The Collected Works of Sigmund Freud. Sigmund Freud
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about come to the end. Perhaps you are disappointed that I have dealt only with theory in this chapter on psychoanalytic therapy, and have said nothing concerning the conditions under which the cure is undertaken, or of the successes which it achieves. But I shall omit both. I shall omit the first because I had intended no practical training in the practice of psychoanalysis, and I shall neglect the second for numerous reasons. At the beginning of our talks I emphasized the fact that under favorable circumstances we attain results which can be favorably compared with the happiest achievements in the field of internal therapy, and, I may add, these results could not have been otherwise achieved. If I were to say more I might be suspected of wishing to drown the voices of disparagement, which have become so loud, by advertising our claims. We psychoanalysts have repeatedly been threatened by our medical colleagues, even in open congresses, that the eyes of the suffering public must be opened to the worthlessness of this method of treatment by a statistical collection of analytic failures and injuries. But such a collection, aside from the biased, denunciatory character of its purpose, would hardly be able to give a correct picture of the therapeutic values of analysis. Analytic therapy is, as you know, still young; it took a long time to establish the technique, and this could be done only during the course of the work and under the influence of accumulating experience. As a result of the difficulties of instruction the physician who begins the practice of psychoanalysis is more dependent upon his capacity to develop on his own account than is the ordinary specialist, and the results he achieves in his first years can never be taken as indicative of the possibilities of analytic therapy.
Many attempts at treatment failed in the early years of analysis because they were made on cases that were not at all suited to the procedure, and which today we exclude by our classification of symptoms. But this classification could be made only after practice. In the beginning we did not know that paranoia and dementia praecox are, in their fully developed phases, inaccessible, and we were justified in trying out our method on all kinds of conditions. Besides, the greatest number of failures in those first years were not due to the fault of the physician or because of unsuitable choice of subjects, but rather to the unpropitiousness of external conditions. We have hitherto spoken only of internal resistances, those of the patient, which are necessary and may be overcome. External resistances to psychoanalysis, due to the circumstances of the patient and his environment, have little theoretical interest, but are of great practical importance. Psychoanalytic treatment may be compared to a surgical operation, and has the right to be undertaken under circumstances favorable to its success. You know what precautions the surgeon is accustomed to take: a suitable room, good light, assistance, exclusion of relatives, etc. How many operations would be successful, do you think, if they had to be performed in the presence of all the members of the family, who would put their fingers into the field of operation and cry aloud at every cut of the knife? The interference of relatives in psychoanalytical treatment is a very great danger, a danger one does not know how to meet. We are armed against the internal resistances of the patient which we recognize as necessary, but how are we to protect ourselves against external resistance? It is impossible to approach the relatives of the patient with any sort of explanation, one cannot influence them to hold aloof from the whole affair, and one cannot get into league with them because we then run the danger of losing the confidence of the patient, who rightly demands that we in whom he confides take his part. Besides, those who know the rifts that are often formed in family life will not be surprised as analysts when they discover that the patient’s nearest relatives are less interested in seeing him cured than in having him remain as he is. Where, as is so often the case, the neurosis is connected with conflicts with members of the family, the healthy member does not hesitate long in the choice between his own interest and that of the cure of the patient. It is not surprising if a husband looks with disfavor upon a treatment in which, as he may correctly suspect, the register of his sins is unrolled; nor are we surprised, and surely we cannot take the blame, when our efforts remain fruitless and are prematurely broken off because the resistance of the husband is added to that of the sick wife. We had only undertaken something which, under the existing circumstance, it was impossible to carry out.
Instead of many cases, I shall tell you of just one in which, because of professional precautions, I was destined to play a sad role. Many years ago I treated a young girl who for a long time was afraid to go on the street, or to remain at home alone. The patient hesitatingly admitted that her phantasy had been caused by accidentally observing affectionate relations between her mother and a well-to-do friend of the family. But she was so clumsy — or perhaps so sly — as to give her mother a hint of what had been discussed during the analysis, and changed her behavior toward her mother, insisting that no one but her mother should protect her against the fear of being alone, and anxiously barring the way when her mother wished to leave the house. The mother had previously been very nervous herself, but had been cured years before in a hydropathic sanatorium. Let us say, in that institution she made the acquaintance of the man with whom she was to enter upon the relationship which was able to satisfy her in every respect. Becoming suspicious of the stormy demands of the girl, the mother suddenly realized the meaning of her daughter’s fear. She must have made herself sick to imprison her mother and to rob her of the freedom she needed to maintain relations with her lover. Immediately the mother made an end to the harmful treatment. The girl was put into a sanatorium for the nervous and exhibited for many years as “a poor victim of psychoanalysis.” For just as long a period I was pursued by evil slander, due to the unfavorable outcome of this case. I maintained silence because I thought myself bound by the rules of professional discretion. Years later I learned from a colleague who had visited the institution, and had seen the agoraphobic girl there, that the relationship between the mother and the wealthy friend of the family was known all over town, and apparently connived at by the husband and father. It was to this “secret” that our treatment had been sacrificed.
In the years before the war, when the influx of patients from all parts made me independent of the favor or disfavor of my native city, I followed the rule of not treating anyone who was not sui juris, was not independent of all other persons in his essential relations of life. Every psychoanalyst cannot do this. You may conclude from my warning against the relatives of patients that for purposes of psychoanalysis we should take the patients away from their families, and should limit this therapy to the inmates of sanatoriums. I should not agree with you in this; it is much more beneficial for the patients, if they are not in a stage of great exhaustion, to continue in the same circumstances under which they must master the tasks set for them during the treatment. But the relatives ought not to counteract this advantage by their behavior, and above all, they should not antagonize and oppose the endeavors of the physician. But how are we to contend against these influences which are so inaccessible to us! You see how much the prospects of a treatment are determined by the social surroundings and the cultural conditions of a family.
This offers a sad outlook indeed for the effectiveness of psychoanalysis as a therapy, even if we can explain the great majority of our failures by putting the blame on such disturbing external factors! Friends of analysis have advised us to counterbalance such a collection of failures by means of a statistical compilation on our part of our successful cases. Yet I could not try myself to do this. I tried to explain that statistics would be worthless if the collected cases were not comparable, and in fact, the various neuroses which we have undertaken to treat could, as a matter of fact, hardly be compared on the same basis, since they differed in many fundamental respects. Besides, the period of time over which we could report was too short to permit us to judge the permanency of our cures, and concerning certain cases we could not have given any information whatever. They related to persons who had kept their ailments, as well as their treatment, secret, and whose cure must necessarily be kept secret as well. The strongest hindrance, however, lay in the knowledge that men behave most irrationally in matters of therapy, and that we have no prospect of attaining anything by an appeal to reason. A therapeutic novelty is received either with frenzied enthusiasm, as was the case when Koch first made public his tuberculin against tuberculosis, or it is treated with abysmal distrust, as was the really blessed vaccination of Jenner, which even today retains implacable opponents. There was a very obvious prejudice against psychoanalysis. When we had cured a very difficult case we would hear it said: “That is no proof, he would have become well by himself in all this time.” Yet when a patient who had already gone through four cycles of depression and mania came into my care during a temporary