Freud - Complete Works (420 page)
An analysis such as this of
someone who is practically healthy will, as may be imagined, remain
incomplete. Anyone who can appreciate the high value of the
self-knowledge and increase in self-control thus acquired will,
when it is over, continue the analytic examination of his
personality in the form of a self-analysis, and be content to
realize that, within himself as well as in the external world, he
must always expect to find something new. But anyone who has
scorned to take the precaution of being analysed himself will not
merely be punished by being incapable of learning more than a
certain amount from his patients, he will risk a more serious
danger and one which may become a danger to others. He will easily
fall into the temptation of projecting outwards some of the
peculiarities of his own personality, which he has dimly perceived,
into the field of science, as a theory having universal validity;
he will bring the psycho-analytic method into discredit, and lead
the inexperienced astray.
Recommendations To Physicians Practising Psycho-Analysis
2472
(
g
) I shall now add a few
other rules, that will serve as a transition from the attitude of
the doctor to the treatment of the patient.
Young and eager psycho-analysts
will no doubt be tempted to bring their own individuality freely
into the discussion, in order to carry the patient along with them
and lift him over the barriers of his own narrow personality. It
might be expected that it would be quite allowable and indeed
useful, with a view to overcoming the patient’s existing
resistances, for the doctor to afford him a glimpse of his own
mental defects and conflicts and, by giving him intimate
information about his own life, enable him to put himself on an
equal footing. One confidence deserves another, and anyone who
demands intimacy from someone else must be prepared to give it in
return.
But in psycho-analytic relations
things often happen differently from what the psychology of
consciousness might lead us to expect. Experience does not speak in
favour of an affective technique of this kind. Nor is it hard to
see that it involves a departure from psycho-analytic principles
and verges upon treatment by suggestion. It may induce the patient
to bring forward sooner and with less difficulty things he already
knows but would otherwise have kept back for a time through
conventional resistances. But this technique achieves nothing
towards the uncovering of what is unconscious to the patient. It
makes him even more incapable of overcoming his deeper resistances,
and in severer cases it invariably fails by encouraging the patient
to be insatiable: he would like to reverse the situation, and finds
the analysis of the doctor more interesting than his own. The
resolution of the transference, too - one of the main tasks of the
treatment - is made more difficult by an intimate attitude on the
doctor’s part, so that any gain there may be at the beginning
is more than outweighed at the end. I have no hesitation,
therefore, in condemning this kind of technique as incorrect. The
doctor should be opaque to his patients and, like a mirror, should
show them nothing but what is shown to him. In practice, it is
true, there is nothing to be said against a psychotherapist
combining a certain amount of analysis with some suggestive
influence in order to achieve a perceptible result in a shorter
time - as is necessary, for instance, in institutions. But one has
a right to insist that he himself should be in no doubt about what
he is doing and should know that his method is not that of true
psycho-analysis.
Recommendations To Physicians Practising Psycho-Analysis
2473
(
h
) Another temptation
arises out of the educative activity which, in psycho-analytic
treatment, devolves on the doctor without any deliberate intention
on his part. When the developmental inhibitions are resolved, it
happens of itself that the doctor finds himself in a position to
indicate new aims for the trends that have been liberated. It is
then no more than a natural ambition if he endeavours to make
something specially excellent of a person whom he has been at such
pains to free from his neurosis and if he prescribes high aims for
his wishes. But here again the doctor should hold himself in check,
and take the patient’s capacities rather than his own desires
as guide. Not every neurotic has a high talent for sublimation; one
can assume of many of them that they would not have fallen ill at
all if they had possessed the art of sublimating their instincts.
If we press them unduly towards sublimation and cut them off from
the most accessible and convenient instinctual satisfactions, we
shall usually make life even harder for them than they feel it in
any case. As a doctor, one must above all be tolerant to the
weakness of a patient, and must be content if one has won back some
degree of capacity for work and enjoyment for a person even of only
moderate worth. Educative ambition is of as little use as
therapeutic ambition. It must further be borne in mind that many
people fall ill precisely from an attempt to sublimate their
instincts beyond the degree permitted by their organization and
that in those who have a capacity for sublimation the process
usually takes place of itself as soon as their inhibitions have
been overcome by analysis. In my opinion, therefore, efforts
invariably to make use of the analytic treatment to bring about
sublimation of instinct are, though no doubt always laudable, far
from being in every case advisable.
