Freud - Complete Works (277 page)

   In spite of all these
limitations, the number of persons suitable for psycho-analytic
treatment is extraordinarily large and the extension which has come
to our therapeutic powers from this method is, according to Freud,
very considerable. Freud requires long periods, six months to three
years, for an effective treatment; yet he informs us that up to the
present, owing to various circumstances which can easily be
guessed, he has for the most part been in a position to try his
treatment only on very severe cases: patients have come to him
after many years of illness, completely incapacitated for life,
and, after being disappointed by all kinds of treatments, have had
recourse as a last resort to a method which is novel and has been
greeted with many doubts. In cases of less severe illness the
duration of the treatment might well be much shorter, and very
great advantage in the direction of future prevention might be
achieved.

1561

ON PSYCHOTHERAPY

(1905)

1562

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1563

ON PSYCHOTHERAPY

Gentlemen, - Some eight years have passed
since I had the opportunity, on the invitation of your much
respected chairman, Professor von Reder, of speaking here on the
subject of hysteria. Shortly before that occasion I had published,
in 1895, in collaboration with Dr. Josef Breuer, the
Studies on
Hysteria
in which, on the basis of the new knowledge which we
owe to his researches, an attempt was made to introduce a new
method of treating the neuroses. I am glad to be able to say that
the efforts we made in our
Studies
have met with success;
the ideas expressed in them concerning the effects produced by
psychical traumas owing to retention of affect, as well as the
conception of hysterical symptoms as the results of an excitation
transposed from the sphere of the mental to the physical - ideas
for which we coined the terms ‘abreaction’ and
‘conversion’ - are to-day generally known and
understood. There is, at least in German speaking countries, no
presentation of hysteria to-day that does not take them to some
extent into account, and we have no colleagues who do not, for a
short distance at least, follow the road pointed out by us. And
yet, while they were still new, these theorems and this terminology
must have sounded not a little strange.

   I cannot say the same of the
therapeutic procedure which was introduced to our colleagues at the
same time as our theory; it is still struggling for recognition.
There may be special reasons for this. At that time the technique
of the method was as yet undeveloped; it was impossible for me to
give medical readers of the book the directions necessary to enable
them to carry through the treatment completely. But causes of a
general nature have certainly also played a part. To many
physicians, even to-day, psychotherapy seems to be a product of
modern mysticism and, compared with our physico-chemical remedies
which are applied on the basis of physiological knowledge, appears
positively unscientific and unworthy of the attention of a serious
investigator. Allow me, therefore, to defend the cause of
psychotherapy before you, and to point out to you what may be
described as unjust or mistaken in this condemnation of it.

On Psychotherapy

1564

   In the first place, let me remind
you that psychotherapy is in no way a modern method of treatment.
On the contrary, it is the most ancient form of therapy in
medicine. In Löwenfeld’s instructive
Lehrbuch der
gesamten Psychotherapie
many of the methods of primitive and
ancient medical science are described. The majority of them must be
classed under the head of psychotherapy; in order to effect a cure
a condition of ‘expectation coloured by faith’ was
induced in sick persons - a condition which answers a similar
purpose for us to-day. Even since physicians have come upon other
remedies, psychotherapeutic endeavours of one kind or another have
never completely disappeared from medicine.

   Secondly, let me draw your
attention to the fact that we physicians cannot discard
psychotherapy, if only because another person intimately concerned
in the process of recovery - the patient - has no intention of
discarding it. You will know of the increase in knowledge on this
subject that we owe to the Nancy school, to Liébeault and
Bernheim. A factor dependent on the psychical disposition of the
patient contributes, without any intention on our part, to the
effect of every therapeutic process initiated by a physician; most
frequently it is favourable to recovery, but often it acts as an
inhibition. We have learned to use the word
‘suggestion’ for this phenomenon, and Möbius has
taught us that the unreliability which we deplore in so many of our
therapeutic measures may be traced back to the disturbing influence
of this very powerful factor. All physicians, therefore, yourselves
included, are continually practising psychotherapy, even when you
have no intention of doing so and are not aware of it; it is a
disadvantage, however, to leave the mental factor in your treatment
so completely in the patient’s hands. Thus it is impossible
to keep a check on it, to administer it in doses or to intensify
it. Is it not then a justifiable endeavour on the part of a
physician to seek to obtain command of this factor, to use it with
a purpose, and to direct and strengthen it? This and nothing else
is what scientific psychotherapy proposes.

