CHAPTER VIII.

ON PSYCHOTHERAPY.
Gentlemen:

It is almost eight years since, at the request of your deceased
chairman, Prof. v. Reder, I had the pleasure of speaking in your
midst on the subject of hysteria. Shortly before (1895) I had
published the “Studien über Hysterie” together with Dr. J.
Breuer, and on the basis of a new knowledge for which we are
thankful to this investigator, I have attempted to introduce a new
way of treating the neurosis. Fortunately, I can say that the
endeavors of our " Studies ” have met with success, and that the
ideas which they advocate concerning the effects of psychic trau-
mas through the restraint of affects and the conception of the
hysterical symptom as a result of a displacement of excitement
from the psychic to the physical—ideas for which we have created
the terms “ab-reaction “ and conversion ”—are today generally
known and understood. At least in German-speaking countries
there are no descriptions of hysteria which do not to a certain
extent take cognizance of them, and no colleague who does not at
least partially follow this theory. And yet as long as they were
new these theories and these terms must have sounded strange
enough!

I can not say the same thing about the therapeutic procedure
which we have proposed to our colleagues together with our
theory. It still struggles for recognition. This may have its
special reasons. The technique of the procedure was at that time
still rudimentary. I was unable to give those indications to the
medical reader of the book which would enable him to perform
such a treatment. But surely there were other causes of a gen-
eral nature. To many physicians psychotherapy even today ap-
pears as a product of modern mysticism, and in comparison to
our physico-chemical remedies the application of which is based
on physiological insight, psychotherapy appears quite unscientific

1 Lecture delivered before the Vienna Medic. Doktorenkollegium, on
December 12, 1904.

175

176 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

and unworthy of the interest of a natural philosopher. You will
therefore allow me to present to you the subject of psycho-
therapy, and to point out to you what part of this verdict can be
designated as unjust or erroneous.

In the first place let me remind you that psychotherapy is not
a modern therapeutic procedure. On the contrary it is one of
the oldest remedies used in medicine. In Lôwenfeld’s instructive
work (Lehrbuch der gesamten Psychotherapie) you will find the
methods employed in primitive and ancient medicine. Most of
them were of a psychotherapeutic nature. In order to cure a
patient he was transferred into a state of * credulous expecta-
tion,” which acts in a similar manner even today. Even after the
doctors found other remedial agents psychotherapeutic endeavors
never disappeared from this or that branch of medicine.

Secondly, I call your attention to the fact that we doctors really
can not abandon psychotherapy if only because another very much
to be considered party in the treatment—namely the patient—
has no intention of abandoning it. You know how much we owe
to the Nancy school (Liébault, Bernheim) for these explanations.
Without our intention, an independent factor from the patient`s
psychic disposition enters into the activity of every remedial agent
introduced by the doctor, acting mostly in a favorable sense but
often also in an inhibiting sense. We have learned to apply to
this factor the word “suggestion,” and Moebius taught us that
the failures of some of our remedies are to be ascribed to the dis-
turbing influences of this very powerful moment. You doctors,
all of you, constantly practice psychotherapy, even when you do
not know it, or do not intend it, but it has one disadvantage, you
leave entirely to the patient the psychic factor of your influence.
It then becomes uncontrollable, it can not be divided into doses
and can not be increased. Is it not a justified endeavor of the
doctor to become master of this factor, to make use of it inten-
tionally, to direct and enforce it? It is nothing other than that,
that scientific psychotherapy expects of you.

In the third place, gentlemen, I wish to refer you to the well
known experience, namely, that certain maladies and particularly
the psychoneuroses, are more accessible to psychic influences
than to any other medications. It is no modern talk but a dictum
of old physicians that these diseases are not cured by the drug,

ON PSYCHOTHERAPY, 177

but by the doctor, to wit, by the personality of the physician in
so far as it exerts a psychic influence. I am well aware, gentle-
men, that you like very much the idea which the æsthete Vischer,
in his parody on Faust (Faust, der Tragödie, III Teil) endowed
with a classical expression: “I know that the physical often acts
on the moral.”

