Chapter XVIII: Part 18

How can this resistance be got rid of? In the same way: by finding it out and telling the patient about it. The resistance too arises in a repression, either from the very one which we are endeavouring to dispel, or in one that occurred earlier. It is set up by the counter-charge which rose up to repress the repellent impulse. So that we now do just the same as we were trying to do before; we interpret, identify, and inform the patient; but this time we are doing it at the right spot. The counter-charge or the resistance is not part of the Unconscious, but of the Ego which co-operates with us, and this is so, even if it is not actually conscious. We know that a difficulty arises here in the ambiguity of the word ‘unconscious,’ on the one hand, as a phenomenon, on the other hand, as a system. That sounds very obscure and difficult; but after all it is only a repetition of what we have said before, is it not? We have come to this point already long ago.—Well then, we expect that this resistance will be abandoned, and the counter-charge withdrawn, when we have made the recognition of them possible by our work of interpretation. What are the instinctive propelling forces at our disposal to make this possible? First, the patient’s desire for recovery, which impelled him to submit himself to the work in co-operation with us, and secondly, the aid of his intelligence which we reinforce by our interpretation. There is no doubt that it is easier for the patient to recognize the resistance with his intelligence, and to identify the idea in his Unconscious which corresponds to it, if we have first given him an idea which rouses his expectations in regard to it. If I say to you: “Look up at the sky and you will see a balloon,” you will find it much more quickly than if I merely tell you to look up and see whether you can see anything; a student who looks through a microscope for the first time is told by the instructor what he is to see; otherwise he sees nothing, although it is there and quite visible.

And now for the fact! In quite a number of the various forms of nervous illness, in the hysterias, anxiety conditions, obsessional neuroses, our hypothesis proves sound. By seeking out the repression in this way, discovering the resistances, indicating the repressed, it is actually possible to accomplish the task, to overcome the resistances, to break down the repression, and to change something unconscious into something conscious. As we do this we get a vivid impression of how, as each individual resistance is being mastered, a violent battle goes on in the soul of the patient—a normal mental struggle between two tendencies on the same ground, between the motives striving to maintain the counter-charge and those which are ready to abolish it. The first of these are the old motives which originally erected the repression; among the second are found new ones more recently acquired, which it is hoped will decide the conflict in our favour. We have succeeded in revivifying the old battle of the repression again, in bringing the issue, so long ago decided, up for revision again. The new contribution we make to it lies, first of all, in demonstrating that the original solution led to illness and in promising that a different one would pave the way to health, and secondly, in pointing out that the circumstances have all changed immensely since the time of that original repudiation of these impulses. Then, the Ego was weak, infantile, and perhaps had reason to shrink with horror from the claims of the Libido as being dangerous to it. To-day it is strong and experienced and moreover has a helper at hand in the physician. So we may expect to lead the revived conflict through to a better outcome than repression; and, as has been said, in hysteria, anxiety-neurosis, and the obsessional neurosis success in the main justifies our claims.

There are other forms of illness, however, with which our therapeutic treatment never is successful, in spite of the similarity of the conditions. In them also there was originally a conflict between Ego and Libido, leading to repression—although this conflict may be characterized by topographical differences from the conflict of the transference neuroses; in them too it is possible to trace out the point in the patient’s life at which the repressions occurred; we apply the same method, are ready to make the same assurances, offer the same assistance by telling the patient what to look out for; and here also the interval in time between the present and the point at which the repressions were established is all in favour of a better outcome of the conflict. And yet we cannot succeed in overcoming one resistance or in removing one of the repressions. These patients, paranoiacs, melancholics, and those suffering from dementia præcox, remain on the whole unaffected, proof against psycho-analytic treatment. What can be the cause of this? It is not due to lack of intelligence; a certain degree of intellectual capacity must naturally be stipulated for analysis, but there is no deficiency in this respect in, for instance, the very quick-witted deductive paranoiac. Nor are any of the other propelling forces regularly absent: melancholics, for instance, in contrast to paranoiacs, experience a very high degree of realization that they are ill and that their sufferings are due to this; but they are not on that account any more accessible to influence. In this we are confronted with a fact that we do not understand, and are therefore called upon to doubt whether we have really understood all the conditions of the success possible with the other neuroses.

When we keep to consideration of hysterical and obsessional neurotics we are very soon confronted with a second fact, for which we were quite unprepared. After the treatment has proceeded for a while we notice that these patients behave in a quite peculiar manner towards ourselves. We thought indeed that we had taken into account all the motive forces affecting the treatment and had reasoned out the situation between ourselves and the patient fully, so that it balanced like a sum in arithmetic; and then after all something seems to slip in which was quite left out of our calculation. This new and unexpected feature is in itself many-sided and complex; I will first of all describe some of its more frequent and simpler forms to you.

