Part 7
Furthermore, a man cannot be considered an anarchist, simply because he believes that legislative statutes—in the view of their very origin—cannot very well be regarded as something holy that must never be touched. Legislative measures sometimes are insufficient, or gradually become that, at the same time outraging our innate sense for justice and common sense. Then the time is on hand, where there is no other means of correcting such unbearable conditions than to simply trespass against such laws. It seems advisable, for the purpose of maintaining respect for laws and ordinances, not to enact any which may be difficult to enforce.
Much of what has been said here about the application of psychoanalysis by physicians would have to be repeated with regard to lay-analyses proper, which the legislatures of some countries are now prepared to prohibit. In view of the fact that the application of the analysis is a very simple procedure, consisting merely of conversation without resorting to instruments or prescriptions, it would be rather difficult to prove that a layman actually employed psychoanalysis, if he stoutly maintained that he had merely benefited a person by administering a good “talking to.” Such assistance, to a person in need of it, could not very well be prohibited simply because a physician may once in a while resort to the identical thing!
In English speaking countries, Christian Science has gained tremendous popularity. To my mind, it constitutes a dialectic abnegation of such evils as life presents, by resorting to the teaching of Christian religion. I do not hesitate to state that such measures strike me as a regrettable fallacy of the human mind. But who in the United States or England would ever think of prohibiting Christian Science or seek to punish its followers?
Generally speaking, is governmental authority always so certain to be on the right side? Assumed even that many, left to their own devices, would encounter danger and experience harm, would it not just the same be much better if governmental authority would merely indicate dangerous ground, but on the whole leave it to the individual to be taught by experience and mutual influence?
Psychoanalysis is so new, the broad masses so insufficiently informed about it, the official view of science still so vacillating, that it appears to me as premature to impede its progress by legislative measures.
Why not leave it to the patients themselves to learn that it is dangerous for them to apply for psychological assistance to persons who are not sufficiently informed?
If people are sufficiently enlightened and warned, prohibition will surely prove superfluous.
On Italian highways, poles, carrying high tension electric power, display this warning: “_Chi tocca, muore!_” Which has proven perfectly sufficient. In contrast to this, in other countries, for example Austria and Germany, this warning is of an insulting verbosity:— “Inasmuch as touching these high tension wires is dangerous to life, it is herewith strictly prohibited to meddle with them!” Why this prohibition? Whoever cherishes his life will not touch them, and whoever wants to commit suicide will surely not be detained by the warning.
“But there are cases which may be quoted as precedent for the prohibition of lay-analyses. For example, the law against the practice of hypnosis by laymen, and another enacted against occult séances and the organization of spiritualistic societies.”[1]
I must admit that it is beyond me to admire these measures. As far as the last mentioned prohibition is concerned, it surely constitutes a case of grave over-officiousness, encroaching upon intellectual freedom. As far as I am personally concerned, I do not think that anybody would suspect me of having faith in occult phenomena, or of being interested in its general acceptance. However, such prohibitive measures will never serve to stifle the interest that some people manifest for the alleged secrets of an occult world. Such officious interference may do a lot of damage by preventing impartial seekers for truth to arrive at a finding which would do away with occult misconceptions. Here also, we observe the fact that other countries do not interfere with so-called “parapsychic” research, but only Austria.
As far as hypnosis is concerned, it is somewhat different from analysis. Hypnosis is nothing else but induction of an abnormal condition of the soul, serving the layman merely as a means of entertainment. Had hypnotic therapy fulfilled its early promise, conditions would have evolved similar to those now prevailing in psychoanalysis.
Aside from this, the history of hypnosis contributes another precedent for the fate of psychoanalysis. When I was still a young instructor of neuropathology, physicians fervently fought against hypnosis, claiming it to be nothing but a fake, an infernal delusion, a most dangerous practice. Today, this same hypnosis has been monopolized by them. They are resorting to it as a method of examination. For some nerve specialists, hypnosis is their most important stock in trade.
However, I have already told you that I do not intend to discuss whether restriction by law or a hands-off policy would be the most correct procedure, concerning psychoanalysis. I know very well that this is a question of principle which will be decided by the inclination of influential people rather than by strict argumentation. What seems to me to suggest a policy of _laissez faire_ I have already mentioned. But if the decision should be one for active interference, then, to be sure, it would appear to me as a one-sided and unjust measure to enact a sweeping prohibition against the practice of psychoanalysis by laymen. Then, it would be up to the legislature to fix the conditions under which the application of psychoanalysis would be permissible for those who would be privileged to employ it. It would also be necessary to appoint an authority who could be appealed to for information, who would decide what constitutes psychoanalysis, what the training would be, and how to administer it.
