Freud - Complete Works (580 page)

   All the libido, as well as
everything opposing it, is made to converge solely on the relation
with the doctor. In this process the symptoms are inevitably
divested of libido. In place of his patient’s true illness
there appears the artificially constructed transference illness, in
place of the various unreal objects of the libido there appears a
single, and once more imaginary, object in the person of the
doctor. But, by the help of he doctor’s suggestion, the new
struggle around this object is lifted to the highest psychical
level: it takes place as a normal mental conflict. Since a fresh
repression is avoided, the alienation between ego and libido is
brought to an end and the subject’s mental unity is restored.
When the libido is released once more from its temporary object in
the person of the doctor, it cannot return to its earlier objects,
but is at the disposal of the ego. The forces against which we have
been struggling during our work of therapy are, on the one hand,
the ego’s antipathy to certain trends of the libido - an
antipathy expressed in a tendency to repression - and, on the other
hand, the tenacity or adhesiveness of the libido, which dislikes
leaving objects that it has once cathected.

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   Thus our therapeutic work falls
into two phases. In the first, all the libido is forced from the
symptoms into the transference and concentrated there; in the
second, the struggle is waged around this new object and the libido
is liberated from it. The change which is decisive for a favourable
outcome is the elimination of repression in this renewed conflict
so that the libido cannot withdraw once more from the ego by flight
into the unconscious. This is made possible by the alteration of
the ego which is accomplished under the influence of the
doctor’s suggestion. By means of the work of interpretation,
which transforms what is unconscious into what is conscious, the
ego is enlarged at the cost of this unconscious; by means of
instruction, it is made conciliatory towards the libido and
inclined to grant it some satisfaction, and its repugnance to the
claims of the libido is diminished by the possibility of disposing
of a portion of it by sublimation. The more closely events in the
treatment coincide with this ideal description, the greater will be
the success of the psycho-analytic therapy. It finds its limits in
the lack of mobility of the libido, which may refuse to leave its
objects, and the rigidity of narcissism, which will not allow
transference on to objects to increase beyond certain bounds.
Further light may perhaps be thrown on the dynamics of the process
of cure if I say that we get hold of the whole of the libido which
has been withdrawn from the dominance of the ego by attracting a
portion of it on to ourselves by means of the transference.

   It will not be out of place to
give a warning that we can draw no direct conclusion from the
distribution of the libido during and resulting from the treatment
as to how it was distributed during the illness. Suppose we
succeeded in bringing a case to a favourable conclusion by setting
up and then resolving a strong father-transference to the doctor.
It would not be correct to conclude that the patient had suffered
previously from a similar unconscious attachment of his libido to
his father. His father-transference was merely the battlefield on
which we gained control of his libido; the patient’s libido
as directed to it from other positions. A battlefield need not
necessarily coincide with one of the enemy’s key fortresses.
The defence of a hostile capital need not take place just in front
of its gates. Not until after the transference has once more been
resolved can we reconstruct in our thoughts the distribution of the
libido which had prevailed during the illness.

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   From the standpoint of the libido
theory, too, we may say a last word on dreams. A neurotic’s
dreams help us, like his parapraxes and his free associations to
them, to discover the sense of his symptoms and to reveal the way
in which his libido is allocated. They show us, in the form of a
wish-fulfilment, what wishful impulses have been subjected to
repression and to what objects the libido withdrawn from the ego
has become attached. For this reason the interpretation of dreams
plays a large part in a psycho-analytic treatment, and in some
cases it is over long periods the most important instrument of our
work. We already know that the state of sleep in itself leads to a
certain relaxation of the repressions. A repressed impulse, owing
to this reduction in the pressure weighing down upon it, becomes
able to express itself far more clearly in a dream than it can be
allowed to be expressed by a symptom during the day. The study of
dreams therefore becomes the most convenient means of access to a
knowledge of the repressed unconscious, of which the libido
withdrawn from the ego forms a part.

