Part 6

Of course, in the beginning, this condition favors the analysis, but later on, when these sentimental relations gradually become intensified, displaying their inherent nature, difficulties crop up which do not promote the aim of the analysis. You see, an enamoured patient is not satisfied merely to obey the analyst. The patient becomes presumptuous, demanding tenderness and sensual gratification. Eventually, jealousy develops and the lovelorn patient gradually arrives at a stage where more and more clearly, a preparedness for enmity and revenge is shown. Simultaneously, analogous to any other form of love, all other impulses of the soul are repressed, submerging the interest in treatment and recuperation. There is no doubt that love has assumed the place of the neurosis, and that our labors have simply resulted in substituting one disturbance for another.

“That sounds hopeless. What can be done? Perhaps analysis in such a case should be discarded. But since you say that every case yields this result, then analysis in general would have to be discarded.”

First, let us take stock of the situation in order to learn from it. Whatever is thus gained may assist us in mastering the situation. After all, is it not quite remarkable that we should succeed in transforming a neurotic condition into a state of unwholesome attachment?

Our conviction that neurotic conditions arise partly from abnormally directed sentimental tendencies, gains unquestionable corroboration by our findings. Ascertaining these facts, we feel more assured and dare to make this enamoured condition the object of analysis.

We also make another observation. This condition of amorousness, as part of the analysis, is not always so apparent in all cases, as I have tried to picture it to you.

And why isn’t that the case? We shall soon see.

In the same measure as the sensual and hostile aspects of a patient’s attachment endeavor to manifest themselves, the inherent opposition of the patient against such tendencies asserts itself. He combats them and attempts to repress them, before our very eyes. Thus we come to comprehend the whole development:—The patient merely repeats, in the form of being enamoured with the analyst, experiences of his soul life of days gone by. Certain tendencies of his soul, ready to burst forth, and closely connected with the inception of his neurosis, have simply been transferred by him to the analyst. He also repeats before our eyes all those gestures of opposition, gone through before, and would like nothing so much as to repeat in his relations with the analyst, all the phases of that forgotten period of his life.

What the patient is showing us now is accordingly the very nucleus of the most intimate story of his life. He is reproducing this nucleus in a tangible form, as if actual, instead of just remembering this incipient stage of his condition. Thus, the riddle of transferred love has been solved and the analysis, with the assistance of this new discovery which, for a time, almost seemed to wreck it, may be continued.

“That is surely complicated. Does the patient believe so easily that he is not in love, and merely feels forced to revive an old episode, as it were?”

Everything now depends upon the greatest dexterity in handling this “transference,” to achieve our objective. You will easily see that the demands of the analytical technique at this point are very exacting. It is here where the most serious mistakes may be committed, or the most splendid results achieved. Any attempt to evade these difficulties, by suppressing or neglecting the transference, would be senseless. Such evasion would not be deserving of the term of analysis. To send a patient home, as soon as the discomfort of a transference neurosis manifests itself, would also be senseless and would amount to cowardice. It would be approximately analogous to calling forth spirits and then running away, as soon as they put in their appearance.

Of course, there is no other way out sometimes. There are cases in which it is impossible to master an unshackled transference, and the analysis must then be terminated. But at least one should wrestle with these evil spirits to the best of one’s ability.

To give in to the demands of a transference—the desires of a patient for tenderness or sensual gratification—is impossible, not only for moral reasons but also as it would prove impractical, if resorted to as a means to achieve a successful analysis. A neurotic cannot be healed, by being permitted to indulge in uncorrected repetitions of situations which he unconsciously prepared. When making a compromise with a neurotic, by meeting him halfway, it is necessary to take care not to be manœuvred into the ludicrous position of the clergyman, who tried to convert the insurance agent with the result that the insurance agent did not join the church, but the clergyman took out a policy.

The only way out of the dilemma of transference is to delve into the past of the patient and reconstruct events as they were actually lived through by the patient, or else only pictured, with the assistance of his urge-stimulated imagination. For all this, the analyst requires much dexterity, patience, calmness and self-effacement.

“And where, do you think, did the neurotic meet the original of this transference love?”

In his childhood, and, as a rule, in one of his parents. You will readily remember how much importance we had to attach to these earliest of all sentimental relations. Here, the circle is completed.

“You have finished, then? To be frank with you, I am quite bewildered by all you have told me. But, now pray tell me, where to study all that is necessary to practise analysis?”

Two institutes serve this purpose by giving instruction in psychoanalysis. The first is in Berlin, in charge of Dr. Max Eitigon of the local organization. The second is maintained by the Vienna Psychoanalytical Society, with great sacrifice. The authorities, up to now, have thrown many obstacles in the path of the young institute. A third institute will be opened in London, by the local organization there and will be under the direction of Dr. E. Jones.

