PART III GENERAL THEORY OF THE NEUROSES (continued 5)

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

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

As with paranoia, so also with melancholia (under which, by the way, very different clinical types are classified), it has been possible to obtain a glimpse into the inner structure of the disorder. We have perceived that the self-reproaches with which these sufferers torment themselves so mercilessly actually relate to another person, to the sexual object they have lost or whom they have ceased to value on account of some fault. From this we concluded that the melancholic has indeed withdrawn his Libido from the object, but that by a process which we must 357call ‘narcissistic identification’ he has set up the object within the Ego itself, projected it on to the Ego. I can only give you a descriptive representation of this process, and not one expressed in terms of topography and dynamics. The Ego itself is then treated as though it were the abandoned object; it suffers all the revengeful and aggressive treatment which is designed for the object. The suicidal impulses of melancholics also become more intelligible on the supposition that the bitterness felt by the diseased mind concerns the Ego itself at the same time as, and equally with, the loved and hated object. In melancholia, as in the other narcissistic disorders, a feature of the emotional life which, after Bleuler, we are accustomed to call ambivalence comes markedly to the fore; by this we mean a directing of antithetical feelings (affectionate and hostile) towards the same person. It is unfortunate that I have not been able to say more about ambivalence in these lectures.

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

I also told you that by analysis of the narcissistic disorders we hoped to gain some knowledge of the composition of the Ego and of its structure out of various faculties and elements. We have made a beginning towards this at one point. From analysis of the delusion of observation we have come to the conclusion that in the Ego there exists a faculty that incessantly watches, criticizes, and compares, and in this way is set against the other part of the Ego. In our opinion, therefore, the patient reveals a truth which has not been appreciated as such when he complains that at every step he is spied upon and observed, that his every thought is known and examined. He has erred only in attributing this disagreeable power to something outside himself and foreign to him; he perceives within his Ego the rule of a faculty which measures his actual Ego and all his activities by an Ego-ideal, which he has created for himself in the course of his development. 358We also infer that he created this ideal for the purpose of recovering thereby the self-satisfaction bound up with the primary infantile narcissism, which since those days has suffered so many shocks and mortifications. We recognize in this self-criticizing faculty the Ego-censorship, the ‘conscience’; it is the same censorship as that exercised at night upon dreams, from which the repressions against inadmissible wish-excitations proceed. When this faculty disintegrates in the delusion of being observed, we are able to detect its origin and that it arose out of the influence of parents and those who trained the child, together with his social surroundings, by a process of identification with certain of these persons who were taken as a model.

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

359Let me return for a moment to anxiety, in order to throw light upon the one obscure point we left there. We said that the relation between anxiety and Libido, otherwise so well defined, is with difficulty harmonized with the almost indisputable assumption that real anxiety in the face of danger is the expression of the self-preservative instincts. But how if the anxiety-affect is provided, not by self-interest on the part of the Ego-instincts, but by the Ego-Libido? The condition of anxiety is after all invariably detrimental; its disadvantage becomes conspicuous when it reaches an intense degree. It then interferes with the action that alone would be expedient and would serve the purposes of self-preservation, whether it be flight or self-defence. Therefore if we ascribe the affective component of real anxiety to the Ego-Libido, and the action undertaken to the Ego-preservative instincts, every theoretical difficulty will be overcome. You will hardly maintain seriously that we run away because we perceive fear? No, we perceive fear and we take to flight, out of the common impulse that is roused by the perception of danger. Men who have survived experiences of imminent danger to life tell us that they did not perceive any fear, that they simply acted—for instance, pointed their gun at the oncoming beast—which was undoubtedly the best thing they could do.