On Psychotherapy

1565

   And, in the third place,
Gentlemen, I would remind you of the well-established fact that
certain diseases, in particular the psychoneuroses, are far more
readily accessible to mental influences than to any other form of
medication. It is not a modern dictum but an old saying of
physicians that these diseases are not cured by the drug but by the
physician, that is, by the personality of the physician, inasmuch
as through it he exerts a mental influence. I am well aware that
you favour the view which Vischer, the professor of aesthetics,
expressed so well in his parody of Faust:

                                                               
Ich weiß, das Physikalische

                                                               
Wirkt öfters aufs Moralische¹

But would it not be more to the point to say -
and is it not more often the case - moral (that is, mental) means
can influence a man’s moral side?

   There are many ways and means of
practising psychotherapy. All that lead to recovery are good. Our
usual word of comfort, which we dispense so liberally to our
patients - ‘You’ll soon be all right again’ -,
corresponds to one of these psychotherapeutic methods; but now that
we have deeper insight into the neuroses, we are no longer obliged
to confine ourselves to the word of comfort. We have developed the
technique of hypnotic suggestion, and psychotherapy by mental
distraction, by exercise, and by eliciting suitable affects. I
despise none of these methods and would use them all in appropriate
circumstances. If I have actually come to confine myself to one
form of treatment, to the method which Breuer called
cathartic
, but which I myself prefer to call
‘analytic’, it is because I have allowed myself to be
influenced by purely subjective motives. Because of the part I have
played in founding this therapy, I feel a personal obligation to
devote myself to closer investigation of it and to the development
of its technique. And I may say that the analytic method of
psychotherapy is the one that penetrates most deeply and carries
farthest, the one by means of which the most extensive
transformations can be effected in patients. Putting aside for a
moment the therapeutic point of view, I may also say of it that it
is the most interesting method, the only one which informs us at
all about the origin and inter-relation of morbid phenomena. Owing
to the insight which we gain into mental illness by this method, it
alone should be capable of leading us beyond its own limits and of
pointing out the way to other forms of therapeutic influence.

  
¹
[I know that the physical

      Often
influences the moral.]

On Psychotherapy

1566

   Permit me now to correct a few
mistakes that have been made in regard to this cathartic or
analytic method of psychotherapy, and to give a few explanations on
the subject.

   (
a
) I have observed that
this method is very often confused with hypnotic treatment by
suggestion; I have noticed this because it happens comparatively
often that colleagues who do not ordinarily confide their cases to
me send me patients refractory patients, of course - with a request
that I should hypnotize them. Now I have not used hypnosis for
therapeutic purposes for some eight years (except for a few special
experiments) so that I habitually send back these cases with the
recommendation that anyone who relies upon hypnosis may employ it
himself. There is, actually, the greatest possible antithesis
between suggestive and analytic technique - the same antithesis
which, in regard to the fine arts, the great Leonardo da Vinci
summed up in the formulas:
per via di porre
and
per via
di levare
. Painting, says Leonardo, works
per via di
porre
, for it applies a substance - particles of colour - where
there was no thing before, on the colourless canvas; sculpture,
however, proceeds
per via di levare
, since it takes away
from the block of stone all that hides the surface of the statue
contained in it. In a similar way, the technique of suggestion aims
at proceeding
per via di porre
; it is not concerned with the
origin, strength and meaning of the morbid symptoms, but instead,
it superimposes something - a suggestion - in the expectation that
it will be strong enough to restrain the pathogenic idea from
coming to expression. Analytic therapy, on the other hand, does not
seek to add or to introduce anything new, but to take away
something, to bring out something; and to this end concerns itself
with the genesis of the morbid symptoms and the psychical context
of the pathogenic idea which it seeks to remove. It is by the use
of this mode of investigation that analytic therapy has increased
our knowledge so notably. I gave up the suggestive technique, and
with it hypnosis, so early in my practice because I despaired of
making suggestion powerful and enduring enough to effect permanent
cures. In every severe case I saw the suggestions which had been
applied crumble away again; after which the disease or some
substitute for it was back once more. Besides all this I have
another reproach to make against this method, namely, that it
conceals from us all insight into the play of mental forces; it
does not permit us, for example, to recognize the
resistance
with which the patient clings to his disease and thus even fights
against his own recovery; yet it is this phenomenon of resistance
which alone makes it possible to understand his behaviour in daily
life.

