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The Psycho-Analytic View Of Psychogenic Disturbance Of Vision

2371

   Yet another line of thought
extending into organic research branches off from psycho-analysis.
We may ask ourselves whether the suppression of sexual component
instincts which is brought about by environmental influences is
sufficient in itself to call up functional disturbances in organs,
or whether special constitutional conditions must be present in
order that the organs may be led to an exaggeration of their
erotogenic role and consequently provoke repression of the
instincts. We should have to see in those conditions the
constitutional part of the disposition to fall ill of psychogenic
and neurotic disorders. This is the factor to which, as applied to
hysteria, I gave the provisional name of ‘somatic
compliance’.

 
2372

‘WILD’ PSYCHO-ANALYSIS

(1910)

2373

Intentionally left blank

2374

‘WILD’ PSYCHO-ANALYSIS

A few days ago a middle-aged lady, under the
protection of a female friend, called upon me for a consultation,
complaining of anxiety-states. She was in the second half of her
forties, fairly well preserved, and had obviously not yet finished
with her womanhood. The precipitating cause of the outbreak of her
anxiety-states had been a divorce from her last husband; but the
anxiety had become considerably intensified, according to her
account, since she had consulted a young physician in the suburb
she lived in, for he had informed her that the cause of her anxiety
was her lack of sexual satisfaction. He said that she could not
tolerate the loss of intercourse with her husband, and so there
were only three ways by which she could recover her health - she
must either return to her husband, or take a lover, or obtain
satisfaction from herself. Since then she had been convinced that
she was incurable, for she would not return to her husband, and the
other two alternatives were repugnant to her moral and religious
feelings. She had come to me, however, because the doctor had said
that this was a new discovery for which I was responsible, and that
she had only to come and ask me to confirm what he said, and I
should tell her that this and nothing else was the truth. The
friend who was with her, an older, dried-up and unhealthy-looking
woman, then implored me to assure the patient that the doctor was
mistaken; it could not possibly be true, for she herself had been a
widow for many years, and had nevertheless remained respectable
without suffering from anxiety.

   I will not dwell on the awkward
predicament in which I was placed by this visit, but instead will
consider the conduct of the practitioner who sent this lady to me.
First, however, let us bear a reservation in mind which may
possibly not be superfluous - indeed we will hope so. Long years of
experience have taught me - as they could teach everyone else - not
to accept straight away as true what patients, especially nervous
patients, relate about their physician. Not only does a
nerve-specialist easily become the object of many of his
patients’ hostile feelings, whatever method of treatment he
employs; he must also sometimes resign himself to accepting
responsibility, by a kind of projection, for the buried repressed
wishes of his nervous patients. It is a melancholy but significant
fact that such accusations nowhere find credence more readily than
among other physicians.

'Wild' Psycho-Analysis

2375

   I therefore have reason to hope
that this lady gave me a tendentiously distorted account of what
her doctor had said and that I do a man who is unknown to me an
injustice by connecting my remarks about ‘wild’
psycho-analysis with this incident. But by doing so I may perhaps
prevent others from doing harm to their patients.

   Let us suppose, therefore, that
her doctor spoke to the patient exactly as she reported. Everyone
will at once bring us the criticism that if a physician thinks it
necessary to discuss the question of sexuality with a woman he must
do so with tact and consideration. Compliance with this demand,
however, coincides with carrying out certain
technical rules
of psycho-analysis. Moreover, the physician in question was
ignorant of a number of the
scientific theories
of
psycho-analysis or had misapprehended them, and thus showed how
little he had penetrated into an understanding of its nature and
purposes.

