Selected Papers on Hysteria and Other Psychoneuroses/Chapter 11
Concerning "Wild" Psychoanalysis.
During my consultation hours some days ago an elderly woman called on me accompanied by a protecting friend and complained of states of anxiety. She was in the latter half of her fortieth year, quite well preserved and seemingly had not yet reached her menopause. The separation from her last husband was supposed to have been the cause of her disease, but according to her statement the anxiety had considerably increased since she had consulted a young physician in her suburban town. He explained to her that the cause of her anxiety lay in her sexual demands; that she could not dispense with sexual relations and that for that reason she had only three roads to health—either to return to her husband, to take a lover or to gratify herself. Since that time she became convinced that she was incurable as she did not wish to return to her husband and her moral and religious feelings were against the other two measures. She came to me because the physician had told her that this was a new viewpoint for which I was responsible and urged her to come to me for corroboration of the definite assertions. Her friend, a still older, embittered and unhealthy looking woman, then adjured me to assure the patient that this physician had been mistaken. She insisted that his statement could not be true for she herself had been a widow for many years and remained respectable without suffering from states of anxiety.
I shall not dwell upon the delicate situation into which I was placed by this visit but I shall explain the conduct of the colleague who had sent me this patient. First, I wish to advise caution which is perhaps—or let us hope—not superfluous. Experience of many years has taught me—as it could teach everyone else—not to accept readily as true that which patients, particularly nervous ones, relate in regard to their physician. No matter what the treatment is the neurologist not only becomes the target for the manifold hostile feelings of the patient, but through a form of projection he must also occasionally be willing to assume responsibility for the patient's secret repressed wishes and it is a sad but significant fact that such thrusts find nowhere more ready credence than among other physicians.
I have, therefore, the right to hope that during the consultation the woman had given me a purposive distorted report of her physician's utterances and that I would be doing an injustice to one who was unknown to me if I based my observations concerning "wild" psychoanalysis on this particular case. However, in doing this I may be able to restrain others from doing injustice to their patients.
Let us therefore assume that the physician advised exactly what the patient reported. Everyone will then justly criticize that when a physician finds it necessary to discuss the theme of sexuality with a woman he should do it with tact and delicacy. However, these requirements are only a part of certain technical rules of psychoanalysis. Besides the physician has misconstrued or misunderstood a number of scientific theories of psychoanalysis and thereby proven how little he has advanced towards the understanding of its essentials and objects.
Let us begin with the latter—the scientific errors. The physician's advice clearly shows in what sense he grasps the "sexual life." He grasps it in the popular sense—namely, that under sexual demands nothing else is understood except the need for coitus or its analogy, the processes causing the orgasm or the ejaculation of the sexual product. But it could not have remained unknown to the physician that psychoanalysis was wont to be reproached for extending the idea of the sexual far beyond its usual limits. The fact is correct, though whether it is just to apply it as a reproach will not be discussed here. In psycho-analysis the idea of the sexual has a much greater compass; both above and below it far exceeds the popular sense. This extension justifies itself genetically; we also ascribe to the "sexual life" all manifestations of tender feelings which originated from the source of primitive sexual emotions, even if those emotions experience inhibition in their original sexual aim or have substituted this aim by another no longer sexual. We, therefore, also prefer to speak of psychosexuality, thus laying stress on the fact that the psychic factor of the sexual life should neither be overlooked nor underestimated. We use the word "sexuality" in the same broad sense as the word "love" in the English language. We have also known for a long time that lack of psychic gratification with all its consequences may exist where there is no lack of normal sexual intercourse, and as therapeutists we always remember that only a small proportion of the ungratified sexual strivings whose substitutive gratification in the form of nervous symptoms we are trying to combat, can be done away with through coitus and other sexual acts.
Whoever does not share this conception of psychosexuality has no right to refer to the doctrines of psychoanalysis in which the etiological meaning of sexuality is dealt with. To be sure he has simplified the problem for himself by the exclusive emphasis of the somatic factor of sexuality, but he alone should be responsible for his action.
Still a second and equally serious misunderstanding is obvious from the advice of the physician.
It is true that psychoanalysis specifies that the lack of sexual gratification is the cause of nervous affliction, but does it not say more? Should one leave aside as too complicated the fact that it teaches that nervous symptoms result from a conflict between two forces, a libido (mostly of excessive growth), and an all too strong sexual rejection or repression? Whoever does not forget the second factor, which was not actually assigned to second rank, can never believe that sexual gratification as such is a universally reliable remedy for the complaints of the neurotic. A great many of these persons are incapable of obtaining gratification under the given conditions or under any conditions. If they were capable of it and had they not their inner resistances the force of the impulse would point out the way to gratification, even without the advice of the physician. What then is the use of such advice as the physician ostensibly gave this woman?
Even if it were justified scientifically it would nevertheless be unfeasible for her. If she had no inner resistances against onanism or against an intrigue she would long since, have grasped one of these means. Or does the physician think that a woman of over forty years knows nothing of the possibility of taking a paramour, or does he so greatly overestimate his influence as to believe that without medical approval she could never decide on such a step?
