Freud, Sigmund (1910-006/1924.en): The future prospects of psycho-analytic therapy

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XXV

THE FUTURE PROSPECTS OF PSYCHO-
ANALYTIC THERAPY¹

AN ADDRESS DELIVERED BEFORE THE SECOND INTER-
NATIONAL PSYCHO-ANALYTICAL CONGRESS AT
NUREMBERG IN 1910

(1910)

SINCE the objects for which we are assembled here
to-day are mainly practical, I shall choose a
practical theme for my introductory address and
appeal to your interest in medical, not in scientific,
matters. I can imagine what your opinion about the
success of our therapy probably is, and I assume that
most of you have already passed through the two
stages which all beginners go through, that of en-
thusiasm at the unexpected increase in our therapeutic
achievements, and that of depression at the magnitude
of the difficulties which stand in the way of our efforts.
Whichever of these stages in development, however,
each of you may happen to be going through at the
moment, my intention to-day is to show you that
we have by no means come to the end of our resources
for combating the neuroses, and that we may expect a
substantial improvement in our therapeutic prospects
before very long.

This improvement will come, I think, from three
sources:

1. From internal progress.
2. From increased prestige.
3. From the general effect of our work.

¹First published in Zentralblatt, Bd. I., 1910; reprinted in Samm-
lung, Dritte Folge. [Translated by Joan Riviere.]

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I. Under ‘internal progress’ I understand advances
(a) in our analytical knowledge, (b) in our technique.
(a) Advances in our knowledge. We are, of course,
still a long way from knowing all that is required for
an understanding of the unconscious minds of our
patients. Now it is clear that every advance in our
knowledge means an increase in the power of our
therapy. As long as we understood nothing, we
accomplished nothing; the more we understand the
more we shall achieve. At its beginning psycho-
analytic treatment was inexorable and exhaustive.
The patient had to say everything himself, and the
physician’s part consisted of urging him on incessantly.
To-day things have a more friendly air. The treatment
is made up of two parts, out of what the physician
infers and tells the patient, and out of the patient’s
work of assimilation, of ‘working through’, what he
hears. The mechanism of our curative method is
indeed quite easy to understand; we give the patient
the conscious idea of what he may expect to find
(bewusste Erwartungsvorstellung), and the similarity of
this with the repressed unconscious one leads him to
come upon the latter himself. This is the intellectual
help which makes it easier for him to overcome the
resistances between conscious and unconscious. In-
cidentally, I may remark that it is not the only
mechanism made use of by the analytic method;
you all know that far more powerful one which lies
in the use of the ‘transference’. I intend soon to
undertake an exposition of these various factors, which
are so important for an understanding of the cure, in a
Practice of Psycho-Analysis. And, further, in speaking
to you I need not rebut the objection that the way
in which we practise the method to-day obscures its
testimony to the correctness of our hypotheses; you
will not forget that this evidence is to be found else-
where, and that a therapeutic procedure cannot be per-
formed in the same way as a theoretical investigation.
Now let me refer briefly to various fields in which

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we both have much to learn that is new and do actually
make new discoveries daily. First of all, there is the
matter of symbolism in dreams and in the unconscious
—a fiercely contested subject, as you know! It is
no small credit to our colleague, W. Stekel, that,
indifferent to all the objections of our opponents, he
has undertaken a study of dream-symbols. In this
there is indeed much still to learn; my Traumdeutung,
which was written in 1899, awaits important amplifica-
tion from researches into symbolism.

I will say a few words about one of the symbols that
has lately been recognized. Not long ago it came to
my knowledge that a psychologist whose views are
not too distant from ours had remarked to one of us
that we undoubtedly overestimate the hidden sexual
significance of dreams; his most frequent dream was
of going upstairs, and there could certainly be nothing
sexual about that. Our attention being thus drawn
to it, we began to study the incidence of stairs, steps
and ladders in dreams, and soon could establish the
fact that stairs and such things are certainly a symbol
of coitus. The underlying element which the two
things have in common is not difficult to discover; one
climbs an acclivity in rhythmic movements, accom-
panied by increasing breathlessness, and in a few rapid
leaps can be down below again. Thus the rhythm of
coitus reappears in climbing steps. We will not forget
to adduce the usages of speech in this connection. It
shows us that ‘mounting’ is used quite simply as a
symbol for the sexual act. In German one says ‘the
man is a Steiger, nachsteigen’. In French the steps
of a stair are called ‘marches’; ‘un vieux marcheur’,
‘ein alter Steiger’ both mean an old profligate. The
dream-material from which these newly recognized
symbols are derived will in due time be put before you
by the committee we are about to form for collecting
and studying symbols. An account of another interest-
ing symbol, of the idea of ‘rescue’ and its changes in
significance, will appear in the second volume of our

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Jahrbuch. However, I must break off here or I shall
not reach my other points.

