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THE FUTURE PROSPECTS OF PSYCHO-ANALYTIC THERAPY
(1910)
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THE FUTURE PROSPECTS OF PSYCHO-ANALYTIC THERAPY
GENTLEMEN, - Since the objects for which we are assembled here to-day are mainly practical, I shall choose a practical theme for my introductory address and appeal to your medical, not to your scientific, interest. I can imagine your probable views on the results of our therapy, and I assume that most of you have already passed through the two stages which all beginners go through, the stage of enthusiasm at the unexpected increase in our therapeutic achievements, and the stage of depression at the magnitude of the difficulties which stand in the way of our efforts. At whatever point in this development, however, each of you may happen to be, my intention to-day is to show you that we have by no means come to the end of our resources for combating the neuroses, and that we may expect a substantial improvement in our therapeutic prospects before long.
This reinforcement will come, I think, from three directions:
(1) from internal progress,
(2) from increased authority, and
(3) from the general effect of our work.
(1) Under ‘internal progress’ I include advances (a) in our analytic knowledge, (b) in our technique.
(a) Advances in our knowledge. We are, of course, still a long way from knowing all that is required for an understanding of the unconscious in our patients. It is clear that every advance in our knowledge means an increase in our therapeutic power. As long as we have understood nothing, we have accomplished nothing; the more we understand, the more we shall achieve. At its beginning psycho-analytic treatment was inexorable and exhausting. The patient had to say everything himself, and the physician’s activity consisted of urging him on incessantly. To-day things have a more friendly air. The treatment is made up of two parts - what the physician infers and tells the patient, and the patient’s working-over of what he has heard. The mechanism of our assistance is easy to understand: we give the patient the conscious anticipatory idea and he then finds the repressed unconscious idea in himself on the basis of its similarity to the anticipatory one. This is the intellectual help which makes it easier for him to overcome the resistances between conscious and unconscious. Incidentally, I may remark that it is not the only mechanism made use of in analytic treatment; you all know the far more powerful one which lies in the use of the ‘transference’. It is my intention in the near future to deal with these various factors, which are so important for an understanding of the treatment, in an Allgemeine Methodik der Psychoanalyse. And further, in speaking to you I need not rebut the objection that the evidential value in support of the correctness of our hypotheses is obscured in our treatment as we practise it to-day; you will not forget that this evidence is to be found elsewhere, and that a therapeutic procedure cannot be carried out in the same way as a theoretical investigation.
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Let me now touch upon one or two fields in which we have new things to learn and do in fact discover new things every day. Above all, there is the field of symbolism in dreams and in the unconscious - a fiercely contested subject, as you know. It is no small merit in our colleague, Wilhelm Stekel, that, untroubled by all the objections raised by our opponents, he has undertaken a study of dream-symbols. There is indeed still much to learn here; my Interpretation of Dreams, which was written in 1899, awaits important amplification from researches into symbolism.
I will say a few words about one of the symbols that has newly been recognized. A little time ago I heard that a psychologist whose views are somewhat different from ours had remarked to one of us that, when all was said and done, we did undoubtedly exaggerate the hidden sexual significance of dreams: his own commonest dream was of going upstairs, and surely there could not be anything sexual in that. We were put on the alert by this objection, and began to turn our attention to the appearance of steps, staircases and ladders in dreams and were soon in a position to show that staircases (and analogous things) were unquestionably symbols of copulation. It is not hard to discover the basis of the comparison: we come to the top in a series of rhythmical movements and with increasing breathlessness and then, with a few rapid leaps, we can get to the bottom again. Thus the rhythmical pattern of copulation is reproduced in going upstairs. Nor must we omit to bring in the evidence of linguistic usage. It shows us that ‘mounting’ [German ‘steigen’] is used as a direct equivalent for the sexual act. We speak of a man as a ‘Steiger’ [a ‘mounter’] and of ‘nachsteigen’ [‘to run after’, literally ‘to climb after’]. In French the steps on a staircase are called ‘marches’ and ‘un vieux marcheur’ has the same meaning as our ‘ein alter Steiger’ [‘an old rake’]. The dream-material from which these newly recognized symbols are derived will in due time be put before you by the committee we are about to form for a collective study of symbolism. You will find some remarks on another interesting symbol, on ‘rescue’ and its changes in significance, in the second volume of our Jahrbuch. But I must break off here or I shall not get to my other points.
