Part 39

So you cannot explain the therapeutic effect of psycho-analysis by supposing that it permits patients free sexual indulgence; you must look round for something else. I think that one of the remarks I made while I was disposing of this conjecture on your part will have put you on the right track. Probably it is the substitution of something conscious for something unconscious, the transformation of the unconscious thoughts into conscious thoughts, that makes our work effective. You are right; that is exactly what it is. By extending the unconscious into consciousness the repressions are raised, the conditions of symptom-formation are abolished, and the pathogenic conflict exchanged for a normal one which must be decided one way or the other. We do nothing for our patients but enable this one mental change to take place in them; the extent to which it is achieved is the extent of the benefit we do them. Where there is no repression or mental process analogous to it to be undone there is nothing for our therapy to do.

The aim of our efforts may be expressed in various formulas—making conscious the unconscious, removing the repressions, filling in the gaps in memory; they all amount to the same thing. But perhaps you are dissatisfied with this declaration; you imagined the recovery of a nervous person rather differently, that after he had been subjected to the laborious process of psycho-analysis he would emerge a different person altogether, and then you hear that the whole thing only amounts to his having a little less that is unconscious and a little more that is conscious in him than before. Well, you probably do not appreciate the importance of an inner change of this kind. A neurotic who has been cured has really become a different person, although at bottom of course he remains the same—that is, he has become his best self, what he would have been under the most favourable conditions. That, however, is a great deal. Then when you hear of all that has to be done, of the tremendous exertion required to carry out this apparently trifling change in his mental life, the significance attached to these differences between the various mental levels will appear more comprehensible to you.

I will digress a moment to enquire whether you know what ‘a causal therapy’ means? This name is given to a procedure which puts aside the manifestations of a disease and looks for a point of attack in order to eradicate the cause of the illness. Now is psycho-analysis a causal therapy or not? The answer is not a simple one, but it may give us an opportunity to convince ourselves of the futility of such questions. In so far as psycho-analytic therapy does not aim immediately at removing the symptoms it is conducted like a causal therapy. In other respects you may say it is not, for we have followed the causal chain back far beyond the repressions to the instinctive predispositions, their relative intensity in the constitution, and the aberrations in the course of their development. Now suppose that it were possible by some chemical means to affect this mental machinery, to increase or decrease the amount of Libido available at any given moment, or to reinforce the strength of one impulse at the expense of another—that would be a causal therapy in the literal sense, and our analysis would be the indispensable preliminary work of reconnoitring the ground. As you know, there is at present no question of any such influence upon the processes of the Libido; our mental therapy makes its attack at another point in the concatenation, not quite at the place where we perceive the manifestations to be rooted, but yet comparatively far behind the symptoms themselves, at a place which becomes accessible to us in very remarkable circumstances.

What then have we to do in order to bring what is unconscious in the patient into consciousness? At one time we thought that would be very simple; all we need do would be to identify this unconscious matter and then tell the patient what it was. However, we know already that that was a short-sighted mistake. Our knowledge of what is unconscious in him is not equivalent to his knowledge of it; when we tell him what we know he does not assimilate it _in place of_ his own unconscious thoughts, but _alongside_ of them, and very little has been changed. We have rather to regard this unconscious material topographically; we have to look for it in his memory at the actual spot where the repression of it originally ensued. This repression must be removed, and then the substitution of conscious thought for unconscious thought can be effected straightaway. How is a repression such as this to be removed? Our work enters upon a second phase here; first, the discovery of the repression, and then the removal of the resistance which maintains this repression.