360

TWENTY-SEVENTH LECTURE TRANSFERENCE

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

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

Think for a moment! You have already learnt everything essential, from the conditions by which illness is provoked to all the factors which take effect within the diseased mind. Where is the opening in all this for therapeutic influence? First of all there is the hereditary disposition,—we do not often mention it because it is so strongly emphasized in other quarters and we have nothing new to say about it. But do not suppose that we underestimate it; as practitioners we are well aware of its power. In any event we can do nothing to change it; for us also it is a fixed datum in the problem, which sets a limit to our efforts. Next, there is the influence of the experiences of early childhood, which we are accustomed in analysis to rank as very important; they belong to the past, we cannot undo them. Then there is all that unhappiness in life which we have included under ‘privation in reality,’ from which all the absence of love in life proceeds—namely, poverty, family strife, mistaken choice in marriage, 361unfavourable social conditions, and the severity of the demands by which moral convention oppresses the individual. There is indeed a wide opening for a very effective treatment in all this; but it would have to follow the course of the dispensations of Kaiser Joseph in the Viennese legend—the benevolent despotism of a potentate before whose will men bow and difficulties disappear! But who are we that we can exert such beneficence as a therapeutic measure? Poor as we are and without influence socially, with our living to earn by our medical practice, we are not even in a position to extend our efforts to penniless folk, as other physicians with other methods can do; our treatment takes too much time and labour for that. But perhaps you are still clinging on to one of the factors put forward, and believe you see an opening for our influence there. If the conventional restrictions imposed by society have had a part in the privations forced upon the patient, the treatment could give him the courage and even directly advise him to defy these obstacles, and to seize satisfactions and health for himself at the cost of failing to achieve an ideal which, though highly esteemed, is after all often set at naught by the world. Health is to be won by “free living,” then. There would be this blot upon analysis, to be sure, that it would not be serving general morality; what it gave to the individual it would take from the rest of the world.

But now, who has given you such a false impression of analysis? It is out of the question that part of the analytic treatment should consist of advice to “live freely”—if for no other reason because we ourselves tell you that a stubborn conflict is going on in the patient between libidinal desires and sexual repression, between sensual and ascetic tendencies. This conflict is not resolved by helping one side to win a victory over the other. It is true we see that in neurotics asceticism has gained the day; the result of which is that the suppressed sexual impulses have found a vent for themselves in the symptoms. If we were to make victory possible to the sensual side instead, the disregarded forces repressing sexuality would have to indemnify themselves by symptoms. Neither of these measures will succeed in ending the inner conflict; one side in either event will remain unsatisfied. There are but few cases in which the conflict is so unstable that a factor like medical advice can have any effect upon it, and these cases do not really require analytic treatment. People who can be so easily influenced by physicians would have found their own way to that solution without this influence. After all, you know that a young man living in abstinence who makes up his mind to illicit sexual intercourse, or an unsatisfied wife who seeks 362compensation with a lover, does not as a rule wait for the permission of a physician, still less of an analyst, to do so.

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

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

You must not be led away by my eagerness to defend myself against the accusation that in analytic treatment neurotics are encouraged to “live a free life” and conclude from it that we influence them in favour of conventional morality. That is at least as far removed from our purpose as the other. We are not reformers, it is true; we are merely observers; but we cannot avoid observing with critical eyes, and we have found it impossible to give our support to conventional sexual morality or to approve highly of the means by which society attempts to arrange the practical problems of sexuality in life. We can demonstrate with ease that what the world calls its code of morals demands more sacrifices than it is worth, and that its behaviour is neither dictated by honesty nor instituted with wisdom. We do not absolve our patients from listening to these criticisms; we accustom 363them to an unprejudiced consideration of sexual matters like all other matters; and if after they have become independent by the effect of the treatment they choose some intermediate course between unrestrained sexual licence and unconditional asceticism, our conscience is not burdened whatever the outcome. We say to ourselves that anyone who has successfully undergone the training of learning and recognizing the truth about himself is henceforth strengthened against the dangers of immorality, even if his standard of morality should in some respect deviate from the common one. Incidentally, we must beware of overestimating the importance of abstinence in affecting neurosis; only a minority of pathogenic situations due to privation and the subsequent accumulation of Libido thereby induced can be relieved by the kind of sexual intercourse that is procurable without any difficulty.

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

The aim of our efforts may be expressed in various formulas—making conscious the unconscious, removing the repressions, filling in the gaps in memory; they all amount to the same thing. But perhaps you are dissatisfied with this declaration; you imagined the recovery of a nervous person rather differently, that after he had been subjected to the laborious process of psycho-analysis he would emerge a different person altogether, and then you hear that the whole thing only amounts to his having a little less that is unconscious and a little more that is conscious in him than before. Well, you probably do not appreciate the importance of an inner change of this kind. A neurotic who has been cured has really become a different person, although at bottom of 364course he remains the same—that is, he has become his best self, what he would have been under the most favourable conditions. That, however, is a great deal. Then when you hear of all that has to be done, of the tremendous exertion required to carry out this apparently trifling change in his mental life, the significance attached to these differences between the various mental levels will appear more comprehensible to you.

