2372
‘WILD’ PSYCHO-ANALYSIS
(1910)
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A few days ago a middle-aged lady, under the protection of a female friend, called upon me for a consultation, complaining of anxiety-states. She was in the second half of her forties, fairly well preserved, and had obviously not yet finished with her womanhood. The precipitating cause of the outbreak of her anxiety-states had been a divorce from her last husband; but the anxiety had become considerably intensified, according to her account, since she had consulted a young physician in the suburb she lived in, for he had informed her that the cause of her anxiety was her lack of sexual satisfaction. He said that she could not tolerate the loss of intercourse with her husband, and so there were only three ways by which she could recover her health - she must either return to her husband, or take a lover, or obtain satisfaction from herself. Since then she had been convinced that she was incurable, for she would not return to her husband, and the other two alternatives were repugnant to her moral and religious feelings. She had come to me, however, because the doctor had said that this was a new discovery for which I was responsible, and that she had only to come and ask me to confirm what he said, and I should tell her that this and nothing else was the truth. The friend who was with her, an older, dried-up and unhealthy-looking woman, then implored me to assure the patient that the doctor was mistaken; it could not possibly be true, for she herself had been a widow for many years, and had nevertheless remained respectable without suffering from anxiety.
I will not dwell on the awkward predicament in which I was placed by this visit, but instead will consider the conduct of the practitioner who sent this lady to me. First, however, let us bear a reservation in mind which may possibly not be superfluous - indeed we will hope so. Long years of experience have taught me - as they could teach everyone else - not to accept straight away as true what patients, especially nervous patients, relate about their physician. Not only does a nerve-specialist easily become the object of many of his patients’ hostile feelings, whatever method of treatment he employs; he must also sometimes resign himself to accepting responsibility, by a kind of projection, for the buried repressed wishes of his nervous patients. It is a melancholy but significant fact that such accusations nowhere find credence more readily than among other physicians.
'Wild' Psycho-Analysis
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I therefore have reason to hope that this lady gave me a tendentiously distorted account of what her doctor had said and that I do a man who is unknown to me an injustice by connecting my remarks about ‘wild’ psycho-analysis with this incident. But by doing so I may perhaps prevent others from doing harm to their patients.
Let us suppose, therefore, that her doctor spoke to the patient exactly as she reported. Everyone will at once bring us the criticism that if a physician thinks it necessary to discuss the question of sexuality with a woman he must do so with tact and consideration. Compliance with this demand, however, coincides with carrying out certain technical rules of psycho-analysis. Moreover, the physician in question was ignorant of a number of the scientific theories of psycho-analysis or had misapprehended them, and thus showed how little he had penetrated into an understanding of its nature and purposes.
Let us start with the latter, the scientific errors. The doctor’s advice to the lady shows clearly in what sense he understands the expression ‘sexual life’ - in the popular sense, namely, in which by sexual needs nothing is meant but the need for coitus or analogous acts producing orgasm and emission of the sexual substances. He cannot have remained unaware, however, that psycho-analysis is commonly reproached with having extended the concept of what is sexual far beyond its usual range. The fact is undisputed; I shall not discuss here whether it may justly be used as a reproach. In psycho-analysis the concept of what is sexual comprises far more; it goes lower and also higher than its popular sense. This extension is justified genetically; we reckon as belonging to ‘sexual life’ all the activities of the tender feelings which have primitive sexual impulses as their source, even when those impulses have become inhibited in regard to their original sexual aim or have exchanged this aim for another which is no longer sexual. For this reason we prefer to speak of psychosexuality, thus laying stress on the point that the mental factor in sexual life should not be overlooked or underestimated. We use the word ‘sexuality’ in the same comprehensive sense as that in which the German language uses the word lieben [‘to love’]. We have long known, too, that mental absence of satisfaction with all its consequences can exist where there is no lack of normal sexual intercourse; and as therapists we always bear in mind that the unsatisfied sexual trends (whose substitutive satisfactions in the form of nervous symptoms we combat) can often find only very inadequate outlet in coitus or other sexual acts.
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Anyone not sharing this view of psychosexuality has no right to adduce psycho-analytic theses dealing with the aetiological importance of sexuality. By emphasizing exclusively the somatic factor in sexuality he undoubtedly simplifies the problem greatly, but he alone must bear the responsibility for what he does.
A second and equally gross misunderstanding is discernible behind the physician’s advice.
It is true that psycho-analysis puts forward absence of sexual satisfaction as the cause of nervous disorders. But does it not say more than this? Is its teaching to be ignored as too complicated when it declares that nervous symptoms arise from a conflict between two forces - on the one hand, the libido (which has as a rule become excessive), and on the other, a rejection of sexuality, or a repression which is over-severe? No one who remembers this second factor, which is by no means secondary in importance, can ever believe that sexual satisfaction in itself constitutes a remedy of general reliability for the sufferings of neurotics. A good number of these people are, indeed, either in their actual circumstances or in general incapable of satisfaction. If they were capable of it, if they were without their inner resistances, the strength of the instinct itself would point the way to satisfaction for them even though no doctor advised it. What is the good, therefore, of medical advice such as that supposed to have been given to this lady?
Even if it could be justified scientifically, it is not advice that she can carry out. If she had had no inner resistances against masturbation or against a liaison she would of course have adopted one of these measures long before. Or does the physician think that a woman of over forty is unaware that one can take a lover, or does he over-estimate his influence so much as to think that she could never decide upon such a step without medical approval?
