Chapter XXI: Introduction (17)

I know that you do not expect any guidance in the technique of practising analysis for therapeutic purposes. You wish to know only along what general lines psychoanalytic therapy works and approximately what it accomplishes. And you have an undeniable right to know this. I shall not actually tell you, however, but shall insist that you guess it yourselves.

Only think! You know everything essential, from the conditions which precipitate the illness to all the factors at work within. Where is there room for therapeutic influence? In the first place, there is hereditary disposition; we do not speak of it often because it is strongly emphasized from another quarter, and we have nothing new to say about it. But do not think that we underestimate it. Just because we are therapeutists, we feel its power distinctly. At any rate, we cannot change it; it is a given fact which erects a barrier to our efforts. In the second place, there is the influence of the early experiences of childhood, which are in the habit of becoming sharply emphasized under analysis; they belong to the past and we cannot undo them. And then everything that we include in the term "actual forbearance"--misfortunes of life out of which privations of love arise, poverty, family discord, unfortunate choice in marriage, unfavorable social conditions and the severity of moral claims. These would certainly offer a foothold for very effectual therapy. But it would have to be the kind of therapy which, according to the Viennese folk-tale, Emperor Joseph practiced: the beneficial interference of a potentate, before whose will men bow and difficulties vanish. But who are we, to include such charity in the methods of our therapy? Poor as we are, powerless in society, forced to earn our living by practicing medicine, we are not even in a position to treat free of charge those patients who are unable to pay, as physicians who employ other methods of treatment can do. Our therapy is too long drawn-out, too extended for that. But perhaps you are still holding to one of the factors already mentioned, and think that you have found a factor through which our influence may be effective. If the restrictions of morality which are imposed by society have a share in the privation forced upon the patient, treatment might give him the courage, or possibly even the prescription itself, to cross these barriers, might tell him how gratification and health can be secured in the renunciation of that ideal which society has held up to us but often disregards. One grows healthy then, by giving one's sexuality full reign. Such analytic treatment, however, would be darkened by a shadow; it does not serve our recognized morality. The gain to the individual is a loss to society.

But, ladies and gentlemen, who has misinformed you to this degree? It is inconceivable that the advice to give one's sexuality full reign can play a part in analytic therapy, if only from the circumstance we have ourselves described, that there is going on within the patient a bitter conflict between libidinous impulse and sexual suppression, between sensual and ascetic tendencies. This conflict is not abolished by giving one of these tendencies the victory over its opponent. We see that in the case of the nervous, asceticism has retained the upper hand. The consequence of this is that the suppressed sexual desire gains breathing space by the development of symptoms. If, on the other hand, we were to give the victory to sexuality, symptoms would have to replace the sexual suppression, which has been pushed aside. Neither of the two decisions can end the inner conflict, one part always remains unsatisfied. There are only a few cases wherein the conflict is so labile, that a factor such as the intervention of the physician could be decisive, and these cases really require no analytic treatment. Persons who can be so much influenced by a physician would have found some solution without him. You know that when an abstinent young man decides upon illegitimate sex-intercourse, or when an unsatisfied woman seeks compensation from another man, they have generally not waited for the permission of a physician, far less of an analyst, to do this.

In studying the situation, one essential point is generally overlooked, that the pathogenic conflict of the neurotic must not be confused with normal struggles between psychic impulses of which all have their root in the same psychological soil. The neurotic struggle is a strife of forces, one of which has attained the level of the fore-conscious and the conscious, while the other has been held back in the unconscious stage. That is why the conflict can have no outcome; the struggling parties approach each other as little as in the well-known instance of the polar-bear and the whale. A real decision can be reached only if both meet on the same ground. To accomplish this is, I believe, the sole task of therapy.

Moreover, I assure you that you are misinformed if you assume that advice and guidance in the affairs of life is an integral part of the analytic influence. On the contrary, we reject this role of the mentor as far as possible. Above all, we wish to attain independent decisions on the part of the patient. With this intention in mind, we require him to postpone all vital resolutions such as choice of a career, marriage or divorce, until the close of the treatment. You must confess that this is not what you had imagined. It is only in the case of certain very young or entirely helpless persons that we cannot insist upon the desired limitation. Here we must combine the function of physician and educator; we are well aware of the responsibility and behave with the necessary precaution.

