Freud - Complete Works (579 page)

   On the basis of our clinical
impressions we maintained that these patients’
object-cathexes must have been given up and that their
object-libido must have been transformed into ego-libido. Through
this characteristic we distinguished them from the first group of
neurotics (sufferers from hysteria, anxiety-hysteria and
obsessional neurosis). This suspicion is now confirmed by their
behaviour in our attempts at therapy. They manifest no transference
and for that reason are inaccessible to our efforts and cannot be
cured by us.

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LECTURE XXVIII

ANALYTIC THERAPY

LADIES AND
GENTLEMEN
, - You know what we are going to talk about
to-day. You asked me why we do not make use of direct suggestion in
psycho-analytic therapy, when we admit that our influence rests
essentially on transference - that is, on suggestion; and you added
a doubt whether, in view of this predominance of suggestion, we are
still able to claim that our psychological discoveries are
objective. I promised I would give you a detailed reply.

   Direct suggestion is suggestion
aimed against the manifestation of the symptoms; it is a struggle
between your authority and the motives for the illness. In this you
do not concern yourself with these motives; you merely request the
patient to suppress their manifestation in symptoms. It makes no
difference of principle whether you put the patient under hypnosis
or not. Once again Bernheim, with his characteristic perspicacity,
maintained that suggestion was the essential element in the
phenomena of hypnotism, that hypnosis itself was already a result
of suggestion, a suggested state; and he preferred to practise
suggestion in a waking state, which can achieve the same effects as
suggestion under hypnosis.

   Which would you rather hear first
on this question - what experience tells us or theoretical
considerations?

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   Let us begin with the former. I
was a pupil of Bernheim’s, whom I visited at Nancy in 1889
and whose book on suggestion I translated into German. I practised
hypnotic treatment for many years, at first by prohibitory
suggestion and later in combination with Breuer’s method of
questioning the patient. I can therefore speak of the results of
hypnotic or suggestive therapy on the basis of a wide experience.
If, in the words of the old medical aphorism, an ideal therapy
should be rapid, reliable and not disagreeable for the patient,
Bernheim’s method fulfilled at least two of these
requirements. It could be carried through much quicker - or,
rather, infinitely quicker - than analytic treatment and it caused
the patient neither trouble nor unpleasantness. For the doctor it
became, in the long run,
monotonous
: in each case, in the
same way, with the same ceremonial, forbidding the most variegated
symptoms to exist, without being able to learn anything of their
sense and meaning. It was hackwork and not a scientific activity,
and it recalled magic, incantations and hocus-pocus. That could not
weigh, however, against the patient’s interest. But the third
quality was lacking: the procedure was not reliable in any respect.
It could be used with one patient, but not with another; it
achieved a great deal with one and very little with another, and
one never knew why. Worse than the capriciousness of the procedure
was the lack of permanence in its successes. If, after a short
time, one had news of the patient once more, the old ailment was
back again or its place had been taken by a new one. One might
hypnotize him again. But in the background there was the warning
given by experienced workers against robbing the patient of his
self-reliance by frequently repeated hypnosis and so making him an
addict to this kind of therapy as though it were a narcotic.
Admittedly sometimes things went entirely as one would wish: after
a few efforts, success was complete and permanent. But the
conditions determining such a favourable outcome remained unknown.
On one occasion a severe condition in a woman, which I had entirely
got rid of by a short hypnotic treatment, returned unchanged after
the patient had, through no action on my part, got annoyed with me;
after a reconciliation, I removed the trouble again and far more
thoroughly; yet it returned once more after she had fallen foul of
me a second time. On another occasion a woman patient, whom I had
repeatedly helped out of neurotic states by hypnosis, suddenly,
during the treatment of a specially obstinate situation, threw her
arms round my neck. After this one could scarcely avoid, whether
one wanted to or not, investigating the question of the nature and
origin of one’s authority in suggestive treatment.

