Freud - Complete Works (712 page)

The Question Of Lay Analysis

4379

   But I have already told you that
I have no intention of making proposals which are based on the
decision as to whether legal control or letting things go is to be
preferred in the matter of analysis. I know this is a question of
principle on the reply to which the inclinations of persons in
authority will probably have more influence than arguments. I have
already set out what seems to me to speak in favour of a policy of
laissez faire
. If the other decision is taken - for a policy
of active intervention - then it seems to me that in any case a
lame and unjust measure of ruthlessly forbidding analysis by
non-doctors will be an insufficient outcome. More will have to be
considered in that case: the conditions will have to be laid down
under which the practice of analysis shall be permitted to all
those who seek to make use of it, an authority will have to be set
up from whom one can learn what analysis is and what sort of
preparation is needed for it, and the possibilities for instruction
in analysis will have to be encouraged. We must therefore either
leave things alone or establish order and clarity; we must not rush
into a complicated situation with a single isolated prohibition
derived mechanically from a regulation that has become
inadequate.

The Question Of Lay Analysis

4380

VII

   ‘Yes, but the doctors! the
doctors! I cannot induce you to go into the real subject of our
conversations. You still keep on evading me. It is a question of
whether we should not give doctors the exclusive right of
practising analysis - for all I care, after they have fulfilled
certain conditions. The majority of doctors are certainly not
quacks in analysis as you have represented them. You say yourself
that the great majority of your pupils and followers are doctors.
It has come to my ears that they are far from sharing your point of
view on the question of lay analysis. I may no doubt assume that
your pupils agree with your demands for sufficient preparation and
so on; and yet these pupils think it consistent to close the
practice of analysis to laymen. Is that so? and if so, how do you
explain it?’

   I see you are well informed. Yes,
it is so. Not all, it is true, but a good proportion of my medical
colleagues do not agree with me over this, and are in favour of
doctors having an exclusive right to the analytic treatment of
neurotics. This will show you that differences of opinion are
allowed even in our camp. The side I take is well known and the
contradiction on the subject of lay analysis does not interfere
with our good understanding. How can I explain the attitude of
these pupils of mine to you? I do not know for certain; I think it
must be the power of professional feeling. The course of their
development has been different from mine, they still feel
uncomfortable in their isolation from their colleagues, they would
like to be accepted by the ‘profession’ as having
plenary rights, and are prepared, in exchange for that tolerance,
to make a sacrifice at a point whose vital importance is not
obvious to them. Perhaps it may be otherwise; to impute motives of
competition to them would be not only to accuse them of base
sentiments but also to attribute a strange shortsightedness to
them. They are always ready to introduce other doctors into
analysis, and from a material point of view it must be a matter of
indifference to them whether they have to share the available
patients with medical colleagues or with laymen. But something
different probably plays a part. These pupils of mine may be
influenced by certain factors which guarantee a doctor an undoubted
advantage over a layman in analytic practice.

The Question Of Lay Analysis

4381

   ‘Guarantee him an
advantage? There we have it. So you are admitting the advantage at
last? This should settle the question.’

   The admission is not hard for me
to make. It may show you that I am not so passionately prejudiced
as you suppose. I have put off mentioning these things because
their discussion will once again make theoretical considerations
necessary.

   ‘What are you thinking of
now?’

   First there is the question of
diagnosis. When one takes into analysis a patient suffering from
what are described as nervous disorders, one wishes beforehand to
be certain - so far, of course, as certainty can be attained - that
he is suited for this kind of treatment, that one can help him,
that is to say, by this method. That, however, is only the case if
he really has a neurosis.

   ‘I should have thought that
would be recognizable from the phenomena, the symptoms, of which he
complains.’

   This is where a fresh
complication arises. It cannot always be recognized with complete
certainty. The patient may exhibit the external picture of a
neurosis, and yet it may be something else - the beginning of an
incurable mental disease or the preliminary of a destructive
process in the brain. The distinction - the differential diagnosis
- is not always easy and cannot be made immediately in every phase.
The responsibility for such a decision can of course only be
undertaken by a doctor. As I have said, it is not always easy for
him. The illness may have an innocent appearance for a considerable
time, till in the end it after all displays its evil character.
Indeed, it is one of the regular fears of neurotics that they may
become insane. However, if a doctor has been mistaken for a time
over a case of this sort or has been in uncertainty about it, no
harm has been caused and nothing unnecessary has been done. Nor
indeed would the analytic treatment of this case have done any
harm, though it would have been exposed as an unnecessary waste.
And moreover there would certainly be enough people who would blame
the analysis for the unfortunate outcome. Unjustly, no doubt, but
such occasions ought to be avoided.

   ‘But that sounds hopeless.
It strikes at the roots of everything you have told me about the
nature and origin of a neurosis.’

The Question Of Lay Analysis

4382

   Not at all. It merely confirms
once again the fact that neurotics are a nuisance and an
embarrassment for all concerned - including the analysts. But
perhaps I shall clear up your confusion if I state my new
information in more correct terms. It would probably be more
correct to say of the cases we are now dealing with that they have
readily developed a neurosis, but that it is not psychogenic but
somatogenic - that its causes are not mental but physical. Do you
understand?

   ‘Oh, yes, I understand. But
I cannot bring it into harmony with the other side, the
psychological one.’

