutor after the disease broke out. A further development of this becomes possible through the well-known paths of association by which a loved person may be replaced by someone else, e.g. the father by masters or persons in authority. From these observations, which were continually corroborated, we drew the conclusion that persecutory paranoia is the means by which a person defends himself against a homosexual impulse which has become too powerful. The conversion of the affectionate feeling into the hate which, as is well-known, can seriously endanger the life of the loved and hated object then corresponds to the conversion of libidinal impulses into anxiety, which is a regular result of the process of repression. As an illustration I will quote the last case I had of this type. A young doctor had to be sent away from the place where he lived because he had threatened the life of the son of a university professor there who had previously been his greatest friend. He imputed superhuman power and the most devilish intentions to this friend; he was to blame for all the misfortunes which had occurred in recent years to the family of the patient and for all his ill-luck in public and in private. This was not enough, however; the wicked friend and his father, the professor, had caused the war and brought the Russians over the border; he had ruined his life in a thousand ways; our patient was convinced that the death of this criminal would be the end of all evil in the world. And yet his old love for him was still so strong that it had paralysed his hand when he had an opportunity of shooting his enemy at sight. In the short conversation which I had with the patient it came to light that this intimate friendship between the two men went right back to their school-days; on at least one occasion it had passed beyond the boundaries of friendship, a night spent together had been the occasion of complete sexual intercourse. The patient had never developed any of the feeling towards women that would have been natural at his age with his attractive personality. He had been engaged to a handsome, well-connected girl, but she had broken off the engagement because her lover was so cold. Years after, his disease broke out at the very moment when he had for the first time succeeded in giving full sexual gratification to a woman; as she encircled him in her arms in gratitude and devotion he suddenly felt a mysterious stab of pain running like a sharp knife round the crown of his head. Afterwards he described the sensation as being like that of the incision made at a post-mortem to bare the brain; and as his friend was a pathological anatomist he slowly came to the conclusion that he alone could have sent him this woman as a temptation. Then his eyes began to be opened about the other persecutions of which he had been the victim by the machinations of his former friend.

But how about those cases in which the persecutor is of a different sex from that of the persecuted one, and which appear therefore to contradict our explanation of this disease as a defence against homosexual Libido? Some time ago I had an opportunity of examining a case of the kind, and behind the apparent contradiction I was able to elicit a confirmation. A young girl imagined herself persecuted by a man with whom she had twice had intimate relations; actually she had first of all cherished the delusion against a woman who could be recognized to be a mother-substitute. Not until after the second meeting with him did she make the advance of transferring the delusional idea from the woman to the man; so that in this case also the condition that the sex of the persecutor is the same as that of the victim originally held good also. In her complaint to the lawyer and the doctor the patient had not mentioned the previous phase of her delusion and this gave rise to an apparent contradiction of our theory of paranoia.

The homosexual choice of object is originally more closely related to narcissism than the heterosexual; hence, when a strong unwelcome homosexual excitation suffers repudiation, the way back to narcissism is especially easy to find. I have so far had very little opportunity in these lectures of speaking about the fundamental plan on which the course of the love-impulse during life is based, so far as we know it; nor can I supplement it now. I will only select this to tell you: that the choice of object, the step forward in the development of the Libido which comes after the narcissistic stage, can proceed according to two types. These are: either _the narcissistic type_, according to which, in place of the Ego itself, someone as nearly as possible resembling it is adopted as an object; or _the anaclitic type_ (_Anlehnungstypus_)[53] in which those persons who became prized on account of the satisfactions they rendered to the primal needs in life are chosen as objects by the Libido also. A strong Libido-fixation on the narcissistic type of object-choice is also found as a trait in the disposition of manifest homosexuals.

You will remember that in the first lecture given this session I described to you a case of delusional jealousy in a woman. Now that we have so nearly reached the end you will certainly want to know how we account for a delusion psycho-analytically. I have less to say about it than you would expect, however. The inaccessibility of delusions to logical arguments and to actual experience is to be explained, as it is with obsessions, by the connection they bear to the unconscious material which is both expressed by, and held in check by, the delusion or the obsession. The differences between the two are based on the topographical and dynamic differences in the two affections.