   But the dreams of neurotics do
not differ in any important respect from those of normal people; it
is possible, indeed, that they cannot be distinguished from them at
all. It would be absurd to give an account of the dreams of
neurotics which could not also apply to the dreams of normal
people. We must therefore say that the difference between neurosis
and health holds only during the day; it is not prolonged into
dream-life. We are obliged to carry over to healthy people a number
of hypotheses which arise in connection with neurotics as a result
of the link between the latter’s dreams and their symptoms.
We cannot deny that healthy people as well possess in their mental
life what alone makes possible the formation both of dreams and of
symptoms, and we must conclude that they too have carried out
repressions, that they expend a certain amount of energy in order
to maintain them, that their unconscious system conceals repressed
impulses which are still cathected with energy, and that
a
portion of their libido is withdrawn from their ego’s
disposal
. Thus a healthy person, too, is virtually a neurotic;
but dreams appear to be the only symptoms which he is capable of
forming. It is true that if one subjects his waking life to a
closer examination one discovers something that contradicts this
appearance - namely that this ostensibly healthy life is
interspersed with a great number of trivial and in practice
unimportant symptoms.

   The distinction between nervous
health and neurosis is thus reduced to a practical question and is
decided by the outcome - by whether the subject is left with a
sufficient amount of capacity for enjoyment and of efficiency. It
probably goes back to the relative sizes of the quota of energy
that remains free and of that which is bound by repression, and is
of a quantitative not of a qualitative nature. I need not tell you
that this discovery is the theoretical justification for our
conviction that neuroses are in principle curable in spite of their
being based on constitutional disposition.

   The identity of the dreams of
healthy and neurotic people enables us to infer thus much in regard
to defining the characteristics of health. But in regard to dreams
themselves we can make a further inference: we must not detach them
from their connection with neurotic symptoms, we must not suppose
that their essential nature is exhausted by the formula that
describes them as a translation of thoughts into an archaic form of
expression, but we must suppose that they exhibit to us allocations
of the libido and object-cathexes that are really present.

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   We shall soon have reached the
end. You are perhaps disappointed that on the topic of the
psycho-analytic method of therapy I have only spoken to you about
theory and not about the conditions which determine whether a
treatment is to be undertaken or about the results it produces. I
shall discuss neither: the former because it is not my intention to
give you practical instructions on how to carry out a
psycho-analysis, and the latter because several reasons deter me
from it. At the beginning of our talks, I emphasized the fact that
under favourable conditions we achieve successes which are second
to none of the finest in the field of internal medicine; and I can
now add something further - namely that they could not have been
achieved by any other procedure. If I were to say more than this I
should be suspected of trying to drown the loudly raised voices of
depreciation by self-advertisement. The threat has repeatedly been
made against psycho-analysts by our medical
‘colleagues’ - even at public congresses - that a
collection of the failures and damaging results of analysis would
be published which would open the suffering public’s eyes to
the worthlessness of this method of treatment. But, apart from the
malicious, denunciatory character of such a measure, it would not
even be calculated to make it possible to form a correct judgement
of the therapeutic effectiveness of analysis. Analytic therapy, as
you know, is in its youth; it has taken a long time to establish
its technique, and that could only be done in the course of working
and under the influence of increasing experience. In consequence of
the difficulties in giving instruction, the doctor who is a
beginner in psycho-analysis is thrown back to a greater extent than
other specialists on his own capacity for further development, and
the results of his first years will never make it possible to judge
the efficacy of analytic therapy.