   Let us start with the latter, the
scientific
errors. The doctor’s advice to the lady
shows clearly in what sense he understands the expression
‘sexual life’ - in the popular sense, namely, in which
by sexual needs nothing is meant but the need for coitus or
analogous acts producing orgasm and emission of the sexual
substances. He cannot have remained unaware, however, that
psycho-analysis is commonly reproached with having extended the
concept of what is sexual far beyond its usual range. The fact is
undisputed; I shall not discuss here whether it may justly be used
as a reproach. In psycho-analysis the concept of what is sexual
comprises far more; it goes lower and also higher than its popular
sense. This extension is justified genetically; we reckon as
belonging to ‘sexual life’ all the activities of the
tender feelings which have primitive sexual impulses as their
source, even when those impulses have become inhibited in regard to
their original sexual aim or have exchanged this aim for another
which is no longer sexual. For this reason we prefer to speak of
psychosexuality
, thus laying stress on the point that the
mental factor in sexual life should not be overlooked or
underestimated. We use the word ‘sexuality’ in the same
comprehensive sense as that in which the German language uses the
word
lieben
[‘to love’]. We have long known,
too, that mental absence of satisfaction with all its consequences
can exist where there is no lack of normal sexual intercourse; and
as therapists we always bear in mind that the unsatisfied sexual
trends (whose substitutive satisfactions in the form of nervous
symptoms we combat) can often find only very inadequate outlet in
coitus or other sexual acts.

'Wild' Psycho-Analysis

2376

   Anyone not sharing this view of
psychosexuality has no right to adduce psycho-analytic theses
dealing with the aetiological importance of sexuality. By
emphasizing exclusively the somatic factor in sexuality he
undoubtedly simplifies the problem greatly, but he alone must bear
the responsibility for what he does.

   A second and equally gross
misunderstanding is discernible behind the physician’s
advice.

   It is true that psycho-analysis
puts forward absence of sexual satisfaction as the cause of nervous
disorders. But does it not say more than this? Is its teaching to
be ignored as too complicated when it declares that nervous
symptoms arise from a conflict between two forces - on the one
hand, the libido (which has as a rule become excessive), and on the
other, a rejection of sexuality, or a repression which is
over-severe? No one who remembers this second factor, which is by
no means secondary in importance, can ever believe that sexual
satisfaction in itself constitutes a remedy of general reliability
for the sufferings of neurotics. A good number of these people are,
indeed, either in their actual circumstances or in general
incapable of satisfaction. If they were capable of it, if they were
without their inner resistances, the strength of the instinct
itself would point the way to satisfaction for them even though no
doctor advised it. What is the good, therefore, of medical advice
such as that supposed to have been given to this lady?

   Even if it could be justified
scientifically, it is not advice that she can carry out. If she had
had no inner resistances against masturbation or against a liaison
she would of course have adopted one of these measures long before.
Or does the physician think that a woman of over forty is unaware
that one can take a lover, or does he over-estimate his influence
so much as to think that she could never decide upon such a step
without medical approval?

'Wild' Psycho-Analysis

2377

   All this seems very clear, and
yet it must be admitted the there is one factor which often makes
it difficult to form a judgement. Some nervous states which we call
the ‘actual neuroses’, such as typical neurasthenia and
pure anxiety neurosis, obviously depend on the somatic factor in
sexual life, while we have no certain picture as yet of the part
played in them by the psychical factor and by repression. In such
cases it is natural that the physician should first consider some
‘actual’ therapy, some alteration in the
patient’s somatic sexual activity, and he does so with
perfect justification if his diagnosis is correct. The lady who
consulted the young doctor complained chiefly of anxiety-states,
and so he probably assumed that she was suffering from an anxiety
neurosis, and felt justified in recommending a somatic therapy to
her. Again a convenient misapprehension!  A person suffering
from anxiety is not for that reason necessarily suffering from
anxiety neurosis; such a diagnosis of it cannot be based on the
name; one has to know what signs constitute an anxiety neurosis,
and be able to distinguish it from other pathological states which
are also manifested by anxiety. My impression was that the lady in
question was suffering from anxiety
hysteria
, and the whole
value of such nosographical distinctions, one which quite justifies
them, lies in the fact that they indicate a different aetiology and
a different treatment. No one who took into consideration the
possibility of anxiety hysteria in this case would have fallen into
the error of neglecting the mental factors, as this physician did
with his three alternatives.

'Wild' Psycho-Analysis

2378

   Oddly enough, the three
therapeutic alternatives of this so-called psycho-analyst leave no
room for - psycho-analysis! This woman could apparently only be
cured of her anxiety by returning to her husband, or by satisfying
her needs by masturbation or with a lover. And where does analytic
treatment come in, the treatment which we regard as the main remedy
in anxiety-states?