We observe then that the patient, who ought to be thinking of nothing but the solution of his own distressing conflicts, begins to develop a particular interest in the person of the physician. Everything connected with this person seems to him more important than his own affairs and to distract him from his illness. Relations with the patient then become for a time very agreeable; he is particularly docile, endeavours to show his gratitude wherever he can, exhibits a fineness of character and other good qualities which we had perhaps not anticipated in him. The analyst thus forms a very good opinion of the patient and values his luck in being able to render assistance to such an admirable personality. If the physician has occasion to see the patient’s relatives he hears with satisfaction that this esteem is mutual. The patient at home is never tired of praising the analyst and attributing new virtues to him. “He has quite lost his head over you; he puts implicit trust in you; everything you say is like a revelation to him,” say the relatives. Here and there one among this chorus having sharper eyes will say: “It is positively boring the way he never speaks of anything but you: he quotes you all the time.”

We will hope that the physician is modest enough to ascribe the patient’s estimate of his value to the hopes of recovery which he has been able to offer to him, and to the widening in the patient’s intellectual horizon consequent upon the surprising revelations entailed by the treatment and their liberating influence. The analysis too makes splendid progress under these conditions, the patient understands the suggestions offered to him, concentrates upon the tasks appointed by the treatment, the material needed—his recollections and associations—is abundantly available; he astonishes the analyst by the sureness and accuracy of his interpretations, and the latter has only to observe with satisfaction how readily and willingly a sick man will accept all the new psychological ideas that are so hotly contested by the healthy in the world outside. A general improvement in the patient’s condition, objectively confirmed on all sides, also accompanies this harmonious relationship in the analysis.

But such fair weather cannot last for ever. There comes a day when it clouds over. There begin to be difficulties in the analysis; the patient says he cannot think of anything more to say. One has an unmistakable impression that he is no longer interested in the work, and that he is casually ignoring the injunction given him to say everything that comes into his mind and to yield to none of the critical objections that occur to him. His behaviour is not dictated by the situation of the treatment; it is as if he had not made an agreement to that effect with the physician; he is obviously preoccupied with something which at the same time he wishes to reserve to himself. This is a situation in which the treatment is in danger. Plainly a very powerful resistance has risen up. What can have happened?

If it is possible to clear up this state of things, the cause of the disturbance is found to consist in certain intense feelings of affection which the patient has transferred on to the physician, not accounted for by the latter’s behaviour nor by the relationship involved by the treatment. The form in which this affectionate feeling is expressed and the goal it seeks naturally depend upon the circumstances of the situation between the two persons. If one of them is a young girl and the other still a fairly young man, the impression received is that of normal love; it seems natural that a girl should fall in love with a man with whom she is much alone and can speak of very intimate things, and who is in the position of an adviser with authority—we shall probably overlook the fact that in a neurotic girl some disturbance of the capacity for love is rather to be expected. The farther removed the situation between the two persons is from this supposed example, the more unaccountable it is to find that nevertheless the same kind of feeling comes to light in other cases. It may be still comprehensible when a young woman who is unhappily married seems to be overwhelmed by a serious passion for her physician, if he is still unattached, and that she should be ready to seek a divorce and give herself to him, or, where circumstances would prevent this, to enter into a secret love-affair with him. That sort of thing, indeed, is known to occur outside psycho-analysis. But in this situation girls and women make the most astonishing confessions which reveal a quite peculiar attitude on their part to the therapeutic problem: they had always known that nothing but love would cure them, and from the beginning of the treatment they had expected that this relationship would at last yield them what life had so far denied them. It was only with this hope that they had taken such pains over the analysis and had conquered all their difficulties in disclosing their thoughts. We ourselves can add: ‘and had understood so easily all that is usually so hard to accept.’ But a confession of this kind astounds us; all our calculations are blown to the winds. Could it be that we have omitted the most important element in the whole problem?

And actually it is so; the more experience we gain the less possible does it become for us to contest this new factor, which alters the whole problem and puts our scientific calculations to shame. The first few times one might perhaps think that the analytic treatment had stumbled upon an obstruction in the shape of an accidental occurrence, extraneous to its purpose and unconnected with it in origin. But when it happens that this kind of attachment to the physician regularly evinces itself in every fresh case, under the most unfavourable conditions, and always appears in circumstances of a positively grotesque incongruity—in elderly women, in relation to grey-bearded men, even on occasions when our judgement assures us that no temptations exist—then we are compelled to give up the idea of a disturbing accident and to admit that we have to deal with a phenomenon in itself essentially bound up with the nature of the disease.