Thus, things must either be left alone or else order must be created and the situation, in general, clarified. But there is no use in simply interfering with a complicated situation, by means of a prohibition, which is based without much discretion, upon obsolete acts of an antiquated legislature.
VIII
“But the physicians! It seems I am really unable to bring you to the main point of our conversation. You are continually evading me. After all, the question before us is whether physicians should be given the exclusive right to employ psychoanalysis, that is, after they have fulfilled certain conditions, if you should insist upon such. According to your own statement, the majority of ‘quacks,’ dabbling with psychoanalysis, does not consist of physicians. You also admit that the greatest number of your disciples and followers are physicians. I have heard that these do not share your point of view, in regard to lay-analyses.
“Of course, it is to be expected that your disciples agree with you in the question of sufficient training. Just the same, they hold the laymen should be excluded from the practice of psychoanalysis. Is that really the case? And if so, how do you account for it?”
You are correctly informed. Not all, but a great number of my medically trained collaborators do not side with me in this matter, but insist that psychoanalytical treatment of neurotics be exclusively reserved for physicians. From this, you may gather that even within the limits of our own camps, there prevails a difference of opinion. Although my point of view is very well known, the divergence of opinion in matters of lay-analyses, in no way interferes with an otherwise splendid harmony.
How to explain this position of some of my disciples?
I am not so sure, but I assume that professional pride is behind it. You see, their process of development has been different from mine. That they find themselves somewhat isolated from their colleagues, is still annoying them. They would like to be considered, by the profession as a whole, as members in good standing, so to say. Thus, in order to win the tolerance of their Æsculapian brothers, they are willing to make a sacrifice, whose value is apparently not clear to them.
Of course, I may be wrong here. To assume that fear of competition is dictating their position, would not only amount to suspecting them of a low motive, but also condemn them for a peculiar shortsightedness. After all, as long as they are ready to initiate colleagues into psychoanalysis, it can be of no importance to them whether they will have to share prospective patients with them, or with laymen.
Probably, there is something else to be considered. They may be impressed by certain features which, in the practice of psychoanalysis assure the physician of an unquestionable advantage over the layman.
“There you are:—‘Assure the advantage’! At last, you admit this advantage! I should think this admission settles our argument.”
I admit this advantage. Perhaps by doing so I shall prove to you that I am not as passionately deluded as you think. I postponed mentioning these conditions, because in airing them, additional theoretical discussion is necessary.
“What are you driving at now?”
There is first the question of diagnosis. Before admitting a patient, suffering from nervous disturbances, to psychoanalytical treatment, one naturally desires to have as much assurance as possible that this therapy is suitable in that particular case, that is, that the patient has a good chance of being benefited by psychoanalysis. This can only be the case, if he is actually suffering from neurosis.
“I should think that would be easily ascertained, by the symptoms he complains about.”
You are putting your finger just on the point, where new complications may arise. It is not always possible to be perfectly sure of such a case. The patient, in spite of displaying all the visible symptoms of neurosis, may actually be suffering from something else. The incipient stage of a mental disease, for example, or the beginning of a process destroying his brain. To distinguish between such symptoms is not always easy or possible. Responsibility for such a decision must naturally be assumed by the physician alone. And as mentioned before, it is not so easy for him. For the longest time, an ailment may appear absolutely harmless, until finally manifesting its malignant character. Nervous people, as a rule, fear that they may be on the road to some mental disease.
Assumed that a physician has not correctly diagnosed a case, or has been unable to discover its true nature, nothing has been lost, no damage has been done. Analytical treatment, although not doing any harm to the patient, would have been superfluous in such a case. It might have given any number of people a chance to lay the blame for the unfortunate development of the case at the door of psychoanalysis. Unjustly so, to be sure, but such a likelihood should be avoided nevertheless.
“That sounds hopeless. It apparently tears out, by the very roots, everything you told me about the nature and development of a neurosis.”
Not at all. It only strengthens the fact that neurotics are a nuisance and a dilemma for all parties concerned, including the psychoanalysts. I may be able to alleviate your new apprehensions if I make myself clearer. Probably it would be more correct to say of such cases, as we now have under discussion, that they actually present neuroses. However, these neuroses are not psychic but rather somatic, that is, they do not originate from the soul, but rather from the body. Do you understand me?
“I do. But I am at a loss to connect all this with the psychological aspect.”
