Selected Papers on Hysteria and Other Psychoneuroses/Chapter 8
CHAPTER VIII.
On Psychotherapy.[1]
Gentlemen:
It is almost eight years since, at the request of your deceased chairman, Prof. v. Reder, I had the pleasure of speaking in your midst on the subject of hysteria. Shortly before (1895) I had published the "Studien über Hysterie" together with Dr. J. Breuer, and on the basis of a new knowledge for which we are thankful to this investigator, I have attempted to introduce a new way of treating the neurosis. Fortunately, I can say that the endeavors of our " Studies " have met with success, and that the ideas which they advocate concerning the effects of psychic traumas through the restraint of affects and the conception of the hysterical symptom as a result of a displacement of excitement from the psychic to the physical—ideas for which we have created the terms "ab-reaction" and "conversion"—are today generally known and understood. At least in German-speaking countries there are no descriptions of hysteria which do not to a certain extent take cognizance of them, and no colleague who does not at least partially follow this theory. And yet as long as they were new these theories and these terms must have sounded strange enough!
I can not say the same thing about the therapeutic procedure which we have proposed to our colleagues together with our theory. It still struggles for recognition. This may have its special reasons. The technique of the procedure was at that time still rudimentary. I was unable to give those indications to the medical reader of the book which would enable him to perform such a treatment. But surely there were other causes of a general nature. To many physicians psychotherapy even today appears as a product of modern mysticism, and in comparison to our physico-chemical remedies the application of which is based on physiological insight, psychotherapy appears quite unscientific and unworthy of the interest of a natural philosopher. You will therefore allow me to present to you the subject of psychotherapy, and to point out to you what part of this verdict can be designated as unjust or erroneous.
In the first place let me remind you that psychotherapy is not a modern therapeutic procedure. On the contrary it is one of the oldest remedies used in medicine. In Lëwenfeld's instructive work (Lehrbuch der gesamten Psychotherapie) you can find the methods employed in primitive and ancient medicine. Most of them were of a psychotherapeutic nature. In order to cure a patient he was transferred into a state of "credulous expectation" which acts in a similar manner even today. Even after the doctors found other remedial agents psychotherapeutic endeavors never disappeared from this or that branch of medicine.
Secondly, I call your attention to the fact that we doctors really can not abandon psychotherapy if only because another very much to be considered party in the treatment—namely the patient—has no intention of abandoning it. You know how much we owe to the Nancy school (Liébault, Bernheim) for these explanations. Without our intention, an independent factor from the patient's psychic disposition enters into the activity of every remedial agent introduced by the doctor, acting mostly in a favorable sense but often also in an inhibiting sense. We have learned to apply to this factor the word "suggestion," and Moebius taught us that the failures of some of our remedies are to be ascribed to the disturbing influences of this very powerful moment. You doctors, all of you, constantly practice psychotherapy, even when you do not know it, or do not intend it, but it has one disadvantage, you leave entirely to the patient the psychic factor of your influence. It then becomes uncontrollable, it can not be divided into doses and can not be increased. Is it not a justified endeavor of the doctor to become master of this factor, to make use of it intentionally, to direct and enforce it? It is nothing other than that, that scientific psychotherapy expects of you.
In the third place, gentlemen, I wish to refer you to the well known experience, namely, that certain maladies and particularly the psychoneuroses, are more accessible to psychic influences than to any other medications. It is no modern talk but a dictum of old physicians that these diseases are not cured by the drug, but by the doctor, to wit, by the personality of the physician in so far as it exerts a psychic influence. I am well aware, gentlemen, that you like very much the idea which the asthete Vischer, in his parody on Faust (Faust, der Tragödie, III Teil) endowed with a classical expression: "I know that the physical often acts on the moral."
But would it not be more adequate and frequently more correct to influence the moral part of the person with the moral, that is, with psychic means?
There are many ways and means of psychotherapy. All methods are good which produce the aim of the therapy. Our usual consolation, "You will soon be well again," with which we are so generous to our patients, corresponds to one of the psychotherapeutic methods, only that on gaining a profounder insight into the neuroses we are not forced to limit ourselves to this consolation alone. We have developed the technique of hypnotic suggestion, of psychotherapy through diversion, through practice, and through the evocation of serviceable affects. I do not disdain any of them, and would practice them all under suitable conditions. That I have in reality restricted myself to a single therapeutic procedure, to the method called by Breuer "cathartic," which I prefer to call "analytic," is simply due to subjective motives which guided me. Having participated in the elaboration of this therapy I feel it a personal duty to devote myself to its investigation, and to the final development of its technique. I maintain that the analytic method of psychotherapy is one which acts most penetratingly, and carries farthest; through it one can produce the most prolific changes in the patient. If I relinquish for a moment the therapeutic point of view, I can assert that it is the most interesting, and that it alone teaches us something concerning the origin and the connection of the morbid manifestations. Owing to insights which it opens for us into the mechanism of the psychic malady, it can even lead us beyond itself, and show us the way to still other kinds of therapeutic influences.