But would it not be more adequate and frequently more correct
to influence the moral part of the person with the moral, that is,
with psychic means?

There are many ways and means of psychotherapy. All
methods are good which produce the aim of the therapy. Our
usual consolation, “ You will soon be well again,” with which
we are so generous to our patients, corresponds to one of the
psychotherapeutic methods, only that on gaining a profounder
insight into the neuroses we are not forced to limit ourselves to
this consolation alone. We have developed the technique of
hypnotic suggestion, of psychotherapy through diversion, through
practice, and through the evocation of serviceable affects. I do
not disdain any of them, and would practice them all under suit-
able conditions. That I have in reality restricted myself to a
single therapeutic procedure, to the method called by Breuer
“cathartic,” which I prefer to call “analytic,” is simply due to
subjective motives which guided me. Having participated in the
elaboration of this therapy I feel it a personal duty to devote
myself to its investigation, and to the final development of its
technique. I maintain that the analytic method of psychotherapy
is one which acts most penetratingly and carries farthest; through
it one can produce the most prolific changes in the patient. If
I relinquish for a moment the therapeutic point of view, I can
assert that it is the most interesting, and that it alone teaches us
something concerning the origin and the connection of the morbid
manifestations. Owing to insights which it opens for us into
the mechanism of the psychic malady, it can even lead us beyond
itself, and show us the way to still other kinds of therapeutic
influences.

Allow me now to correct some errors, and furnish some ex-
planations concerning this cathartic or analytic method of psy-
chotherapy. R

(a) I notice that this method is often mistaken for the hyp-

178 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

notic suggestive treatment. I notice this by the fact that quite
frequently colleagues whose confidant I am not by any means,
send patients to me, refractory patients, of course, with the
request that I should hypnotize them. Now, for eight years I
have not practiced hypnotism (individual cases excluded) as a
therapeutic aim, and hence I used to return the patients with
the advice that he who relies on hypnosis should do it himself.
In truth, the greatest possible contrast exist between the sug-
gestive and the analytic technique, that contrast which the great
Leonardo da Vinci has expressed for the arts in the formulæ per
via di porre and per via di levare. Said Leonardo, "the art of
painting works per via di porre, that is to say, places little
heaps of paint where they have not been before on the uncolored
canvas; sculpturing, on the other hand, goes per via di levare,
that is to say, it takes away from the stone as much as covers
the surface of the statue therein contained.” Quite similarly,
gentlemen, the suggestive technique acts per via di porre, it does
not concern itself about the origin, force, and significance of the
morbid symptoms, but puts on something, to wit, the suggestion
which it expects will be strong enough to prevent the pathogenic
idea from expression. On the other hand the analytic therapy
does not wish to put on anything, or introduce anything new,
but to take away, and extract, and for this purpose it concerns
itself with the genesis of the morbid symptoms, and the psychic
connection of the pathogenic idea the removal of which is its aim.
This manner of investigation has considerably furthered our un-
derstanding. I have so early given up the technique of sug-
gestion, and with it hypnosis, because I despaired of making the
suggestion as strong and persistent as would be necessary for a
lasting cure. In all grave cases I noticed that the suggestions
which were put on crumbled off again, and then the disease, or
one replacing it, reappeared. Besides, I charge this technique
with concealing from us the psychic play of forces, for example,
it does not permit us to recognize the resistance with which the
patients adhere to their malady, with which they also strive
agains the recovery, and which alone can give us an understand-
ing of their behavior in life.