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Every one of you will know from his own experience what a very different attitude he has towards a new case of illness when once he has thoroughly grasped the structure of a few typical cases. Imagine that we had arrived at a succinct formula of the factors regularly concerned in constructing the various forms of neuroses, as we have so far succeeded in doing for the construction of hysterical symptoms, and consider how firmly it would establish our prognostic judgement! Just as an obstetrician can tell by examining the placenta whether it has been completely expelled or whether noxious fragments of it still remain, so should we, independently of the outcome and of the patient’s condition at the moment, be able to say whether our work had been definitely successful or whether we had to expect relapses and fresh onsets of illness.
(b) I will hasten on to the innovations in the field of technique, where indeed nearly everything still awaits final settlement, and much is only now beginning to become clear. There are now two aims in psycho-analytic technique: to save the physician effort and to give the patient the most unrestricted access to his unconscious. As you know, our technique has undergone a fundamental transformation. At the time of the cathartic treatment what we aimed at was the elucidation of the symptoms; we then turned away from the symptoms and devoted ourselves instead to uncovering the ‘complexes’, to use a word which Jung has made indispensable; now, however, our work is aimed directly at finding out and overcoming the ‘resistances’, and we can justifiably rely on the complexes coming to light without difficulty as soon as the resistances have been recognized and removed. Some of you have since felt a need to be able to make a survey of these resistances and classify them. I will ask you to examine your material and see whether you can confirm the generalized statement that in male patients the most important resistances in the treatment seem to be derived from the father-complex and to express themselves in fear of the father, in defiance of the father and in disbelief of the father.
Other innovations in technique relate to the physician himself. We have become aware of the ‘counter-transference’, which arises in him as a result of the patient’s influence on his unconscious feelings, and we are almost inclined to insist that he shall recognize this counter-transference in himself and overcome it. Now that a considerable number of people are practising psycho-analysis and exchanging their observations with one another, we have noticed that no psycho-analyst goes further than his own complexes and internal resistances permit; and we consequently require that he shall begin his activity with a self-analysis and continually carry it deeper while he is making his observations on his patients. Anyone who fails to produce results in a self-analysis of this kind may at once give up any idea of being able to treat patients by analysis.
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We are also now coming to the opinion that analytic technique must be modified in certain ways according to the nature of the disease and the dominant instinctual trends in the patient. We started out from the treatment of conversion hysteria; in anxiety hysteria (phobias) we must to some extent alter our procedure. For these patient cannot bring out the material necessary for resolving their phobia so long as they feel protected by obeying the condition which it lays down. One cannot, of course, succeed in getting them to give up their protective measures and work under the influence of anxiety from the beginning of the treatment. One must therefore help them by interpreting their unconscious to them until they can make up their minds to do without the protection of their phobia and expose themselves to a now greatly mitigated anxiety. Only after they have done so does the material become accessible, which, when it has been mastered, leads to a solution of the phobia. Other modifications of technique, which seem to me not yet ripe for discussion, will be required in the treatment of obsessional neurosis. In this connection very important questions arise, which have not hitherto been elucidated: how far the instincts which the patient is combating are to be allowed some satisfaction during the treatment, and what difference it makes whether these impulses are active (sadistic) or passive (masochistic) in their nature.
I hope you will have formed an impression that, when we know all that we now only suspect and when we have carried out all the improvements in technique to which deeper observation of our patients is bound to lead us, our medical procedure will reach a degree of precision and certainty of success which is not to be found in every specialized field of medicine.
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(2) I have said that we had much to expect from the increase in authority which must accrue to us as time goes on. I need not say much to you about the importance of authority. Only very few civilized people are capable of existing without reliance on others or are even capable of coming to an independent opinion. You cannot exaggerate the intensity of people’s inner lack of resolution and craving for authority. The extraordinary increase in neuroses since the power of religions has waned may give you a measure of it. The impoverishment of the ego due to the large expenditure of energy on repression demanded of every individual by civilization may be one of the principal causes of this state of things.
