Part 41

All the Libido and the full strength of the opposition against it are concentrated upon the one thing, upon the relationship to the physician; thus it becomes inevitable that the symptoms should be deprived of their Libido; in place of the patient’s original illness appears the artificially-acquired transference, the transference-disorder; in place of a variety of unreal objects of his Libido appears the one object, also ‘phantastic,’ of the person of the physician. This new struggle which arises concerning this object is by means of the analyst’s suggestions lifted to the surface, to the higher mental levels, and is there worked out as a normal mental conflict. Since a new repression is thus avoided, the opposition between the Ego and the Libido comes to an end; unity is restored within the patient’s mind. When the Libido has been detached from its temporary object in the person of the physician it cannot return to its earlier objects, but is now at the disposal of the Ego. The forces opposing us in this struggle during the therapeutic treatment are on the one hand the Ego’s aversion against certain tendencies on the part of the Libido, which had expressed itself in repressing tendencies; and on the other hand the tenacity or ‘adhesiveness’ of the Libido, which does not readily detach itself from objects it has once invested.

The therapeutic work thus falls into two phases; in the first all the Libido is forced away from the symptoms into the transference and there concentrated, in the second the battle rages round this new object and the Libido is made free from it. The change that is decisive for a successful outcome of this renewed conflict lies in the preclusion of repression, so that the Libido cannot again withdraw itself from the Ego by a flight into the Unconscious. It is made possible by changes in the Ego ensuing as a consequence of the analyst’s suggestions. At the expense of the Unconscious the Ego becomes wider by the work of interpretation which brings the unconscious material into consciousness; through education it becomes reconciled to the Libido and is made willing to grant it a certain degree of satisfaction; and its horror of the claims of its Libido is lessened by the new capacity it acquires to expend a certain amount of the Libido in sublimation. The more nearly the course of the treatment corresponds with this ideal description the greater will be the success of the psycho-analytic therapy. Its barriers are found in the lack of mobility in the Libido, which resists being released from its objects, and in the rigidity of the patient’s narcissism, which will not allow more than a certain degree of object-transference to develop. Perhaps the dynamics of the process of recovery will become still clearer if we describe it by saying that, in attracting a part of it to ourselves through transference, we gather in the whole amount of the Libido which has been withdrawn from the Ego’s control.

It is as well here to make clear that the distributions of the Libido which ensue during and by means of the analysis afford no direct inference of the nature of its disposition during the previous illness. Given that a case can be successfully cured by establishing and then resolving a powerful father-transference to the person of the physician, it would not follow that the patient had previously suffered in this way from an unconscious attachment of the Libido to his father. The father-transference is only the battlefield on which we conquer and take the Libido prisoner; the patient’s Libido has been drawn hither away from other ‘positions.’ The battlefield does not necessarily constitute one of the enemy’s most important strongholds; the defence of the enemy’s capital city need not be conducted immediately before its gates. Not until after the transference has been again resolved can one begin to reconstruct in imagination the dispositions of the Libido that were represented by the illness.

In the light of the Libido-theory there is a final word to be said about dreams. The dreams of a neurotic, like his “errors” and his free associations, enable us to find the meaning of the symptoms and to discover the dispositions of the Libido. The forms taken by the wish-fulfilment in them show us what are the wish-impulses that have undergone repression, and what are the objects to which the Libido has attached itself after withdrawal from the Ego. The interpretation of dreams therefore plays a great part in psycho-analytic treatment, and in many cases it is for lengthy periods the most important instrument at work. We already know that the condition of sleep in itself produces a certain relaxation of the repressions. By this diminution in the heavy pressure upon it the repressed desire is able to create for itself a far clearer expression in a dream than can be permitted to it by day in the symptoms. Hence the study of dreams becomes the easiest approach to a knowledge of the repressed Unconscious, which is where the Libido which has withdrawn from the Ego belongs.