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   So much for experiences. They
show us that in renouncing direct suggestion we are not giving up
anything of irreplaceable value. Now let us add a few reflections
to this. The practice of hypnotic therapy makes very small demands
on either the patient or the doctor. It agrees most beautifully
with the estimate in which neuroses are still held by the majority
of doctors. The doctor says to the neurotic patient:
‘There’s nothing wrong with you, it’s only a
question of nerves; so I can blow away your trouble in two or three
minutes with just a few words.’ But our views on the laws of
energy are offended by the notion of its being possible to move a
great weight by a tiny application of force, attacking it directly,
without the outside help of any appropriate appliances. In so far
as the conditions are comparable, experience shows that this feat
is not successfully accomplished in the case of the neuroses
either. But I am aware that this argument is not unimpeachable.
There is such a thing as a ‘trigger-action’.

   In the light of the knowledge we
have gained from psycho-analysis we can describe the difference
between hypnotic and psycho-analytic suggestion as follows.
Hypnotic treatment seeks to cover up and gloss over something in
mental life; analytic treatment seeks to expose and get rid of
something. The former acts like a cosmetic, the latter like
surgery. The former makes use of suggestion in order to forbid the
symptoms; it strengthens the repressions, but, apart from that,
leaves all the processes that have led to the formation of the
symptoms unaltered. Analytic treatment makes its impact further
back towards the roots, where the conflicts are which gave rise to
the symptoms, and uses suggestion in order to alter the outcome of
those conflicts. Hypnotic treatment leaves the patient inert and
unchanged, and for that reason, too, equally unable to resist any
fresh occasion for falling ill. An analytic treatment demands from
both doctor and patient the accomplishment of serious work, which
is employed in lifting internal resistances. Through the overcoming
of these resistances the patient’s mental life is permanently
changed, is raised to a high level of development and remains
protected against fresh possibilities of falling ill. This work of
overcoming resistances is the essential function of analytic
treatment; the patient has to accomplish it and the doctor makes
this possible for him with the help of suggestion operating in an
educative
sense. For that reason psycho-analytic treatment
has justly been described as a kind of
after-education
.

   I hope I have now made it clear
to you in what way our method of employing suggestion
therapeutically differs from the only method possible in hypnotic
treatment. You will understand too, from the fact that suggestion
can be traced back to transference, the capriciousness which struck
us in hypnotic therapy, while analytic treatment remains calculable
within its limits. In using hypnosis we are dependent on the state
of the patient’s capacity for transference without being able
to influence it itself. The transference of a person who is to be
hypnotized may be negative or, as most frequently, ambivalent, or
he may have protected himself against his transference by adopting
special attitudes; of that we learn nothing. In psycho-analysis we
act upon the transference itself, resolve what opposes it, adjust
the instrument with which we wish to make our impact. Thus it
becomes possible for us to derive an entirely fresh advantage from
the power of suggestion; we get it into our hands. The patient does
not suggest to himself whatever he pleases: we guide his suggestion
so far as he is in any way accessible to its influence.