Judging from the zeal with which I defend myself against the accusation that analytic treatment urges the nervous person to give his sexuality full reign, you must not gather that we influence him for the benefit of conventional morality. We are just as far removed from that. We are no reformers, it is true, only observers, but we cannot help observing with critical eyes, and we have found it impossible to take the part of conventional sex morality, or to estimate highly the way in which society has tried to regulate the problems of sexual life in practice. We can prove to society mathematically that its code of ethics has exacted more sacrifices than is its worth, and that its procedure rests neither on veracity nor wisdom. We cannot spare our patients the task of listening to this criticism. We accustom them to weigh sexual matters, as well as others, without prejudice; and when, after the completion of the cure, they have become independent and choose some intermediate course between unrestrained sexuality and asceticism, our conscience is not burdened by the consequences. We tell ourselves: whoever has been successfully educated in being true to himself is permanently protected against the danger of immorality, even if his moral standard diverges from that of society. Let us, moreover, be careful not to overestimate the significance of the problem of abstinence with respect to its influence on neuroses. Only the minority of pathogenic situations of forbearance, with a subsequent condition of pent-up libido, can be resolved without more ado by such sexual intercourse as can be procured with little trouble.

And so you cannot explain the therapeutic influence of psychoanalysis by saying that it simply recommends giving full sway to sexuality. You must seek another solution. I think that while I was refuting this supposition of yours, one of my remarks put you on the right track. Our usefulness consists in replacing the unconscious by the conscious, in translating the unconscious into the conscious. You are right; that is exactly it. By projecting the unconscious into the conscious, we do away with suppressions, we remove conditions of symptom formation and transform a pathogenic into a normal conflict which can be decided in some way or other. This is the only psychic change we produce in our patients; its extent is the extent of our helpfulness. Wherever no suppression and no analogous psychic process can be undone, there is no place for our therapy.

We can express the aim of our efforts by various formulae of rendering the unconscious conscious, removing suppressions, filling out amnestic gaps--it all amounts to the same thing. But perhaps this admission does not satisfy you. You imagined that when a nervous person became cured something very different happened, that after having been subjected to the laborious process of psychoanalysis, he was transformed into a different human being. And now I tell you that the entire result is only that he has a little less of the unconscious, a little more of the conscious within him. Well, you probably underestimate the significance of such an inner change. The person cured of neurosis has really become another human being. Fundamentally, of course, he has remained the same. That is to say, he has only become what he might have been under the most favorable conditions. But that is saying a great deal. When you learn all that has to be done, the effort required to effect apparently so slight a change in psychic life, the significance of such a difference in the psychic realm will be credible to you.

I shall digress for a moment to ask whether you know what is meant by a causal therapy? This name is given to the procedure which does not take the manifestations of disease for its point of departure, but seeks to remove the causes of disease. Is our psychoanalytical therapy causal or not? The answer is not simple, but perhaps it will give us the opportunity of convincing ourselves that this point of departure is comparatively fruitless. In so far as analytical therapy does not concern itself immediately with the removal of symptoms, it may be termed causal. Yet in another respect, you might say this would hardly follow. For we have followed the causal chain back far beyond the suppressions to the instinctive tendencies and their relative intensity as given by the constitution of the patient, and finally the nature of the digression in the abnormal process of its development. Assume for a moment that it were possible to influence these functions chemically, to increase or to decrease the quantity of the libido that happens to be present, to strengthen one impulse at the expense of another. This would be causal therapy in its true sense and our analysis would have furnished the indispensable preparatory work of reconnaissance. You know that there is as yet no possibility of so influencing the processes of the libido. Our psychic therapy interposes elsewhere, not exactly at those sources of the phenomena which have been disclosed to us, but sufficiently far beyond the symptoms, at an opening in the structure of the disease which has become accessible to us by means of peculiar conditions.

What must we do in order to replace the unconscious by the conscious in our patient? At one time we thought this was quite simple, that all we had to do was to reconstruct the unconscious and then tell the patient about it. But we already know this was a shortsighted error. Our knowledge of the unconscious has not the same value as his; if we communicate our knowledge to him it will not stand _in place of_ the unconscious within him, but will exist _beside_ it, and only a very small change will have been effected. We must rather think of the unconscious as _localized_, and must seek it in memory at the point where it came into existence by means of a suppression. This suppression must be removed before the substitution of the conscious for the unconscious can be successfully effected. How can such a suppression be removed? Here our task enters a second phase. First to find the suppression, then to remove the resistance by which this suppression is maintained.

How can we do away with resistance? In the same way--by reconstructing it and confronting the patient with it. For resistance arises from suppression, from the very suppression which we are trying to break up, or from an earlier one. It has been established by the counter-attack that was instigated to suppress the offensive impulse. And so now we do the very thing we intended at the outset: interpret, reconstruct, communicate--but now we do it in the right place. The counter-seizure of the idea or resistance is not part of the unconscious but of the ego, which is our fellow-worker. This holds true even if resistance is not conscious. We know that the difficulty arises from the ambiguity of the word "unconscious," which may connote either a phenomenon or a system. That seems very difficult, but it is only a repetition, isn't it? We were prepared for it a long time ago. We expect resistance to be relinquished, the counter-siege to collapse, when our interpretation has enabled the ego to recognize it. With what impulses are we able to work in such a case? In the first place, the patient's desire to become well, which has led him to accommodate himself to co-operate with us in the task of the cure; in the second place, the help of his intelligence, which is supported by the interpretation we offer him. There is no doubt that after we have made clear to him what he may expect, the patient's intelligence can identify resistances, and find their translation into the suppressions more readily. If I say to you, "Look up into the sky, you can see a balloon there," you will find it more readily than if I had just asked you to look up to see whether you could discover anything. And unless the student who for the first time works with a microscope is told by his teacher what he may look for, he will not see anything, even if it is present and quite visible.