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

What then have we to do in order to bring what is unconscious in the patient into consciousness? At one time we thought that would be very simple; all we need do would be to identify this unconscious matter and then tell the patient what it was. However, we know already that that was a short-sighted mistake. Our knowledge of what is unconscious in him is not equivalent to his knowledge of it; when we tell him what we know he does not assimilate it in place of his own unconscious thoughts, but alongside of them, and very little has been changed. We have rather to regard this unconscious material topographically; we have to look for it in his memory at the actual spot where the repression of it originally ensued. This repression must be removed, and 365then the substitution of conscious thought for unconscious thought can be effected straightaway. How is a repression such as this to be removed? Our work enters upon a second phase here; first, the discovery of the repression, and then the removal of the resistance which maintains this repression.

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

And now for the fact! In quite a number of the various forms of nervous illness, in the hysterias, anxiety conditions, obsessional neuroses, our hypothesis proves sound. By seeking out the repression in this way, discovering the resistances, indicating the repressed, it is actually possible to accomplish the task, to overcome the resistances, to break down the repression, and to change something unconscious into something conscious. 366As we do this we get a vivid impression of how, as each individual resistance is being mastered, a violent battle goes on in the soul of the patient—a normal mental struggle between two tendencies on the same ground, between the motives striving to maintain the counter-charge and those which are ready to abolish it. The first of these are the old motives which originally erected the repression; among the second are found new ones more recently acquired, which it is hoped will decide the conflict in our favour. We have succeeded in revivifying the old battle of the repression again, in bringing the issue, so long ago decided, up for revision again. The new contribution we make to it lies, first of all, in demonstrating that the original solution led to illness and in promising that a different one would pave the way to health, and secondly, in pointing out that the circumstances have all changed immensely since the time of that original repudiation of these impulses. Then, the Ego was weak, infantile, and perhaps had reason to shrink with horror from the claims of the Libido as being dangerous to it. To-day it is strong and experienced and moreover has a helper at hand in the physician. So we may expect to lead the revived conflict through to a better outcome than repression; and, as has been said, in hysteria, anxiety-neurosis, and the obsessional neurosis success in the main justifies our claims.

There are other forms of illness, however, with which our therapeutic treatment never is successful, in spite of the similarity of the conditions. In them also there was originally a conflict between Ego and Libido, leading to repression—although this conflict may be characterized by topographical differences from the conflict of the transference neuroses; in them too it is possible to trace out the point in the patient’s life at which the repressions occurred; we apply the same method, are ready to make the same assurances, offer the same assistance by telling the patient what to look out for; and here also the interval in time between the present and the point at which the repressions were established is all in favour of a better outcome of the conflict. And yet we cannot succeed in overcoming one resistance or in removing one of the repressions. These patients, paranoiacs, melancholics, and those suffering from dementia præcox, remain on the whole unaffected, proof against psycho-analytic treatment. What can be the cause of this? It is not due to lack of intelligence; a certain degree of intellectual capacity must naturally be stipulated for analysis, but there is no deficiency in this respect in, for instance, the very quick-witted deductive paranoiac. Nor are any of the other propelling forces regularly absent: melancholics, 367for instance, in contrast to paranoiacs, experience a very high degree of realization that they are ill and that their sufferings are due to this; but they are not on that account any more accessible to influence. In this we are confronted with a fact that we do not understand, and are therefore called upon to doubt whether we have really understood all the conditions of the success possible with the other neuroses.

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

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

We will hope that the physician is modest enough to ascribe the patient’s estimate of his value to the hopes of recovery which he has been able to offer to him, and to the widening in the patient’s intellectual horizon consequent upon the surprising revelations entailed by the treatment and their liberating influence. 368The analysis too makes splendid progress under these conditions, the patient understands the suggestions offered to him, concentrates upon the tasks appointed by the treatment, the material needed—his recollections and associations—is abundantly available; he astonishes the analyst by the sureness and accuracy of his interpretations, and the latter has only to observe with satisfaction how readily and willingly a sick man will accept all the new psychological ideas that are so hotly contested by the healthy in the world outside. A general improvement in the patient’s condition, objectively confirmed on all sides, also accompanies this harmonious relationship in the analysis.

