Part 40

Where the transference springs from, what difficulties it provides for us, how we can overcome them, and what advantage we can finally derive from it, are questions which can only be adequately dealt with in a technical exposition of the analytic method; I can merely touch upon them here. It is out of the question that we should yield to the demands made by the patient under the influence of his transference; it would be nonsensical to reject them unkindly, and still more so, indignantly. The transference is overcome by showing the patient that his feelings do not originate in the current situation, and do not really concern the person of the physician, but that he is reproducing something that had happened to him long ago. In this way we require him to transform his _repetition_ into _recollection_. Then the transference which, whether affectionate or hostile, every time seemed the greatest menace to the cure becomes its best instrument, so that with its help we can unlock the closed doors in the soul. I should like, however, to say a few words to dispel the unpleasant effects of the shock that this unexpected phenomenon must have been to you. After all, we must not forget that this illness of the patient’s which we undertake to analyse is not a finally accomplished, and as it were consolidated thing; but that it is growing and continuing its development all the time like a living thing. The beginning of the treatment puts no stop to this development; but, as soon as the treatment has taken a hold upon the patient, it appears that the entire productivity of the illness henceforward becomes concentrated in one direction—namely, upon the relationship to the physician. The transference then becomes comparable to the cambium layer between the wood and the bark of a tree, from which proceeds the formation of new tissue and the growth of the trunk in diameter. As soon as the transference has taken on this significance the work upon the patient’s recollections recedes far into the background. It is then not incorrect to say that we no longer have to do with the previous illness, but with a newly-created and transformed neurosis which has replaced the earlier one. This new edition of the old disease has been followed from its inception, one sees it come to light and grow, and is particularly familiar with it since one is oneself its central object. All the patient’s symptoms have abandoned their original significance and have adapted themselves to a new meaning, which is contained in their relationship to the transference; or else only those symptoms remain which were capable of being adapted in this way. The conquest of this new artificially-acquired neurosis coincides with the removal of the illness which existed prior to the treatment, that is, with accomplishing the therapeutic task. The person who has become normal and free from the influence of repressed instinctive tendencies in his relationship to the physician remains so in his own life when the physician has again been removed from it.

The transference has this all-important, absolutely central significance for the cure in hysteria, anxiety-hysteria, and the obsessional neurosis, which are in consequence rightly grouped together as the ‘transference neuroses.’ Anyone who has grasped from analytic experience a true impression of the fact of transference can never again doubt the nature of the suppressed impulses which have manufactured an outlet for themselves in the symptoms; and he will require no stronger proof of their libidinal character. We may say that our conviction of the significance of the symptoms as a substitutive gratification of the Libido was only finally and definitely established by evaluating the phenomenon of transference.

Now, however, we are called upon to correct our former dynamic conception of the process of cure and to bring it into agreement with the new discovery. When the patient has to fight out the normal conflict with the resistances which we have discovered in him by analysis, he requires a powerful propelling force to influence him towards the decision we aim at, leading to recovery. Otherwise it might happen that he would decide for a repetition of the previous outcome, and allow that which had been raised into consciousness to slip back again under repression. The outcome in this struggle is not decided by his intellectual insight—it is neither strong enough nor free enough to accomplish such a thing—but solely by his relationship to the physician. In so far as his transference bears the positive sign, it clothes the physician with authority, transforms itself into faith in his findings and in his views. Without this kind of transference or with a negative one, the physician and his arguments would never even be listened to. Faith repeats the history of its own origin; it is a derivative of love and at first it needed no arguments. Not until later does it admit them so far as to take them into critical consideration if they have been offered by someone who is loved. Without this support arguments have no weight with the patient, never do have any with most people in life. A human being is therefore on the whole only accessible to influence, even on the intellectual side, in so far as he is capable of investing objects with Libido; and we have good cause to recognize, and to fear, in the measure of his narcissism a barrier to his susceptibility to influence, even by the best analytic technique.

The capacity for the radiation of Libido towards other persons in object investment must, of course, be ascribed to all normal people; the tendency to transference in neurotics, so-called, is only an exceptional intensification of a universal characteristic. Now it would be very remarkable if a human character-trait of this importance and universality had never been observed and made use of. And this has really been done. Bernheim, with unerring perspicacity, based the theory of hypnotic manifestations upon the proposition that all human beings are more or less open to suggestion, are ‘suggestible.’ What he called suggestibility is nothing else but the tendency to transference, rather too narrowly circumscribed so that the negative transference did not come within its scope. But Bernheim could never say what suggestion actually was nor how it arises; it was an axiomatic fact to him and he could give no explanation of its origin. He did not recognize the dependence of ‘suggestibility’ on sexuality, on the functioning of the Libido. And we have to admit that we have only abandoned hypnosis in our methods in order to discover suggestion again in the shape of transference.