The dreams of neurotics, however, differ in no essential from those of normal people; they are indeed perhaps not in any way distinguishable from them. It would be illogical to account for the dreams of neurotics in a way that would not also hold good of the dreams of normal people. We have to conclude therefore that the difference between neurosis and health prevails only by day; it is not sustained in dream-life. It thus becomes necessary to transfer to healthy persons a number of conclusions arrived at as a result of the connections between the dreams and the symptoms of neurotics. We have to recognize that the healthy man as well possesses those factors in mental life which alone can bring about the formation of a dream or of a symptom, and we must conclude further that the healthy also have instituted repressions and have to expend a certain amount of energy to maintain them; that their unconscious minds too harbour repressed impulses which are still suffused with energy, and that _a part of the Libido is in them also withdrawn from the disposal of the Ego_. The healthy man too is therefore virtually a neurotic, but the only symptom that he _seems_ capable of developing is a dream. To be sure when you subject his waking life also to a critical investigation you discover something that contradicts this specious conclusion; for this apparently healthy life is pervaded by innumerable trivial and practically unimportant symptom-formations.

The difference between nervous health and nervous illness (neurosis) is narrowed down therefore to a practical distinction, and is determined by the practical result—how far the person concerned remains capable of a sufficient degree of capacity for enjoyment and active achievement in life. The difference can probably be traced back to the proportion of the energy which has remained free relative to that of the energy which has been bound by repression, i.e. it is a quantitative and not a qualitative difference. I do not need to remind you that this view provides a theoretical basis for our conviction that the neuroses are essentially amenable to cure, in spite of their being based on a constitutional disposition.

So much, therefore, in the way of knowledge of the characteristics of health may be inferred from the identity of the dreams dreamt by neurotic and by healthy persons. Of dreams themselves, however, a further inference must be drawn—namely, that it is not possible to detach them from their connection with neurotic symptoms; that we are not at liberty to believe that their essential nature is exhausted by compressing them into the formula of ‘a translation of thoughts into archaic forms of expression’; and that we are bound to conclude that they disclose dispositions of the Libido and objects of desire which are actually in operation and valid at the moment.

We have now come very nearly to the end. Perhaps you are disappointed that under the heading of psycho-analytic therapy I have limited myself to theory, and have told you nothing of the conditions under which the cure is undertaken, or of the results it achieves. I omit both, however: the first, because in fact I never intended to give you a practical training in the exercise of the analytic method; and the last, because I have several motives against it. At the beginning of these discussions I said emphatically that under favourable conditions we achieve cures that are in no way inferior to the most brilliant in other fields of medical therapy; I may perhaps add that these results could be achieved by no other method. If I said more I should be suspected of wishing to drown the depreciatory voices of our opponents by self-advertisement. Medical “colleagues” have, even at public congresses, repeatedly held out a threat to psycho-analysts that by publishing a collection of the failures and harmful effects of analysis they will open the eyes of the injured public to the worthlessness of this method of treatment. Apart from the malicious, denunciatory character of such a measure, however, a collection of that kind would not even be valid evidence upon which a correct estimate of the therapeutic results of analysis might be formed. Analytic therapy, as you know, is still young; it needed many years to elaborate the technique, which could only be done in the course of the work under the influence of increasing experience. On account of the difficulties of imparting instruction in the methods the beginner is thrown much more upon his own resources for development of his capacity than any other kind of specialist, and the results of his early years can never be taken as indicating the full possible achievements of analytic therapy.