The new fact which we are thus unwillingly compelled to recognize we call TRANSFERENCE. By this we mean a transference of feelings on to the person of the physician, because we do not believe that the situation in the treatment can account for the origin of such feelings. We are much more disposed to suspect that the whole of this readiness to develop feeling originates in another source; that it was previously formed in the patient, and has seized the opportunity provided by the treatment to transfer itself on to the person of the physician. The transference can express itself as a passionate petitioning for love, or it can take less extreme forms; where a young girl and an elderly man are concerned, instead of the wish to be wife or mistress, a wish to be adopted as a favourite daughter may come to light, the libidinous desire can modify itself and propose itself as a wish for an everlasting, but ideally platonic friendship. Many women understand how to sublimate the transference and to mould it until it acquires a sort of justification for its existence; others have to express it in its crude, original, almost impossible form. But at bottom it is always the same, and its origin in the same source can never be mistaken.

Before we enquire where we are to range this new fact, we will amplify the description of it a little. How is it with our male patients? There at least we might hope to be spared the troublesome element of sex difference and sex attraction. Well, the answer is very much the same as with women. The same attachment to the physician, the same overestimation of his qualities, the same adoption of his interests, the same jealousy against all those connected with him. The sublimated kinds of transference are the forms more frequently met with between man and man, and the directly sexual declaration more rarely, in the same degree to which the manifest homosexuality of the patient is subordinated to the other ways by which this component-instinct can express itself. Also, it is in male patients that the analyst more frequently observes a manifestation of the transference which at the first glance seems to controvert the description of it just given—that is, the hostile or _negative_ transference.

First of all, let us realize at once that the transference exists in the patient from the beginning of the treatment, and is for a time the strongest impetus in the work. Nothing is seen of it and one does not need to trouble about it as long as its effect is favourable to the work in which the two persons are co-operating. When it becomes transformed into a resistance, attention must be paid to it; and then it appears that two different and contrasting states of mind have supervened in it and have altered its attitude to the treatment: first, when the affectionate attraction has become so strong and betrays signs of its origin in sexual desire so clearly that it was bound to arouse an inner opposition against itself; and secondly, when it consists in antagonistic instead of affectionate feeling. The hostile feelings as a rule appear later than the affectionate and under cover of them; when both occur simultaneously they provide a very good exemplification of that ambivalence in feeling which governs most of our intimate relationships with other human beings. The hostile feelings therefore indicate an attachment of feeling quite similar to the affectionate, just as defiance indicates a similar dependence upon the other person to that belonging to obedience, though with a reversed prefix. There can be no doubt that the hostile feelings against the analyst deserve the name of ‘transference,’ for the situation in the treatment certainly gives no adequate occasion for them; the necessity for regarding the negative transference in this light is a confirmation of our previous similar view of the positive or affectionate variety.

Where the transference springs from, what difficulties it provides for us, how we can overcome them, and what advantage we can finally derive from it, are questions which can only be adequately dealt with in a technical exposition of the analytic method; I can merely touch upon them here. It is out of the question that we should yield to the demands made by the patient under the influence of his transference; it would be nonsensical to reject them unkindly, and still more so, indignantly. The transference is overcome by showing the patient that his feelings do not originate in the current situation, and do not really concern the person of the physician, but that he is reproducing something that had happened to him long ago. In this way we require him to transform his _repetition_ into _recollection_. Then the transference which, whether affectionate or hostile, every time seemed the greatest menace to the cure becomes its best instrument, so that with its help we can unlock the closed doors in the soul. I should like, however, to say a few words to dispel the unpleasant effects of the shock that this unexpected phenomenon must have been to you. After all, we must not forget that this illness of the patient’s which we undertake to analyse is not a finally accomplished, and as it were consolidated thing; but that it is growing and continuing its development all the time like a living thing. The beginning of the treatment puts no stop to this development; but, as soon as the treatment has taken a hold upon the patient, it appears that the entire productivity of the illness henceforward becomes concentrated in one direction—namely, upon the relationship to the physician. The transference then becomes comparable to the cambium layer between the wood and the bark of a tree, from which proceeds the formation of new tissue and the growth of the trunk in diameter. As soon as the transference has taken on this significance the work upon the patient’s recollections recedes far into the background. It is then not incorrect to say that we no longer have to do with the previous illness, but with a newly-created and transformed neurosis which has replaced the earlier one. This new edition of the old disease has been followed from its inception, one sees it come to light and grow, and is particularly familiar with it since one is oneself its central object. All the patient’s symptoms have abandoned their original significance and have adapted themselves to a new meaning, which is contained in their relationship to the transference; or else only those symptoms remain which were capable of being adapted in this way. The conquest of this new artificially-acquired neurosis coincides with the removal of the illness which existed prior to the treatment, that is, with accomplishing the therapeutic task. The person who has become normal and free from the influence of repressed instinctive tendencies in his relationship to the physician remains so in his own life when the physician has again been removed from it.

The transference has this all-important, absolutely central significance for the cure in hysteria, anxiety-hysteria, and the obsessional neurosis, which are in consequence rightly grouped together as the ‘transference neuroses.’ Anyone who has grasped from analytic experience a true impression of the fact of transference can never again doubt the nature of the suppressed impulses which have manufactured an outlet for themselves in the symptoms; and he will require no stronger proof of their libidinal character. We may say that our conviction of the significance of the symptoms as a substitutive gratification of the Libido was only finally and definitely established by evaluating the phenomenon of transference.