As with paranoia, so also with melancholia (under which, by the way, very different clinical types are classified), it has been possible to obtain a glimpse into the inner structure of the disorder. We have perceived that the self-reproaches with which these sufferers torment themselves so mercilessly actually relate to another person, to the sexual object they have lost or whom they have ceased to value on account of some fault. From this we concluded that the melancholic has indeed withdrawn his Libido from the object, but that by a process which we must call ‘narcissistic identification’ he has set up the object within the Ego itself, projected it on to the Ego. I can only give you a descriptive representation of this process, and not one expressed in terms of topography and dynamics. The Ego itself is then treated as though it were the abandoned object; it suffers all the revengeful and aggressive treatment which is designed for the object. The suicidal impulses of melancholics also become more intelligible on the supposition that the bitterness felt by the diseased mind concerns the Ego itself at the same time as, and equally with, the loved and hated object. In melancholia, as in the other narcissistic disorders, a feature of the emotional life which, after Bleuler, we are accustomed to call _ambivalence_ comes markedly to the fore; by this we mean a directing of antithetical feelings (affectionate and hostile) towards the same person. It is unfortunate that I have not been able to say more about ambivalence in these lectures.

There is also, besides the narcissistic, an hysterical form of identification which has long been known to us. I wish it were possible to make the differences between them clear to you in a few definite statements. I can tell you something of the periodic and cyclic forms of melancholia which will interest you. It is possible in favourable circumstances—I have twice achieved it—to prevent the recurrence of the condition, or of its antithesis, by analytic treatment during the lucid intervals between the attacks. One learns from this that in melancholia and mania as well as other conditions a special kind of solution of a conflict is going on, which in all its pre-requisites agrees with those of the other neuroses. You may imagine how much there remains for psycho-analysis to do in this field.

I also told you that by analysis of the narcissistic disorders we hoped to gain some knowledge of the composition of the Ego and of its structure out of various faculties and elements. We have made a beginning towards this at one point. From analysis of the delusion of observation we have come to the conclusion that in the Ego there exists a faculty that incessantly watches, criticizes, and compares, and in this way is set against the other part of the Ego. In our opinion, therefore, the patient reveals a truth which has not been appreciated as such when he complains that at every step he is spied upon and observed, that his every thought is known and examined. He has erred only in attributing this disagreeable power to something outside himself and foreign to him; he perceives within his Ego the rule of a faculty which measures his actual Ego and all his activities by an _Ego-ideal_, which he has created for himself in the course of his development. We also infer that he created this ideal for the purpose of recovering thereby the self-satisfaction bound up with the primary infantile narcissism, which since those days has suffered so many shocks and mortifications. We recognize in this self-criticizing faculty the Ego-censorship, the ‘conscience’; it is the same censorship as that exercised at night upon dreams, from which the repressions against inadmissible wish-excitations proceed. When this faculty disintegrates in the delusion of being observed, we are able to detect its origin and that it arose out of the influence of parents and those who trained the child, together with his social surroundings, by a process of identification with certain of these persons who were taken as a model.

These are some of the results yielded by the application of psycho-analysis to the narcissistic disorders. They are still not very numerous, and many of them still lack that sharpness of outline which cannot be achieved in a new field until some degree of familiarity has been attained. All of them have been made possible by employing the conception of Ego-Libido, or narcissistic Libido, by means of which we can extend the conclusions established for the transference neuroses on to the narcissistic neuroses. But now you will put the question whether it is possible for us to bring all the disorders of the narcissistic neuroses and of the psychoses into the range of the Libido-theory, for us to find the libidinal factor in mental life always and everywhere responsible for the development of disease, and for us never to have to attribute any part in the causation to the same alteration in the functions of the self-preservative instincts. Well now, it seems to me that decision on this point is not very urgent, and above all that the time is not yet ripe for us to make it; we may leave it calmly to be decided by advance in the work of science. I should not be astonished if it should prove that the capacity to induce a pathogenic effect were actually a prerogative of the libidinal impulses, so that the theory of the Libido would triumph all along the line from the actual neuroses to the severest psychotic form of individual derangement. For we know it to be characteristic of the Libido that it refuses to subordinate itself to reality in life, to Necessity. But I consider it extremely probable that the Ego-instincts are involved secondarily and that disturbances in their functions may be necessitated by the pathogenic affections of the Libido. Nor can I see that the direction taken by our investigations will be invalidated if we should have to recognize that in severe psychosis the Ego-instincts themselves are primarily deranged; the future will decide—for you, at least.