Many attempts at treatment made in the beginning of psycho-analysis were failures because they were undertaken with cases altogether unsuited to the procedure, which nowadays we should exclude by following certain indications. These indications, however, could only be discovered by trying. In the beginning we did not know that paranoia and dementia præcox, when fully developed, are not amenable to analysis; we were still justified in trying the method on all kinds of disorders. Most of the failures of those early years, however, were not due to the fault of the physician, or to the unsuitability in the choice of subject, but to unpropitious external conditions. I have spoken only of the inner resistances, those on the part of the patient, which are inevitable and can be overcome. The external resistances which the patient’s circumstances and surroundings set up against analysis have little theoretic interest but the greatest practical importance. Psycho-Analytic treatment is comparable to a surgical operation and, like that, for its success it has the right to expect to be carried out under the most favourable conditions. You know the preliminary arrangements a surgeon is accustomed to make—a suitable room, a good light, expert assistance, exclusion of the relatives, and so on. Now ask yourselves how many surgical operations would be successful if they had to be conducted in the presence of the patient’s entire family poking their noses into the scene of the operation and shrieking aloud at every cut. In psycho-analytic treatment the intervention of the relatives is a positive danger and, moreover, one which we do not know how to deal with. We are armed against the inner resistances of the patient, which we recognize as necessary, but how can we protect ourselves against these outer resistances? It is impossible to get round the relatives by any sort of explanation, nor can one induce them to hold aloof from the whole affair; one can never take them into one’s confidence because then we run the danger of losing the patient’s trust in us, for he—quite rightly, of course—demands that the man he confides in should take his part. Anyone who knows anything of the dissensions commonly splitting up family life will not be astonished in his capacity of analyst to find that those nearest to the patient frequently show less interest in his recovery than in keeping him as he is. When as so often occurs the neurosis is connected with conflicts between different members of a family, the healthy person does not make much of putting his own interest before the patient’s recovery. After all, it is not surprising that the husband does not favour a treatment in which, as he correctly supposes, his sins will all come to light; nor do we wonder at this, but then we cannot blame ourselves when our efforts remain fruitless and are prematurely broken off because the husband’s resistance is added to that of the sick wife. We had simply undertaken something which, under the existing conditions, it was impossible to carry out.

Instead of describing many cases to you I will tell you of one only, in which I had to suffer for the sake of professional conscientiousness. I took a young girl—many years ago—for analytic treatment; for a considerable time previously she had been unable to go out of doors on account of a dread, nor could she stay at home alone. After much hesitation the patient confessed that her thoughts had been a good deal occupied by some signs of affection that she had noticed by chance between her mother and a well-to-do friend of the family. Very tactlessly—or else very cleverly—she then gave the mother a hint of what had been discussed during the analysis; she did this by altering her behaviour to her mother, by insisting that no one but her mother could protect her against the dread of being alone, and by holding the door against her when she attempted to leave the house. The mother herself had formerly been very nervous, but had been cured years before by a visit to a hydropathic establishment—or, putting it otherwise, we may say she had there made the acquaintance of the man with whom she had established a relationship that had proved satisfying in more than one respect. Made suspicious by her daughter’s passionate demands the mother suddenly _understood_ what the girl’s dread signified. She had become ill in order to make her mother a prisoner and rob her of the freedom necessary for her to maintain her relations with her lover. The mother’s decision was instantly taken; she put an end to the harmful treatment. The girl was sent to a home for nervous patients, and for many years was there pointed out as an “unhappy victim of psycho-analysis”; for just as long I was pursued by damaging rumours about the unfortunate results of the treatment. I maintained silence because I supposed myself bound by the rules of professional secrecy. Years later I learned from a colleague who had visited the home and there seen the girl with agoraphobia that the intimacy between the mother and the wealthy man was common knowledge, and that in all probability it was connived at by the husband and father. To this “secret” the girl’s cure had been sacrificed.

In the years before the war, when the influx of patients from many countries made me independent of the goodwill or disfavour of my native city, I made it a rule never to take for treatment anyone who was not _sui juris_, independent of others in all the essential relations of life. Every psycho-analyst cannot make these stipulations. Perhaps you will conclude from my warnings about relatives that one should take the patient out of his family circle in the interests of analysis, and restrict this therapy to those living in private institutions. I could not support this suggestion, however; it is far more advantageous for the patients—those who are not in a condition of severe prostration, at least—to remain during the treatment in those circumstances in which they have to struggle with the demands that their ordinary life makes on them. But the relatives ought not to counteract this advantage by their behaviour, and above all should not oppose their hostility to one’s professional efforts. But how are you going to induce people who are inaccessible to you to take up this attitude? You will naturally also conclude that the social atmosphere and degree of cultivation of the patient’s immediate surroundings have considerable influence upon the prospects of the treatment.