But now I will pause and let you take up the thread. I observe that an objection is invading your thoughts with such violence that it would deprive you of all power of attention if it were not given expression. “So now at last you have confessed that you too work with the aid of suggestion like the hypnotists. We have been thinking so all along. But then, what is the use of all these roundabout routes by way of past experiences, discovering the unconscious material, interpreting and retranslating the distortions, and the enormous expenditure of time, trouble, and money, when after all the only effective agent is suggestion? Why do you not suggest directly against the symptoms, as others do who are honest hypnotists? And besides, if you are going to make out that by these roundabout routes you have made numerous important psychological discoveries, which are concealed in direct suggestion, who is to vouch for their validity? Are not they too the result of suggestion, of unintentional suggestion, that is? Cannot you impress upon the patient what you please and whatever seems good to you in this direction also?”

What you charge me with in this way is exceedingly interesting and must be answered. But I cannot do that to-day; our time is up. Till next time, then. You will see that I shall be answerable to you. To-day I must finish what I began. I promised to explain to you through the factor of the transference why it is that our therapeutic efforts have no success in the narcissistic neuroses.

I can do it in a few words, and you will see how simply the riddle is solved, and how well everything fits together. Experience shows that persons suffering from the narcissistic neuroses have no capacity for transference, or only insufficient remnants of it. They turn from the physician, not in hostility, but in indifference. Therefore they are not to be influenced by him; what he says leaves them cold, makes no impression on them, and therefore the process of cure which can be carried through with others, the revivification of the pathogenic conflict and the overcoming of the resistance due to the repressions, cannot be effected with them. They remain as they are. They have often enough undertaken attempts at recovery on their own account which have led to pathological results; we can do nothing to alter this.

On the basis of our clinical observations of these patients we stated that they must have abandoned the investment of objects with Libido and transformed object-Libido into Ego-Libido. By this we differentiated them from the first group of neurotics (hysteria, anxiety, and obsessional neurosis). Their behaviour during the attempt to cure them confirms this suspicion. They produce no transference, and are, therefore, inaccessible to our efforts, not to be cured by us.

TWENTY-EIGHTH LECTURE THE ANALYTIC THERAPY

You know what we are going to discuss to-day. When I admitted that the influence of the psycho-analytic therapy is essentially founded upon transference, i.e. upon suggestion, you asked me why we do not make use of direct suggestion, and you linked this up with a doubt whether, in view of the fact that suggestion plays such a large part, we can still vouch for the objectivity of our psychological discoveries. I promised to give you a comprehensive answer.

Direct suggestion is suggestion delivered directly against the forms taken by the symptoms, a struggle between your authority and the motives underlying the disease. In this struggle you do not trouble yourself about these motives, you only require the patient to suppress the manifestation of them in the form of symptoms. In the main it makes no difference whether you place the patient under hypnosis or not. Bernheim, with his characteristic acuteness, repeatedly stated that suggestion was the essence of the manifestations of hypnotism, and that hypnosis itself was already a result of suggestion, a suggested condition; he preferred to use suggestion in the waking state, which can achieve the same results as suggestion in hypnosis.

Now which shall I take first, the results of experience or theoretical considerations?