(5) It seems to me that a very widespread mistake among my
colleagues is the idea that the technique of the investigation for

ON PSYCHOTHERAPY. 179

the causes of the disease and the removal of the manifestations
by this investigation is easy and self-evident. I concluded this
from the fact that of the many who interest themselves in my
therapy and express a definite opinion on the same, no one has
yet asked me how to do it. There can only be one reason for it,
they believe there is nothing to ask, that it is a matter of course.
I occasionally also hear with surprise that in this or that division
of the hospital a young interne is requested by his chief to under-
take a “psychoanalysis” with a hysterical woman. I am con-
vinced that he would not intrust him with the examination of an
extirpated tumor without previously assuring himself that he is
acquainted with the histological technique. Likewise I am in-
formed that this or that colleague has made appointments with a
patient for psychic treatment, whereas I am certain that he does
not know the technique of such a treatment. He must, there-
fore, expect that the patient will bring him her secrets, or he
seeks salvation in some kind of a confession or confidence. I
should not wonder if the patient thus treated would rather be
harmed than benefited. The mental instrument is really not at
all easy to play. On such occasion I can not help thinking of
the speech of a world-renowned neurotic, who really never came
under a doctor’s treatment, and only lived in the fancy of the
poet. I mean Prince Hamlet of Denmark. The king has sent
the two courtiers, Rosencrantz and Guildenstern, to investigate
him and rob him of his secret. While he defended himself, pipes
were brought on the stage. Hamlet took a pipe and requested
one of his tormentors to play on it, saying that it is as easy to
play as lying. The courtier hesitated because he knew no touch
of it, and as he could not be moved to attempt to play the pipe,
Hamlet finally burst forth: “ Why, look you now, how unworthy
a thing you make of me! You would play upon me; you would
seem to know my stops; you would pluck out the heart of my
mystery ; you would sound me from my lowest note to the top
of my compass; and there is much music, excellent voice, in
this little organ, yet you cannot make it speak. ”Sblood! do you
think I am easier to be played on than a pipe? Call me what
instrument you will, though you can fret me, you cannot play
upon me." (Act III, Scene 2.)

(¢) You will have surmised from some of my observations

180 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

that the analytic cure contains qualities which keep it away from
the ideal of a therapy. Tuto, cito, iucunde; the investigation and
examination does not really mean rapidity of success, and the
allusion to the resistance has prepared you for the expectation of
inconveniences. Certainly the psychoanalytic method lays high
claims on the patient as well as the physician. From the first it
requires the sacrifice of perfect candor, it takes up much of his
time, and is therefore also expensive; for the physician it also
means the loss of much time, and due to the technique which he
has to learn to practice, it is quite laborious. I even find it
quite justified to employ more suitable remedies as long as there
is a prospect to achieve something with them. It comes to this
point only: if we gain by the more laborious and cumbersome
procedure considerably more than by the short and easy one, the
first is justified despite everything. Just think, gentlemen, by
how much the Finsen therapy of lupus is more inconvenient and
expensive than the formerly used cauterization and scraping, and
yet it means a great progress, merely because it achieves more, it
actually cures the lupus radically. I do not really wish to carry
through the comparison, but psychoanalysis can claim for itself
a similar privilege. In reality I could develop and test my thera-
peutic method in grave and in the gravest of cases only; my
material at first consisted of patients who tried everything un-
successfully, and had spent years in asylums. I hardly gained
enough experience to be able to tell you how my therapy behaves
in those lighter, episodically appearing diseases which we see
cured under the most diverse influences, and also spontaneously.
The psychoanalytic method was created for patients who are
permanently incapacitated, and its triumph is to make a grati-
fying number of such, permanently capacited. Against this suc-
cess all expense is insignificant. We can not conceal from our-
selves what we were wont to disavow to the patient, namely, that
the significance of a grave neurosis for the individual subjected
to it is not less than any cachexia or any of the generally feared
maladies.

(d) In view of the many practical limitations which I have
encountered in my work, I can hardly definitely enumerate the
indications and contra-indications of this treatment. However,
I will attempt to discuss with you a few points:

ON PSYCHOTHERAPY. 181
.

