Freud - Complete Works (769 page)

   I propose further, Ladies and
Gentlemen, to say a few words to you about psycho-analysis as a
form of therapy. I discussed the theoretical side of this question
fifteen years ago and I cannot formulate it in any other manner
to-day; I have now to tell you of our experience during this
interval. As you know, psycho-analysis originated as a method of
treatment; it has far outgrown this, but it has not abandoned its
home-ground and it is still linked to its contact with patients for
increasing its depth and for its further development. The
accumulated impressions from which we derive our theories could be
arrived at in no other way. The failures we meet with as therapists
are constantly setting us new tasks and the demands of real life
are an effective guard against an overgrowth of the speculation
which we cannot after all do without in our work. I have already
discussed long ago the means used by psycho-analysis in helping
patients, when it does help them, and the method by which it does
so; to-day I shall enquire how much it achieves.

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   You are perhaps aware that I have
never been a therapeutic enthusiast; there is no danger of my
misusing this lecture by indulging in eulogies. I would rather say
too little than too much. During the period at which I was the only
analyst, people who were ostensibly friendly to my ideas used to
say to me: ‘That’s all very nice and clever; but show
me a case that you have cured by analysis.’ This was one of
the many formulas which in the course of time have succeeded one
another in performing the function of pushing the uncomfortable
novelty aside. To-day it is as out of date as many others: the
analyst, too, has a heap of letters in his files from grateful
patients who have been cured. The analogy does not stop at that.
Psycho-analysis is really a method of treatment like others. It has
its triumphs and its defeats, its difficulties, its limitations,
its indications. At one time a complaint was made against analysis
that it was not to be taken seriously as a treatment since it did
not dare to issue any statistics of its successes. Since then, the
Psycho-Analytic Institute in Berlin, which was founded by Dr. Max
Eitingon, has published a statement of its results during its first
ten years. Its therapeutic successes give grounds neither for
boasting nor for being ashamed. But statistics of that kind are in
general uninstructive; the material worked upon is so heterogeneous
that only very large numbers would show anything. It is wiser to
examine one’s individual experiences. And here I should like
to add that I do not think our cures can compete with those of
Lourdes. There are so many more people who believe in the miracles
of the Blessed Virgin than in the existence of the unconscious. If
we turn to mundane competitors, we must compare psycho-analytic
treatment with other kinds of psychotherapy. To-day organic
physical methods of treating neurotic states need scarcely be
mentioned. Analysis as a psycho-therapeutic procedure does not
stand in opposition to other methods used in this specialized
branch of medicine; it does not diminish their value nor exclude
them. There is no theoretical inconsistency in a doctor who likes
to call himself a psychotherapist using analysis on his patients
alongside of any other method of treatment according to the
peculiarities of the case and the favourable or unfavourable
external circumstances. It is in fact technique that necessitates
the specialization in medical practice. Thus in the same way
surgery and orthopaedics were obliged to separate. Psycho-analytic
activity is arduous and exacting; it cannot well be handled like a
pair of glasses that one puts on for reading and takes off when one
goes for a walk. As a rule psycho-analysis possesses a doctor
either entirely or not at all. Those psychotherapists who make use
of analysis among other methods, occasionally, do not to my
knowledge stand on firm analytic ground; they have not accepted the
whole of analysis but have watered it down - have drawn its fangs,
perhaps; they cannot be counted as analysts. This is, I think, to
be regretted. But co-operation in medical practice between an
analyst and a psychotherapist who restricts himself to other
techniques would serve quite a useful purpose.

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   Compared with the other
psychotherapeutic procedures psycho-analysis is beyond any doubt
the most powerful. It is just and fair, too, that this should be so
for it is also the most laborious and time-consuming; it would not
be used on slight cases. In suitable cases it is possible by its
means to get rid of disturbances and bring about changes for which
in pre-analytic times one would not have ventured to hope. But it
has its very appreciable limits. The therapeutic ambition of some
of my adherents has made the greatest efforts to overcome these
obstacles so that every sort of neurotic disorder might be curable
by psycho-analysis. They have endeavoured to compress the work of
analysis into a shorter duration, to intensify transference so that
it may be able to overcome any resistance, to unite other forms of
influence with it so as to compel a cure. These efforts are
certainly praiseworthy, but, in my opinion, they are vain. They
bring with them, too, a danger of being oneself forced away from
analysis and drawn into a boundless course of experimentation. The
expectation that every neurotic phenomenon can be cured may, I
suspect, be derived from the layman’s belief that the
neuroses are something quite unnecessary which have no right
whatever to exist. Whereas in fact they are severe,
constitutionally fixed illnesses, which rarely restrict themselves
to only a few attacks but persist as a rule over long periods or
throughout life. Our analytic experience that they can be
extensively influenced, if the historical precipitating causes and
accidental auxiliary factors of the illness can be dealt with, has
led us to neglect the constitutional factor in our therapeutic
practice, and in any case we can do nothing about it; but in theory
we ought always to bear it in mind. The radical inaccessibility of
the psychoses to analytic treatment should, in view of their close
relationship to the neuroses, restrict our pretensions in regard to
these latter. The therapeutic effectiveness of psycho-analysis
remains cramped by a number of weighty and scarcely assailable
factors. In the case of children, where one might count on the
greatest successes, the difficulties are the external ones
connected with their relation to their parents, though these
difficulties are after all a necessary part of being a child. In
the case of adults the difficulties arise in the first instance
from two factors: the amount of psychical rigidity present and the
form of the illness with all that that covers in the way of deeper
determinants.