Now, however, we are called upon to correct our former dynamic conception of the process of cure and to bring it into agreement with the new discovery. When the patient has to fight out the normal conflict with the resistances which we have discovered in him by analysis, he requires a powerful propelling force to influence him towards the decision we aim at, leading to recovery. Otherwise it might happen that he would decide for a repetition of the previous outcome, and allow that which had been raised into consciousness to slip back again under repression. The outcome in this struggle is not decided by his intellectual insight—it is neither strong enough nor free enough to accomplish such a thing—but solely by his relationship to the physician. In so far as his transference bears the positive sign, it clothes the physician with authority, transforms itself into faith in his findings and in his views. Without this kind of transference or with a negative one, the physician and his arguments would never even be listened to. Faith repeats the history of its own origin; it is a derivative of love and at first it needed no arguments. Not until later does it admit them so far as to take them into critical consideration if they have been offered by someone who is loved. Without this support arguments have no weight with the patient, never do have any with most people in life. A human being is therefore on the whole only accessible to influence, even on the intellectual side, in so far as he is capable of investing objects with Libido; and we have good cause to recognize, and to fear, in the measure of his narcissism a barrier to his susceptibility to influence, even by the best analytic technique.

The capacity for the radiation of Libido towards other persons in object investment must, of course, be ascribed to all normal people; the tendency to transference in neurotics, so-called, is only an exceptional intensification of a universal characteristic. Now it would be very remarkable if a human character-trait of this importance and universality had never been observed and made use of. And this has really been done. Bernheim, with unerring perspicacity, based the theory of hypnotic manifestations upon the proposition that all human beings are more or less open to suggestion, are ‘suggestible.’ What he called suggestibility is nothing else but the tendency to transference, rather too narrowly circumscribed so that the negative transference did not come within its scope. But Bernheim could never say what suggestion actually was nor how it arises; it was an axiomatic fact to him and he could give no explanation of its origin. He did not recognize the dependence of ‘suggestibility’ on sexuality, on the functioning of the Libido. And we have to admit that we have only abandoned hypnosis in our methods in order to discover suggestion again in the shape of transference.

But now I will pause and let you take up the thread. I observe that an objection is invading your thoughts with such violence that it would deprive you of all power of attention if it were not given expression. “So now at last you have confessed that you too work with the aid of suggestion like the hypnotists. We have been thinking so all along. But then, what is the use of all these roundabout routes by way of past experiences, discovering the unconscious material, interpreting and retranslating the distortions, and the enormous expenditure of time, trouble, and money, when after all the only effective agent is suggestion? Why do you not suggest directly against the symptoms, as others do who are honest hypnotists? And besides, if you are going to make out that by these roundabout routes you have made numerous important psychological discoveries, which are concealed in direct suggestion, who is to vouch for their validity? Are not they too the result of suggestion, of unintentional suggestion, that is? Cannot you impress upon the patient what you please and whatever seems good to you in this direction also?”

What you charge me with in this way is exceedingly interesting and must be answered. But I cannot do that to-day; our time is up. Till next time, then. You will see that I shall be answerable to you. To-day I must finish what I began. I promised to explain to you through the factor of the transference why it is that our therapeutic efforts have no success in the narcissistic neuroses.

I can do it in a few words, and you will see how simply the riddle is solved, and how well everything fits together. Experience shows that persons suffering from the narcissistic neuroses have no capacity for transference, or only insufficient remnants of it. They turn from the physician, not in hostility, but in indifference. Therefore they are not to be influenced by him; what he says leaves them cold, makes no impression on them, and therefore the process of cure which can be carried through with others, the revivification of the pathogenic conflict and the overcoming of the resistance due to the repressions, cannot be effected with them. They remain as they are. They have often enough undertaken attempts at recovery on their own account which have led to pathological results; we can do nothing to alter this.

On the basis of our clinical observations of these patients we stated that they must have abandoned the investment of objects with Libido and transformed object-Libido into Ego-Libido. By this we differentiated them from the first group of neurotics (hysteria, anxiety, and obsessional neurosis). Their behaviour during the attempt to cure them confirms this suspicion. They produce no transference, and are, therefore, inaccessible to our efforts, not to be cured by us.

TWENTY-EIGHTH LECTURE
THE ANALYTIC THERAPY

You know what we are going to discuss to-day. When I admitted that the influence of the psycho-analytic therapy is essentially founded upon transference, i.e. upon suggestion, you asked me why we do not make use of direct suggestion, and you linked this up with a doubt whether, in view of the fact that suggestion plays such a large part, we can still vouch for the objectivity of our psychological discoveries. I promised to give you a comprehensive answer.