Hitherto, this authority, with its enormous weight of suggestion, has been against us. All our therapeutic successes have been achieved in the face of this suggestion: it is surprising that any successes at all could be gained in such circumstances. I must not let myself be led into describing my agreeable experiences during the period when I alone represented psycho-analysis. I can only say that when I assured my patients that I knew how to relieve them permanently of their sufferings they looked round my modest abode, reflected on my lack of fame and title, and regarded me like the possessor of an infallible system at a gambling-resort, of whom people say that if he could do what he professes he would look very different himself. Nor was it really pleasant to carry out a psychical operation while the colleagues whose duty it should have been to assist took particular pleasure in spitting into the field of operation, and while at the first signs of blood or restlessness in the patient his relatives began threatening the operating surgeon. An operation is surely entitled to produce reactions; in surgery we became accustomed to that long ago. People simply did not believe me, just as even to-day people do not much believe any of us. Under such conditions not a few attempts were bound to fail. To estimate the increase in our therapeutic prospects when we have received general recognition, you should think of the position of a gynaecologist in Turkey and in the West. In Turkey, all he may do is to feel the pulse of all arm stretched out to him through a hole in the wall: and his medical achievements are in proportion to the inaccessibility of their object. Our opponents in the West wish to allow us much the same degree of access to our patient’s minds. But now that the force of social suggestion drives sick women to the gynaecologist, he has become their helper and saviour. I trust you will not say that the fact of the authority of society coming to our aid and increasing our successes so greatly would do nothing to prove the validity of our hypotheses - arguing as you might that, since suggestion is supposed to be able to do anything, our successes would then be successes of suggestion and not of psycho-analysis. Social suggestion is at present favourable to treating nervous patients by hydropathy, dieting and electro-therapy, but that does not enable such measures to get the better of neuroses. Time will show whether psycho-analytic treatment can accomplish more.
Now, however, I must once more damp your expectations. Society will not be in a hurry to grant us authority. It is bound to offer us resistance, for we adopt a critical attitude towards it; we point out to it that it itself plays a great part in causing neuroses. Just as we make an individual our enemy by uncovering what is repressed in him, so society cannot respond with sympathy to a relentless exposure of its injurious effects and deficiencies. Because we destroy illusions we are accused of endangering ideals. It might seem, therefore, as though the condition from which I expect such great advantages for our therapeutic prospects will never be fulfilled. And yet the situation is not so hopeless as one might think at the present time. Powerful though men’s emotions and self-interest may be, yet intellect is a power too - a power which makes itself felt, not, it is true, immediately, but all the more certainly in the end. The harshest truths are heard and recognized at last, after the interests they have injured and the emotions they have roused have exhausted their fury. It has always been so, and the unwelcome truths which we psycho-analysts have to tell the world will have the same fate. Only it will not happen very quickly; we must be able to wait.
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(3) Finally, I have to explain to you what I mean by the ‘general effect’ of our work, and how I come to set hopes on it. What we have here is a very remarkable therapeutic constellation, the like of which is perhaps not to be found anywhere else and which will appear strange to you too at first, until you recognize in it something you have long been familiar with. You know, of course, that the psychoneuroses are substitutive satisfactions of some instinct the presence of which one is obliged to deny to oneself and others. Their capacity to exist depends on this distortion and lack of recognition. When the riddle they present is solved and the solution is accepted by the patients these diseases cease to be able to exist. There is hardly anything like this in medicine, though in fairy tales you hear of evil spirits whose power is broken as soon as you can tell them their name - the name which they have kept secret.
In place of a single sick person let us put society - suffering as a whole from neuroses, though composed of sick and healthy members; and in place of individual acceptance in the one case let us put general recognition in the other. A little reflection will then show you that this substitution cannot in any way alter the outcome. The success which the treatment can have with the individual must occur equally with the community. Sick people will not be able to let their various neuroses become known - their anxious over-tenderness which is meant to conceal their hatred, their agoraphobia which tells of disappointed ambition, their obsessive actions which represent self-reproaches for evil intentions and precautions against them - if all their relatives and every stranger from whom they wish to conceal their mental processes know the general meaning of such symptoms, and if they themselves know that in the manifestations of their illness they are producing nothing that other people cannot instantly interpret. The effect, however, will not be limited to the concealment of the symptoms which, incidentally, it is often impossible to carry out; for this necessity for concealment destroys the use of being ill. Disclosure of the secret will have attacked, at its most sensitive point, the ‘aetiological equation’ from which neuroses arise - it will have made the gain from the illness illusory; and consequently the final outcome of the changed situation brought about by the physician’s indiscretion can only be that the production of the illness will be brought to a stop.