Allow me now to correct some errors, and furnish some explanations concerning this cathartic or analytic method of psycho-therapy.
(a) I notice that this method is often mistaken for the hypnotic suggestive treatment. I notice this by the fact that quite frequently colleagues whose confidant I am not by any means, send patients to me, refractory patients, of course, with the request that I should hypnotize them. Now, for eight years I have not practiced hypnotism (individual cases excluded) as a therapeutic aim, and hence I used to return the patients with the advice that he who relies on hypnosis should do it himself. In truth, the greatest possible contrast exist between the suggestive and the analytic technique, that contrast which the great Leonardo da Vinci has expressed for the arts in the formulae per via di porre and per via di levare. Said Leonardo, "the art of painting works per via di porre, that is, to say, places little heaps of paint where they have not been before on the uncolored canvas; sculpturing, on the other hand, goes per via di levare, that is to say, it takes away from the stone as much as covers the surface of the statue therein contained." Quite similarly, gentlemen, the suggestive technique acts per via di porre, it does not concern itself about the origin, force, and significance of the morbid symptoms, but puts on something, to wit, the suggestion which it expects will be strong enough to prevent the pathogenic idea from expression. On the other hand the analytic therapy does not wish to put on anything, or introduce anything new, but to take away, and extract, and for this purpose it concerns itself with the genesis of the morbid symptoms, and the psychic connection of the pathogenic idea the removal of which is its aim.
This manner of investigation has considerably furthered our understanding. I have so early given up the technique of suggestion, and with it hypnosis, because I despaired of making the suggestion as strong and persistent as would be necessary for a lasting cure. In all grave cases I noticed that the suggestions which were put on crumbled ofif again, and then the disease, or one replacing it, reappeared. Besides, I charge this technique with concealing from us the psychic play of forces, for example, it does not permit us to recognize the resistance with which the patients adhere to their malady, with which they also strive against the recovery, and which alone can give us an understanding of their behavior in life.
(b) It seems to me that a very widespread mistake among my colleagues is the idea that the technique of the investigation for the causes of the disease and the removal of the manifestations by this investigation is easy and self-evident. I concluded this from the fact that of the many who interest themselves in my therapy and express a definite opinion on the same, no one has yet asked me how I do it. There can only be one reason for it, they believe there is nothing to ask, that it is a matter of course. I occasionally also hear with surprise that in this or that division of the hospital a young interne is requested by his chief to undertake a "psychoanalysis" with a hysterical woman. I am convinced that he would not intrust him with the examination of an extirpated tumor without previously assuring himself that he is acquainted with the histological technique. Likewise I am informed that this or that colleague has made appointments with a patient for psychic treatment, whereas I am certain that he does not know the technique of such a treatment. He must, therefore, expect that the patient will bring him her secrets, or he seeks salvation in some kind of a confession or confidence. I should not wonder if the patient thus treated would rather be harmed than benefited. The mental instrument is really not at all easy to play. On such occasions I can not help but think of the speech of a world-renowned neurotic, who really never came under a doctor's treatment, and only lived in the fancy of the poet. I mean Prince Hamlet of Denmark. The king has sent the two couriers, Rosencrantz and Guildenstern, to investigate him and rob him of his secret. While he defended himself, pipes were brought on the stage. Hamlet took a pipe and requested one of his tormentors to play on it, saying that it is as easy to play as lying. The courtier hesitated because he knew no touch of it, and as he could not be moved to attempt to play the pipe, Hamlet finally burst forth: "Why, look you now, how unworthy a thing you make of me! You would play upon me; you would seem to know my stops; you would pluck out the heart of my mystery; you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice, in this little organ, yet you cannot make it speak. 'Sblood! do you think I am easier to be played on than a pipe? Call me what instrument you will, though you can fret me, you cannot play upon me." (Act III, Scene 2.)