Direct suggestion is suggestion delivered directly against the forms taken by the symptoms, a struggle between your authority and the motives underlying the disease. In this struggle you do not trouble yourself about these motives, you only require the patient to suppress the manifestation of them in the form of symptoms. In the main it makes no difference whether you place the patient under hypnosis or not. Bernheim, with his characteristic acuteness, repeatedly stated that suggestion was the essence of the manifestations of hypnotism, and that hypnosis itself was already a result of suggestion, a suggested condition; he preferred to use suggestion in the waking state, which can achieve the same results as suggestion in hypnosis.

Now which shall I take first, the results of experience or theoretical considerations?

Let us begin with experience. I sought out Bernheim in Nancy in 1889 and became a pupil of his; I translated his book on suggestion into German. For years I made use of hypnotic treatment, first with prohibitory suggestions and later combined with Breuer’s system of the fullest enquiry into the patient’s life; I can therefore speak from wide experience about the results of the hypnotic or suggestive therapy. According to an old medical saying an ideal therapy should be rapid, reliable and not disagreeable to the patient; Bernheim’s method certainly fulfilled two of these requirements. It was much more rapid, that is, incomparably more rapid in its course than the analytic, and it involved the patient in no trouble or discomfort. For the physician it eventually became monotonous; it meant treating every case in the same way, always employing the same ritual to prohibit the existence of the most diverse symptoms, without being able to grasp anything of their meaning or significance. It was a sort of mechanical drudgery—hodman’s work—not scientific work; it was reminiscent of magic, conjuring, and hocus-pocus, yet in the patient’s interests one had to ignore that. In the third desideratum, however, it failed; it was not reliable in any respect. It could be employed in certain cases only and not in others; with some much could be achieved by it, and with others very little, one never knew why. But worse than its capricious nature was the lack of permanence in the results; after a time, if one heard from the patient again, the old malady had reappeared or had been replaced by another. Then one could begin to hypnotize again. In the background there was the warning of experienced men against robbing the patient of his independence by frequent repetitions of hypnosis, and against accustoming him to this treatment as though it were a narcotic. It is true, on the other hand, that at times everything fell out just as one could wish; one obtained complete and lasting success with little difficulty; but the conditions of this satisfactory outcome remained hidden. In one case, when I had completely removed a severe condition by a short hypnotic treatment, it recurred unchanged after the patient (a woman) had developed ill feeling against me without just cause; then after a reconciliation I was able to effect its disappearance again and this time far more thoroughly; but it reappeared again when she had a second time become hostile to me. Another time I had the following experience; during the treatment of an especially obstinate attack in a patient whom I had several times relieved of nervous symptoms, she suddenly threw her arms round my neck. Whether one wished to do so or not, this kind of thing finally made it imperative to enquire into the problem of the nature and source of one’s suggestive authority.

So much for experience; it shows that in abandoning direct suggestion we have given up nothing irreplaceable. Now let us link on to the facts a few comments. The exercise of the hypnotic method makes as little demand for effort on the part of the patient as it does on the physician. The method is in complete harmony with the view of the neuroses generally accepted by the majority of medical men. The practitioner says to the nervous person: “There is nothing the matter with you; it is merely nervousness, therefore a few words from me will scatter all your troubles to the winds in five minutes.” But it is contrary to all our beliefs about energy in general that a minimal exertion should be able to remove a heavy load by approaching it directly without the assistance of any suitably-devised appliance. In so far as the circumstances are at all comparable, experience shows that this trick cannot be performed successfully with the neuroses. I know, however, that this argument is not unassailable; there are such things as explosions.

In the light of the knowledge we have obtained through psycho-analysis, the difference between hypnotic and psycho-analytic suggestion may be described as follows: The hypnotic therapy endeavours to cover up and as it were to whitewash something going on in the mind, the analytic to lay bare and to remove something. The first works cosmetically, the second surgically. The first employs suggestion to interdict the symptoms; it reinforces the repressions, but otherwise it leaves unchanged all the processes that have led to symptom-formation. Analytic therapy takes hold deeper down nearer the roots of the disease, among the conflicts from which the symptoms proceed; it employs suggestion to change the outcome of these conflicts. Hypnotic therapy allows the patient to remain inactive and unchanged, consequently also helpless in the face of every new incitement to illness. Analytic treatment makes as great demands for efforts on the part of the patient as on the physician, efforts to abolish the inner resistances. The patient’s mental life is permanently changed by overcoming these resistances, is lifted to a higher level of development, and remains proof against fresh possibilities of illness. The labour of overcoming the resistances is the essential achievement of the analytic treatment; the patient has to accomplish it and the physician makes it possible for him to do this by suggestions which are in the nature of an _education_. It has been truly said therefore, that psycho-analytic treatment is a kind of _re-education_.

