Freud - Complete Works (276 page)

FIXATION
   The ground
prepared by the psychical factors which have just been
enumerated

                  
affords a favourable basis for such stimulations of infantile
sexuality as are experienced accidentally. The latter (first and
foremost, seduction by other children or by adults) provide the
material which, with the help of the former, can become fixated as
a permanent disorder. A good proportion of the deviations from
normal sexual life which are later observed both in neurotics and
in perverts are thus established from the very first by the
impressions of childhood - a period which is regarded as being
devoid of sexuality. The causation is shared between a compliant
constitution, precocity, the characteristic of increased
pertinacity of early impressions and the chance stimulation of the
sexual instinct by extraneous influences.

   The unsatisfactory conclusion,
however, that emerges from these investigations of the disturbances
of sexual life is that we know far too little of the biological
processes constituting the essence of sexuality to be able to
construct from our fragmentary information a theory adequate to the
understanding alike of normal and of pathological conditions.

  
¹
Increase in pertinacity may also possibly
be the effect of an especially intense somatic manifestation of
sexuality in early years.

1553

FREUD’S PSYCHO-ANALYTIC PROCEDURE

(1904)

1554

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1555

FREUD’S PSYCHO-ANALYTIC PROCEDURE

The particular psychotherapeutic procedure
which Freud practises and describes as
‘psycho-analysis’ is an outgrowth of what was known as
the ‘cathartic’ method and was discussed by him in
collaboration with Josef Breuer in their
Studies on Hysteria
(1895). This cathartic therapy was a discovery of Breuer’s,
and was first used by him some ten years earlier in the successful
treatment of a hysterical woman patient, in the course of which he
obtained an insight into the pathogenesis of her symptoms. As the
result of a personal suggestion from Breuer, Freud revived this
procedure and tested it on a considerable number of patients.

   The cathartic method of treatment
presupposed that the patient could be hypnotized, and was based on
the widening of consciousness that occurs under hypnosis. Its aim
was the removal of the pathological symptoms, and it achieved this
by inducing the patient to return to the psychical state in which
the symptom had appeared for the first time. When this was done,
there emerged in the hypnotized patient’s mind memories,
thoughts and impulses which had previously dropped out of his
consciousness; and, as soon as he had related these to the
physician, to the accompaniment of intense expressions of emotion,
the symptom was overcome and its return prevented. This experience,
which could be regularly repeated, was taken by the authors in
their joint paper to signify that the symptom takes the place of
suppressed processes which have not reached consciousness, that is,
that it represents a transformation (‘conversion’) of
these processes. They explained the therapeutic effectiveness of
their treatment as due to the discharge of what had previously
been, as it were, ‘strangulated’ affect attaching to
the suppressed mental acts ( ‘abreaction’). But in
practice the simple schematic outline of the therapeutic operation
was almost always complicated by the circumstance that it was not a
single
(‘traumatic’) impression, but in most
cases a
series
of impressions - not easily scanned - which
had participated in the creation of the symptom.

Freud's Psycho-Analytic Procedure

1556

   The main characteristic of the
cathartic method, in contrast to all other methods used in
psychotherapy, consists in the fact that its therapeutic efficacy
does not lie in The expectation is rather that the symptoms will
disappear automatically as soon as the operation, based on certain
hypotheses concerning the psychical mechanism, succeeds in
diverting the course of mental processes from their previous
channel, which found an outlet in the formation of the symptom.

   The changes which Freud
introduced in Breuer’s cathartic method of treatment were at
first changes in technique; these, however, led to new findings and
have finally necessitated a different though not contradictory
conception of the therapeutic process.

   The cathartic method had already
renounced suggestion; Freud went a step further and gave up
hypnosis as well. At the present time he treats his patients as
follows. Without exerting my other kind of influence, he invites
them to lie down in a comfortable attitude on a sofa, while he
himself sits on a chair behind them outside their field of vision.
He does not even ask them to close their eyes, and avoids touching
them in any way, as well as any other procedure which might be
reminiscent of hypnosis. The session thus proceeds like a
conversation between two people equally awake, but one of whom is
spared every muscular exertion and every distracting sensory
impression which might divert his attention from his own mental
activity.