And now for the fact! In a large number of forms of nervous illness, in hysteria, conditions of anxiety and compulsion neuroses, one hypothesis is correct. By finding the suppression, revealing resistance, interpreting the thing suppressed, we really succeed in solving the problem, in overcoming resistance, in removing suppression, in transforming the unconscious into the conscious. While doing this we gain the clearest impression of the violent struggle that takes place in the patient's soul for the subjugation of resistance--a normal psychological struggle, in one psychic sphere between the motives that wish to maintain the counter-siege and those which are willing to give it up. The former are the old motives that at one time effected suppression; among the latter are those that have recently entered the conflict, to decide it, we trust, in the sense we favor. We have succeeded in reviving the old conflict of the suppression, in reopening the case that had already been decided. The new material we contribute consists in the first place of the warning, that the former solution of the conflict had led to illness, and the promise that another will pave the way to health; secondly, the powerful change of all conditions since the time of that first rejection. At that time the ego had been weak, infantile and may have had reason to denounce the claims of the libido as if they were dangerous. Today it is strong, experienced and is supported by the assistance of the physician. And so we may expect to guide the revived conflict to a better issue than a suppression, and in hysteria, fear and compulsion neuroses, as I have said before, success justifies our claims.

There are other forms of illness, however, in which our therapeutic procedure never is successful, even though the causal conditions are similar. Though this may be characterized topically in a different way, in them there was also an original conflict between the ego and libido, which led to suppression. Here, too, it is possible to discover the occasions when suppressions occurred in the life of the patient. We employ the same procedure, are prepared to furnish the same promises, give the same kind of help. We again present to the patient the connections we expect him to discover, and we have in our favor the same interval in time between the treatment and these suppressions favoring a solution of the conflict; yet in spite of these conditions, we are not able to overcome the resistance, or to remove the suppression. These patients, suffering from paranoia, melancholia, and dementia praecox, remain untouched on the whole, and proof against psychoanalytic therapy. What is the reason for this? It is not lack of intelligence; we require, of course, a certain amount of intellectual ability in our patients; but those suffering from paranoia, for instance, who effect such subtle combinations of facts, certainly are not in want of it. Nor can we say that other motive forces are lacking. Patients suffering from melancholia, in contrast to those afflicted with paranoia, are profoundly conscious of being ill, of suffering greatly, but they are not more accessible. Here we are confronted with a fact we do not understand, which bids us doubt if we have really understood all the conditions of success in other neuroses.

In the further consideration of our dealings with hysterical and compulsion neurotics we soon meet with a second fact, for which we were not at all prepared. After a while we notice that these patients behave toward us in a very peculiar way. We thought that we had accounted for all the motive forces that could come into play, that we had rationalized the relation between the patient and ourselves until it could be as readily surveyed as an example in arithmetic, and yet some force begins to make itself felt that we had not considered in our calculations. This unexpected something is highly variable. I shall first describe those of its manifestations which occur frequently and are easy to understand.

We see our patient, who should be occupying himself only with finding a way out of his painful conflicts, become especially interested in the person of the physician. Everything connected with this person is more important to him than his own affairs and diverts him from his illness. Dealings with him are very pleasant for the time being. He is especially cordial, seeks to show his gratitude wherever he can, and manifests refinements and merits of character that we hardly had expected to find. The physician forms a very favorable opinion of the patient and praises the happy chance that permitted him to render assistance to so admirable a personality. If the physician has the opportunity of speaking to the relatives of the patient he hears with pleasure that this esteem is returned. At home the patient never tires of praising the physician, of prizing advantages which he constantly discovers. "He adores you, he trusts you blindly, everything you say is a revelation to him," the relatives say. Here and there one of the chorus observes more keenly and remarks, "It is a positive bore to hear him talk, he speaks only of you; you are his only subject of conversation."

Let us hope that the physician is modest enough to ascribe the patient's estimation of his personality to the encouragement that has been offered him and to the widening of his intellectual horizon through the astounding and liberating revelations which the cure entails. Under these conditions analysis progressed splendidly. The patient understands every suggestion, he concentrates on the problems that the treatment requires him to solve, reminiscences and ideas flood his mind. The physician is surprised by the certainty and depth of these interpretations and notices with satisfaction how willingly the sick man receives the new psychological facts which are so hotly contested by the healthy persons in the world outside. An objective improvement in the condition of the patient, universally admitted, goes hand in hand with this harmonious relation of the physician to the patient under analysis.