In all these institutes, the disciples themselves are analysed, and are then given theoretical instruction in all subjects important for them. When permitted to analyse their first, simple cases, they have the advantage of being under the supervision of more experienced analysts. The course usually requires about two years, but even after this period, a disciple is still a beginner, and not by far to be considered a master. What else the young analyst needs, he acquires thorough practice, and by intercourse with older colleagues.

The preparatory work for the analytical training is not at all simple: the work is hard, the responsibility tremendous.

Whoever attended such a course, has been analysed himself, has grasped the Psychology of the Unconscious, as far as it can be taught today, is sufficiently versed in the science of sex, and has acquired the difficult technique of psychoanalysis, including the art of interpretation, the method of combating resistances and the manner in which to handle transferences, can no longer be considered a layman, in the field of psychoanalysis. He is able to treat neurotic disturbances and will, in time, be in a position to achieve all that may be expected of this therapy.

VII

“You have explained to me, at great length, what psychoanalysis is, and what knowledge is necessary to practise it with a chance for success. It certainly could not have hurt me to listen to you.

“However, I do not see how your informations are expected to influence my personal view. Neuroses, it would appear, are a certain form of disturbance, and psychoanalysis a certain method to treat such cases—a special medical treatment, as it were.

“I understand that it is the rule that any physician who intends to specialize in the one phase or the other of his science is not satisfied with the training he received before winning his diploma, but rather goes on studying the intricacies of his special field. This is especially a necessity, in case he intends to establish himself in a big city, the only place which opens a satisfactory field for specialists. Anybody who is going to specialize in surgical work, will practise, for a few years, in the surgical ward. Corresponding specialized work will be taken up by the eye or the nose and throat specialist, and the psychiatrist may forever remain on the staff of a city or county institution or a private sanitarium.

“The same method of development may be expected of the psychoanalyst. Whoever decides to take up this new medical specialty, after finishing his studies proper, will have to attend those institutes, for the duration of two years, which you have mentioned before, provided it really takes as long as that to gain the necessary knowledge. He will then also learn that it would be to his advantage to join a psychoanalytical society, in order to remain in contact with his colleagues.

“I really cannot understand why there is any necessity for raising this question of lay-analyses?”

Any physician, proceeding along the lines you suggested, shall be welcome to us. As a matter of fact, four-fifths of those whom I consider my disciples, are physicians. However, permit me to enlighten you as to relations, as they actually developed between physicians and psychoanalysis, and what development they appear to be taking in the future.

Past developments do not give physicians any right to claim a monopoly of psychoanalysis. As a matter of fact, physicians, in the past, have done about everything to damage psychoanalysis, beginning with superficial mockery and going even so far as to indulge in serious defamation. Of course, you may correctly say that all this belongs to the past, and should not have any influence on the future. I fully agree, but I am afraid that the future will not live up to your expectations.

At this point, permit me to interpret for you the term of “quack,” not in the way it is legally employed, but rather in the sense in which it should be logically applied. As far as the law is concerned, a “quack” is an individual who treats sick people, without being in the possession of a diploma. I, however, would rather qualify the term “quack” in this way: A “quack” is anybody who undertakes the treatment of a disease, without having the indispensable knowledge and ability.

On the basis of this definition, I venture to assert that—not only in the European countries—physicians, as far as psychoanalysis is concerned, constitute the majority of “quacks.” Frequently, physicians will employ psychoanalysis, without having studied it, and without sufficiently understanding it.

Do not tell me that this would display a lack of conscience, which you would not suspect in any physician. You might be tempted to say that, after all, a physician ought to know that a medical diploma does not constitute a “Letter of Marque,” and that a sick person should not be considered outlawed. As far as a physician is concerned, it should be taken for granted that he is proceeding in good faith, even if he makes a mistake.

However, facts are facts. Let us hope that it will be possible to explain these facts in a manner, which you apparently wish. I, for my part, shall try to explain to you how it is possible that a physician, in matters of psychoanalysis, takes liberties he would carefully avoid in any other specialized field.

In the first place, it must be taken in consideration that the training the medical student received is almost the very opposite of that which would be required of him, as a preparation for psychoanalysis. His attention has simply been focused upon facts which may be objectively ascertained, such as present themselves in anatomy, physics, and chemistry, and which must be understood properly and applied correctly, to achieve results.