I hope I have now made clear to you the difference between our method of employing suggestion therapeutically and the method which is the only possible one in hypnotic therapy. Since we have traced the influence of suggestion back to the transference, you also understand the striking capriciousness of the effect in hypnotic therapy, and why analytic therapy is within its limits dependable. In employing hypnosis we are entirely dependent upon the condition of the patient’s transference and yet we are unable to exercise any influence upon this condition itself. The transference of a patient being hypnotized may be negative, or, as most commonly, ambivalent, or he may have guarded himself against his transference by adopting special attitudes; we gather nothing about all this. In psycho-analysis we work upon the transference itself, dissipate whatever stands in the way of it, and manipulate the instrument which is to do the work. Thus it becomes possible for us to derive entirely new benefits from the power of suggestion; we are able to control it; the patient alone no longer manages his suggestibility according to his own liking, but in so far as he is amenable to its influence at all, we guide his suggestibility.

Now you will say that, regardless of whether the driving force behind the analysis is called transference or suggestion, the danger still remains that our influence upon the patient may bring the objective certainty of our discoveries into doubt; and that what is an advantage in therapy is harmful in research. This is the objection that has most frequently been raised against psycho-analysis; and it must be admitted that, even though it is unjustified, it cannot be ignored as unreasonable. If it were justified, psycho-analysis after all would be nothing else but a specially well-disguised and particularly effective kind of suggestive treatment; and all its conclusions about the experiences of the patient’s past life, mental dynamics, the Unconscious, and so on, could be taken very lightly. So our opponents think; the significance of sexual experiences in particular, if not the experiences themselves, we are supposed to have “put into the patient’s mind,” after having first concocted these conglomerations in our own corrupt minds. These accusations are more satisfactorily refuted by the evidence of experience than by the aid of theory. Anyone who has himself conducted psycho-analyses has been able to convince himself numberless times that it is impossible to suggest things to a patient in this way. There is no difficulty, of course, in making him a disciple of a particular theory, and thus making it possible for him to share some mistaken belief possibly harboured by the physician. He behaves like anyone else in this, like a pupil; but by this one has only influenced his intellect, not his illness. The solving of his conflicts and the overcoming of his resistances succeeds only when what he is told to look for in himself corresponds with what actually does exist in him. Anything that has been inferred wrongly by the physician will disappear in the course of the analysis; it must be withdrawn and replaced by something more correct. One’s aim is, by a very careful technique, to prevent temporary successes arising through suggestion; but if they do arise no great harm is done, for we are not content with the first result. We do not consider the analysis completed unless all obscurities in the case are explained, the gaps in memory filled out, and the original occasions of the repressions discovered. When results appear prematurely, one regards them as obstacles rather than as furtherances of the analytic work, and one destroys them again by continually exposing the transference on which they are founded. Fundamentally it is this last feature which distinguishes analytic treatment from that of pure suggestion, and which clears the results of analysis from the suspicion of being the results of suggestion. In every other suggestive treatment the transference is carefully preserved and left intact; in analysis it is itself the object of the treatment and is continually being dissected in all its various forms. At the conclusion of the analysis the transference itself must be dissolved; if success then supervenes and is maintained it is not founded on suggestion, but on the overcoming of the inner resistances effected by the help of suggestion, on the inner change achieved within the patient.

That which probably prevents single effects of suggestion from arising during the treatment is the struggle that is incessantly being waged against the resistances, which know how to transform themselves into a negative (hostile) transference. Nor will we neglect to point to the evidence that a great many of the detailed findings of analysis, which would otherwise be suspected of being produced by suggestion, are confirmed from other, irreproachable sources. We have unimpeachable witnesses on these points, namely, dements and paranoiacs, who are of course quite above any suspicion of being influenced by suggestion. All that these patients relate in the way of phantasies and translations of symbols, which have penetrated through into their consciousness, corresponds faithfully with the results of our investigations into the Unconscious of transference neurotics, thus confirming the objective truth of the interpretations made by us which are so often doubted. I do not think you will find yourselves mistaken if you choose to trust analysis in these respects.

We now need to complete our description of the process of recovery by expressing it in terms of the Libido-theory. The neurotic is incapable of enjoyment or of achievement—the first because his Libido is attached to no real object, the last because so much of the energy which would otherwise be at his disposal is expended in maintaining the Libido under repression, and in warding off its attempts to assert itself. He would be well if the conflict between his Ego and his Libido came to an end, and if his Ego again had the Libido at its disposal. The task of the treatment, therefore, consists in the task of loosening the Libido from its previous attachments, which are beyond the reach of the Ego, and in making it again serviceable to the Ego. Now where is the Libido of a neurotic? Easily found: it is attached to the symptoms, which offer it the substitutive satisfaction that is all it can obtain as things are. We must master the symptoms then, dissolve them—just what the patient asks of us. In order to dissolve the symptoms it is necessary to go back to the point at which they originated, to review the conflict from which they proceeded, and with the help of propelling forces which at that time were not available to guide it towards a new solution. This revision of the process of repression can only partially be effected by means of the memory-traces of the processes which led up to repression. The decisive part of the work is carried through by creating—in the relationship to the physician, in “the transference”—new editions of those early conflicts, in which the patient strives to behave as he originally behaved, while one calls upon all the available forces in his soul to bring him to another decision. The transference is thus the battlefield where all the contending forces must meet.