Every one of you will know from his own experience
the total change in one’s attitude to a new case when
once one has thoroughly mastered the structure of some
typical cases of illness. Assuming now that we had
narrowly defined the regular elements in the com-
position of the various forms of neurosis, just as we
have already succeeded in doing for hysterical symptom-
formation, how much more assured we should be in
our prognoses! Just as an obstetrician knows by
examining the placenta whether it has been completely
expelled or whether noxious fragments of it still
remain, so we should be able, independently of the
success of the cure and the patient’s present condition,
to say whether the work had been completely carried to
an end or whether we had to expect relapses and fresh
onsets of illness.

(b) I will hasten on to the innovations in the field
of technique, where indeed nearly everything still
awaits definitive settlement, and much is only now
beginning to come clear. There are now two aims in
psycho-analytic technique: to save the physician
effort and to open up for the patient the freest access
to his unconscious. You know that our technique has
been transformed in important respects. At the time
of the cathartic treatment we set ourselves the aim
of elucidating the symptoms, then we turned away
from the symptoms to discovering the ‘complexes’,
to use Jung’s indispensable word; now, however, our
work is aimed directly at finding out and overcoming
the ‘resistances’, and we can with justification rely
on the complexes coming to light as soon as the
resistances have been recognized and removed. Some
of you have since shown a desire to formulate and
classify these resistances. Now I beg you to examine
your material and see whether you can confirm the
following statement: In male patients the most
important resistances to the treatment seem to be

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derived from the father-complex and to express them-
selves in fear of the father, and in defiance and
incredulity towards him.
Other innovations in technique relate to the
physician himself. We have begun to consider the
‘counter-transference’, which arises in the physician
as a result of the patient’s influence on his unconscious
feelings, and have nearly come to the point of requiring
the physician to recognize and overcome this counter-
transference in himself. Now that a larger number
of people have come to practise psycho-analysis and
mutually exchange their experiences, we have noticed
that every analyst’s achievement is limited by what
his own complexes and resistances permit, and con-
sequently we require that he should begin his practice
with a self-analysis and should extend and deepen
this constantly while making his observations on his
patients. Anyone who cannot succeed in this self-
analysis may without more ado regard himself as
unable to treat neurotics by analysis.
We are also now coming to the opinion that the
analytic technique must undergo certain modifications
according to the nature of the disease and the dominat-
ing instinctual trends in the patient. Our therapy
was, in fact, first designed for conversion-hysteria ;
in anxiety-hysteria (phobias) we must alter our
procedure to some extent. The fact is that these
patients cannot bring out the material necessary for
resolving the phobia so long as they feel protected
by retaining their phobic condition. One cannot, of
course, induce them to give up their protective measures
and work under the influence of anxiety from the
beginning of the treatment. One must therefore help
them by interpreting their unconscious to them until
they can make up their minds to do without the
protection of their phobia and expose themselves to a
now comparatively moderate degree of anxiety. Only
when they have done so does the material necessary
for achieving solution of the phobia become accessible.

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Other modifications of technique which seem to me not
yet ready for discussion will be required in the treatment
of obsessional neurosis. In this connection very im-
portant questions arise, which are not yet elucidated :
how far the instincts involved in the conflict in
the patient are to be allowed some gratification during
the treatment, and what difference it then makes
whether these impulses are active (sadistic) or passive
(masochistic) in nature.

I hope you have received the impression that, when
all that can at present be merely glimpsed is known
and when we have established all the improvements in
technique to which deeper experience with our patients
must lead us, then our medical practice will reach a
degree of precision and certainty of success which is not
to be had in all medical specialities.

2. I said that we had much to expect from the
increase in prestige which must accrue to us as time
goes on. I need hardly say much to you about the
importance of authority. Only very few civilized
persons are capable of existing without reliance on
others or are even capable of coming to an independent
opinion. You cannot exaggerate the intensity of man’s
inner irresolution and craving for authority. The
extraordinary increase in the neuroses since the power
of religion has waned may give you some indication
of it. The impoverishment of the ego due to the
tremendous effort in repression demanded of every
individual by culture may be one of the principal causes
of this state of things.