I. The former value of the person should not be overlooked in
the disease, and you should refuse a patient who does not possess
a certain degree of education, and whose character is not in a
measure reliable. We must not forget that there are also healthy
persons who are good for nothing, and that if they only show a
mere touch of the neurosis, one is only too much inclined to blame
the disease for incapacitating such inferior persons. I maintain
that the neurosis does not in any way stamp its bearer as a
dégéneré, but that frequently enough it is found in the same indi-
vidual associated with the manifestations of degeneration. The
analytic psychotherapy is therefore no procedure for the treat-
ment of neuropathic degeneration, on the contrary it is limited by
it. It is also not to be applied in persons who are not prompted
by their own suffering to seek the treatment, but subject them- |
selves to it by order of their relatives. The characteristic feature
upon which the usefulness of the psychoanalytic treatment de-
pends, the educability, we will still have to consider from another
point of view.

2. If one wishes to take a safe course he should limit his
selection to persons of a normal state, for, in psychoanalytic pro-
cedures, it is from the normal that we seize upon the morbid.
Psychoses, confusional states, and marked (I might say toxic)
depressions, are unsuitable for analysis, at least as it is practiced
today. I do not think it at all impossible that with the proper
changes in the procedure it will be possible to disregard this
contraindication, and thus claim a psychotherapy for the psy-
choses.

3. The age of the patient also plays a part in the selection for
the psychoanalytic treatment. Persons near or over the age of
fifty lack, on the one hand, the plasticity of the psychic processes
upon which the therapy depends—old people are no longer
educable—and on the other hand, the material which has to be
elaborated, and the duration of the treatment is immensely in-
creased. The earliest age limit is to be individually determined;
youthful persons, even before puberty, are excellent subjects for
influence.

4. One should not attempt psychoanalysis when it is a question
of rapidly removing a threatening manifestation, as, for example,
in the case of an hysterical anorexia.

182 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

You have now gained the impression that the sphere of applica-
tion of the analytic psychotherapy is a very limited one, for you
really heard me enumerate nothing but contraindications. Never-
theless, there remain sufficient cases and morbid states, such as
all chronic forms of hysteria with remnant manifestations, the
extensive realm of compulsive states, abulias, etc., on which this
therapy can be tried.

It is pleasing that particularly the worthiest and highest de-
veloped persons can thus be most helped. Where the analytic
psychotherapy has accomplished but little one can cheerfully
assert that any other treatment would have certainly resulted in
nothing.

(e) You will surely wish to ask me about the possibility of
doing harm through the application of psychoanalysis. To this
I will reply that if you will judge justly you will meet this pro-
cedure with the same critical good-feeling as you have met our
other therapeutic methods, and doing this you will have to agree
with me that a rationally executed analytic treatment entails no
dangers for the patient. One who, like a layman, is accustomed
to ascribe to the treatment everything occurring during the
disease, will probably judge differently. It is really not so long
since our hydrotherapeutic asylums met with similar opposition.
Thus one who was advised to go to such an asylum became
thoughtful because he had an acquaintance who entered the
asylum as nervous and there became insane. As you surmise
we deal with cases of initial general paresis who in the first stages
could still be sent to hydrotherapeutic asylums, and who there
merged into the irresistible course leading to manifest insanity.
For the layman the water was the cause and author of this sad
transformation. Where it is a question of unfamiliar influences,
even doctors are not free from such mistaken judgment. I recall
having once attempted to treat a woman by psychotherapy who
passed a great part of her existence by alternating between mania
and melancholia. I began to treat her at the end of a melan-
cholia and everything seemed to go well for two weeks, but in the
third week she was again merging into a mania. It was surely a
spontaneous alteration of the morbid picture, for two weeks is
no time in which anything can be accomplished by psychotherapy,
but the prominent—now deceased—physician who saw the case

ON PSYCHOTHERAPY. 183

with me could not refrain from remarking that this decline must
have been due to the psychotherapy. I am quite convinced that
he would have been more critical under different conditions.