Let us begin with experience. I sought out Bernheim in Nancy in 1889 and became a pupil of his; I translated his book on suggestion into German. For years I made use of hypnotic treatment, first with prohibitory suggestions and later combined with Breuer’s system of the fullest enquiry into the patient’s life; I can therefore speak from wide experience about the results of the hypnotic or suggestive therapy. According to an old medical saying an ideal therapy should be rapid, reliable and not disagreeable to the patient; Bernheim’s method certainly fulfilled two of these requirements. It was much more rapid, that is, incomparably more rapid in its course than the analytic, and it involved the patient in no trouble or discomfort. For the physician it eventually became monotonous; it meant treating every case in the same way, always employing the same ritual to prohibit the existence of the most diverse symptoms, without being able to grasp anything of their meaning or significance. It was a sort of mechanical drudgery—hodman’s work—not scientific work; it was reminiscent of magic, conjuring, and hocus-pocus, yet in the patient’s interests one had to ignore that. In the third desideratum, however, it failed; it was not reliable in any respect. It could be employed in certain cases only and not in others; with some much could be achieved by it, and with others very little, one never knew why. But worse than its capricious nature was the lack of permanence in the results; after a time, if one heard from the patient again, the old malady had reappeared or had been replaced by another. Then one could begin to hypnotize again. In the background there was the warning of experienced men against robbing the patient of his independence by frequent repetitions of hypnosis, and against accustoming him to this treatment as though it were a narcotic. It is true, on the other hand, that at times everything fell out just as one could wish; one obtained complete and lasting success with little difficulty; but the conditions of this satisfactory outcome remained hidden. In one case, when I had completely removed a severe condition by a short hypnotic treatment, it recurred unchanged after the patient (a woman) had developed ill feeling against me without just cause; then after a reconciliation I was able to effect its disappearance again and this time far more thoroughly; but it reappeared again when she had a second time become hostile to me. Another time I had the following experience; during the treatment of an especially obstinate attack in a patient whom I had several times relieved of nervous symptoms, she suddenly threw her arms round my neck. Whether one wished to do so or not, this kind of thing finally made it imperative to enquire into the problem of the nature and source of one’s suggestive authority.

So much for experience; it shows that in abandoning direct suggestion we have given up nothing irreplaceable. Now let us link on to the facts a few comments. The exercise of the hypnotic method makes as little demand for effort on the part of the patient as it does on the physician. The method is in complete harmony with the view of the neuroses generally accepted by the majority of medical men. The practitioner says to the nervous person: “There is nothing the matter with you; it is merely nervousness, therefore a few words from me will scatter all your troubles to the winds in five minutes.” But it is contrary to all our beliefs about energy in general that a minimal exertion should be able to remove a heavy load by approaching it directly without the assistance of any suitably-devised appliance. In so far as the circumstances are at all comparable, experience shows that this trick cannot be performed successfully with the neuroses. I know, however, that this argument is not unassailable; there are such things as explosions.

In the light of the knowledge we have obtained through psycho-analysis, the difference between hypnotic and psycho-analytic suggestion may be described as follows: The hypnotic therapy endeavours to cover up and as it were to whitewash something going on in the mind, the analytic to lay bare and to remove something. The first works cosmetically, the second surgically. The first employs suggestion to interdict the symptoms; it reinforces the repressions, but otherwise it leaves unchanged all the processes that have led to symptom-formation. Analytic therapy takes hold deeper down nearer the roots of the disease, among the conflicts from which the symptoms proceed; it employs suggestion to change the outcome of these conflicts. Hypnotic therapy allows the patient to remain inactive and unchanged, consequently also helpless in the face of every new incitement to illness. Analytic treatment makes as great demands for efforts on the part of the patient as on the physician, efforts to abolish the inner resistances. The patient’s mental life is permanently changed by overcoming these resistances, is lifted to a higher level of development, and remains proof against fresh possibilities of illness. The labour of overcoming the resistances is the essential achievement of the analytic treatment; the patient has to accomplish it and the physician makes it possible for him to do this by suggestions which are in the nature of an _education_. It has been truly said therefore, that psycho-analytic treatment is a kind of _re-education_.

I hope I have now made clear to you the difference between our method of employing suggestion therapeutically and the method which is the only possible one in hypnotic therapy. Since we have traced the influence of suggestion back to the transference, you also understand the striking capriciousness of the effect in hypnotic therapy, and why analytic therapy is within its limits dependable. In employing hypnosis we are entirely dependent upon the condition of the patient’s transference and yet we are unable to exercise any influence upon this condition itself. The transference of a patient being hypnotized may be negative, or, as most commonly, ambivalent, or he may have guarded himself against his transference by adopting special attitudes; we gather nothing about all this. In psycho-analysis we work upon the transference itself, dissipate whatever stands in the way of it, and manipulate the instrument which is to do the work. Thus it becomes possible for us to derive entirely new benefits from the power of suggestion; we are able to control it; the patient alone no longer manages his suggestibility according to his own liking, but in so far as he is amenable to its influence at all, we guide his suggestibility.