Hitherto the weight of authority with its enormous
‘suggestive’ force has been against us. All our thera-
peutic successes have been achieved in spite of this
suggestion ; it is surprising that any success was to be
had at all in the circumstances. I will not let myself
go to the extent of describing to you the agreeable
things that happened during the time when I alone
represented psycho-analysis. I know that when I
assured my patients that I knew how to relieve them

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permanently of their sufferings they looked round
my modest abode, thought of my want of fame and
honours, and regarded me like a man who possesses an
infallible system in a gambling-
place, of whom people
say that if he could do what he professes he would
look very different. Nor was it really at all pleasant to
operate on people’s minds while colleagues whose duty
it was to assist took a pleasure in spitting into the
field of operation, and while at the first signs of blood or
restlessness in him the patient’s relatives threatened
one. An operation may surely cause reactions ; in
surgery we became used to that long ago. Nobody
believed in me, in fact, just as even to-
day very few
believe in us ; under such conditions many an attempt
was bound to fail. To estimate the increase in our
therapeutic capacities that will ensue when general
recognition is accorded us, you should think of the
different positions of gynæcologists in Turkey and in
the West. All that a woman’s physician may do there
is to feel the pulse of an arm which is stretched out to
him through a hole in the wall. And his curative
results are in proportion to the inaccessibility of their
object ; our opponents in the West wish to restrict
our access over our patients’ minds to something very
similar. But now that the force of public opinion
drives sick women to the gynæcologist, he has become
their helper and saviour. Now do not say that, even
if the weight of public opinion comes to our aid and so
much increases our successes, that will in no way prove
the validity of our hypotheses. Suggestion is supposed
to be able to do anything, and our successes would then
be results of suggestion and not of psycho-
analysis.
Public opinion is at present suggesting hydropathic
cures, diet cures, electricity cures for nervous persons,
but that does not enable these measures to remove the
neuroses. It will be seen whether psycho-
analytic
treatment can accomplish more than they.
But now, to be sure, I must damp the ardour of
your expectations. The community will not hasten

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to grant authority to us. It is bound to offer resistance
to us, for we adopt a critical attitude towards it ; we
accuse it of playing a great part itself in causing the
neuroses. Just as we make any single person our
enemy by discovering what is repressed in him, so the
community cannot respond with sympathy to a relent-
less exposure of its injurious effects and deficiencies ;
because we destroy illusions we are accused of endanger-
ing ideals. It seems, therefore, that the state of things
from which I expect such great advantages for our
therapeutic results will never arrive. And yet the
situation is not so hopeless as one might think at the
present time. Powerful though the feelings and the
self-interest of men may be, yet intellect is a power too.
It has not, perhaps, the power that makes itself felt
immediately, but one that is all the more certain in the
end. The most mordant verities are heard at last,
after the interests they injure and the emotions they
rouse have exhausted their frenzy. It has always
been so, and the unwelcome truths which we psycho-
analysts have to tell the world will undergo the same
fate. Only it will not come very quickly ; we must be
able to wait.

3. Finally, I have to explain to you what I mean
by the ‘general effect’ of our work, and how I come
to set my hopes on it. This consists in a very remark-
able therapeutic constellation which could perhaps not
be repeated anywhere else and which will appear strange
to you too at first, until you recognize in it something
you have long been familiar with. You know, of course,
that the psychoneuroses are substitutive gratifications
of instincts the existence of which one is forced to deny
to oneself and others. Their capacity to exist depends
on this distortion and disguise. When the riddle they
hold is solved and the solution accepted by the sufferers
these diseases will no longer be able to exist. There is
hardly anything quite like it in medicine ; in fairy-tales
you hear of evil spirits whose power is broken when you
can tell them their name which they have kept secret.

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Now in place of a single sick person put the whole
community of persons liable to neuroses, persons ill
and persons well; in place of the acceptance of the
solution in the first put a general recognition in the
second; and a little reflection will show you that this
substitution cannot alter the result at all. The success
which the therapy has with individuals must appear in
the many too. Diseased people cannot let their various
neuroses become known—their apprehensive over-
anxiousness which is to conceal their hatred, their
agoraphobia which betrays disappointed ambition,
their obsessive actions which represent self-reproaches
for evil intentions and precautions against them—
when all their relatives and every stranger from whom
they wish to conceal their thoughts and feelings know
the general meaning of these symptoms, and when they
know themselves that the manifestations of their
disease produce nothing which others cannot instantly
understand. The effect, however, will not be merely
that they will conceal their symptoms—a design, by
the way, which would be impossible to execute; for
this concealment will destroy the purpose of the illness.
Disclosure of the secret will have attacked, at its most
sensitive point, the ‘ætiological equation’ from which
the neuroses descend, will have made the ‘advantage
through illness’ illusory, and consequently in the end
nothing can come of the changed situation brought
about by the indiscretions of physicians but an end of
producing these illnesses.