As far as the psychological aspects of life are concerned, no interest is created in the medical student. The study of higher mental achievements is not considered to belong within the field of medicine, but rather into the realm of another science. Psychiatry alone is supposed to attend to disturbances of psychological functions, and it is only too well known in which way, and with what objective in view this is done: psychiatry simply tries to discover the physical reasons for psychological disturbances, treating them in turn like any other ailment.

Psychiatry is correct in that respect, and medical training apparently excellent. Should it be maintained that psychiatry is one-sided, it will be necessary to fix the point of view from which such a reproach may arise.

Inherently, all science is one-sided, and must be one-sided, inasmuch as any science is limited to certain subjects, points of view, and methods. It is a nonsense which I do not wish to support that one science may be played against any other. Physics after all, does not minimize the value of chemistry; it cannot replace the latter nor be substituted for it. And, surely, psychoanalysis is especially one-sided, as the science of the psychological Unconscious.

Thus, the right to one-sidedness should not be denied to medicine.

However, a more practical point of view is gained if observations are not made as to scientific medicine, but rather as to practical healing. Sick people, presenting complicated problems, should impress upon us the fact that psychological manifestations—be they ever so hard to comprehend—cannot be simply eliminated from the picture. The neurotic, more than any other patient, presents an undesirable complication. He offers a dilemma, not less embarrassing to medicine than to law. However, as long as such cases exist, they are a responsibility especially of medicine. Nevertheless, medical training, sorry to say, is not paying sufficient attention to such conditions,—doing nothing for them. Absolutely nothing at all!

As there are very close inter-relations between those things we consider physical and those which we look upon as psychological, it may be expected that the day will come when organic biology and chemistry will finally approach the understanding of neurotic manifestations. This day, to be sure, seems to be in the distant future. At present, such ailments are still unapproachable, from a medical angle.

If medical training would only deny information to the student in the field of neurosis, this would be tolerable. But medical training is doing more. It implants into the young student an incorrect and harmful point of view. Physicians, whose interest for psychological facts has not been awakened, have naturally a tendency of making little of such facts, going even so far as to decry them as unscientific. Conditions of neurotic character are hardly ever taken seriously by them, while their lack of knowledge serves to breed disrespect for psychological research. Thus, neurosis is not accorded sufficient attention.

Of course, these neurotics must be treated when they consult physicians, and new discoveries must be tried out right along. But why go in for a protracted period of preparation? It can be done without that! After all, who knows whether there is really any value to that which is taught in psychoanalytical institutes?

Thus, as usual, lack of information results in a most daring spirit of enterprise. Only true initiates are modest, because they realize how insufficient their knowledge is!

From all this, it follows that it is impossible to draw upon a comparison of psychoanalysis with other branches of medicine, as you attempted to do.

As far as surgery, and ophthalmology, are concerned, medical schools and post graduate courses offer sufficient opportunities for training. The psychoanalytical institutes are limited in number, young in years, and lack the aureola of authority. Medical science has not recognized them, nor does it give a hoot about them. On the other hand, the young physician who has been forced to believe his teachers, to such a degree, that he hardly ever had a chance to form his own judgment, will only be too glad to try his hand at playing the critic, in a field where there is no established authority as yet.

There are still other circumstances which favor the mushroom-like increase of young physicians as psychoanalytical “quacks.”

If a physician would undertake cataract operations, without sufficient training as an eye specialist, he would soon enough lose his patients. Compared to this, the application of psychoanalysis hardly involves any danger. The public, generally observing effective cataract operations, expects results from a physician pretending to be an eye specialist. However, if a nerve specialist does not achieve results, apparently nobody is surprised. We surely have not been spoiled by the efficacy of therapeutical treatment of nerve cases, and it seems to suffice that the physician “tried everything.” Nature must simply assert herself and time exert its healing propensities.

If the patient happens to be a young girl, it is first the menstruation which is expected to work wonders, then marriage, and in later years, change of life. In the end, death itself may finally prove the great healer.

Moreover, whatever the medical analyst employed in the treatment of such a case, is so inconspicuous, as to offer no cause for reproach. After all, he did not resort to instruments, nor did he write prescriptions. He just talked and talked, trying either to talk something into the patient, or out of the patient.

How could such treatment do any damage, especially as extreme care had been taken not to touch upon painful or exciting matters? The medical analyst, once he has thrown the strict instructions overboard that were given to him, will surely have tried to improve upon psychoanalysis by extracting from it certain features—poisonous fangs, as it were—to make analysis more acceptable to the patient. How splendid, if he really went only as far as that and not so far as to awaken resistances which he would be unable to cope with. He would be apt to make himself disliked in such a case!