Let me return for a moment to anxiety, in order to throw light upon the one obscure point we left there. We said that the relation between anxiety and Libido, otherwise so well defined, is with difficulty harmonized with the almost indisputable assumption that real anxiety in the face of danger is the expression of the self-preservative instincts. But how if the anxiety-affect is provided, not by self-interest on the part of the Ego-instincts, but by the Ego-Libido? The condition of anxiety is after all invariably detrimental; its disadvantage becomes conspicuous when it reaches an intense degree. It then interferes with the action that alone would be expedient and would serve the purposes of self-preservation, whether it be flight or self-defence. Therefore if we ascribe the affective component of real anxiety to the Ego-Libido, and the action undertaken to the Ego-preservative instincts, every theoretical difficulty will be overcome. You will hardly maintain seriously that we run away _because_ we perceive fear? No, we perceive fear _and_ we take to flight, out of the common impulse that is roused by the perception of danger. Men who have survived experiences of imminent danger to life tell us that they did not perceive any fear, that they simply acted—for instance, pointed their gun at the oncoming beast—which was undoubtedly the best thing they could do.

TWENTY-SEVENTH LECTURE TRANSFERENCE

Now that we are coming to the end of our discussions you will feel a certain expectation which must not be allowed to mislead you. You are probably thinking that I surely have not led you through all these complicated mazes of psycho-analysis only to dismiss you at the end without a word about the therapy, upon which after all the possibility of undertaking psycho-analytic work depends. As a matter of fact I could not possibly leave out this aspect of it; for some of the phenomena belonging to it will teach you a new fact, without knowledge of which you would be quite unable to assimilate properly your understanding of the diseases we have been studying.

I know you do not expect directions in the technique of practising analysis for therapeutic purposes; you only want to know in a general way by what means the psycho-analytic therapy works and to gain a general idea of what it accomplishes. And you have an undeniable right to learn this; nevertheless I am not going to tell you—I am going to insist upon your finding it out for yourselves.

Think for a moment! You have already learnt everything essential, from the conditions by which illness is provoked to all the factors which take effect within the diseased mind. Where is the opening in all this for therapeutic influence? First of all there is the hereditary disposition,—we do not often mention it because it is so strongly emphasized in other quarters and we have nothing new to say about it. But do not suppose that we underestimate it; as practitioners we are well aware of its power. In any event we can do nothing to change it; for us also it is a fixed datum in the problem, which sets a limit to our efforts. Next, there is the influence of the experiences of early childhood, which we are accustomed in analysis to rank as very important; they belong to the past, we cannot undo them. Then there is all that unhappiness in life which we have included under ‘privation in reality,’ from which all the absence of love in life proceeds—namely, poverty, family strife, mistaken choice in marriage, unfavourable social conditions, and the severity of the demands by which moral convention oppresses the individual. There is indeed a wide opening for a very effective treatment in all this; but it would have to follow the course of the dispensations of Kaiser Joseph in the Viennese legend—the benevolent despotism of a potentate before whose will men bow and difficulties disappear! But who are we that we can exert such beneficence as a therapeutic measure? Poor as we are and without influence socially, with our living to earn by our medical practice, we are not even in a position to extend our efforts to penniless folk, as other physicians with other methods can do; our treatment takes too much time and labour for that. But perhaps you are still clinging on to one of the factors put forward, and believe you see an opening for our influence there. If the conventional restrictions imposed by society have had a part in the privations forced upon the patient, the treatment could give him the courage and even directly advise him to defy these obstacles, and to seize satisfactions and health for himself at the cost of failing to achieve an ideal which, though highly esteemed, is after all often set at naught by the world. Health is to be won by “free living,” then. There would be this blot upon analysis, to be sure, that it would not be serving general morality; what it gave to the individual it would take from the rest of the world.