That can easily be done, if only complications of the living substance are sufficiently taken into consideration. What was the inherent feature of a neurosis? That the “I,” constituting the very essence of the soul, so to speak, developed and improved by the influence of the outer world, proved unable to fulfill its mediating functions between the “It” and reality; that the “I,” on account of its weakness, shirked its duties in regard to the “It,” thus incurring repressions from which it suffers. It is because such weakness of the “I” regularly takes place in all of us in childhood that events of our tender years exert such great importance in later life.
In the few years of our childhood, we have to cover the enormous distance of development from primitive man of the Stone Age to civilized man of today. In addition to this tremendous burden, the child has to ward off the urges of an early sexuality. Small wonder, then, that our “I” takes recourse to repressions, thus exposing itself to childhood neuroses, the effects of which in turn furnish the disposition for nervous disturbances in more mature years.
Everything now depends upon how the growing up individual will be treated by fate. If life is too hard, the divergence between urges and the opposition of reality too great, the “I” may remain unsuccessful in its endeavors to mediate between the two. This is the more probable, the more the “I” is encroached upon by such infantile dispositions as it may have acquired in tender years. Thus, the process of repression is repeated; urges tear themselves free from the sovereignty of the “I” to gain, by way of regression, a substitute for the gratification they crave, while the poor “I” has become helplessly neurotic.
Let us hold on firmly to this: that the most important, the pivotal point in the whole situation, so to speak, is the relative strength of the “I” in all its phases. It is easy, then, to complete our whole etiological survey, that is our endeavor to assign causes to the phenomena observed. We already know the normal causes for nervousness to be the infantile weakness of the “I,” the checking of early sexual urges, and the influence of chance episodes in our childhood.
But is there no possibility that there are also some other contributory factors, antedating childhood? For example, an inborn strength and unruliness of those urges which constitute the “It,” presenting right from the very start a task much too difficult for the “I”? Or could a certain weakness, existing for reasons unknown, in the development of the “I” be held responsible? Of course, all these possibilities will exert an etiological importance, in some cases of surpassing value.
The specific driving power of the “It” must always be taken into consideration, and wherever it is developed to an excessive degree, there are only meagre chances for a successful application of our therapy. Of the reasons that block the development of the “I,” we still know too little to account for such cases of neurosis which arise on a constitutional basis. It may be assumed that neurosis hardly ever develops unless there are constitutional or congenital factors increasing the possibility for such a condition. However, if it is correct that the relative weakness of the “I” is the deciding factor for the development of neuroses, then it would also appear possible that later, physical disturbances may result in a neurosis provided it also results in a weakening of the “I.”
This happens only too frequently. Such a physical disturbance may aim at the “It,” intensifying its urges to an extent where the “I” is not able to cope with them any more. As an example for such developments, the changes induced in woman by the disturbances of menstruation and menopause could perhaps be drawn upon. Other reasons that may weaken the “I” are general physical disturbances, organic diseases of the central nervous system. All of these may result in interference with those sources from which the soul apparatus draws its strength, to lead, in turn, to an encroachment of its more delicate functions, which are necessary to maintain unimpaired the whole “I” organization. In all these cases, neurosis presents about the same picture. However, while manifesting the same psychological mechanism, neuroses develop on the basis of a multifarious, frequently highly complicated etiology; that is, they arise from a great number of various causes.
“That suits me better. At last you have spoken like a physician. And now I am waiting for you to admit that so complicated a condition as a neurosis should only be treated by a physician.”
I am afraid you are expecting too much. What we have just discussed belonged in the realm of pathology. Psychoanalysis, however, is a therapeutical process. I admit, no, I even insist, that a physician should first diagnose each and every case where psychoanalysis seems applicable. Fortunately, the greater number of neuroses are of a psychical nature and not pathologically induced. As soon as the physician has ascertained this, he may safely leave the treatment to the lay-analyst. We have always followed this procedure within our analytical societies. Thanks to this close coöperation between the medically trained and non-trained members, errors almost never occur.
There is another emergency when the analyst has to invite the assistance of a physician. It is possible that, in the course of psychoanalytical treatment, symptoms—mostly of physical nature—appear which may either be part of the neurosis, or else manifestations of independent, organic disturbances. Here, the decision must once more be left to the physician.
“From all this, there follows that the analysts, even during the analysis, cannot dispense with the physician. This is another argument against lay-analyses.”
No, this possibility cannot be drawn upon as an argument against lay-analyses, because in an analogous case the medically trained analyst would not proceed any differently.
“I do not understand that.”
There is a rule that even a medically trained analyst, running across such dubious symptoms in the course of the treatment, is not to depend on his own judgment, but to consult some colleague, preferably a specialist of internal diseases.