Recommendations To Physicians Practising Psycho-Analysis
2474
(
i
) To what extent should
the patient’s intellectual co-operation be sought for in the
treatment? It is difficult to say anything of general
applicability on this point: the patient’s personality is the
determining factor. But in any case caution and self-restraint must
be observed in this connection. It is wrong to set a patient tasks,
such as collecting his memories or thinking over some particular
period of his life. On the contrary, he has to learn above all -
what never comes easily to anyone - that mental activities such as
thinking something over or concentrating the attention solve none
of the riddles of a neurosis; that can only be done by patiently
obeying the psycho-analytic rule, which enjoins the exclusion of
all criticism of the unconscious or of its derivatives. One must be
especially unyielding about obedience to that rule with patients
who practise the art of sheering off into intellectual discussion
during their treatment, who speculate a great deal and often very
wisely about their condition and in that way avoid doing anything
to overcome it. For this reason I dislike making use of analytic
writings as an assistance to my patients; I require them to learn
by personal experience, and I assure them that they will acquire
wider and more valuable knowledge than the whole literature of
psycho-analysis could teach them. I recognize, however, that under
institutional conditions it may be of great advantage to employ
reading as a preparation for patients in analysis and as a means of
creating an atmosphere of influence.
I must give a most earnest
warning against any attempt to gain the confidence or support of
parents or relatives by giving them psycho-analytic books to read,
whether of an introductory or an advanced kind. This well-meant
step usually has the effect of bringing on prematurely the natural
opposition of the relatives to the treatment - an opposition which
is bound to appear sooner or later - so that the treatment is never
ever begun.
Let me express a hope that the
increasing experience of psycho-analysts will soon lead to
agreement on questions of technique and on the most effective
method of treating neurotic patients. As regards the treatment of
their relatives I must confess myself utterly at a loss, and I have
in general little faith in any individual treatment of them.
2475
ON BEGINNING THE TREATMENT
(FURTHER RECOMMENDATIONS ON THE TECHNIQUE
OF PSYCHO-ANALYSIS I)
(1913)
2476
Intentionally left blank
2477
ON BEGINNING THE TREATMENT
(FURTHER RECOMMENDATIONS ON THE TECHNIQUE
OF PSYCHO-ANALYSIS I)
Anyone who hopes to learn the noble game of
chess from book will soon discover that only the openings and
end-games admit of an exhaustive systematic presentation and that
the infinite variety of moves which develop after the opening defy
any such description. This gap in instruction can only be filled by
a diligent study of games fought out by masters. The rules which
can be laid down for the practice of psycho-analytic treatment are
subject to similar limitations.
In what follows I shall endeavour
to collect together for the use of practising analysts some of the
rules for the beginning of the treatment. Among them there are some
which may seem to be petty details, as, indeed, they are. Their
justification is that they are simply rules of the game which
acquire their importance from their relation to the general plan of
the game. I think I am well-advised, however, to call these rules
‘recommendations’ and not to claim any unconditional
acceptance for them. The extraordinary diversity of the psychical
constellations concerned, the plasticity of all mental processes
and the wealth of determining factors oppose any mechanization of
the technique; and they bring it about that a course of action that
is as a rule justified may at times prove ineffective, whilst one
that is usually mistaken may once in a while lead to the desired
end. These circumstances, however, do not prevent us from laying
down a procedure for the physician which is effective on the
average.
Some years ago I set out the most
important indications for selecting patients¹ and I shall
therefore not repeat them here. They have in the meantime been
approved by other psycho-analysts. But I may add that since then I
have made it my habit, when I know little about a patient, only to
take him on at first provisionally, for a period of one to two
weeks. If one breaks off within this period one spares the patient
the distressing impression of an attempted cure having failed. One
has only been undertaking a ‘sounding’ in order to get
to know the case and to decide whether it is a suitable one for
psycho-analysis. No other kind of preliminary examination but this
procedure is at our disposal; the most lengthy discussions and
questionings in ordinary consultations would offer no substitute.
This preliminary experiment, however, is itself the beginning of a
psycho-analysis and must conform to its rules. There may perhaps be
this distinction made, that in it one lets the patient do nearly
all the talking and explains nothing more than what is absolutely
necessary to get him to go on with what he is saying.
¹
‘On Psychotherapy’
(1905
a
).