All the Libido and the full strength of the opposition against it are concentrated upon the one thing, upon the relationship to the physician; thus it becomes inevitable that the symptoms should be deprived of their Libido; in place of the patient’s original illness appears the artificially-acquired transference, the transference-disorder; in place of a variety of unreal objects of his Libido appears the one object, also ‘phantastic,’ of the person of the physician. This new struggle which arises concerning this object is by means of the analyst’s suggestions lifted to the surface, to the higher mental levels, and is there worked out as a normal mental conflict. Since a new repression is thus avoided, the opposition between the Ego and the Libido comes to an end; unity is restored within the patient’s mind. When the Libido has been detached from its temporary object in the person of the physician it cannot return to its earlier objects, but is now at the disposal of the Ego. The forces opposing us in this struggle during the therapeutic treatment are on the one hand the Ego’s aversion against certain tendencies on the part of the Libido, which had expressed itself in repressing tendencies; and on the other hand the tenacity or ‘adhesiveness’ of the Libido, which does not readily detach itself from objects it has once invested.

The therapeutic work thus falls into two phases; in the first all the Libido is forced away from the symptoms into the transference and there concentrated, in the second the battle rages round this new object and the Libido is made free from it. The change that is decisive for a successful outcome of this renewed conflict lies in the preclusion of repression, so that the Libido cannot again withdraw itself from the Ego by a flight into the Unconscious. It is made possible by changes in the Ego ensuing as a consequence of the analyst’s suggestions. At the expense of the Unconscious the Ego becomes wider by the work of interpretation which brings the unconscious material into consciousness; through education it becomes reconciled to the Libido and is made willing to grant it a certain degree of satisfaction; and its horror of the claims of its Libido is lessened by the new capacity it acquires to expend a certain amount of the Libido in sublimation. The more nearly the course of the treatment corresponds with this ideal description the greater will be the success of the psycho-analytic therapy. Its barriers are found in the lack of mobility in the Libido, which resists being released from its objects, and in the rigidity of the patient’s narcissism, which will not allow more than a certain degree of object-transference to develop. Perhaps the dynamics of the process of recovery will become still clearer if we describe it by saying that, in attracting a part of it to ourselves through transference, we gather in the whole amount of the Libido which has been withdrawn from the Ego’s control.

It is as well here to make clear that the distributions of the Libido which ensue during and by means of the analysis afford no direct inference of the nature of its disposition during the previous illness. Given that a case can be successfully cured by establishing and then resolving a powerful father-transference to the person of the physician, it would not follow that the patient had previously suffered in this way from an unconscious attachment of the Libido to his father. The father-transference is only the battlefield on which we conquer and take the Libido prisoner; the patient’s Libido has been drawn hither away from other ‘positions.’ The battlefield does not necessarily constitute one of the enemy’s most important strongholds; the defence of the enemy’s capital city need not be conducted immediately before its gates. Not until after the transference has been again resolved can one begin to reconstruct in imagination the dispositions of the Libido that were represented by the illness.

In the light of the Libido-theory there is a final word to be said about dreams. The dreams of a neurotic, like his “errors” and his free associations, enable us to find the meaning of the symptoms and to discover the dispositions of the Libido. The forms taken by the wish-fulfilment in them show us what are the wish-impulses that have undergone repression, and what are the objects to which the Libido has attached itself after withdrawal from the Ego. The interpretation of dreams therefore plays a great part in psycho-analytic treatment, and in many cases it is for lengthy periods the most important instrument at work. We already know that the condition of sleep in itself produces a certain relaxation of the repressions. By this diminution in the heavy pressure upon it the repressed desire is able to create for itself a far clearer expression in a dream than can be permitted to it by day in the symptoms. Hence the study of dreams becomes the easiest approach to a knowledge of the repressed Unconscious, which is where the Libido which has withdrawn from the Ego belongs.

The dreams of neurotics, however, differ in no essential from those of normal people; they are indeed perhaps not in any way distinguishable from them. It would be illogical to account for the dreams of neurotics in a way that would not also hold good of the dreams of normal people. We have to conclude therefore that the difference between neurosis and health prevails only by day; it is not sustained in dream-life. It thus becomes necessary to transfer to healthy persons a number of conclusions arrived at as a result of the connections between the dreams and the symptoms of neurotics. We have to recognize that the healthy man as well possesses those factors in mental life which alone can bring about the formation of a dream or of a symptom, and we must conclude further that the healthy also have instituted repressions and have to expend a certain amount of energy to maintain them; that their unconscious minds too harbour repressed impulses which are still suffused with energy, and that _a part of the Libido is in them also withdrawn from the disposal of the Ego_. The healthy man too is therefore virtually a neurotic, but the only symptom that he _seems_ capable of developing is a dream. To be sure when you subject his waking life also to a critical investigation you discover something that contradicts this specious conclusion; for this apparently healthy life is pervaded by innumerable trivial and practically unimportant symptom-formations.