(f) In conclusion, gentlemen, I must say to myself that it will
not do to lay claim to your attention so long in favor of the
analytic psychotherapy without telling you of what this treatment
consists, and on what it is based. To be sure I can only indicate
it, as I have to be brief. This therapy is founded on the under-
standing that unconscious ideas—or rather the unconsciousness
of certain psychic processes—are the main causes of a morbid
symptom. We share this conviction with the French school
(Janet) which, moreover, by gross schematization reduces the
hysterical symptom to an unconscious idée fixe. Do not fear
now that we will thus merge too far into the obscurest philosophy.
Our unconscious is not quite the same as that of the philosophers
and what is more, most philosophers wish to know nothing of
the “psychical unconscious." But if you will put yourselves in
our position, you will understand that the interpretation of this
unconscious, in patients’ psychic life, into the conscious, must
result in a correction of their deviation from the normal, and in
an abrogation of the compulsion’ controlling their psychic life.
For the conscious will reaches as far as the conscious psychic
processes and every psychic compulsion is substantiated by the
unconscious. You need never fear that the patient will be harmed
by the emotion produced in the entrance of his unconscious
into consciousness, for you can theoretically readily understand
that the somatic and affective activity of the emotion which be-
came conscious can never become as great as those of the uncon-
scious. For we only control all our emotions by directing upon
them our highest psychic activities which are connected with
consciousness.

We can still choose another point of view for the understand-
ing of the psychoanalytic treatment. The revealing and inter-
preting of the unconscious takes place under constant resistance
on the part of the patient. The emerging of the unconscious
is connected with displeasure and owing to this displeasure it is
continuously repulsed by the patient. It is upon this conflict in
the patient’s psychic life that you encroach, and if you succeed
in prevailing upon him to accept something, for motives of better

184 PAPERS ON HYSTERIA AND OTHER PSYCHONEUROSES.

insight, which he has thus far repulsed (repressed) on account
of the automatic adjustment of displeasure, you have achieved
in him a piece of educational work. For it is really an educa-
tion if you can induce a person to leave his bed early in the
morning despite his unwillingness to do so. As such an after
training for the overcoming of inner resistance you can con-
ceive the psychoanalytic treatment in quite a general manner.
But in no sphere of the nervous patients is such an after train-
ing so essential as in the psychic elements of their sexual life.
For nowhere have culture and education produced so much harm
as here, and it is here, as experience will show you, that the con-
trolling etiologies of the neuroses are found. The other etiolog-
ical element, the constitutional contribution, is really given to us
as something immutable. But this gives rise to an important
demand on the doctor. Not only must he be of unblemished char-
acter—“ morality is really a matter of course,” as the principal
person in Th. Vischer’s “ Auch Einer ” used to say—but he must
have overcome in his own personality the mixture of lewdness
and prudishness with which so many others are wont to meet the
sexual problems.

This is perhaps the place for another observation. I know
that the emphasis which I laid on the sexual rôle in the origin of
the psychoneuroses has become widely known. But I also know
that restriction and nearer determinations are of little use with
the great public; the multitude has little room in its memory, and
generally retains from a statement the bare nucleus, thus creating
for itself an easily remembered extreme. The same might also
have happened to some physicians when the faint notion that
they have of my theory is that I trace back the neurosis in the
last place to sexual privation. Of such there is surely no dearth
under the vital conditions of our society. But if that supposition
were true would it not seem obvious that in order to avoid the
roundabout way of the psychic treatment and tend directly to-
wards the cure, we should directly recommend sexual participa-
tion as the remedy? I really do not know what could induce me
to suppress these conclusions if they were justified. But the state
of affairs is different. The sexual need or privation is merely one
of the factors playing a part in the mechanism of the neurosis,
and if it alone existed the result would not be a disease but a

ON PSYCHOTHERAPY. 185

dissipation. The other equally indispensable factor, which one is
only too ready to forget, is the sexual repugnance of neurotics,
their inability to love; it is that psychic feature which I have
designated as “ repression.” It is only from the conflict between
the two strivings that the neurotic malady originates, and it is for
this reason that the advice for sexual participation in the psycho-
neuroses can really only seldom be designated as good.

Allow me to conclude with this guarded remark. Let us hope
that with an interest for psychotherapy, purified of all hostile
prejudice, you will help us to do some good in the treatment of
the severe cases of psychoneuroses.