But we cannot always expect to have fair weather. There comes a day when the storm breaks. Difficulties turn up in the treatment. The patient asserts that he can think of nothing more. We are under the impression that he is no longer interested in the work, that he lightly passes over the injunction that, heedless of any critical impulse, he must say everything that comes to his mind. He behaves as though he were not under treatment, as though he had closed no agreement with the physician; he is clearly obsessed by something he does not wish to divulge. This is a situation which endangers the success of the treatment. We are distinctly confronted with a tremendous resistance. What can have happened?

Provided we are able once more to clarify the situation, we recognize the cause of the disturbance to have been intense affectionate emotions, which the patient has transferred to the physician. This is certainly not justified either by the behavior of the physician or by the relations the treatment has created. The way in which this affection is manifested and the goals it strives for will depend on the personal affiliations of the two parties involved. When we have here a young girl and a man who is still young we receive the impression of normal love. We find it quite natural that a girl should fall in love with a man with whom she is alone a great deal, with whom she discusses intimate matters, who appears to her in the advantageous light of a beneficent adviser. In this we probably overlook the fact that in a neurotic girl we should rather presuppose a derangement in her capacity to love. The more the personal relations of physician and patient diverge from this hypothetical case, the more are we puzzled to find the same emotional relation over and over again. We can understand that a young woman, unhappy in her marriage, develops a serious passion for her physician, who is still free; that she is ready to seek divorce in order to belong to him, or even does not hesitate to enter into a secret love affair, in case the conventional obstacles loom too large. Similar things are known to occur outside of psychoanalysis. Under these circumstances, however, we are surprised to hear women and girls make remarks that reveal a certain attitude toward the problems of the cure. They always knew that love alone could cure them, and from the very beginning of their treatment they anticipated that this relationship would yield them what life had denied. This hope alone has spurred them on to exert themselves during the treatments, to overcome all the difficulties in communicating their disclosures. We add on our own account--"and to understand so easily everything that is generally most difficult to believe." But we are amazed by such a confession; it upsets our calculations completely. Can it be that we have omitted the most important factor from our hypothesis?

And really, the more experience we gain, the less we can deny this correction, which shames our knowledge. The first few times we could still believe that the analytic cure had met with an accidental interruption, not inherent to its purpose. But when this affectionate relation between physician and patient occurs regularly in every new case, under the most unfavorable conditions and even under grotesque circumstances; when it occurs in the case of the elderly woman, and is directed toward the grey-beard, or to one in whom, according to our judgment, no seductive attractions exist, we must abandon the idea of an accidental interruption, and realize that we are dealing with a phenomenon which is closely interwoven with the nature of the illness.

The new fact which we recognize unwillingly is termed _transference_. We mean a transference of emotions to the person of the physician, because we do not believe that the situation of the cure justifies the genesis of such feelings. We rather surmise that this readiness toward emotion originated elsewhere, that it was prepared within the patient, and that the opportunity given by analytic treatment caused it to be transferred to the person of the physician. Transference may occur as a stormy demand for love or in a more moderate form; in place of the desire to be his mistress, the young girl may wish to be adopted as the favored daughter of the old man, the libidinous desire may be toned down to a proposal of inseparable but ideal and platonic friendship. Some women understand how to sublimate the transference, how to modify it until it attains a kind of fitness for existence; others manifest it in its original, crude and generally impossible form. But fundamentally it is always the same and can never conceal that its origin is derived from the same source.

Before we ask ourselves how we can accommodate this new fact, we must first complete its description. What happens in the case of male patients? Here we might hope to escape the troublesome infusion of sex difference and sex attraction. But the answer is pretty much the same as with women patients. The same relation to the physician, the same over-estimation of his qualities, the same abandon of interest toward his affairs, the same jealousy toward all those who are close to him. The sublimated forms of transference are more frequent in men, the direct sexual demand is rarer to the extent to which manifest homosexuality retreats before the methods by which these instinct components may be utilized. In his male patients more often than in his women patients, the physician observes a manifestation of transference which at first sight seems to contradict everything previously described: a hostile or _negative_ transference.

In the first place, let us realize that the transference occurs in the patient at the very outset of the treatment and is, for a time, the strongest impetus to work. We do not feel it and need not heed it as long as it acts to the advantage of the analysis we are working out together. When it turns into resistance, however, we must pay attention to it. Then we discover that two contrasting conditions have changed their relation to the treatment. In the first place there is the development of an affectionate inclination, clearly revealing the signs of its origin in sexual desire which becomes so strong as to awaken an inner resistance against it. Secondly, there are the hostile instead of the tender impulses. The hostile feelings generally appear later than the affectionate impulses or succeed them. When they occur simultaneously they exemplify the ambivalence of emotions which exists in most of the intimate relations between all persons. The hostile feelings connote an emotional attachment just as do the affectionate impulses, just as defiance signifies dependence as well as does obedience, although the activities they call out are opposed. We cannot doubt but that the hostile feelings toward the physician deserve the name of transference, since the situation which the treatment creates certainly could not give sufficient cause for their origin. This necessary interpretation of negative transference assures us that we have not mistaken the positive or affectionate emotions that we have similarly named.