How can this resistance be got rid of? In the same way: by finding it out and telling the patient about it. The resistance too arises in a repression, either from the very one which we are endeavouring to dispel, or in one that occurred earlier. It is set up by the counter-charge which rose up to repress the repellent impulse. So that we now do just the same as we were trying to do before; we interpret, identify, and inform the patient; but this time we are doing it at the right spot. The counter-charge or the resistance is not part of the Unconscious, but of the Ego which co-operates with us, and this is so, even if it is not actually conscious. We know that a difficulty arises here in the ambiguity of the word ‘unconscious,’ on the one hand, as a phenomenon, on the other hand, as a system. That sounds very obscure and difficult; but after all it is only a repetition of what we have said before, is it not? We have come to this point already long ago.—Well then, we expect that this resistance will be abandoned, and the counter-charge withdrawn, when we have made the recognition of them possible by our work of interpretation. What are the instinctive propelling forces at our disposal to make this possible? First, the patient’s desire for recovery, which impelled him to submit himself to the work in co-operation with us, and secondly, the aid of his intelligence which we reinforce by our interpretation. There is no doubt that it is easier for the patient to recognize the resistance with his intelligence, and to identify the idea in his Unconscious which corresponds to it, if we have first given him an idea which rouses his expectations in regard to it. If I say to you: “Look up at the sky and you will see a balloon,” you will find it much more quickly than if I merely tell you to look up and see whether you can see anything; a student who looks through a microscope for the first time is told by the instructor what he is to see; otherwise he sees nothing, although it is there and quite visible.

And now for the fact! In quite a number of the various forms of nervous illness, in the hysterias, anxiety conditions, obsessional neuroses, our hypothesis proves sound. By seeking out the repression in this way, discovering the resistances, indicating the repressed, it is actually possible to accomplish the task, to overcome the resistances, to break down the repression, and to change something unconscious into something conscious. As we do this we get a vivid impression of how, as each individual resistance is being mastered, a violent battle goes on in the soul of the patient—a normal mental struggle between two tendencies on the same ground, between the motives striving to maintain the counter-charge and those which are ready to abolish it. The first of these are the old motives which originally erected the repression; among the second are found new ones more recently acquired, which it is hoped will decide the conflict in our favour. We have succeeded in revivifying the old battle of the repression again, in bringing the issue, so long ago decided, up for revision again. The new contribution we make to it lies, first of all, in demonstrating that the original solution led to illness and in promising that a different one would pave the way to health, and secondly, in pointing out that the circumstances have all changed immensely since the time of that original repudiation of these impulses. Then, the Ego was weak, infantile, and perhaps had reason to shrink with horror from the claims of the Libido as being dangerous to it. To-day it is strong and experienced and moreover has a helper at hand in the physician. So we may expect to lead the revived conflict through to a better outcome than repression; and, as has been said, in hysteria, anxiety-neurosis, and the obsessional neurosis success in the main justifies our claims.

There are other forms of illness, however, with which our therapeutic treatment never is successful, in spite of the similarity of the conditions. In them also there was originally a conflict between Ego and Libido, leading to repression—although this conflict may be characterized by topographical differences from the conflict of the transference neuroses; in them too it is possible to trace out the point in the patient’s life at which the repressions occurred; we apply the same method, are ready to make the same assurances, offer the same assistance by telling the patient what to look out for; and here also the interval in time between the present and the point at which the repressions were established is all in favour of a better outcome of the conflict. And yet we cannot succeed in overcoming one resistance or in removing one of the repressions. These patients, paranoiacs, melancholics, and those suffering from dementia præcox, remain on the whole unaffected, proof against psycho-analytic treatment. What can be the cause of this? It is not due to lack of intelligence; a certain degree of intellectual capacity must naturally be stipulated for analysis, but there is no deficiency in this respect in, for instance, the very quick-witted deductive paranoiac. Nor are any of the other propelling forces regularly absent: melancholics, for instance, in contrast to paranoiacs, experience a very high degree of realization that they are ill and that their sufferings are due to this; but they are not on that account any more accessible to influence. In this we are confronted with a fact that we do not understand, and are therefore called upon to doubt whether we have really understood all the conditions of the success possible with the other neuroses.