This is a gloomy outlook for the efficacy of psycho-analysis as a therapy, even if we may explain the overwhelming majority of our failures by taking into account these disturbing external factors! Friends of analysis have advised us to counterbalance a collection of failures by drawing up a statistical enumeration of our successes. I have not taken up this suggestion either. I brought forward the argument that statistics would be valueless if the units collated were not alike, and the cases which had been treated were in fact not equivalent in many respects. Further, the period of time that could be reviewed was too short for one to be able to judge of the permanence of the cures; and of many cases it would be impossible to give any account. They were persons who had kept both their illness and their treatment secret, and whose recovery in consequence had similarly to be kept secret. The strongest reason against it, however, lay in the recognition of the fact that in matters of therapy humanity is in the highest degree irrational, so that there is no prospect of influencing it by reasonable arguments. A novelty in therapeutics is either taken up with frenzied enthusiasm, as for instance when Koch first published his results with tuberculin; or else it is regarded with abysmal distrust, as happened for instance with Jenner’s vaccination, actually a heaven-sent blessing, but one which still has its implacable opponents. A very evident prejudice against psycho-analysis made itself apparent. When one had cured a very difficult case one would hear: “That is no proof of anything; he would have got well of himself after all this time.” And when a patient who had already gone through four cycles of depression and mania came to me in an interval after the melancholia and three weeks later again began to develop an attack of mania, all the members of the family, and also all the high medical authorities who were called in, were convinced that the fresh attack could be nothing but a consequence of the attempted analysis. Against prejudice one can do nothing, as you can now see once more in the prejudices that each group of the nations at war has developed against the other. The most sensible thing to do is to wait and allow them to wear off with the passage of time. A day comes when the same people regard the same things in quite a different light from what they did before; why they thought differently before remains a dark secret.

It is possible that the prejudice against the analytic therapy has already begun to relax. The continual spread of analytic doctrine and the numbers of medical men taking up analytic treatment in many countries seem to point in that direction. As a young man I was caught in just such a storm of indignation roused in the medical profession by the hypnotic suggestion-treatment, which nowadays is held up in opposition to psycho-analysis by the “sober-minded.” As a therapeutic instrument, however, hypnotism did not bear out the hopes placed in it; we psycho-analysts may claim to be its rightful heirs and should not forget how much encouragement and theoretic enlightenment we owe to it. The harmful effects reported of psycho-analysis are essentially confined to transitory manifestations of an exacerbation of the conflict, which may occur when the analysis is clumsily handled, or when it is broken off suddenly. You have heard an account of what we do with our patients, and you can form your own judgement whether our efforts are likely to lead to lasting injury. Misuse of analysis is possible in various ways: the transference especially, in the hands of an unscrupulous physician, is a dangerous instrument. But no medical remedy is proof against misuse; if a knife will not cut, neither will it serve a surgeon.

I have now reached the end. It is more than a conventional formality when I say that I myself am heavily oppressed by the many defects of the lectures I have delivered before you. I regret most of all that I have so often promised to return again in another place to a subject that I had just touched upon shortly, and that then the context in which I could keep my word did not offer itself. I undertook to give you an account of a thing that is still unfinished, still developing, and now my short summary itself has become an incomplete one. In many places I laid everything ready for drawing a conclusion, and then I did not draw it. But I could not aim at making you experts in psycho-analysis; I only wished to put you in the way of some understanding of it, and to arouse your interest in it.