The origin of this transference, the difficulties it causes us, the means of overcoming it, the use we finally extract from it--these matters must be dealt with in the technical instruction of psychoanalysis, and can only be touched upon here. It is out of the question to yield to those demands of the patient which take root from the transference, while it would be unkind to reject them brusquely or even indignantly. We overcome transference by proving to the patient that his feelings do not originate in the present situation, and are not intended for the person of the physician, but merely repeat what happened to him at some former time. In this way we force him to transform his repetition into a recollection. And so transference, which whether it be hostile or affectionate, seems in every case to be the greatest menace of the cure, really becomes its most effectual tool, which aids in opening the locked compartments of the psychic life. But I should like to tell you something which will help you to overcome the astonishment you must feel at this unexpected phenomenon. We must not forget that this illness of the patient which we have undertaken to analyze is not consummated or, as it were, congealed; rather it is something that continues its development like a living being. The beginning of the treatment does not end this development. When the cure, however, first has taken possession of the patient, the productivity of the illness in this new phase is concentrated entirely on one aspect: the relation of the patient to the physician. And so transference may be compared to the cambrium layer between the wood and the bark of a tree, from which the formation of new tissues and the growth of the trunk proceed at the same time. When the transference has once attained this significance the work upon the recollections of the patient recedes into the background. At that point it is correct to say that we are no longer concerned with the patient's former illness, but with a newly created, transformed neurosis, in place of the former. We followed up this new edition of an old condition from the very beginning, we saw it originate and grow; hence we understand it especially well, because we ourselves are the center of it, its object. All the symptoms of the patient have lost their original meaning and have adapted themselves to a new meaning, which is determined by its relation to transference. Or, only such symptoms as are capable of this transformation have persisted. The control of this new, artificial neurosis coincides with the removal of the illness for which treatment was sought in the first place, namely, with the solution of our therapeutic problem. The human being who, by means of his relations to the physician, has freed himself from the influences of suppressed impulses, becomes and stays free in his individual life, when the influence of the physician is subsequently removed.

Transference has attained extraordinary significance, has become the centre of the cure, in the conditions of hysteria, anxiety and compulsion neuroses. Their conditions therefore are properly included under the term transference neuroses. Whoever in his analytic experience has come into contact with the existence of transference can no longer doubt the character of those suppressed impulses that express themselves in the symptoms of these neuroses and requires no stronger proof of their libidinous character. We may say that our conviction that the meaning of the symptoms is substituted libidinous gratification was finally confirmed by this explanation of transference.

Now we have every reason to correct our former dynamic conception of the healing process, and to bring it into harmony with our new discernment. If the patient is to fight the normal conflict that our analysis has revealed against the suppressions, he requires a tremendous impetus to influence the desirable decision which will lead him back to health. Otherwise he might decide for a repetition of the former issue and allow those factors which have been admitted to consciousness to slip back again into suppression. The deciding vote in this conflict is not given by his intellectual penetration--which is neither strong nor free enough for such an achievement--but only by his relation to the physician. Inasmuch as his transference carries a positive sign, it invests the physician with authority and is converted into faith for his communications and conceptions. Without transference of this sort, or without a negative transfer, he would not even listen to the physician and to his arguments. Faith repeats the history of its own origin; it is a derivative of love and at first requires no arguments. When they are offered by a beloved person, arguments may later be admitted and subjected to critical reflection. Arguments without such support avail nothing, and never mean anything in life to most persons. Man's intellect is accessible only in so far as he is capable of libidinous occupation with an object, and accordingly we have good ground to recognize and to fear the limit of the patient's capacity for being influenced by even the best analytical technique, namely, the extent of his narcism.

The capacity for directing libidinous occupation with objects towards persons as well must also be accorded to all normal persons. The inclination to transference on the part of the neurotic we have mentioned, is only an extraordinary heightening of this common characteristic. It would be strange indeed if a human trait so wide-spread and significant had never been noticed and turned to account. But that has been done. Bernheim, with unerring perspicacity, based his theory of hypnotic manifestations on the statement that all persons are open to suggestion in some way or other. Suggestibility in his sense is nothing more than an inclination to transference, bounded so narrowly that there is no room for any negative transfer. But Bernheim could never define suggestion or its origin. For him it was a fundamental fact, and he could never tell us anything regarding its origin. He did not recognize the dependence of suggestibility upon sexuality and the activity of the libido. We, on the other hand, must realize that we have excluded hypnosis from our technique of neurosis only to rediscover suggestion in the shape of transference.