“Why this rule, apparently so superfluous?”
This rule is not superfluous at all. There are several reasons for it. In the first place, it is hard to combine organic and psychical treatment. In the second place, the particular condition of transference frequently prevailing in analyses may make it inadvisable for the analyst to subject his patient to physical examination. In the third place, there are all the reasons in the world for the analyst to doubt his own opinion, inasmuch as he is so intensely interested in the psychical aspects of the case.
“I now understand your position towards lay-analyses. You insist that there must be lay-analysts. However, as you have to admit their insufficiency for the task, you compile everything that could serve to excuse them, and make things in general easier for them. To be frank with you, I cannot understand why we should have lay-analysts at all, inasmuch as they would never be more than second-class therapeutists. This need not include those few laymen who have already received their training, but institutes for psychological training should not accept laymen any more.”
I would assent to all this, if I could be shown that such restrictions would benefit all parties interested. You will admit that these interests are tri-fold:—There is the interest of the patient, the interest of the physicians, and last but not least, the interest of science which, in turn, includes the interest of all patients of the future. Let us investigate these three points.
It does not matter whether the patient be analysed by a physician or a layman, as long as any danger of mistaking his condition is excluded by being properly examined by a physician before the beginning of the treatment, or re-examined as soon as developments, in the course of the analysis, make this advisable. It is much more important for the patient that the analyst possesses those personal qualities which invite full confidence, and that he has that knowledge and experience which alone qualify him to apply psychoanalysis. To some people, it may seem that it might undermine the authority of the analyst to have his patient know that he is no physician and must obtain the advice of a medically trained expert in certain matters. However, although we have never kept a patient in the dark, as to the qualifications of an analyst, we have come to the conclusion that the patients have no prejudice against a non-medically trained analyst; they are only too glad to accept the benefits of treatment, wherever they offer themselves—a fact resented by the medical profession for the longest time.
It also must be considered that analysts, practising today, are men and women with academic training and degrees, pedagogues, of great experience and impressive personality. The analysis, to which all candidates of psychoanalytical institutes are required to submit, is the best means of testing their personal suitability for the performance of so exerting an activity as an analysis presents.
In reference to the interest of the physicians, I do not believe that medicine has anything to gain by annexing psychoanalysis. Today, medical training requires five years, with almost a whole sixth year taken up with examinations. Ever so often, new demands in regard to training are made with which the young student must comply, if his medical education is to be considered adequate. Generally speaking, while it is difficult today to enter the medical profession, the practice of medicine is neither very satisfactory nor very advantageous. And as soon as the undoubtedly justified necessity is realized that the physician be also informed of the psychological aspects of diseases, thus including in medical training a partial preparation for psychoanalysis, there would follow an extension of the medical curriculum and a corresponding extension of the period of training. I do not know how physicians would like such a development, arising from the monopoly they claim on psychoanalysis. But these demands would then have to be fulfilled and at a time when, in general, the material aspects of those strata of society which contribute the greatest contingent to the medical profession, are such that young physicians must establish a practice, as soon as possible.
However, the medical profession may not intend to include preparation for psychoanalysis into the medical curriculum proper. The general opinion may be that it is much more practical for the young physician to acquire psychoanalytical knowledge only after having completed his medical education. It may be said that such a procedure would not involve any actual loss of time, inasmuch as a young man under thirty never gains that confidence of patients which is an indispensable condition for benefiting a patient psychoanalytically. Of course, it could be said that a young physician, too, who has just won his diploma, cannot command too much respect, as regards his opinion of the physical ailments of his patients, and that the young analyst could very well utilize his time, by working in a psychological clinic, under the supervision of an experienced practitioner.
It seems to me that the aforementioned demand amounts to a waste of energy which, in view of economic conditions, does not seem justified. Although analytical training invades the field of medical training, it neither includes this training, nor is included by it. If a psychoanalytical college were to be organized, which today may strike one as being a fantastic idea, the curriculum of this institution would have to include much of what is taught in medical schools. Aside from the Psychology of the Depths, which would naturally always be the main subject taught, Biology would have to be included in the course, and Science of Sex would also be one of the major subjects. In addition, adequate instruction would have to be given on such disturbances which belong in the realm of Psychiatry. Psychoanalytical training would have to include a number of subjects which have no connection with medicine, and never enter the physician’s practice, such as History of Civilization, Mythology, Psychology of Religion, and Literature. Without being well acquainted with these subjects, the analyst will be unable to grasp the problems that will face him in the course of his practice.