'Wild' Psycho-Analysis
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All this seems very clear, and yet it must be admitted the there is one factor which often makes it difficult to form a judgement. Some nervous states which we call the ‘actual neuroses’, such as typical neurasthenia and pure anxiety neurosis, obviously depend on the somatic factor in sexual life, while we have no certain picture as yet of the part played in them by the psychical factor and by repression. In such cases it is natural that the physician should first consider some ‘actual’ therapy, some alteration in the patient’s somatic sexual activity, and he does so with perfect justification if his diagnosis is correct. The lady who consulted the young doctor complained chiefly of anxiety-states, and so he probably assumed that she was suffering from an anxiety neurosis, and felt justified in recommending a somatic therapy to her. Again a convenient misapprehension! A person suffering from anxiety is not for that reason necessarily suffering from anxiety neurosis; such a diagnosis of it cannot be based on the name; one has to know what signs constitute an anxiety neurosis, and be able to distinguish it from other pathological states which are also manifested by anxiety. My impression was that the lady in question was suffering from anxiety hysteria, and the whole value of such nosographical distinctions, one which quite justifies them, lies in the fact that they indicate a different aetiology and a different treatment. No one who took into consideration the possibility of anxiety hysteria in this case would have fallen into the error of neglecting the mental factors, as this physician did with his three alternatives.
'Wild' Psycho-Analysis
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Oddly enough, the three therapeutic alternatives of this so-called psycho-analyst leave no room for - psycho-analysis! This woman could apparently only be cured of her anxiety by returning to her husband, or by satisfying her needs by masturbation or with a lover. And where does analytic treatment come in, the treatment which we regard as the main remedy in anxiety-states?
This brings us to the technical errors which are to be seen in the doctor’s procedure in this alleged case. It is a long superseded idea, and one derived from superficial appearances, that the patient suffers from a sort of ignorance, and that if one removes this ignorance by giving him information (about the causal connection of his illness with his life, about his experiences in childhood, and so on) he is bound to recover. The pathological factor is not his ignorance in itself, but the root of this ignorance in his inner resistances; it was they that first called this ignorance into being, and they still maintain it now. The task of the treatment lies in combating these resistances. Informing the patient of what he does not know because he has repressed it is only one of the necessary preliminaries to the treatment. If knowledge about the unconscious were as important for the patient as people inexperienced in psycho-analysis imagine, listening to lectures or reading books would be enough to cure him. Such measures, however, have as much influence on the symptoms of nervous illness as a distribution of menu-cards in a time of famine has upon hunger. The analogy goes even further than its immediate application; for informing the patient of his unconscious regularly results in an intensification of the conflict in him and an exacerbation of his troubles.
'Wild' Psycho-Analysis
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Since, however, psycho-analysis cannot dispense with giving this information, it lays down that this shall not be done before two conditions have been fulfilled. First, the patient must, through preparation, himself have reached the neighbourhood of what he has repressed, and secondly, he must have formed a sufficient attachment (transference) to the physician for his emotional relationship to him to make a fresh flight impossible.
Only when these conditions have been fulfilled is it possible to recognize and to master the resistances which have led to the repression and the ignorance. Psycho-analytic intervention, therefore, absolutely requires a fairly long period of contact with the patient. Attempts to ‘rush’ him at first consultation, by brusquely telling him the secrets which have been discovered by the physician, are technically objectionable. And they mostly bring their own punishment by inspiring a hearty enmity towards the physician on the patient’s part and cutting him off from having any further influence.
Besides all this, one may sometimes make a wrong surmise, and one is never in a position to discover the whole truth. Psycho-analysis provides these definite technical rules to replace the indefinable ‘medical tact’ which is looked upon as some special gift.
It is not enough, therefore, for a physician to know a few of the findings of psycho-analysis; he must also have familiarized himself with its technique if he wishes his medical procedure to be guided by a psycho-analytic point of view. This technique cannot yet be learnt from books, and it certainly cannot be discovered independently without great sacrifices of time, labour and success. Like other medical techniques, it is to be learnt from those who are already proficient in it. It is a matter of some significance, therefore, in forming a judgement on the incident which I took as a starting-point for these remarks, that I am not acquainted with the physician who is said to have given the lady such advice and have never heard his name.
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Neither I myself nor my friends and co-workers find it agreeable to claim a monopoly in this way in the use of a medical technique. But in face of the dangers to patients and to the cause of psycho-analysis which are inherent in the practice that is to be foreseen of a ‘wild’ psycho-analysis, we have had no other choice. In the spring of 1910 we founded an International Psycho-Analytical Association, to which its members declare their adherence by the publication of their names, in order to be able to repudiate responsibility for what is done by those who do not belong to us and yet call their medical procedure ‘psycho-analysis’. For as a matter of fact ‘wild’ analysts of this kind do more harm to the cause of psycho-analysis than to individual patients. I have often found that a clumsy procedure like this, even if at first it produced an exacerbation of the patient’s condition, led to a recovery in the end. Not always but still often. When he has abused the physician enough and feels far enough away from his influence, his symptoms give way, or he decides to take some step which leads along the path to recovery. The final improvement then comes about ‘of itself’, or is ascribed to some totally indifferent treatment by some other doctor to whom the patient has later turned. In the case of the lady whose complaint against her physician we have heard, I should say that, despite everything, the ‘wild’ psycho-analyst did more for her than some highly respected authority who might have told her she was suffering from a ‘vasomotor neurosis’. He forced her attention to the real cause of her trouble, or in that direction, and in spite of all her opposition this intervention of his cannot be without some favourable results. But he has done himself harm and helped to intensify the prejudices which patients feel, owing to their natural affective resistances, against the methods of psycho-analysis. And this can be avoided.