(c) You will have surmised from some of my observations that the analytic cure contains quahties which keep it away from the ideal of a therapy. Tuto, cito, iucunde; the investigation and examination does not really mean rapidity of success, and the allusion to the resistance has prepared you for the expectation of inconveniences. Certainly the psychoanalytic method lays high claims on the patient as well as the physician. From the first it requires the sacrifice of perfect candor, it takes up much of his time, and is therefore also expensive; for the physician it also means the loss of much time, and due to the technique which he has to learn and practice, it is quite laborious. I even find it quite justified to employ more suitable remedies as long as there is a prospect to achieve something with them. It comes to this point only: if we gain by the more laborious and cumbersome procedure considerably more than by the short and easy one, the first is justified despite everything. Just think, gentlemen, by how much the Finsen therapy of lupus is more inconvenient and expensive than the formerly used cauterization and scraping, and yet it means a great progress, merely because it achieves more, it actually cures the lupus radically. I do not really wish to carry through the comparison, but psychoanalysis can claim for itself a similar privilege. In reality I could develop and test my therapeutic method in grave and in the gravest of cases only; my material at first consisted of patients who tried everything unsuccessfully, and had spent years in asylums. I hardly gained enough experience to be able to tell you how my therapy behaves in those lighter, episodically appearing diseases which we see cured under the most diverse influences, and also spontaneously. The psychoanalytic method was created for patients who are permanently incapacitated, and its triumph is to make a gratifying number of such, permanently capacitated. Against this success all expense is insignificant. We can not conceal from ourselves what we were wont to disavow to the patient, namely, that the significance of a grave neurosis for the individual subjected to it is not less than any cachexia or any of the generally feared maladies.
(d) In view of the many practical limitations which I have encountered in my work, I can hardly definitely enumerate the indications and contra-indications of this treatment. However, I will attempt to discuss with you a few points:
1. The former value of the person should not be overlooked in the disease, and you should refuse a patient who does not possess a certain degree of education, and whose character is not in a measure reliable. We must not forget that there are also healthy persons who are good for nothing, and that if they only show a mere touch of the neurosis, one is only too much inclined to blame the disease for incapacitating such inferior persons. I maintain that the neurosis does not in any way stamp its bearer as a degenere, but that frequently enough it is found in the same individual associated with the manifestations of degeneration. The analytic psychotherapy is therefore no procedure for the treatment of neuropathic degeneration, on the contrary it is limited by it. It is also not to be applied in persons who are not prompted by their own suffering to seek the treatment, but subject themselves to it by order of their relatives. The characteristic feature upon which the usefulness of the psychoanalytic treatment depends, the educability, we will still have to consider from another point of view.
2. If one wishes to take a safe course he should limit his selection to persons of a normal state, for, in psychoanalytic procedures, it is from the normal that we seize upon the morbid. Psychoses, confusional states, and marked (I might say toxic) depressions, are unsuitable for analysis, at least as it is practiced today. I do not think it at all impossible that with the proper changes in the procedure it will be possible to disregard this contraindication, and thus claim a psychotherapy for the psychoses.
3. The age of the patient also plays a part in the selection for the psychoanalytic treatment. Persons near or over the age of fifty lack, on the one hand, the plasticity of the psychic processes upon which the therapy depends—old people are no longer educable—and on the other hand, the material which has to be elaborated, and the duration of the treatment is immensely increased. The earliest age limit is to be individually determined; youthful persons, even before puberty, are excellent subjects for influence.
4. One should not attempt psychoanalysis when it is a question of rapidly removing a threatening manifestation, as, for example, in the case of an hysterical anorexia.
You have now gained the impression that the sphere of application of the analytic psychotherapy is a very limited one, for you really heard me enumerate nothing but contraindications. Nevertheless, there remain sufficient cases and morbid states, such as all chronic forms of hysteria with remnant manifestations, the extensive realm of compulsive states, abulias, etc., on which this therapy can be tried.
It is pleasing that particularly the worthiest and highest developed persons can thus be most helped. Where the analytic psychotherapy has accomplished but little one can cheerfully assert that any other treatment would have certainly resulted in nothing.
(e) You will surely wish to ask me about the possibility of doing harm through the application of psychoanalysis. To this I will reply that if you will judge justly you will meet this procedure with the same critical good- feeling as you have met our other therapeutic methods, and doing this you will have to agree with me that a rationally executed analytic treatment entails no dangers for the patient. One who, like a layman, is accustomed to ascribe to the treatment everything occurring during the disease, will probably judge differently. It is really not so long since our hydrotherapeutic asylums met with similar opposition. Thus one who was advised to go to such an asylum became thoughtful because he had an acquaintance who entered the asylum as nervous and there became insane. As you surmise we deal with cases of initial general paresis who in the first stages could still be sent to hydrotherapeutic asylums, and who there merged into the irresistible course leading to manifest insanity. For the layman the water was the cause and author of this sad transformation. Where it is a question of unfamiliar influences, even doctors are not free from such mistaken judgment. I recall having once attempted to treat a woman by psychotherapy who passed a great part of her existence by alternating between mania and melancholia. I began to treat her at the end of a melancholia and everything seemed to go well for two weeks, but in the third week she was again merging into a mania. It was surely a spontaneous alteration of the morbid picture, for two weeks is no time in which anything can be accomplished by psychotherapy, but the prominent—now deceased—physician who saw the case with me could not refrain from remarking that this decline must have been due to the psychotherapy. I am quite convinced that he would have been more critical under different conditions.