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   But you will now tell me that, no
matter whether we call the motive force of our analysis
transference or suggestion, there is a risk that the influencing of
our patient may make the objective certainty of our findings
doubtful. What is advantageous to our therapy is damaging to our
researches. This is the objection that is most often raised against
psycho-analysis, and it must be admitted that, though it is
groundless, it cannot be rejected as unreasonable. If it were
justified, psycho-analysis would be nothing more than a
particularly well-disguised and particularly effective form of
suggestive treatment and we should have to attach little weight to
all that it tells us about what influences our lives, the dynamics
of the mind or the unconscious. That is what our opponents believe;
and in especial they think that we have ‘talked’ the
patients into everything relating to the importance of sexual
experiences - or even into those experiences themselves - after
such notions have grown up in our own depraved imagination. These
accusations are contradicted more easily by an appeal to experience
than by the help of theory. Anyone who has himself carried out
psycho-analyses will have been able to convince himself on
countless occasions that it is impossible to make suggestions to a
patient in that way. The doctor has no difficulty, of course, in
making him a supporter of some particular theory and in thus making
him share some possible error of his own. In this respect the
patient is behaving like anyone else - like a pupil - but this only
affects his intelligence, not his illness. After all, his conflicts
will only be successfully solved and his resistances overcome if
the anticipatory ideas he is given tally with what is real in him.
Whatever in the doctor’s conjectures is inaccurate drops out
in the course of the analysis; it has to be withdrawn and replaced
by something more correct. We endeavour by a careful technique to
avoid the occurrence of premature successes due to suggestion; but
no harm is done even if they do occur, for we are not satisfied by
a first success. We do not regard an analysis as at an end until
all the obscurities of the case are cleared up, the gaps in the
patient’s memory filled in, the precipitating causes of the
repressions discovered. We look upon successes that set in too soon
as obstacles rather than as a help to the work of analysis; and we
put an end to such successes by constantly resolving the
transference on which they are based. It is this last
characteristic which is the fundamental distinction between
analytic and purely suggestive therapy, and which frees the results
of analysis from the suspicion of being successes due to
suggestion. In every other kind of suggestive treatment the
transference is carefully preserved and left untouched; in analysis
it is itself subjected to treatment and is dissected in all the
shapes in which it appears. At the end of an analytic treatment the
transference must itself be cleared away; and if success is then
obtained or continues, it rests, not on suggestion, but on the
achievement by its means of an overcoming of internal resistances,
on the internal change that has been brought about in the
patient.

   The acceptance of suggestions on
individual points is no doubt discouraged by the fact that during
the treatment we are struggling unceasingly against resistances
which are able to transform themselves into negative (hostile)
transferences. Nor must we fail to point out that a large number of
the individual findings of analysis, which might otherwise be
suspected to being products of suggestion, are confirmed from
another and irreproachable source. Our guarantors in this case are
the sufferers from dementia praecox and paranoia, who are of course
far above any suspicion of being influenced by suggestion. The
translations of symbols and the phantasies, which these patients
produce for us and which in them have forced their way through into
consciousness, coincide faithfully with the results of our
investigations into the unconscious of transference neurotics and
thus confirm the objective correctness of our interpretations, on
which doubt is so often thrown. You will not, I think, be going
astray if you trust analysis on these points.

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   I will now complete my picture of
the mechanism of cure by clothing it in the formulas of the libido
theory. A neurotic is incapable of enjoyment and of efficiency -
the former because his libido is not directed on to any real object
and the latter because he is obliged to employ a great deal of this
available energy on keeping his libido under repression and on
warding off its assaults. He would become healthy if the conflict
between his ego and his libido came to an end and if his ego had
his libido again at its disposal. The therapeutic task consists,
therefore, in freeing the libido from its present attachments,
which are withdrawn from the ego, and in making it once more
serviceable to the ego. Where, then, is the neurotic’s libido
situated? It is easily found: it is attached to the symptoms, which
yield it the only substitutive satisfaction possible at the time.
We must therefore make ourselves masters of the symptoms and
resolve them - which is precisely the same thing that the patient
requires of us. In order to resolve the symptoms, we must go back
as far as their origin, we must renew the conflict from which they
arose, and, with the help of motive forces which were not at the
patient’s disposal in the past, we must guide it to a
different outcome. This revision of the process of repression can
be accomplished only in part in connection with the memory traces
of the processes which led to repression. The decisive part of the
work is achieved by creating in the patient’s relation to the
doctor - in the ‘transference’ - new editions of the
old conflicts; in these the patient would like to behave in the
same way as he did in the past, while we, by summoning up every
available mental force, compel him to come to a fresh decision.
Thus the transference becomes the battlefield on which all the
mutually struggling forces should meet one another.