   This brings us to the
technical
errors which are to be seen in the doctor’s
procedure in this alleged case. It is a long superseded idea, and
one derived from superficial appearances, that the patient suffers
from a sort of ignorance, and that if one removes this ignorance by
giving him information (about the causal connection of his illness
with his life, about his experiences in childhood, and so on) he is
bound to recover. The pathological factor is not his ignorance in
itself, but the root of this ignorance in his
inner
resistances
; it was they that first called this ignorance into
being, and they still maintain it now. The task of the treatment
lies in combating these resistances. Informing the patient of what
he does not know because he has repressed it is only one of the
necessary preliminaries to the treatment. If knowledge about the
unconscious were as important for the patient as people
inexperienced in psycho-analysis imagine, listening to lectures or
reading books would be enough to cure him. Such measures, however,
have as much influence on the symptoms of nervous illness as a
distribution of menu-cards in a time of famine has upon hunger. The
analogy goes even further than its immediate application; for
informing the patient of his unconscious regularly results in an
intensification of the conflict in him and an exacerbation of his
troubles.

'Wild' Psycho-Analysis

2379

   Since, however, psycho-analysis
cannot dispense with giving this information, it lays down that
this shall not be done before two conditions have been fulfilled.
First, the patient must, through preparation, himself have reached
the neighbourhood of what he has repressed, and secondly, he must
have formed a sufficient attachment (transference) to the physician
for his emotional relationship to him to make a fresh flight
impossible.

   Only when these conditions have
been fulfilled is it possible to recognize and to master the
resistances which have led to the repression and the ignorance.
Psycho-analytic intervention, therefore, absolutely requires a
fairly long period of contact with the patient. Attempts to
‘rush’ him at first consultation, by brusquely telling
him the secrets which have been discovered by the physician, are
technically objectionable. And they mostly bring their own
punishment by inspiring a hearty enmity towards the physician on
the patient’s part and cutting him off from having any
further influence.

   Besides all this, one may
sometimes make a wrong surmise, and one is never in a position to
discover the whole truth. Psycho-analysis provides these definite
technical rules to replace the indefinable ‘medical
tact’ which is looked upon as some special gift.

   It is not enough, therefore, for
a physician to know a few of the findings of psycho-analysis; he
must also have familiarized himself with its technique if he wishes
his medical procedure to be guided by a psycho-analytic point of
view. This technique cannot yet be learnt from books, and it
certainly cannot be discovered independently without great
sacrifices of time, labour and success. Like other medical
techniques, it is to be learnt from those who are already
proficient in it. It is a matter of some significance, therefore,
in forming a judgement on the incident which I took as a
starting-point for these remarks, that I am not acquainted with the
physician who is said to have given the lady such advice and have
never heard his name.

'Wild' Psycho-Analysis

2380

   Neither I myself nor my friends
and co-workers find it agreeable to claim a monopoly in this way in
the use of a medical technique. But in face of the dangers to
patients and to the cause of psycho-analysis which are inherent in
the practice that is to be foreseen of a ‘wild’
psycho-analysis, we have had no other choice. In the spring of 1910
we founded an International Psycho-Analytical Association, to which
its members declare their adherence by the publication of their
names, in order to be able to repudiate responsibility for what is
done by those who do not belong to us and yet call their medical
procedure ‘psycho-analysis’. For as a matter of fact
‘wild’ analysts of this kind do more harm to the cause
of psycho-analysis than to individual patients. I have often found
that a clumsy procedure like this, even if at first it produced an
exacerbation of the patient’s condition, led to a recovery in
the end. Not always but still often. When he has abused the
physician enough and feels far enough away from his influence, his
symptoms give way, or he decides to take some step which leads
along the path to recovery. The final improvement then comes about
‘of itself’, or is ascribed to some totally indifferent
treatment by some other doctor to whom the patient has later
turned. In the case of the lady whose complaint against her
physician we have heard, I should say that, despite everything, the
‘wild’ psycho-analyst did more for her than some highly
respected authority who might have told her she was suffering from
a ‘vasomotor neurosis’. He forced her attention to the
real cause of her trouble, or in that direction, and in spite of
all her opposition this intervention of his cannot be without some
favourable results. But he has done himself harm and helped to
intensify the prejudices which patients feel, owing to their
natural affective resistances, against the methods of
psycho-analysis. And this can be avoided.