But now I shall pause and let you put in a word. I see that an objection is looming so large within you that if it were not voiced you would be unable to listen to me. "So at last you confess that like the hypnotists, you work with the aid of suggestion. That is what we have been thinking for a long time. But why choose the detour over reminiscences of the past, revealing of the unconscious, interpretation and retranslation of distortions, the tremendous expenditure of time and money, if the only efficacious thing is suggestion? Why do you not use suggestion directly against symptoms, as the others do, the honest hypnotists? And if, furthermore, you offer the excuse that by going your way you have made numerous psychological discoveries which are not revealed by direct suggestion, who shall vouch for their accuracy? Are not they, too, a result of suggestion, that is to say, of unintentional suggestion? Can you not, in this realm also, thrust upon the patient whatever you wish and whatever you think is so?"

Your objections are uncommonly interesting, and must be answered. But I cannot do it now for lack of time. Till the next time, then. You shall see, I shall be accountable to you. Today I shall only end what I have begun. I promised to explain, with the aid of the factor of transference, why our therapeutic efforts have not met with success in narcistic neuroses.

This I can do in a few words and you will see how simply the riddle can be solved, how well everything harmonizes. Observation shows that persons suffering from narcistic neuroses have no capacity for transference, or only insufficient remains of it. They reject the physician not with hostility, but with indifference. That is why he cannot influence them. His words leave them cold, make no impression, and so the mechanism of the healing process, which we are able to set in motion elsewhere, the renewal of the pathogenic conflict and the overcoming of the resistance to the suppression, cannot be reproduced in them. They remain as they are. Frequently they are known to attempt a cure on their own account, and pathological results have ensued. We are powerless before them.

On the basis of our clinical impressions of these patients, we asserted that in their case libidinous occupation with objects must have been abandoned, and object-libido must have been transformed into ego-libido. On the strength of this characteristic we had separated it from the first group of neurotics (hysteria, anxiety and compulsion neuroses). Their behavior under attempts at therapy confirms this supposition. They show no neurosis. They, therefore, are inaccessible to our efforts and we cannot cure them.

TWENTY-EIGHTH LECTURE

GENERAL THEORY OF THE NEUROSES

_Analytical Therapy_

You know our subject for today. You asked me why we do not make use of direct suggestion in psychoanalytic therapy, when we admit that our influence depends substantially upon transference, i.e., suggestion, for you have come to doubt whether or not we can answer for the objectivity of our psychological discoveries in the face of such a predominance of suggestion. I promised to give you a comprehensive answer.

Direct suggestion is suggestion directed against the expression of the symptoms, a struggle between your authority and the motives of the disease. You pay no attention during this process to the motives, but only demand of the patient that he suppress their expression in symptoms. So it makes no difference in principle whether you hypnotize the patient or not. Bernheim, with his usual perspicacity, asserted that suggestion is the essential phenomenon underlying hypnotism, that hypnotism itself is already a result of suggestion, is a suggested condition. Bernheim was especially fond of practising suggestion upon a person in the waking state, and could achieve the same results as with suggestion under hypnosis.

What shall I deal with first, the evidence of experience or theoretic considerations?

Let us begin with our experiences. I was a pupil of Bernheim's, whom I sought out in Nancy in 1889, and whose book on suggestion I translated into German. For years I practised hypnotic treatment, at first by means of prohibitory suggestions alone, and later by this method in combination with investigation of the patient after the manner of Breuer. So I can speak from experience about the results of hypnotic or suggestive therapy. If we judge Bernheim's method according to the old doctor's password that an ideal therapy must be rapid, reliable and not unpleasant for the patient, we find it fulfills at least two of these requirements. It can be carried out much more rapidly, indescribably more rapidly than the analytic method, and it brings the patient neither trouble nor discomfort. In the long run it becomes monotonous for the physician, since each case is exactly the same; continually forbidding the existence of the most diverse symptoms under the same ceremonial, without being able to grasp anything of their meaning or their significance. It is second-rate work, not scientific activity, and reminiscent of magic, conjuring and hocus-pocus; yet in the face of the interest of the patient this cannot be considered. The third requisite, however, was lacking. The procedure was in no way reliable. It might succeed in one case, and fail with the next; sometimes much was accomplished, at other times little, one knew not why. Worse than this capriciousness of the technique was the lack of permanency of the results. After a short time, when the patient was again heard from, the old malady had reappeared, or it had been replaced by a new malady. We could start in again to hypnotize. At the same time we had been warned by those who were experienced that by frequent repetitions of hypnotism we would deprive the patient of his self-reliance and accustom him to this therapy as though it were a narcotic. Granted that we did occasionally succeed as well as one could wish; with slight trouble we achieved complete and permanent results. But the conditions for such a favorable outcome remained unknown. I have had it happen that an aggravated condition which I had succeeded in clearing up completely by a short hypnotic treatment returned unchanged when the patient became angry and arbitrarily developed ill feeling against me. After a reconciliation I was able to remove the malady anew and with even greater thoroughness, yet when she became hostile to me a second time it returned again. Another time a patient whom I had repeatedly helped through nervous conditions by hypnosis, during the treatment of an especially stubborn attack, suddenly threw her arms around my neck. This made it necessary to consider the question, whether one wanted to or not, of the nature and source of the suggestive authority.