On Beginning The Treatment
2478
There are also diagnostic reasons
for beginning the treatment with a trial period of this sort
lasting for one or two weeks. Often enough, when one sees a
neurosis with hysterical or obsessional symptoms, which is not
excessively marked and has not been in existence for long - just
the type of case, that is, that one would regard as suitable for
treatment - one has to, reckon with the possibility that it may be
a preliminary stage of what is known as dementia praecox
(‘schizophrenia’, in Bleuler’s terminology;
‘paraphrenia’, as I have proposed to call it), and that
sooner or later it will show a well-marked picture of that
affection. I do not agree that it is always possible to make the
distinction so easily. I am aware that there are psychiatrists who
hesitate less often in their differential diagnosis, but I have
become convinced that just as often they make mistakes. To make a
mistake, moreover, is of far greater moment for the psycho-analyst
than it is for the clinical psychiatrist, as he is called. For the
latter is not attempting to do anything that will be of use,
whichever kind of case it may be. He merely runs the risk of making
a theoretical mistake, and his diagnosis is of no more than
academic interest. Where the psycho-analyst is concerned, however,
if the case is unfavourable he has committed a practical error; he
has been responsible for wasted expenditure and has discredited his
method of treatment. He cannot fulfil his promise of cure if the
patient is suffering, not from hysteria or obsessional neurosis,
but from paraphrenia, and he therefore has particularly strong
motives for avoiding mistakes in diagnosis. In an experimental
treatment of a few weeks he will often observe suspicious signs
which may determine him not to pursue the attempt any further.
Unfortunately I cannot assert that an attempt of this kind always
enables us to arrive at a certain decision; it is only one wise
precaution the more.¹
¹
There is a great deal to be said about this
uncertainty in diagnosis, about the prospects of success in
analysing mild forms of paraphrenia and about the reasons for the
similarity between the two disorders; but I cannot enlarge on these
subjects in the present context. I should be glad to follow Jung in
contrasting hysteria and obsessional neurosis as
‘transference neuroses’ with the paraphrenic affections
as ‘introversion neuroses’, if it were not that such a
usage would deprive the concept of ‘introversion’ (of
the libido) of its sole legitimate meaning.
On Beginning The Treatment
2479
Lengthy preliminary discussions
before the beginning of the analytic treatment, previous treatment
by another method and also previous acquaintance between the doctor
and the patient who is to be analysed, have special disadvantageous
consequences for which one must be prepared. They result in the
patient’s meeting the doctor with a transference attitude
which is already established and which the doctor must first slowly
uncover instead of having the opportunity to observe the growth and
development of the transference from the outset. In this way the
patient gains a temporary start upon us which we do not willingly
grant him in the treatment.
One must mistrust all prospective
patients who want to make a delay before beginning their treatment.
Experience show that when the time agreed upon has arrived they
fail to put in an appearance, even though the motive for the delay
- i.e. their rationalization of their intention - seems to the
uninitiated to be above suspicion.
Special difficulties arise when
the analyst and his new patient or their families are on terms of
friendship or have social ties with one another. The psycho-analyst
who is asked to undertake the treatment of the wife or child of a
friend must be prepared for it to cost him that friendship, no
matter what the outcome of the treatment may be: nevertheless he
must make the sacrifice if he cannot find a trustworthy
substitute.
Both lay public and doctors -
still ready to confuse psycho-analysis with treatment by suggestion
- are inclined to attribute great importance to the expectations
which the patient brings to the new treatment. They often believe
in the case of one patient that he will not give much trouble,
because he has great confidence in psycho-analysis and is fully
convinced of its truth and efficacy; whereas in the case of
another, they think that he will undoubtedly prove more difficult,
because he has a sceptical outlook and will not believe anything
until he has experienced its successful results on his own person.
Actually, however, this attitude on the part of the patient has
very little importance. His initial trust or distrust is almost
negligible compared with the internal resistances which hold the
neurosis firmly in place. It is true that the patient’s happy
trustfulness makes our earliest relationship with him a very
pleasant one; we are grateful to him for that, but we warn him that
his favourable prepossession will be shattered by the first
difficulty that arises in the analysis. To the sceptic we say that
the analysis requires no faith, that he may be as critical and
suspicious as he pleases and that we do not regard his attitude as
the effect of his judgement at all, for he is not in a position to
form a reliable judgement on these matters; his distrust is only a
symptom like his other symptoms and it will not be an interference,
provided he conscientiously carries out what the rule of the
treatment requires of him.
No one who is familiar with the
nature of neurosis will be astonished to hear that even a man who
is very well able to carry out an analysis on other people can
behave like any other mortal and be capable of producing the most
intense resistances as soon as he himself becomes the object of
analytic investigation. When this happens we are once again
reminded of the dimension of depth in the mind, and it does not
surprise us to find that the neurosis has its roots in psychical
strata to which an intellectual knowledge of analysis has not
penetrated.
On Beginning The Treatment
2480
Points of importance at the
beginning of the analysis are arrangements about
time
and
money
.