Justice demands that it be admitted that an untrained analyst cannot do as much harm to a patient, as an untrained surgeon. The possible injury may amount to unnecessary expenditure of money and time, and chances for a cure may have either been destroyed, or else spoilt to a certain degree. In addition to this, the reputation of psychoanalytical therapy as a whole would suffer. All this is quite undesirable, but surely not as serious as the damage that may arise from the knife of a surgical “quack.” According to my observations, permanent aggravation of an ailment is not to be expected from the incorrect application of psychoanalysis. Reactions of an undesirable nature disappear quickly. In comparison to the traumata inflicted by life itself, which resulted in the disturbances, a little incorrect treatment does not amount to anything. The unsuitable therapeutical attempt has simply not benefited the patient.

“I have listened to your description of the ‘quack’ without interrupting you, and have gained the impression that your position in regard to physicians is barbed with hostility. The reason for this enmity is obvious, from the many hints you have dropped. At any rate, I am of the opinion that as long as psychoanalysis is to be employed, it should be only by such persons as are thoroughly trained for it. But it seems that you believe that even those physicians who may take up psychoanalysis, in the course of time, will not go in for the necessary thorough training?”

Exactly! As long as the relation between the medical schools and the psychological institutes prevail as they do today, I do not think that young physicians will resist the temptation of making things easy for themselves.

“It appears to me that you constantly avoid making any direct statement in regard to the problem of lay-analyses. Apparently, what you wish me to surmise now is that it would be your suggestion to withhold, as a means of revenge, as an act of punishment, so to speak, the monopoly of practising psychoanalysis from physicians, because such physicians as employ analysis, are beyond control. You would, however, permit the application of such medical activity to laymen.”

I am not so sure that you surmised my motives correctly. Perhaps, I may later on be in a position to prove to you that my point of view is not as partial as all that. But be that as it may, _I strongly emphasize my demand that nobody should be permitted to practise psychoanalysis, unless he has obtained this privilege on the basis of thorough training_. Whether such a person is a qualified physician or not does not seem important to me.

“What, then, are your practical suggestions?”

I am not as far as that yet. I don’t even know whether I shall ever get that far. There is some other question which I wish to take up with you, and by way of introduction, touch upon a certain point.

It is reported that the authorities, on the strength of suggestions made by medical bodies, may put a sweeping prohibition for the practise of psychoanalysis by laymen on the statute books. Such prohibition would naturally also hit the non-medical members of psychoanalytical societies—men and women who have undergone a very thorough training and improved themselves greatly by practice. Should such a sweeping prohibition become an actual fact, the incongruous condition would then present itself whereby people really capable of applying psychoanalysis properly, would be excluded from this practice, while on the other hand, this privilege would be extended to individuals insufficiently informed, and not specially trained for such work.

Of course, no legislature aims at so absurd an effect.

But the dilemma that presents itself with this piece of legislature, is neither important nor difficult. It would concern only a handful of people who would not even suffer appreciably. Analogous to measures enacted by monarchical Austria, republican Austria could also resort to exception laws. Under the Hapsburg régime, it happened that certain “quacks” whose ability in the treatment of certain diseases was convincing, were privileged _ad personam_ to treat sick people. These were mostly cases of rustic healers, who enjoyed the recommendation of one of those exalted, once so plentiful, archduchesses. However, it should be possible to assume that the benefit of such exception laws should also pertain to city inhabitants, who are recommended by mere experts.

Of course, if the law is put on the statutes in accordance with the wording of the bill now pending, the Vienna Psychoanalytical Institute, for example, would no longer be permitted to accept students, unless they belonged to the medical profession. All these endeavors to restrict the application of psychoanalysis hark back, more or less, to obsolete legislature, dealing with quackery as such. This seems anachronistic, inasmuch as at the time of the enactment of these anti-quackery laws, the particular nature of neurotic disturbances had not yet been discovered and psychoanalysis did not yet exist.

I am now approaching the question which appears most essential to me: Is the practice of psychoanalysis of such a nature as to lend itself to the interference of legislative authorities, or would it not be much better to leave psychoanalysis to its natural development?

Of course, I shall not decide this question, but I am taking the liberty of submitting it to you. It appears that in Austria, not unlike other countries, by the way, there prevails a real _furor prohibendi_, a veritable mania for prohibition and general interference, a trend which usually, as is only too well known, makes for unsatisfactory results. According to my own personal view, a superabundance of ordinances and prohibitions will only serve to injure the dignity of the law. It may usually be observed that wherever there are just a few laws, these laws are strictly adhered to, whereas where laws exist in great numbers, the temptation arises to break them.