Now you will say that, regardless of whether the driving force behind the analysis is called transference or suggestion, the danger still remains that our influence upon the patient may bring the objective certainty of our discoveries into doubt; and that what is an advantage in therapy is harmful in research. This is the objection that has most frequently been raised against psycho-analysis; and it must be admitted that, even though it is unjustified, it cannot be ignored as unreasonable. If it were justified, psycho-analysis after all would be nothing else but a specially well-disguised and particularly effective kind of suggestive treatment; and all its conclusions about the experiences of the patient’s past life, mental dynamics, the Unconscious, and so on, could be taken very lightly. So our opponents think; the significance of sexual experiences in particular, if not the experiences themselves, we are supposed to have “put into the patient’s mind,” after having first concocted these conglomerations in our own corrupt minds. These accusations are more satisfactorily refuted by the evidence of experience than by the aid of theory. Anyone who has himself conducted psycho-analyses has been able to convince himself numberless times that it is impossible to suggest things to a patient in this way. There is no difficulty, of course, in making him a disciple of a particular theory, and thus making it possible for him to share some mistaken belief possibly harboured by the physician. He behaves like anyone else in this, like a pupil; but by this one has only influenced his intellect, not his illness. The solving of his conflicts and the overcoming of his resistances succeeds only when what he is told to look for in himself corresponds with what actually does exist in him. Anything that has been inferred wrongly by the physician will disappear in the course of the analysis; it must be withdrawn and replaced by something more correct. One’s aim is, by a very careful technique, to prevent temporary successes arising through suggestion; but if they do arise no great harm is done, for we are not content with the first result. We do not consider the analysis completed unless all obscurities in the case are explained, the gaps in memory filled out, and the original occasions of the repressions discovered. When results appear prematurely, one regards them as obstacles rather than as furtherances of the analytic work, and one destroys them again by continually exposing the transference on which they are founded. Fundamentally it is this last feature which distinguishes analytic treatment from that of pure suggestion, and which clears the results of analysis from the suspicion of being the results of suggestion. In every other suggestive treatment the transference is carefully preserved and left intact; in analysis it is itself the object of the treatment and is continually being dissected in all its various forms. At the conclusion of the analysis the transference itself must be dissolved; if success then supervenes and is maintained it is not founded on suggestion, but on the overcoming of the inner resistances effected by the help of suggestion, on the inner change achieved within the patient.

That which probably prevents single effects of suggestion from arising during the treatment is the struggle that is incessantly being waged against the resistances, which know how to transform themselves into a negative (hostile) transference. Nor will we neglect to point to the evidence that a great many of the detailed findings of analysis, which would otherwise be suspected of being produced by suggestion, are confirmed from other, irreproachable sources. We have unimpeachable witnesses on these points, namely, dements and paranoiacs, who are of course quite above any suspicion of being influenced by suggestion. All that these patients relate in the way of phantasies and translations of symbols, which have penetrated through into their consciousness, corresponds faithfully with the results of our investigations into the Unconscious of transference neurotics, thus confirming the objective truth of the interpretations made by us which are so often doubted. I do not think you will find yourselves mistaken if you choose to trust analysis in these respects.

We now need to complete our description of the process of recovery by expressing it in terms of the Libido-theory. The neurotic is incapable of enjoyment or of achievement—the first because his Libido is attached to no real object, the last because so much of the energy which would otherwise be at his disposal is expended in maintaining the Libido under repression, and in warding off its attempts to assert itself. He would be well if the conflict between his Ego and his Libido came to an end, and if his Ego again had the Libido at its disposal. The task of the treatment, therefore, consists in the task of loosening the Libido from its previous attachments, which are beyond the reach of the Ego, and in making it again serviceable to the Ego. Now where is the Libido of a neurotic? Easily found: it is attached to the symptoms, which offer it the substitutive satisfaction that is all it can obtain as things are. We must master the symptoms then, dissolve them—just what the patient asks of us. In order to dissolve the symptoms it is necessary to go back to the point at which they originated, to review the conflict from which they proceeded, and with the help of propelling forces which at that time were not available to guide it towards a new solution. This revision of the process of repression can only partially be effected by means of the memory-traces of the processes which led up to repression. The decisive part of the work is carried through by creating—in the relationship to the physician, in “the transference”—new editions of those early conflicts, in which the patient strives to behave as he originally behaved, while one calls upon all the available forces in his soul to bring him to another decision. The transference is thus the battlefield where all the contending forces must meet.