INDEX

ABEL, C., 150, 194

ABRAHAM, K., 275, 346

Act: accidental, 48 sexual, 271, 297, 326 introductory, 257, 260, 271 symptomatic, 48, 209, 215

Actions, erroneous performance of, 62

Actual neuroses, 322–7

ADLER, A., 201, 318, 339

‘Advantage through illness,’ 320

Ætiology of neuroses, 216, 287–93, 295, 303–5, 308, 313, 322

Affects: anxiety and, 330, 337 in dreams, 181–2 James-Lange theory of, 331 repression and, 336, 341–2

Agoraphobia, 224, 229, 334, 386

ALEXANDER, the Great, 14 dream of, 69, 200

Altruism, 348

Ambivalence, 279, 357, 370, 377

Amnesia: of childhood, 168, 239, 263, 274 of neuroses, 239, 240

Anal-erotism, 265, 268

Anal-sadistic stage of libido-development, 275–6, 289

ANDREAS, LOU, 265

_Anthropophyteia_, 137–8

Antithetical sense of primal words, 150, 194

Anus, 257, 265

Anxiety, 225, 328–44, 359 development of, 330, 338, 342 ‘free-floating,’ 332, 334 in children, 338 in dreams, 181–3, 230

Anxiety-equivalents, 334

Anxiety-hysteria, 229, 244, 252, 304, 334, 372

Anxiety-neurosis, 325, 332, 335, 337, 365–6, 374

Anxious readiness, 330

_Apotropaea_, 138

Apprehensiveness, 338–40

ARISTOTLE, 71

Art, and phantasy, 314

Association-experiment, 90

Associations: resistance against, 96, 243 to dreams, 87, 90, 94–102, 126, 198 to names, 88 to numbers, 88

Attention theory, 22

Auto-erotism, 199, 265, 276, 298, 307–10

BERNHEIM, 84, 234, 373, 375

BINET, 292

BINZ, 70

Birth: experience of, 331 infantile theories of, 135, 268 symbolism of, 128, 135

BLEULER, 90, 357

BLOCH, I., 258

BOECKLIN, 145

BÖLSCHE, W., 297

Breasts, 131, 165

BREUER, J., 218, 228, 232, 247 FREUD and, 233, 236, 246, 375

BREUGHEL, P., 256

Brothers and sisters, 172, 280 symbols of, 128, 134

BRÜCKE, von, 286

Castration, 175, 267, 309–11 circumcision and, 139 symbolism of, 131, 139, 161, 227

CHARCOT, 122

‘Charge of energy,’ 301

Childhood-experiences, 169, 302–11, 360, 378

Childhood-memories, 169, 281, 308

Children: anxiety in, 338 birth-phantasies of, 135, 268 dreams of, 105–13, 180 egoism in, 172, 279 intimidation of, 266, 309 neurosis in, 304 phobias in, 340 purity of, 177, 263, 273 sexual curiosity of, 176, 186, 190, 267, 274, 280 sexual life of, 176, 261–84, 296, 302–11

Clitoris, 130, 226, 267

_Coitus interruptus_, 335

Complex, 90 the castration, 175, 267 the Oedipus, 175, 277–84

Component-instincts (component-impulses), 266, 271–2, 275–6, 288–90, 302–3, 313

Compromise-formations, 52, 108, 253, 300

Compulsions, 220, 337

Condensation, 301, 307 in dreams, 144, 160, 199, 250, 307

Conflict, mental, 260, 293–5, 300–2, 306, 312–13, 319, 345, 351, 361–3, 366, 372, 379

Conscience, 358

Conscious, _see_ Mental Processes

Consciousness, 16, 211, 239, 248–50, 301–2, 336, 363 psychology of, 16, 235

Conversion-hysteria, 252, 326, 334

Convictions, 207

COPERNICUS, 241

‘Countercharge,’ 301, 314, 342, 365

DARWIN, C., 61, 241

Day-dreams, 80, 109, 312, 314

Death, symbols of, 129, 136