On Psychotherapy

1567

   (
b
) It seems to me that
there is a widespread and erroneous impression among my colleagues
that this technique of searching for the origins of an illness and
removing its manifestations by that means is an easy one which can
be practised off-hand, as it were. I conclude this from the fact
that not one of all the people who have shown an interest in my
therapy and passed definite judgements upon it has ever asked me
how I actually go about it. There can be only one reason for this:
that they think there is nothing to enquire about, that the thing
is perfectly self-evident. Again, I am now and then astonished to
hear that in this or that department of a hospital a young
assistant has received an order from his chief to undertake a
‘psycho-analysis’ of a hysterical patient. I am sure he
would not be allowed to examine an extirpated tumour unless he had
convinced his chiefs that he was conversant with histological
technique. Similarly, reports reach my ears that this or that
colleague has arranged appointments with a patient in order to
undertake a mental treatment of the case, though I am certain he
knows nothing of the technique of any such therapy. His expectation
must be therefore that the patient will make him a present of his
secrets, or perhaps that he is looking for salvation in some sort
of confession or confidence. I should not be surprised if a patient
were injured rather than benefited by being treated in such a
fashion. For it is not so easy to play upon the instrument of the
mind. I am reminded on such occasions of the words of a
world-famous neurotic - though it is true that he was never treated
by a physician but existed only in a poet’s imagination -
Hamlet, Prince of Denmark. The King has ordered two courtiers,
Rosenkranz and Guildenstern, to follow him, to question him and
drag the secret of his depression out of him. He wards them off.
Then some recorders are brought on the stage and Hamlet, taking one
of them, begs one of his tormentors to play upon it, telling him
that it is as easy as lying. The courtier excuses himself, for he
knows no touch of the instrument, and when he cannot be persuaded
to try it, Hamlet finally breaks out with these words: ‘Why,
look you now, how unworthy a thing you make of me! You would play
upon me; . . . 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.)

On Psychotherapy

1568

   (
c
) From certain of my
remarks you will have gathered that there are many characteristics
in the analytic method which prevent it from being an ideal form of
therapy.
Tuto, cito, jucunde
: investigation and probing do
not indicate speedy results, and the resistance I have mentioned
would prepare you to expect unpleasantness of various kinds.
Psycho-analytic treatment certainly makes great demands upon the
patient as well as upon the physician. From the patient it requires
perfect sincerity - a sacrifice in itself; it absorbs time and is
therefore also costly; for the physician it is no less
time-absorbing, and the technique which he must study and practise
is fairly laborious. I consider it quite justifiable to resort to
more convenient methods of treatment as long as there is any
prospect of achieving anything by their means. That, after all, is
the only point at issue. If the more difficult and lengthy method
accomplishes considerably more than the short and easy one, then,
in spite of everything, the use of the former is justified. Only
consider, Gentlemen, how much more inconvenient and costly is the
Finsen therapy of lupus than the method of cauterizing and scraping
previously employed; and yet the use of the former signifies a
great advance, for it performs a radical cure. Although I do not
wish to carry this comparison to extremes, the psycho-analytic
method may claim a similar privilege. Actually, I have been able to
elaborate and to test my therapeutic method only on severe, indeed
on the severest cases; at first my material consisted entirely of
patients who had tried everything else without success, and had
spent long years in sanatoria. I have scarcely been able to bring
together sufficient material to enable me to say how my method
works with those slighter, episodic cases which we see recovering
under all kinds of influences and even spontaneously.
Psycho-analytic therapy was created through and for the treatment
of patients permanently unfit for existence, and its triumph has
been that it has made a satisfactorily large number of these
permanently
fit
for existence. In the face of such an
achievement all the effort expended seems trivial. We cannot
conceal from ourselves what, as physicians, we are in the habit of
denying to our patients, namely, that a severe neurosis is no less
serious for the sufferer than any cachexia or any of the dreaded
major diseases.