The difference between nervous health and nervous illness (neurosis) is narrowed down therefore to a practical distinction, and is determined by the practical result—how far the person concerned remains capable of a sufficient degree of capacity for enjoyment and active achievement in life. The difference can probably be traced back to the proportion of the energy which has remained free relative to that of the energy which has been bound by repression, i.e. it is a quantitative and not a qualitative difference. I do not need to remind you that this view provides a theoretical basis for our conviction that the neuroses are essentially amenable to cure, in spite of their being based on a constitutional disposition.

So much, therefore, in the way of knowledge of the characteristics of health may be inferred from the identity of the dreams dreamt by neurotic and by healthy persons. Of dreams themselves, however, a further inference must be drawn—namely, that it is not possible to detach them from their connection with neurotic symptoms; that we are not at liberty to believe that their essential nature is exhausted by compressing them into the formula of ‘a translation of thoughts into archaic forms of expression’; and that we are bound to conclude that they disclose dispositions of the Libido and objects of desire which are actually in operation and valid at the moment.

We have now come very nearly to the end. Perhaps you are disappointed that under the heading of psycho-analytic therapy I have limited myself to theory, and have told you nothing of the conditions under which the cure is undertaken, or of the results it achieves. I omit both, however: the first, because in fact I never intended to give you a practical training in the exercise of the analytic method; and the last, because I have several motives against it. At the beginning of these discussions I said emphatically that under favourable conditions we achieve cures that are in no way inferior to the most brilliant in other fields of medical therapy; I may perhaps add that these results could be achieved by no other method. If I said more I should be suspected of wishing to drown the depreciatory voices of our opponents by self-advertisement. Medical “colleagues” have, even at public congresses, repeatedly held out a threat to psycho-analysts that by publishing a collection of the failures and harmful effects of analysis they will open the eyes of the injured public to the worthlessness of this method of treatment. Apart from the malicious, denunciatory character of such a measure, however, a collection of that kind would not even be valid evidence upon which a correct estimate of the therapeutic results of analysis might be formed. Analytic therapy, as you know, is still young; it needed many years to elaborate the technique, which could only be done in the course of the work under the influence of increasing experience. On account of the difficulties of imparting instruction in the methods the beginner is thrown much more upon his own resources for development of his capacity than any other kind of specialist, and the results of his early years can never be taken as indicating the full possible achievements of analytic therapy.

Many attempts at treatment made in the beginning of psycho-analysis were failures because they were undertaken with cases altogether unsuited to the procedure, which nowadays we should exclude by following certain indications. These indications, however, could only be discovered by trying. In the beginning we did not know that paranoia and dementia præcox, when fully developed, are not amenable to analysis; we were still justified in trying the method on all kinds of disorders. Most of the failures of those early years, however, were not due to the fault of the physician, or to the unsuitability in the choice of subject, but to unpropitious external conditions. I have spoken only of the inner resistances, those on the part of the patient, which are inevitable and can be overcome. The external resistances which the patient’s circumstances and surroundings set up against analysis have little theoretic interest but the greatest practical importance. Psycho-Analytic treatment is comparable to a surgical operation and, like that, for its success it has the right to expect to be carried out under the most favourable conditions. You know the preliminary arrangements a surgeon is accustomed to make—a suitable room, a good light, expert assistance, exclusion of the relatives, and so on. Now ask yourselves how many surgical operations would be successful if they had to be conducted in the presence of the patient’s entire family poking their noses into the scene of the operation and shrieking aloud at every cut. In psycho-analytic treatment the intervention of the relatives is a positive danger and, moreover, one which we do not know how to deal with. We are armed against the inner resistances of the patient, which we recognize as necessary, but how can we protect ourselves against these outer resistances? It is impossible to get round the relatives by any sort of explanation, nor can one induce them to hold aloof from the whole affair; one can never take them into one’s confidence because then we run the danger of losing the patient’s trust in us, for he—quite rightly, of course—demands that the man he confides in should take his part. Anyone who knows anything of the dissensions commonly splitting up family life will not be astonished in his capacity of analyst to find that those nearest to the patient frequently show less interest in his recovery than in keeping him as he is. When as so often occurs the neurosis is connected with conflicts between different members of a family, the healthy person does not make much of putting his own interest before the patient’s recovery. After all, it is not surprising that the husband does not favour a treatment in which, as he correctly supposes, his sins will all come to light; nor do we wonder at this, but then we cannot blame ourselves when our efforts remain fruitless and are prematurely broken off because the husband’s resistance is added to that of the sick wife. We had simply undertaken something which, under the existing conditions, it was impossible to carry out.