But now, who has given you such a false impression of analysis? It is out of the question that part of the analytic treatment should consist of advice to “live freely”—if for no other reason because we ourselves tell you that a stubborn conflict is going on in the patient between libidinal desires and sexual repression, between sensual and ascetic tendencies. This conflict is not resolved by helping one side to win a victory over the other. It is true we see that in neurotics asceticism has gained the day; the result of which is that the suppressed sexual impulses have found a vent for themselves in the symptoms. If we were to make victory possible to the sensual side instead, the disregarded forces repressing sexuality would have to indemnify themselves by symptoms. Neither of these measures will succeed in ending the inner conflict; one side in either event will remain unsatisfied. There are but few cases in which the conflict is so unstable that a factor like medical advice can have any effect upon it, and these cases do not really require analytic treatment. People who can be so easily influenced by physicians would have found their own way to that solution without this influence. After all, you know that a young man living in abstinence who makes up his mind to illicit sexual intercourse, or an unsatisfied wife who seeks compensation with a lover, does not as a rule wait for the permission of a physician, still less of an analyst, to do so.

In considering this question people usually overlook the essential point of the whole difficulty—namely, that the pathogenic conflict in a neurotic must not be confounded with a normal struggle between conflicting impulses all of which are in the same mental field. It is a battle between two forces of which one has succeeded in coming to the level of the preconscious and conscious part of the mind, while the other has been confined on the unconscious level. That is why the conflict can never have a final outcome one way or the other; the antagonists meet each other as little as the whale and the polar bear in the well-known story. An effective decision can be reached only when they confront each other on the same ground. And, in my opinion, to accomplish this is the sole task of the treatment.

Besides this, I can assure you that you are quite misinformed if you imagine that advice and guidance concerning conduct in life forms an integral part of the analytic method. On the contrary, so far as possible we refrain from playing the part of mentor; we want nothing better than that the patient should find his own solutions for himself. To this end we expect him to postpone all vital decisions affecting his life, such as choice of career, business enterprises, marriage or divorce, during treatment and to execute them only after it has been completed. Now confess that you had imagined something very different. Only with certain very young or quite helpless and defenceless persons is it impossible to keep within such strict limitations as we should wish. With them we have to combine the positions of physician and educator; we are then well aware of our responsibility and act with the necessary caution.

You must not be led away by my eagerness to defend myself against the accusation that in analytic treatment neurotics are encouraged to “live a free life” and conclude from it that we influence them in favour of conventional morality. That is at least as far removed from our purpose as the other. We are not reformers, it is true; we are merely observers; but we cannot avoid observing with critical eyes, and we have found it impossible to give our support to conventional sexual morality or to approve highly of the means by which society attempts to arrange the practical problems of sexuality in life. We can demonstrate with ease that what the world calls its code of morals demands more sacrifices than it is worth, and that its behaviour is neither dictated by honesty nor instituted with wisdom. We do not absolve our patients from listening to these criticisms; we accustom them to an unprejudiced consideration of sexual matters like all other matters; and if after they have become independent by the effect of the treatment they choose some intermediate course between unrestrained sexual licence and unconditional asceticism, our conscience is not burdened whatever the outcome. We say to ourselves that anyone who has successfully undergone the training of learning and recognizing the truth about himself is henceforth strengthened against the dangers of immorality, even if his standard of morality should in some respect deviate from the common one. Incidentally, we must beware of overestimating the importance of abstinence in affecting neurosis; only a minority of pathogenic situations due to privation and the subsequent accumulation of Libido thereby induced can be relieved by the kind of sexual intercourse that is procurable without any difficulty.