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   The first of these factors is
often unjustly overlooked. However great may be the plasticity of
mental life and the possibility of reviving old conditions, not
everything can be brought to life again. Some changes seem to be
definitive and correspond to scars formed when a process has run
its course. On other occasions one has an impression of a general
stiffening of mental life; the psychical processes, to which one
could very well indicate other paths, seem incapable of abandoning
the old ones. But perhaps this is the same thing as what I
mentioned just now, only looked at differently. All too often one
seems to see that it is only the treatment’s lack of the
necessary motive force that prevents one from bringing the change
about. One particular dependent relation, one special instinctual
component, is too powerful in comparison with the opposing forces
that we are able to mobilize. This is quite generally true with the
psychoses. We understand them well enough to know the point at
which the levers should be applied, but they would not be able to
move the weight. It is here, indeed, that hope for the future lies:
the possibility that our knowledge of the operation of the hormones
(you know what they are) may give us the means of successfully
combating the quantitative factors of the illnesses: but we are far
from that to-day. I realize that the uncertainty in all these
matters is a constant instigation towards perfecting analysis and
in particular the transference. Beginners in analysis especially
are left in doubt in case of a failure whether they should blame
the peculiarities of the case or their own clumsy handling of the
therapeutic procedure. But, as I have said already, I do not think
much can be achieved by efforts in this direction.

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   The second limitation upon
analytic successes is given by the form of the illness. You know
already that the field of application of analytic therapy lies in
the transference neuroses - phobias, hysteria, obsessional neurosis
- and further, abnormalities of character which have been developed
in place of these illnesses. Everything differing from these,
narcissistic and psychotic conditions, is unsuitable to a greater
or less extent. It would be entirely legitimate to guard against
failures by carefully excluding such cases. This precaution would
lead to a great improvement in the statistics of analysis. There
is, however, a pitfall here. Our diagnoses are very often made only
after the event. They resemble the Scottish King’s test for
identifying witches that I read about in Victor Hugo. This king
declared that he was in possession of an infallible method of
recognizing a witch. He had the women stewed in a cauldron of
boiling water and then tasted the broth. Afterwards he was able to
say: ‘That was a witch’, or ‘No, that was not
one.’ It is the same with us, except that
we
are the
sufferers. We cannot judge the patient who comes for treatment (or,
in the same way, the candidate who comes for training) till we have
studied him analytically for a few weeks or months. We are in fact
buying a pig in a poke. The patient brings along indefinite general
ailments which do not admit of a conclusive diagnosis. After this
period of testing it may turn out that the case is an unsuitable
one. If so we send him away if he is a candidate, or continue the
trial a little longer if he is a patient on the chance that we may
yet see things in a more favourable light. The patient has his
revenge by adding to our list of failures, and the rejected
candidate does so perhaps, if he is paranoid, by writing books on
psycho-analysis himself. As you see, our precautions have been of
no avail.

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   I am afraid these detailed
discussions are exhausting your interest. But I should be still
more sorry if you were to think it is my intention to lower your
opinion of psycho-analysis as a therapy. Perhaps I really made a
clumsy start. For I wanted to do the opposite: to excuse the
therapeutic limitations of analysis by pointing out their
inevitability. With the same aim in view I turn to another point:
the reproach against analytic treatment that it takes a
disproportionately long time. On this it must be said that
psychical changes do in fact only take place slowly; if they occur
rapidly, suddenly, that is a bad sign. It is true that the
treatment of a fairly severe neurosis may easily extend over
several years; but consider, in case of success, how long the
illness would have lasted. A decade, probably, for every year of
treatment: the illness, that is to say (as we see so often in
untreated cases), would not have ended at all. In some cases we
have reasons for resuming an analysis many years afterwards. Life
had developed fresh pathological reactions to fresh precipitating
causes; but in the meantime our patient had been well. The first
analysis had not in fact brought to light all his pathological
dispositions, and it was natural for the analysis to have been
stopped when success was achieved. There are also severely
handicapped people who are kept under analytic supervision all
through their lives and are taken back into analysis from time to
time. But these people would otherwise have been altogether
incapable of existence and we must feel glad that they can be kept
on their feet by this piecemeal and recurrent treatment. The
analysis of character disorders also calls for long periods of
treatment; but it is often successful; and do you know of any other
therapy with which such a task could even be approached?
Therapeutic ambition may feel unsatisfied by such results; but we
have learnt from the example of tuberculosis and lupus that success
can only be obtained when the treatment has been adapted to the
characteristics of the illness.

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   I have told you that
psycho-analysis began as a method of treatment; but I did not want
to commend it to your interest as a method of treatment but on
account of the truths it contains, on account of the information it
gives us about what concerns human beings most of all - their own
nature - and on account of the connections it discloses between the
most different of their activities. As a method of treatment it is
one among many, though, to be sure,
primus inter pares
. If
it was without therapeutic value it would not have been discovered,
as it was, in connection with sick people and would not have gone
on developing for more than thirty years.

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LECTURE XXXV