If this hope seems utopian to you, you may
remember that certain neurotic phenomena have
already been dispelled by this means, although only
in quite isolated instances. Think how common
hallucinations of the Virgin Mary were in peasant-girls
in former times. So long as such a phenomenon brought
a flock of believers and resulted perhaps in a chapel
being built on the sacred spot, the visionary state of
these maidens was inaccessible to influence. To-day
even the priesthood has changed its attitude to such

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things ; it allows police and medical men to visit the
seer, and since then the Virgin appears very seldom.
Or allow me to study the same processes, that I have
been describing as taking place in the future, in an
analogous situation which is on a smaller scale and
consequently more easily appreciated. Suppose that
a number of ladies and gentlemen in good society had
planned a picnic at an inn in the forest one day. The
ladies make up their minds that if one of them wants
to relieve a natural need she will say aloud that she is
going to pick flowers ; but a wicked fellow hears of
this secret and has printed on the programme which
is sent round to the whole party—‘If the ladies wish to
retire they are requested to say that they are going to
pick flowers’. Of course after this no lady will think
of availing herself of this flowery pretext, and other
freshly devised formulas of the same kind will be
seriously compromised by it. What will be the result ?
The ladies will own up to their natural needs without
shame and none of the men will take exception to it.
Let us return to the serious aspect of our problem. A
number of people who find life’s conflicts too difficult
to solve have taken flight into neurosis and in this way
won an unmistakable, although in the end too costly,
advantage through illness. What would these people
have to do if their flight into illness were barred by the
indiscreet revelations of psycho-
analysis ? They would
have to be honest, own up to the instincts that are at
work in them, face the conflict, fight for what they
want or go without, and the tolerance from the com-
munity which is bound to ensue as a result of psycho-
analytical knowledge would help them in their task.
Let us remember, however, that it is not for us
to advance upon life as fanatical hygienists or thera-
peutists. We must admit that this ideal prevention
of all neurotic illness would not be advantageous to
every individual. A good number of those who now
take flight into illness would not support the conflict
under the conditions we have assumed, but would

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rapidly succumb or would commit some outrage which
would be worse than if they themselves fell ill of a
neurosis. The neuroses have in fact their biological
function as defensive measures and their social justifi-
cation; the ‘advantage through illness’ that they
provide is not always a purely subjective one. Is there
one of you who has not at some time caught a glimpse
behind the scenes in the causation of a neurosis and
had to allow that it was the least of the evils possible
in the circumstances? And should one really require
such sacrifices in order to exterminate the neuroses,
while the world is all the same full of other inextinguish-
able miseries?

Should we therefore abandon our efforts to explain
the hidden meaning of neurotic manifestations, regard-
ing it as dangerous to the individual and harmful to
the interests of society; should we give up drawing
the practical conclusion from a piece of scientific
insight? No; I think that nevertheless our duty lies
in the other direction. The ‘advantage through
illness’ provided by the neuroses is indeed on the
whole and in the end detrimental to the individual
as well as to society. The distress that our work of
revelation may cause will but affect a few. The
change to a more honest and honourable attitude in
the world in general will not be bought too dearly by
these sacrifices. But above all, all the energies which
are to-day consumed in the production of neurotic
symptoms, to serve the purposes of a world of phantasy
out of touch with reality, will, even if they cannot at
once be put to uses in life, help to strengthen the outcry
for those changes in our civilization from which alone
we can hope for better things for our descendants.

I will let you go, therefore, with the assurance that
you do your duty in more than one sense by treating
your patients psycho-analytically. You are not merely
working in the service of science, by using the only
and irreplaceable opportunity for discovering the
secrets of the neuroses; you are not only giving your

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XXV

patients the most efficacious remedy for their sufferings
available at the present time ; but you are contributing
your share to that enlightenment of the many from
which we expect to gain the authority of the community
in general and thus to achieve the most far-reaching
prophylaxis against neurotic disorders.