   That can be managed, though, if
one bears in mind the complexities of living substance. In what did
we find the essence of a neurosis? In the fact that the ego, the
higher organization of the mental apparatus (elevated through the
influence of the external world), is not able to fulfil its
function of mediating between the id and reality, that in its
feebleness it draws back from some instinctual portions of the id
and, to make up for this, has to put up with the consequences of
its renunciation in the form of restrictions, symptoms and
unsuccessful reaction-formations.

   A feebleness of the ego of this
sort is to be found in all of us in childhood; and that is why the
experiences of the earliest years of childhood are of such great
importance for later life. Under the extraordinary burden of this
period of childhood we have in a few years to cover the enormous
developmental distance between stone-age primitive men and the
participants in contemporary civilization, and, at the same time
and in particular, we have to fend off the instinctual impulses of
the early sexual period - under this burden, then, our ego takes
refuge in repression and lays itself open to a childhood neurosis,
the precipitate of which it carries with it into maturity as a
disposition to a later nervous illness. Everything now depends on
how the growing organism is treated by fate. If life becomes too
hard, if the gulf between instinctual claims and the demands of
reality becomes too great, the ego may fail in its efforts to
reconcile the two, and the more readily, the more it is inhibited
by the disposition carried over by it from infancy. The process of
repression is then repeated, the instincts tear themselves away
from the ego’s domination, find their substitutive
satisfactions along the paths of regression, and the poor ego has
become helplessly neurotic.

The Question Of Lay Analysis

4383

   Only let us hold fast to this:
the nodal point and pivot of the whole situation is the relative
strength of the ego organization. We shall then find it easy to
complete our aetiological survey. As what may be called the normal
causes of neurotic illness we already know the feebleness of the
childhood ego, the task of dealing with the early sexual impulses
and the effects of the more or less chance experiences of
childhood. Is it not possible, however, that yet other factors play
a part, derived from the time before the beginning of the
child’s life? For instance, an innate strength and unruliness
of the instinctual life in the id, which from the outset sets the
ego tasks too hard for it? Or a special developmental feebleness of
the ego due to unknown reasons? Such factors must of course acquire
an aetiological importance, in some cases a transcendent one. We
have invariably to reckon with the instinctual strength of the id;
if it has developed to excess, the prospects of our therapy are
poor. We still know too little of the causes of a developmental
inhibition of the ego. These then would be the cases of neurosis
with an essentially constitutional basis. Without some such
constitutional, congenital favouring factors a neurosis can, no
doubt, scarcely come about.

   But if the relative feebleness of
the ego is the decisive factor for the genesis of a neurosis, it
must also be possible for a later physical illness to produce a
neurosis, provided that it can bring about an enfeeblement of the
ego. And that, once again, is very frequently found. A physical
disorder of this kind can affect the instinctual life in the id and
increase the strength of the instincts beyond the limit up to which
the ego is capable of coping with them. The normal model of such
processes is perhaps the alteration in women caused by the
disturbances of menstruation and the menopause. Or again, a general
somatic illness, indeed an organic disease of the nervous central
organ, may attack the nutritional conditions of the mental
apparatus and compel it to reduce its functioning and to bring to a
halt its more delicate workings, one of which is the maintenance of
the ego organization. In all these cases approximately the same
picture of neurosis emerges; neurosis always has the same
psychological mechanism, but, as we see, a most varied and often
very complex aetiology.

The Question Of Lay Analysis

4384

   ‘You please me better now.
You have begun talking like a doctor at last. And now I expect you
to admit that such a complicated medical affair as a neurosis can
only be handled by a doctor.’

   I fear you are overshooting the
mark. What we have been discussing was a piece of pathology, what
we are concerned with in analysis is a therapeutic procedure. I
allow - no, I insist - that in every case which is under
consideration for analysis the diagnosis shall be established first
by a doctor. Far the greater number of neuroses which occupy us are
fortunately of a psychogenic nature and give no grounds for
pathological suspicions. Once the doctor has established this, he
can confidently hand over the treatment to a lay analyst. In our
analytical societies matters have always been arranged in that way.
Thanks to the intimate contact between medical and non-medical
members, mistakes such as might be feared have been as good as
completely avoided. There is a further contingency, again, in which
the analyst has to ask the doctor’s help. In the course of an
analytic treatment, symptoms - most often physical symptoms - may
appear about which one is doubtful whether they should be regarded
as belonging to the neurosis or whether they should be related to
an independent organic illness that has intervened. The decision on
this point must once again be left to a doctor.

   ‘So that even during the
course of an analysis a lay analyst cannot do without a doctor. A
fresh argument against their fitness.’

   No. No argument against lay
analysts can be manufactured out of this possibility, for in such
circumstances a medical analyst would not act differently.

   ‘I do not understand
that.’

   There is a technical rule that an
analyst, if dubious symptoms like this emerge during the treatment,
shall not submit them to his own judgement but shall get them
reported upon by a doctor who is not connected with analysis - a
consultant physician, perhaps - even if the analyst himself is a
doctor and still well versed in his medical knowledge.

   ‘And why should a rule be
made that seems to me so uncalled-for?’

The Question Of Lay Analysis

4385

   It is not uncalled-for; in fact
there are several reasons for it. In the first place it is not a
good plan for a combination of organic and psychical treatment to
be carried out by one and the same person. Secondly the relation in
the transference may make it inadvisable for the analyst to examine
the patient physically. And thirdly the analyst has every reason
for doubting whether he is unprejudiced, since his interests are
directed so intensely to the psychical factors.