(f) In conclusion, gentlemen, I must say to myself that it will not do to lay claim to your attention so long in favor of the analytic psychotherapy without telling you of what this treatment consists, and on what it is based. To be sure I can only indicate it as I have to be brief. This therapy is founded on the understanding that unconscious ideas—or rather the unconsciousness of certain psychic processes—are the main causes of a morbid symptom. We share this conviction with the French school (Janet) which moreover by gross schematization reduces the hysterical symptom to an unconscious idee fixe. Do not fear now that we will thus merge too far into the obscurest philosophy. Our unconscious is not quite the same as that of the philosophers and what is more, most philosophers wish to know nothing of the "psychical unconscious." But if you will put yourselves in our -position, you will understand that the interpretation of this unconscious, in patients' psychic life, into the conscious, must result in a correction of their deviation from the normal, and in an abrogation of the compulsion controlling their psychic life. For the conscious will reaches as far as the conscious psychic processes and every psychic compulsion is substantiated by the unconscious. You need never fear that the patient will be harmed by the emotion produced in the entrance of his unconscious into consciousness, for you can theoretically readily understand that the somatic and affective activity of the emotion which became conscious can never become as great as those of the unconscious. For we only control all our emotions by directing upon them our highest psychic activities which are connected with consciousness.
We can still choose another point of view for the understanding of the psychoanalytic treatment. The revealing and interpreting of the unconscious takes place under constant resistance on the part of the patient. The emerging of the unconscious is connected with displeasure and owing to this displeasure it is continuously repulsed by the patient. It is upon this conflict in the patient's psychic life that you encroach, and if you succeed in prevailing upon him to accept something, for motives of better insight, which he has thus far repulsed (repressed) on account of the automatic adjustment of displeasure, you have achieved in him a piece of educational work. For it is really an education if you can induce a person to leave his bed early in the morning despite his unwillingness to do so. As such an after training for the overcoming of inner resistances you can conceive the psychoanalytic treatment in quite a general manner. But in no sphere of the nervous patients is such an after training so essential as in the psychic elements of their sexual life. For nowhere have culture and education produced as much harm as here, and it is here, as experience will show you, that the controlling etiologies of the neuroses are found. The other etiological element, the constitutional contribution, is really given to us as something immutable. But this gives rise to an important demand on the doctor. Not only must he be of unblemished character—"morality-is really a matter of course" as the principal person in Th. Vischer's "Auch Einer" used to say—but he must have overcome in his own personality the mixture of lewdness and prudishness with which so many others are wont to meet the sexual problems.
This is perhaps the place for another observation. I know that the emphasis which I laid on the sexual role in the origin of the psychoneuroses has become widely known. But I also know that restriction and nearer determinations are of little use with the great public; the multitude has little room in its memory, and generally retains from a statement the bare nucleus, thus creating for itself an easily remembered extreme. The same might also have happened to some physicians when the faint notion that they have of my theory is that I trace back the neurosis in the last place to sexual privation. Of such there is surely no dearth under the vital conditions of our society. But if that supposition were true would it not seem obvious that in order to avoid the roundabout way of the psychic treatment and tend directly towards the cure, we should directly recommend sexual participation as the remedy? I really do not know what could induce me to suppress these conclusions if they were justified. But the state of affairs is different. The sexual need or privation is merely one of the factors playing a part in the mechanism of the neurosis, and if it alone existed the result would not be a disease but a dissipation. The other equally indispensable factor, which one is only too ready to forget, is the sexual repugnance of neurotics, their inability to love ; it is that psychic feature which I have designated as " repression." It is only from the conflict between the two strivings that the neurotic malady originates, and it is for this reason that the advice for sexual participation in the psycho-neuroses can really only seldom be designated as good.
Allow me to conclude with this guarded remark. Let us hope that with an interest for psychotherapy, purified of all hostile prejudice, you will help us to do some good in the treatment of the severe cases of psychoneuroses.
- ↑ Lecture delivered before the Vienna Medic. Doktorenkollegium, on December 12, 1904.