When we keep to consideration of hysterical and obsessional neurotics we are very soon confronted with a second fact, for which we were quite unprepared. After the treatment has proceeded for a while we notice that these patients behave in a quite peculiar manner towards ourselves. We thought indeed that we had taken into account all the motive forces affecting the treatment and had reasoned out the situation between ourselves and the patient fully, so that it balanced like a sum in arithmetic; and then after all something seems to slip in which was quite left out of our calculation. This new and unexpected feature is in itself many-sided and complex; I will first of all describe some of its more frequent and simpler forms to you.

We observe then that the patient, who ought to be thinking of nothing but the solution of his own distressing conflicts, begins to develop a particular interest in the person of the physician. Everything connected with this person seems to him more important than his own affairs and to distract him from his illness. Relations with the patient then become for a time very agreeable; he is particularly docile, endeavours to show his gratitude wherever he can, exhibits a fineness of character and other good qualities which we had perhaps not anticipated in him. The analyst thus forms a very good opinion of the patient and values his luck in being able to render assistance to such an admirable personality. If the physician has occasion to see the patient’s relatives he hears with satisfaction that this esteem is mutual. The patient at home is never tired of praising the analyst and attributing new virtues to him. “He has quite lost his head over you; he puts implicit trust in you; everything you say is like a revelation to him,” say the relatives. Here and there one among this chorus having sharper eyes will say: “It is positively boring the way he never speaks of anything but you: he quotes you all the time.”

We will hope that the physician is modest enough to ascribe the patient’s estimate of his value to the hopes of recovery which he has been able to offer to him, and to the widening in the patient’s intellectual horizon consequent upon the surprising revelations entailed by the treatment and their liberating influence. The analysis too makes splendid progress under these conditions, the patient understands the suggestions offered to him, concentrates upon the tasks appointed by the treatment, the material needed—his recollections and associations—is abundantly available; he astonishes the analyst by the sureness and accuracy of his interpretations, and the latter has only to observe with satisfaction how readily and willingly a sick man will accept all the new psychological ideas that are so hotly contested by the healthy in the world outside. A general improvement in the patient’s condition, objectively confirmed on all sides, also accompanies this harmonious relationship in the analysis.

But such fair weather cannot last for ever. There comes a day when it clouds over. There begin to be difficulties in the analysis; the patient says he cannot think of anything more to say. One has an unmistakable impression that he is no longer interested in the work, and that he is casually ignoring the injunction given him to say everything that comes into his mind and to yield to none of the critical objections that occur to him. His behaviour is not dictated by the situation of the treatment; it is as if he had not made an agreement to that effect with the physician; he is obviously preoccupied with something which at the same time he wishes to reserve to himself. This is a situation in which the treatment is in danger. Plainly a very powerful resistance has risen up. What can have happened?

If it is possible to clear up this state of things, the cause of the disturbance is found to consist in certain intense feelings of affection which the patient has transferred on to the physician, not accounted for by the latter’s behaviour nor by the relationship involved by the treatment. The form in which this affectionate feeling is expressed and the goal it seeks naturally depend upon the circumstances of the situation between the two persons. If one of them is a young girl and the other still a fairly young man, the impression received is that of normal love; it seems natural that a girl should fall in love with a man with whom she is much alone and can speak of very intimate things, and who is in the position of an adviser with authority—we shall probably overlook the fact that in a neurotic girl some disturbance of the capacity for love is rather to be expected. The farther removed the situation between the two persons is from this supposed example, the more unaccountable it is to find that nevertheless the same kind of feeling comes to light in other cases. It may be still comprehensible when a young woman who is unhappily married seems to be overwhelmed by a serious passion for her physician, if he is still unattached, and that she should be ready to seek a divorce and give herself to him, or, where circumstances would prevent this, to enter into a secret love-affair with him. That sort of thing, indeed, is known to occur outside psycho-analysis. But in this situation girls and women make the most astonishing confessions which reveal a quite peculiar attitude on their part to the therapeutic problem: they had always known that nothing but love would cure them, and from the beginning of the treatment they had expected that this relationship would at last yield them what life had so far denied them. It was only with this hope that they had taken such pains over the analysis and had conquered all their difficulties in disclosing their thoughts. We ourselves can add: ‘and had understood so easily all that is usually so hard to accept.’ But a confession of this kind astounds us; all our calculations are blown to the winds. Could it be that we have omitted the most important element in the whole problem?