   Since, as we all know, it depends
upon the choice of the patient whether he can be hypnotized or not,
no matter what the skill of the physician may be, and since a large
number of neurotic patients cannot be hypnotized by any means
whatever, it followed that with the abandonment of hypnosis the
applicability of the treatment was assured to an unlimited number
of patients. On the other hand, the widening of consciousness,
which had supplied the physician with precisely the psychical
material of memories and images by the help of which the
transformation of the symptoms and the liberation of the affects
was accomplished, was now missing. Unless a substitute could be
produced for this missing element, any therapeutic effect was out
of the question.

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1557

   Freud found such a substitute -
and a completely satisfactory one - in the
‘associations’ of his patients; that is, in the
involuntary thoughts (most frequently regarded as disturbing
elements and therefore ordinarily pushed aside) which so often
break across the continuity of a consecutive narrative.

   In order to secure these ideas
and associations he asks the patient to ‘let himself
go’ in what he says, ‘as you would do in a conversation
in which you were rambling on quite disconnectedly and at
random’. Before he asks them for a detailed account of their
case history he insists that they must include in it whatever comes
into their heads, even if they think it unimportant or irrelevant
or nonsensical; he lays special stress on their not omitting any
thought or idea from their story because to relate it would be
embarrassing or distressing to them. In the course of collecting
this material of otherwise neglected ideas Freud made the
observations which became the determining factor of his entire
theory. Gaps appear in the patient’s memory even while he
narrates his case: actual occurrences are forgotten, the
chronological order is confused, or causal connections are broken,
with unintelligible results. No neurotic case history is without
amnesia of some kind or other. If the patient is urged to fill
these gaps in his memory by an increased application of attention,
it is noticed that all the ideas which occur to him are pushed back
by every possible critical expedient, until at last he feels
positive discomfort when the memory really returns. From this
experience Freud concludes that the amnesias are the result of a
process which he calls ‘
repression
’ and the
motive for which he finds in feelings of unpleasure. The psychical
forces which have brought about this repression can also be
detected, according to him, in the ‘
resistance
’
which operates against the recovery of the lost memories.

   The factor of resistance has
become one of the corner-stones of his theory. The ideas which are
normally pushed aside on every sort of excuse - such as those
mentioned above - are regarded by him as derivatives of the
repressed psychical phenomena (thoughts and impulses), distorted
owing to the resistance against their reproduction. Ideas which are
normally pushed aside on every sort of excuse - such as those
mentioned above - are regarded by him as derivatives of the
repressed psychical phenomena (thoughts and impulses),
distorted owing to the resistance against their reproduction.

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1558

   The greater the resistance, the
greater is the distortion. The value of these unintentional
thoughts for the purposes of therapeutic technique lies in this
relation of theirs to the repressed psychical material. If one
possesses a procedure which makes it possible to arrive at the
repressed material from the associations, at the distorted material
from the distortions, then what was formerly unconscious in mental
life can be made accessible to consciousness even without
hypnosis.

   Freud has developed on this basis
an art of interpretation which takes on the task of, as it were,
extracting the pure metal of the repressed thoughts from the ore of
the unintentional ideas. This work of interpretation is applied not
only to the patient’s ideas but also to his dreams, which
open up the most direct approach to a knowledge of the unconscious,
to his unintentional as well as to his purposeless actions
(symptomatic acts) and to the blunders he makes in everyday life
(slips of the tongue, bungled actions, and so on). The details of
this technique of interpretation or translation have not yet been
published by Freud. According to indications he has given, they
comprise a number of rules, reached empirically, of how the
unconscious material may be reconstructed from the associations,
directions on how to know what it means when the patient’s
ideas cease to flow, and experiences of the most important typical
resistances that arise in the course of such treatments. A bulky
volume called
The Interpretation of Dreams
, published by
Freud in 1900, may be regarded as the forerunner of an initiation
into his technique.