All this seems very clear and still it must be admitted that there is one factor which often hinders the passing of sentence. Some of the nervous affections, the so-called actual neuroses, such as the typical neurasthenia and the pure anxiety neuroses, apparently depend on the somatic factor of the sexual life, while we have not yet any definite conception concerning the role played in them by the psychic factors and the repression. In such cases it is natural for the physician to have in view, first of all, an actual therapy, an alteration of the somatic sexual activity and he would be fully justified in so doing were his diagnosis correct. The woman who consulted this young physician complained above all of states of anxiety. He thus probably concluded that she was suffering from anxiety neurosis and felt justified in recommending her a somatic therapy. Again a convenient misunderstanding! He who suffers from anxiety does not necessarily have an anxiety neurosis. This diagnosis is not to be derived from the name. One must know what manifestations constitute anxiety neurosis and how to differentiate them from other morbid states which are also manifested through fear. According to my impression the yvoman in question suffered from an anxiety hysteria and the whole as well as the full value of such nosographic distinctions lies in the fact that they point to a different etiology and a different therapy. Whoever has in mind the possibility of such an anxiety hysteria would not have failed to neglect the psychic factors as shown in the alternative advice of the physician.
Strangely enough in the therapeutic alternative of this supposed psychoanalyst there is no place left for psychoanalysis. This woman could be freed of her anxiety only were she to return to her husband, or gratify herself by resorting to onanism, or to a paramour. And where would the analytical treatment enter which is the principal remedy in states of anxiety?
We thus come to the technical errors which we recognize in the procedure of the physician in the admitted case. It is easy to refer it to ignorance. It is a conception long since combated, based on a most superficial judgment, that the patient suffers from a lack of knowledge and when this ignorance is removed through enlightenment (concerning the causative relation of his illness with his life, regarding his childhood experiences, etc.) he must become well. It is not this lack of knowledge in itself that is the pathogenic motive, but the determination of this ignorance by inner resistances which first called forth this ignorance and still supports it. The task of the therapy lies in the combating of these resistances. To impart that which the patient does not know because he has repressed it is only one of the necessary preparations for the therapy. If the knowledge of the unconscious were as important to the patient as the inexperienced psychoanalyst believes the cure would be effected if the patient attended lectures or read books on the subject. But these measures have just as much influence on the symptoms of nervous complaints as the distribution of menus has on hunger during a famine. The comparison is useful even beyond its original application, as the imparting of the unconscious to the patient regularly has the result of sharpening his conflict and of exaggerating his complaints.
But as the psychoanalysis cannot dispense with such information it dictates that it should be imparted only after the two following conditions have been fulfilled. First, after the patient has through preparation, himself come into the surrounding of his repression; and secondly, after he has become so attached to the physician (transference) that his feeling toward the latter would make the newer flight impossible.
Only through the fulfillment of these conditions does it become possible to recognize and master the resistances which have led to repression and ignorance. Hence a psychoanalytical procedure assumes from the beginning a longer contact with the patient; and attempts to surprise the patient by brusquely imparting to him his secrets guessed by the physician during his first consultation hour are technical errors which usually avenge themselves by the doctor's incurring the cordial enmity of the patient which thus cuts off every future influence.
We shall leave out of consideration the fact that one sometimes advises wrongly and that one is never in a position to guess everything. By the aid of these unequivocal technical rules psychoanalysis replaces the demand of the vague "medical tact" in which one looks for a special endowment.
It is therefore not enough that the physician should know some of the results of psychoanalysis, but he must also be well versed in its technique if he wishes to guide his medical actions by psychoanalytic viewpoints. This technique can not yet be learned from books and to acquire it through one's self requires great sacrifices of time, effort and success. Like other medical techniques it is best learned from those who have already mastered it. It is therefore certainly not a matter of indifference for the criticism of the case on which I base my remarks, that I do not know nor have I ever heard the name of the physician who is supposed to have given such advice.
It is neither agreeable to me nor to my friends and coworkers to monopolize in such manner the claim to the practice of a medical technique. But in view of the dangers which may be anticipated from the practice of "wild" psychoanalysis for the patients as well as for the subject of psychoanalysis, no other course was left to us. In the spring of 1910 we founded an international psychoanalytic society, in order to be able to disclaim responsibility for the acts of all who do not belong to us and who call their medical practice "psychoanalysis." For as a matter of fact such wild analysts do more harm to the subject than to the individual patient. It has often been my experience that such an awkward procedure, even if it at first caused an aggravation of the symptoms, has nevertheless achieved a cure in the end. Not always, but quite often. After the patient has railed against the physician long enough and feels himself far enough removed from his influence his symptoms abate, or he decides to take a step which leads to the road of recovery. The final improvement is then supposed to have come "of itself," or is attributed to the most indifferent treatment of the physician who treated the patient last. As for the case of the women who complained against the physician we have heard, I should say that the wild psycho-analyst had nevertheless done more for his patient than any eminent authority who would have told her that she was suffering from a "vasomotor neurosis." He forced her attention to, or near, the real cause of her illness, and in spite of the patient's opposition this intervention will not remain without favorable results. He harmed himself, however, and helped to increase the prejudices against the activity of the psychoanalysts, which arise in the patients as a consequence of comprehensible affective resistances. And this can be avoided.