And actually it is so; the more experience we gain the less possible does it become for us to contest this new factor, which alters the whole problem and puts our scientific calculations to shame. The first few times one might perhaps think that the analytic treatment had stumbled upon an obstruction in the shape of an accidental occurrence, extraneous to its purpose and unconnected with it in origin. But when it happens that this kind of attachment to the physician regularly evinces itself in every fresh case, under the most unfavourable conditions, and always appears in circumstances of a positively grotesque incongruity—in elderly women, in relation to grey-bearded men, even on occasions when our judgement assures us that no temptations exist—then we are compelled to give up the idea of a disturbing accident and to admit that we have to deal with a phenomenon in itself essentially bound up with the nature of the disease.

The new fact which we are thus unwillingly compelled to recognize we call TRANSFERENCE. By this we mean a transference of feelings on to the person of the physician, because we do not believe that the situation in the treatment can account for the origin of such feelings. We are much more disposed to suspect that the whole of this readiness to develop feeling originates in another source; that it was previously formed in the patient, and has seized the opportunity provided by the treatment to transfer itself on to the person of the physician. The transference can express itself as a passionate petitioning for love, or it can take less extreme forms; where a young girl and an elderly man are concerned, instead of the wish to be wife or mistress, a wish to be adopted as a favourite daughter may come to light, the libidinous desire can modify itself and propose itself as a wish for an everlasting, but ideally platonic friendship. Many women understand how to sublimate the transference and to mould it until it acquires a sort of justification for its existence; others have to express it in its crude, original, almost impossible form. But at bottom it is always the same, and its origin in the same source can never be mistaken.

Before we enquire where we are to range this new fact, we will amplify the description of it a little. How is it with our male patients? There at least we might hope to be spared the troublesome element of sex difference and sex attraction. Well, the answer is very much the same as with women. The same attachment to the physician, the same overestimation of his qualities, the same adoption of his interests, the same jealousy against all those connected with him. The sublimated kinds of transference are the forms more frequently met with between man and man, and the directly sexual declaration more rarely, in the same degree to which the manifest homosexuality of the patient is subordinated to the other ways by which this component-instinct can express itself. Also, it is in male patients that the analyst more frequently observes a manifestation of the transference which at the first glance seems to controvert the description of it just given—that is, the hostile or _negative_ transference.

First of all, let us realize at once that the transference exists in the patient from the beginning of the treatment, and is for a time the strongest impetus in the work. Nothing is seen of it and one does not need to trouble about it as long as its effect is favourable to the work in which the two persons are co-operating. When it becomes transformed into a resistance, attention must be paid to it; and then it appears that two different and contrasting states of mind have supervened in it and have altered its attitude to the treatment: first, when the affectionate attraction has become so strong and betrays signs of its origin in sexual desire so clearly that it was bound to arouse an inner opposition against itself; and secondly, when it consists in antagonistic instead of affectionate feeling. The hostile feelings as a rule appear later than the affectionate and under cover of them; when both occur simultaneously they provide a very good exemplification of that ambivalence in feeling which governs most of our intimate relationships with other human beings. The hostile feelings therefore indicate an attachment of feeling quite similar to the affectionate, just as defiance indicates a similar dependence upon the other person to that belonging to obedience, though with a reversed prefix. There can be no doubt that the hostile feelings against the analyst deserve the name of ‘transference,’ for the situation in the treatment certainly gives no adequate occasion for them; the necessity for regarding the negative transference in this light is a confirmation of our previous similar view of the positive or affectionate variety.