   From these remarks on the
technique of the psycho-analytic method the conclusion might be
drawn that its inventor has given himself needless trouble and has
made a mistake in abandoning the less complicated hypnotic mode of
procedure. However, in the first place, the technique of
psycho-analysis is much easier in practice, when once one has
learnt it, than any description of it would indicate; and,
secondly, there is no other way which leads to the desired goal, so
that the hard road is still the shortest one to travel. The
objection to hypnosis is that it conceals the resistance and for
that reason has obstructed the physician’s insight into the
play of psychical forces. Hypnosis does not do away with the
resistance but only evades it and therefore yields only incomplete
information and transitory therapeutic success.

Freud's Psycho-Analytic Procedure

1559

   The task which the
psycho-analytic method seeks to perform may be formulated in
different ways, which are, however, in their essence equivalent. It
may, for instance, be stated thus: the task of the treatment is to
remove the amnesias. When all gaps in memory have been filled in,
all the enigmatic products of mental life elucidated, the
continuance and even a renewal of the morbid condition are made
impossible. Or the formula may be expressed in this fashion: all
repressions must be undone. The mental condition is then the same
as one in which all amnesias have been removed. Another formulation
reaches further: the task consists in making the unconscious
accessible to consciousness, which is done by overcoming the
resistances. But it must be remembered that an ideal condition such
as this is not present even in the normal, and further that it is
only rarely possible to carry the treatment to a point approaching
it. Just as health and sickness are not different from each other
in essence but are only separated by a quantitative line of
demarcation which can be determined in practice, so the aim of the
treatment will never be anything else but the
practical
recovery of the patient, the restoration of his ability to lead an
active life and of his capacity for enjoyment. In a treatment which
is incomplete or in which success is not perfect, one may at any
rate achieve a considerable improvement in the general mental
condition, while the symptoms (though now of smaller importance to
the patient) may continue to exist without stamping him as a sick
man.

   The therapeutic procedure remains
the same, apart from insignificant modifications, for all the
various clinical pictures that may be presented in hysteria, and
all forms of obsessional neurosis. This does not imply, however,
that it can have an unlimited application. The nature of the
psycho-analytic method involves indications and contra-indications
with respect to the person to be treated as well as with respect to
the clinical picture. Chronic cases of psychoneuroses without any
very violent or dangerous symptoms are the most favourable ones for
psycho-analysis: thus in the first place every species of
obsessional neurosis, obsessive thinking and acting, and cases of
hysteria in which phobias and aboulias play the most important
part; further, all somatic expressions of hysteria whenever they do
not, as in anorexia, require the physician to attend promptly to
the speedy removal of symptoms. In acute cases of hysteria it will
be necessary to wait for a calmer stage; in all cases where nervous
exhaustion dominates the clinical picture a treatment which in
itself demands effort, brings only slow improvement and for a time
cannot take the persistence of the symptoms into account, will have
to be avoided.

Freud's Psycho-Analytic Procedure

1560

   Various qualifications are
required of anyone who is to be beneficially affected by
psycho-analysis. To begin with, he must be capable of a psychically
normal condition; during periods of confusion or melancholic
depression nothing can be accomplished even in cases of hysteria.
Furthermore, a certain measure of natural intelligence and ethical
development are to be required of him; if the physician has to deal
with a worthless character, he soon loses the interest which makes
it possible for him to enter profoundly into the patient’s
mental life. Deep-rooted malformations of character, traits of an
actually degenerate constitution, show themselves during treatment
as sources of a resistance that can scarcely be overcome. In this
respect the constitution of the patient sets a general limit to the
curative effect of psychotherapy. If the patient’s age is in
the neighbourhood of the fifties the conditions for psycho-analysis
become unfavourable. The mass of psychical material is then no
longer manageable; the time required for recovery is too long; and
the ability to undo psychical processes begins to grow weaker.