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

If it is possible to clear up this state of things, the cause of the disturbance is found to consist in certain intense feelings of affection which the patient has transferred on to the physician, not accounted for by the latter’s behaviour nor by the relationship involved by the treatment. The form in which this affectionate feeling is expressed and the goal it seeks naturally depend upon the circumstances of the situation between the two persons. If one of them is a young girl and the other still a fairly young man, the impression received is that of normal love; it seems natural that a girl should fall in love with a man with whom she is much alone and can speak of very intimate things, and who is in the position of an adviser with authority—we shall probably overlook the fact that in a neurotic girl some disturbance of the capacity for love is rather to be expected. The farther removed the situation between the two persons is from this supposed example, the more unaccountable it is to find that nevertheless the same kind of feeling comes to light in other cases. It may be still comprehensible when a young woman who is unhappily married seems to be overwhelmed by a serious passion for her physician, if he is still unattached, and that she 369should be ready to seek a divorce and give herself to him, or, where circumstances would prevent this, to enter into a secret love-affair with him. That sort of thing, indeed, is known to occur outside psycho-analysis. But in this situation girls and women make the most astonishing confessions which reveal a quite peculiar attitude on their part to the therapeutic problem: they had always known that nothing but love would cure them, and from the beginning of the treatment they had expected that this relationship would at last yield them what life had so far denied them. It was only with this hope that they had taken such pains over the analysis and had conquered all their difficulties in disclosing their thoughts. We ourselves can add: ‘and had understood so easily all that is usually so hard to accept.’ But a confession of this kind astounds us; all our calculations are blown to the winds. Could it be that we have omitted the most important element in the whole problem?

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

The new fact which we are thus unwillingly compelled to recognize we call Transference. By this we mean a transference of feelings on to the person of the physician, because we do not believe that the situation in the treatment can account for the origin of such feelings. We are much more disposed to suspect that the whole of this readiness to develop feeling originates in another source; that it was previously formed in the patient, and has seized the opportunity provided by the treatment to transfer itself on to the person of the physician. The transference can express itself as a passionate petitioning for love, or it can take less extreme forms; where a young girl and an elderly man are concerned, instead of the wish to be wife or mistress, a wish to be adopted as a favourite daughter 370may come to light, the libidinous desire can modify itself and propose itself as a wish for an everlasting, but ideally platonic friendship. Many women understand how to sublimate the transference and to mould it until it acquires a sort of justification for its existence; others have to express it in its crude, original, almost impossible form. But at bottom it is always the same, and its origin in the same source can never be mistaken.

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

First of all, let us realize at once that the transference exists in the patient from the beginning of the treatment, and is for a time the strongest impetus in the work. Nothing is seen of it and one does not need to trouble about it as long as its effect is favourable to the work in which the two persons are co-operating. When it becomes transformed into a resistance, attention must be paid to it; and then it appears that two different and contrasting states of mind have supervened in it and have altered its attitude to the treatment: first, when the affectionate attraction has become so strong and betrays signs of its origin in sexual desire so clearly that it was bound to arouse an inner opposition against itself; and secondly, when it consists in antagonistic instead of affectionate feeling. The hostile feelings as a rule appear later than the affectionate and under cover of them; when both occur simultaneously they provide a very good exemplification of that ambivalence in feeling which governs most of our intimate relationships with other human beings. The hostile feelings therefore indicate an attachment of feeling quite similar to the affectionate, just as defiance indicates a similar dependence upon the other person to that belonging 371to obedience, though with a reversed prefix. There can be no doubt that the hostile feelings against the analyst deserve the name of ‘transference,’ for the situation in the treatment certainly gives no adequate occasion for them; the necessity for regarding the negative transference in this light is a confirmation of our previous similar view of the positive or affectionate variety.

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 372particularly 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 373have 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 374suggestion, 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.

375

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 376the 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 377to 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 378attitudes; 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 379memory 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 380Libido 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.

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 381rages 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 382forms 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 383which 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 384course 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 385of 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 386a 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 387irrational, 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 388no 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.

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