In regard to time, I adhere
strictly to the principle of leasing a definite hour. Each patient
is allotted a particular hour of my available working day; it
belongs to him and he is liable for it, even if he does not make
use of it. This arrangement, which is taken as a matter of course
for teachers of music or languages in good society, may perhaps
seem too rigorous in a doctor, or even unworthy of his profession.
There will be an inclination to point to the many accidents which
may prevent the patient from attending every day at the same hour
and it will be expected that some allowance shall be made for the
numerous intercurrent ailments which may occur in the course of a
longish analytic treatment. But my answer is: no other way is
practicable. Under a less stringent régime the
‘occasional’ non-attendances increase so greatly that
the doctor finds his material existence threatened; whereas when
the arrangement is adhered to, it turns out that accidental
hindrances do not occur at all and intercurrent illnesses only very
seldom. The analyst is hardly ever put in the position of enjoying
a leisure hour which he is paid for and would be ashamed of; and he
can continue his work without interruptions, and is spared the
distressing and bewildering experience of finding that a break for
which he cannot blame himself is always bound to happen just when
the work promises to be especially important and rich in content.
Nothing brings home to one so strongly the significance of the
psychogenic factor in the daily life of men, the frequency of
malingering and the non-existent of chance, as a few years’
practice of psycho-analysis on the strict principle of leasing by
the hour. In cases of undoubted organic illnesses, which, after
all, cannot be excluded by the patient’s having a psychical
interest in attending, I break off the treatment, consider myself
entitled to dispose elsewhere of the hour which becomes free, and
take the patient back again as soon as he has recovered and I have
another hour vacant.
I work with my patients every day
except on Sundays and public holidays - that is, as a rule, six
days a week. For slight cases or the continuation of a treatment
which is already well advanced, three days a week will be enough.
Any restrictions of time beyond this bring no advantage either to
the doctor or the patient; and at the beginning of an analysis they
are quite out of the question. Even short interruptions have a
slightly, obscuring effect on the work. We used to speak jokingly
of the ‘Monday crust’ when we began work again after
the rest on Sunday. When the hours of work are less frequent, there
is a risk of not being able to keep pace with the patient’s
real life and of the treatment losing contact with the present and
being forced into by-paths. Occasionally, too, one comes across
patients to whom one must give more than the average time of one
hour a day, because the best part of an hour is gone before they
begin to open up and to become communicative at all.
On Beginning The Treatment
2481
An unwelcome question which the
patient asks the doctor at the outset is: ‘How long will the
treatment take? How much time will you need to relieve me of my
trouble?’ If one has proposed a trial treatment of a few
weeks one can avoid giving a direct answer to this question by
promising to make a more reliable pronouncement at the end of the
trial period. Our answer is like the answer given by the
Philosopher to the Wayfarer in Aesop’s fable. When the
Wayfarer asked how long a journey lay ahead, the Philosopher merely
answered ‘Walk!’ and afterwards explained his
apparently unhelpful reply on the ground that he must know the
length of the Wayfarer’s stride before he could tell how long
his journey would take. This expedient helps one over the first
difficulties; but the comparison is not a good one, for the
neurotic can easily alter his pace and may at times make only very
slow progress. In point of fact, the question as to the probable
duration of a treatment is almost unanswerable.
As the combined result of lack of
insight on the part of patients and disingenuousness on the part of
doctors, analysis finds itself expected to fulfil the most
boundless demands, and that in the shortest time. Let me, as an
example, give some details from a letter which I received a few
days ago from a lady in Russia. She is 53 years old, her illness
began twenty-three years ago and for the last ten years she has no
longer been able to do any continuous work. ‘Treatment in a
number of institutions for nervous cases’ have not succeeded
in making an ‘active life’ possible for her. She hopes
to be completely cured by psycho-analysis, which she has read
about, but her illness has already cost her family so much money
that she cannot manage to come to Vienna for longer than six weeks
or two months. Another added difficulty is that she wishes from the
very start to ‘explain’ herself in writing only, since
any discussion of her complexes would cause an explosion of feeling
in her or ‘render her temporarily unable to speak’. -
No one would expect a man to lift a heavy table with two fingers as
if it were a light stool, or to build a large house in the time it
would take to put up a wooden hut; but as soon as it becomes a
question of the neuroses - which do not seem so far to have found a
proper place in human thought - even intelligent people forget that
a necessary proportion must be observed between time, work and
success. This, incidentally, is an understandable result of the
deep ignorance which prevails about the aetiology of the neuroses.
Thanks to this ignorance, neurosis is looked or as a kind of
‘maiden from afar’. ‘None knew whence she
came’; so they expected that one day she would vanish.