So much for experience. It shows us that in renouncing direct suggestion we have given up nothing that is not replaceable. Now let us add a few further considerations. The practice of hypnotic therapy demands only a slight amount of work of the patient as well as of the physician. This therapy fits in perfectly with the estimation of neuroses to which the majority of physicians subscribe. The physician says to the neurotic, "There is nothing the matter with you; you are only nervous, and so I can blow away all your difficulties with a few words in a few minutes." But it is contrary to our dynamic conceptions that we should be able to move a great weight by an inconsiderable force, by attacking it directly and without the aid of appropriate preparations. So far as conditions are comparable, experience shows us that this performance does not succeed with the neurotic. But I know this argument is not unassailable; there are also "redeeming features."

In the light of the knowledge we have gained from psychoanalysis we can describe the difference between hypnotic and psychoanalytic suggestion as follows: Hypnotic therapy seeks to hide something in psychic life, and to gloss it over; analytic therapy seeks to lay it bare and to remove it. The first method works cosmetically, the other surgically. The first uses suggestion in order to prevent the appearance of the symptoms, it strengthens suppression, but leaves unchanged all other processes that have led to symptom development. Analytic therapy attacks the illness closer to its sources, namely in the conflicts out of which the symptoms have emerged, it makes use of suggestion to change the solution of these conflicts. Hypnotic therapy leaves the patient inactive and unchanged, and therefore without resistance to every new occasion for disease. Analytic treatment places upon the physician, as well as upon the patient, a difficult responsibility; the inner resistance of the patient must be abolished. The psychic life of the patient is permanently changed by overcoming these resistances, it is lifted upon a higher plane of development and remains protected against new possibilities of disease. The work of overcoming resistance is the fundamental task of the analytic cure. The patient, however, must take it on himself to accomplish this, while the physician, with the aid of suggestion, makes it possible for him to do so. The suggestion works in the nature of an _education_. We are therefore justified in saying that analytic treatment is a sort of _after-education_.

I hope I have made it clear to you wherein our technique of using suggestion differs therapeutically from the only use possible in hypnotic therapy. With your knowledge of the relation between suggestion and transference you will readily understand the capriciousness of hypnotic therapy which attracted our attention, and you will see why, on the other hand, analytic suggestion can be relied upon to its limits. In hypnosis we depend on the condition of the patient's capacity for transference, yet we are unable to exert any influence on this capacity. The transference of the subject may be negative, or, as is most frequent, ambivalent; the patient may have protected himself against suggestion by very special adjustments, yet we are unable to learn anything concerning them. In psychoanalysis we work with the transference itself, we do away with the forces opposing it, prepare the instrument with which we are to work. So it becomes possible to derive entirely new uses from the power of suggestion; we are able to control it, the patient does not work himself into any state of mind he pleases, but in so far as we are able to influence him at all, we can guide the suggestion.

Now you will say, regardless of whether we call the driving force of our analysis transference or suggestion, there is still the danger that through our influence on the patient the objective certainty of our discoveries becomes doubtful. That which becomes a benefit to therapy works harm to the investigation. This objection is most often raised against psychoanalysis, and it must be admitted that even if it does not hit the mark, it cannot be waved aside as stupid. But if it were justified, psychoanalysis would be nothing more than an extraordinarily well disguised and especially workable kind of treatment by suggestion, and we may lay little weight upon all its assertions concerning the influences of life, psychic dynamics, and the unconscious. This is in fact the opinion held by our opponents; we are supposed especially to have "balked into" the patients everything that supports the importance of sexual experiences, and often the experiences themselves, after the combinations themselves have grown up in our degenerate imaginations. We can refute these attacks most easily by calling on the evidence of experience rather than by resorting to theory. Anyone who has himself performed a psychoanalysis has been able to convince himself innumerable times that it is impossible thus to suggest anything to the patient. There is no difficulty, of course, in making the patient a disciple of any one theory, and thus causing him to share the possible error of the physician. With respect to this he behaves just like any other person, like a student, but he has influenced only his intelligence, not his disease. The solving of his conflicts and the overcoming of his resistances succeeds only if we have aroused in him representations of such expectations as can agree with reality. What was inapplicable in the assumptions of the physician falls away during the course of the analysis; it must be withdrawn and replaced by something more nearly correct. By employing a careful technique we seek to prevent the occurrence of temporary results arising out of suggestion, yet there is no harm if such temporary results occur, for we are never satisfied with early successes. We do not consider the analysis finished until all the obscurities of the case are cleared up, all amnestic gaps filled out and the occasions which originally called out the suppressions discovered. We see in results that are achieved too quickly a hindrance rather than a furtherance of analytic work and repeatedly we undo these results again by purposely breaking up the transference upon which they rest. Fundamentally it is this feature which distinguishes analytical treatment from the purely suggestive technique and frees analytic results from the suspicion of having been suggested. Under every other suggestive treatment the transference itself is most carefully upheld and the influence left unquestioned; in analytic treatment, however, the transference becomes the subject of treatment and is subject to criticism in whatever form it may appear. At the end of an analytic cure the transference itself must be abolished; therefore the effect of the treatment, whether positive or negative, must be founded not upon suggestion but upon the overcoming of inner resistances, upon the inner change achieved in the patient, which the aid of suggestion has made possible.