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   Many attempts at treatment
miscarried during the early period of analysis because they were
undertaken in cases which were altogether unsuited to the procedure
and which we should exclude to-day on the basis of our present view
of the indications for treatment. But these indications, too, could
only be arrived at by experiment. In those days we did not know
a priori
that paranoia and dementia praecox in strongly
marked forms are inaccessible, and we had a right to make trial of
the method on all kinds of disorders. But most of the failures of
those early years were due not to the doctor’s fault or an
unsuitable choice of patients but to unfavourable external
conditions. Here we have only dealt with internal resistances,
those of the patient, which are inevitable and can be overcome. The
external resistances which arise from the patient’s
circumstances, from his environment, are of small theoretical
interest but of the greatest practical importance. Psycho-analytic
treatment may be compared with a surgical operation and may
similarly claim to be carried out under arrangements that will be
the most favourable for its success. You know the precautionary
measures adopted by a surgeon: a suitable room, good lighting,
assistants, exclusion of the patient’s relatives, and so on.
Ask yourselves now how many of these operations would turn out
successfully if they had to take place in the presence of all the
members of the patient’s family, who would stick their noses
into the field of the operation and exclaim aloud at every
incision. In psycho-analytic treatments the intervention of
relatives is a positive danger and a danger one does not know how
to meet. One is armed against the patient’s internal
resistances which one knows are inevitable, but how can one ward
off these external resistances? No kind of explanations make any
impression on the patient’s relatives; they cannot be induced
to keep at a distance from the whole business, and one cannot make
common cause with them because of the risk of losing the confidence
of the patient, who - quite rightly moreover - expects the person
in whom he has put his trust to take his side. No one who has any
experience of the rifts which so often divide a family will, if he
is an analyst, be surprised to find that the patient’s
closest relatives sometimes betray less interest in his recovering
than in his remaining as he is. When, as so often, the neurosis is
related to conflicts between members of a family, the healthy party
will not hesitate long in choosing between his own interest and the
sick party’s recovery. It is not to be wondered at, indeed,
if a husband looks with disfavour on a treatment in which, as he
may rightly suspect, the whole catalogue of his sins will be
brought to light. Nor do we wonder at it; but we cannot in that
case blame ourselves if our efforts remain unsuccessful and the
treatment is broken off prematurely because the husband’s
resistance is added to that of his sick wife. We had in fact
undertaken something which in the prevailing circumstances was
unrealizable.

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   Instead of reporting a number of
cases, I will tell you the story of a single one, in which, from
considerations of medical discretion, I was condemned to play a
long-suffering part. I undertook the analytic treatment - it was
many years ago - of a girl who had for some time been unable, owing
to anxiety, to go out in the street or to stay at home by herself.
The patient slowly brought out an admission that her imagination
had been seized by chance observations of the affectionate
relations between her mother and a well-to-do friend of the family.
But she was so clumsy - or so subtle - that she gave her mother a
hint of what was being talked about in the analytic sessions. She
brought this about by changing her behaviour towards her mother, by
insisting on being protected by no one but her mother from her
anxiety at being alone and by barring the door to her in her
anxiety if she tried to leave the house. Her mother had herself
been very neurotic in the past, but had been cured years before in
a hydropathic establishment. Or rather, she had there made the
acquaintance of the man with whom she was able to enter into a
relation that was in every way satisfying to her. The girl’s
passionate demands took her aback, and she suddenly understood the
meaning of her daughter’s anxiety: the girl had made herself
ill in order to keep her mother prisoner and to rob her of the
freedom of movement that her relations with her lover required. The
mother quickly made up her mind and brought the obnoxious treatment
to an end. The girl was taken to a sanatorium for nervous diseases
and was demonstrated for many years as ‘a poor victim of
psycho-analysis’. All this time, too, I was pursued by the
calumny of responsibility for the unhappy end of the treatment. I
kept silence, for I thought I was bound by the duty of medical
discretion. Long afterwards I learnt from one of my colleagues, who
visited the sanatorium and had seen the agoraphobic girl there,
that the
liaison
between her mother and the well-to-do
friend of the family was common knowledge in the city and that it
was probably connived at by the husband and father. Thus it was to
this ‘secret’ that the treatment had been
sacrificed.