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If this hope seems Utopian to you, you may remember that neurotic phenomena have actually been dispelled already by this means, although only in quite isolated instances. Think how common hallucinations of the Virgin Mary used to be among peasant girls in former times. So long as such a phenomenon brought a flock of believers and might lead to a chapel being built on the sacred spot, the visionary state of these girls was inaccessible to influence. To-day even our clergy have changed their attitude to such things; they allow police and doctors to examine the visionary, and now the Virgin makes only very rare appearances.
Or let me examine these developments, which I have been describing as taking place in the future, in an analogous situation which is on a smaller scale and consequently easier to take in. Suppose a number of ladies and gentlemen in good society have planned to have a picnic one day at an inn in the country. The ladies have arranged among themselves that if one of them wants to relieve a natural need she will announce that she is going to pick flowers. Some malicious person, however, has got wind of this secret and has had printed on the programme which is sent round to the whole party: ‘Ladies who wish to retire are requested to announce that they are going to pick flowers.’ After this, of course, no lady will think of availing herself of this flowery pretext, and, in the same way, other similar formulas, which may be freshly agreed upon, will be seriously compromised. What will be the result? The ladies will admit their natural needs without shame and none of the men will object.
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Let us return to our more serious case. A certain number of people, faced in their lives by conflicts which they have found too difficult to solve, have taken flight into neurosis and in this way won an unmistakable, although in the long run too costly, gain from illness. What will these people have to do if their flight into illness is barred by the indiscreet revelations of psycho-analysis? They will have to be honest, confess to the instincts that are at work in them, face the conflict, fight for what they want, or go without it; and the tolerance of society, which is bound to ensue as a result of psycho-analytic enlightenment, will help them in their task.
Let us remember, however, that our attitude to life ought not to be that of a fanatic for hygiene or therapy. We must admit that the ideal prevention of neurotic illnesses which we have in mind would not be of advantage to every individual. A good number of those who now take flight into illness would not, under the conditions we have assumed, support the conflict but would rapidly succumb or would cause a mischief greater than their own neurotic illness. Neuroses have in fact their biological function as a protective contrivance and they have their social justification: the ‘gain from illness’ they provide is not always a purely subjective one. Is there one of you who has not at some time looked into the causation of a neurosis and had to allow that it was the mildest possible outcome of the situation? And should such heavy sacrifices be made in order to eradicate the neuroses in particular, when the world is full of other unavoidable misery?
Are we, then, to abandon our efforts to explain the hidden meaning of neurosis as being in the last resort dangerous to the individual and harmful to the workings of society? Are we to give up drawing the practical conclusion from a piece of scientific insight? No; I think that in spite of this our duty lies in the other direction. The gain from illness provided by the neuroses is nevertheless on the whole and in the end detrimental to individuals as well as to society. The unhappiness that our work of enlightenment may cause will after all only affect some individuals. The change-over to a more realistic and creditable attitude on the part of society will not be bought too dearly by these sacrifices. But above all, all the energies which are to-day consumed in the production of neurotic symptoms serving the purposes of a world of phantasy isolated from reality, will, even if they cannot at once be put to uses in life, help to strengthen the clamour for the changes in our civilization through which alone we can look for the well-being of future generations.
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I should therefore like to let you go with an assurance that in treating your patients psycho-analytically you are doing your duty in more senses than one. You are not merely working in the service of science, by making use of the one and only opportunity for discovering the secrets of the neuroses; you are not only giving your patients the most efficacious remedy for their sufferings that is available to-day; you are contributing your share to the enlightenment of the community from which we expect to achieve the most radical prophylaxis against neurotic disorders along the indirect path of social authority.