Presumably the creation of the separate suggestions is counteracted, in the course of the cure, by our being continually forced to attack resistances which have the ability to change themselves into negative (hostile) transferences. Furthermore, let me call your attention to the fact that a large number of results of analysis, otherwise perhaps subject to the suspicion that they are products of suggestion, can be confirmed from other unquestionable sources. As authoritative witnesses in this case we refer to the testimony of dements and paranoiacs, who are, naturally far removed from any suspicion of suggestive influence. Whatever these patients can tell us about symbolic translations and phantasies which have forced their way into their consciousness agrees faithfully with the results of our investigations upon the unconscious of transference-neurotics, and this gives added weight to the objective correctness of our interpretations which are so often doubted. I believe you will not go wrong if you give your confidence to analysis with reference to these factors.

We now want to complete our statement concerning the mechanism of healing, by including it within the formulae of the libido theory. The neurotic is incapable both of enjoyment and work; first, because his libido is not directed toward any real object, and second because he must use up a great deal of his former energy to keep his libido suppressed and to arm himself against its attacks. He would become well if there could be an end to the conflict between his ego and his libido, and if his ego could again have the libido at its disposal. The task of therapy, therefore, consists of freeing the libido from its present bonds, which have estranged it from the ego, and furthermore to bring it once more into the service of the ego. Where is the libido of the neurotics? It is easy to find; it is bound to the symptoms which at that time furnish it with the only available substitute satisfaction. We have to become master of the symptoms, and abolish them, which is of course exactly what the patient asks us to do. To abolish the symptoms it becomes necessary to go back to their origin, to renew the conflict out of which they emerged, but this time with the help of motive forces that were originally not available, to guide it toward a new solution. This revision of the process of suppression can be accomplished only in part by following the traces in memory of the occurrences which led to the suppression. The decisive part of the cure is accomplished by means of the relationship to the physician, the transference, by means of which new editions of the old conflict are created. Under this situation the patient would like to behave as he had behaved originally, but by summoning all his available psychic power we compel him to reach a different decision. Transference, then, becomes the battlefield on which all the contending forces are to meet.

The full strength of the libido, as well as the entire resistance against it, is concentrated in this relationship to the physician; so it is inevitable that the symptoms of the libido should be laid bare. In place of his original disturbance the patient manifests the artificially constructed disturbance of transference; in place of heterogeneous unreal objects for the libido you now have only the person of the physician, a single object, which, however, is also fantastic. The new struggle over this object is, however, raised to the highest psychic level with the aid of the physician's suggestions, and proceeds as a normal psychic conflict. By avoiding a new suppression the estrangement between the ego and the libido comes to an end, the psychic unity of the personality is restored. When the libido again becomes detached from the temporary object of the physician it cannot return to its former objects, but is now at the disposal of the ego. The forces we have overcome in the task of therapy are on the one hand the aversion of the ego for certain directions of the libido, which had expressed itself as a tendency to suppression, and on the other hand the tenacity of the libido, which is loathe to leave an object which it has once occupied.

Accordingly the work of therapy falls into two phases: first, all the libido is forced from the symptoms into the transference, and concentrated there; secondly, the struggle over this new object is carried on and the libido set free. The decisive change for the better in this renewed conflict is the throwing out of the suppression, so that the libido cannot this time again escape the ego by fleeing into the unconscious. This is accomplished by the change in the ego under the influence of the physician's suggestion. In the course of the work of interpretation, which translates unconscious into conscious, the ego grows at the expense of the unconscious; it learns forgiveness toward the libido, and becomes inclined to permit some sort of satisfaction for it. The ego's timidity in the face of the demands of the libido is now lessened by the prospect of occupying some of the libido through sublimation. The more the processes of the treatment correspond to this theoretic description the greater will be the success of psychoanalytic therapy. It is limited by the lack of mobility of the libido, which can stand in the way of releasing its objects, and by the obstinate narcism which will not permit the object-transference to effect more than just so much. Perhaps we shall obtain further light on the dynamics of the healing process by the remark that we are able to gather up the entire libido which has become withdrawn from the control of the ego by drawing a part of it to ourselves in the process of transference.