Psychoanalysis and Psychiatry

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Psychoanalysis and Psychiatry

I am very glad to welcome you back to continue our discussions. I last lectured to you on the psychoanalytic treatment of errors and of the dream. To-day I should like to introduce you to an understanding of neurotic phenomena, which, as you soon will discover, have much in common with both of those topics. But I shall tell you in advance that I cannot leave you to take the same attitude toward me that you had before. At that time I was anxious to take no step without complete reference to your judgment. I discussed much with you, I listened to your objections, in short, I deferred to you and to your "normal common sense." That is no longer possible, and for a very simple reason. As phenomena, the dream and errors were not strange to you. One might say that you had as much experience as I, or that you could easily acquire as much. But neuroses are foreign to you; since you are not doctors yourselves you have had access to them only through what I have told you. Of what use is the best judgment if it is not supported by familiarity with the material in question?

Do not, however, understand this as an announcement of dogmatic lectures which demand your unconditional belief. That would be a gross misunderstanding. I do not wish to convince you. I am out to stimulate your interest and shake your prejudices. If, in consequence of not knowing the facts, you are not in a position to judge, neither should you believe nor condemn. Listen and allow yourselves to be influenced by what I tell you. One cannot be so easily convinced; at least if he comes by convictions without effort, they soon prove to be valueless and unable to hold their own. He only has a right to conviction who has handled the same material for many years and who in so doing has gone through the same new and surprising experiences again and again. Why, in matters of intellect these lightning conversions, these momentary repulsions? Do you not feel that a coup de foudre, that love at first sight, originates in quite a different field, namely, in that of the emotions? We do not even demand that our patients should become convinced of and predisposed to psychoanalysis. When they do, they seem suspicious to us. The attitude we prefer in them is one of benevolent scepticism. Will you not also try to let the psychoanalytic conception develop in your mind beside the popular or "psychiatric"? They will influence each other, mutually measure their strength, and some day work themselves into a decision on your part.

On the other hand, you must not think for a moment that what I present to you as the psychoanalytic conception is a purely speculative system. Indeed, it is a sum total of experiences and observations, either their direct expression or their elaboration. Whether this elaboration is done adequately and whether the method is justifiable will be tested in the further progress of the science. After two and a half decades, now that I am fairly advanced in years, I may say that it was particularly difficult, intensive and all-absorbing work which yielded these observations. I have often had the impression that our opponents were unwilling to take into consideration this objective origin of our statements, as if they thought it were only a question of subjective ideas arising haphazard, ideas to which another may oppose his every passing whim. This antagonistic behavior is not entirely comprehensible to me. Perhaps the physician's habit of steering clear of his neurotic patients and listening so very casually to what they have to say allows him to lose sight of the possibility of deriving anything valuable from his patients' communications, and therefore, of making penetrating observations on them. I take this opportunity of promising you that I shall carry on little controversy in the course of my lectures, least of all with individual controversialists. I have never been able to convince myself of the truth of the saying that controversy is the father of all things. I believe that it comes down to us from the Greek sophist philosophy and errs as does the latter through the overvaluation of dialectics. To me, on the contrary, it seems as if the so-called scientific criticism were on the whole unfruitful, quite apart from the fact that it is almost always carried on in a most personal spirit. For my part, up to a few years ago, I could even boast that I had entered into a regular scientific dispute with only one scholar (Lowenfeld, of Munich). The end of this was that we became friends and have remained friends to this day. But I did not repeat this attempt for a long time, because I was not certain that the outcome would be the same.

Now you will surely judge that so to reject the discussion of literature must evidence stubborness, a very special obtuseness against objections, or, as the kindly colloquialisms of science have it, "a complete personal bias." In answer, I would say that should you attain to a conviction by such hard labor, you would thereby derive a certain right to sustain it with some tenacity. Furthermore, I should like to emphasize the fact that I have modified my views on certain important points in the course of my researches, changed them and replaced them by new ones, and that I naturally made a public statement of that fact each time. What has been the result of this frankness? Some paid no attention at all to my self-corrections and even to-day criticize me for assertions which have long since ceased to have the same meaning for me. Others reproach me for just this deviation, and on account of it declare me unreliable. For is anyone who has changed his opinions several times still trustworthy; is not his latest assertion, as well, open to error? At the same time he who holds unswervingly to what he has once said, or cannot be made to give it up quickly enough, is called stubborn and biased. In the face of these contradictory criticisms, what else can one do but be himself and act according to his own dictates? That is what I have decided to do, and I will not allow myself to be restrained from modifying and adapting my theories as the progress of my experience demands. In the basic ideas I have hitherto found nothing to change, and I hope that such will continue to be the case.

Now I shall present to you the psychoanalytic conception of neurotic manifestations. The natural thing for me to do is to connect them to the phenomena we have previously treated, for the sake of their analogy as well as their contrast. I will select as symptomatic an act of frequent occurrence in my office hour. Of course, the analyst cannot do much for those who seek him in his medical capacity, and lay the woes of a lifetime before him in fifteen minutes. His deeper knowledge makes it difficult for him to deliver a snap decision as do other physicians—"There is nothing wrong with you"—and to give the advice, "Go to a watering-place for a while." One of our colleagues, in answer to the question as to what he did with his office patients, said, shrugging his shoulders, that he simply "fines them so many kronen for their mischief-making." So it will not surprise you to hear that even in the case of very busy analysts, the hours for consultation are not very crowded. I have had the ordinary door between my waiting room and my office doubled and strengthened by a covering of felt. The purpose of this little arrangement cannot be doubted. Now it happens over and over again that people who are admitted from my waiting room omit to close the door behind them; in fact, they almost always leave both doors open. As soon as I have noticed this I insist rather gruffly that he or she go back in order to rectify the omission, even though it be an elegant gentleman or a lady in all her finery. This gives an impression of misapplied pedantry. I have, in fact, occasionally discredited myself by such a demand, since the individual concerned was one of those who cannot touch even a door knob, and prefer as well to have their attendants spared this contact. But most frequently I was right, for he who conducts himself in this way, and leaves the door from the waiting room into the physician's consultation room open, belongs to the rabble and deserves to be received inhospitably. Do not, I beg you, defend him until you have heard what follows. For the fact is that this negligence of the patient's only occurs when he has been alone in the waiting room and so leaves an empty room behind him, never when others, strangers, have been waiting with him. If that latter is the case, he knows very well that it is in his interest not to be listened to while he is talking to the physician, and never omits to close both the doors with care.

This omission of the patient's is so predetermined that it becomes neither accidental nor meaningless, indeed, not even unimportant, for, as we shall see, it throws light upon the relation of this patient to the physician. He is one of the great number of those who seek authority, who want to be dazzled, intimidated. Perhaps he had inquired by telephone as to what time he had best call, he had prepared himself to come on a crowd of suppliants somewhat like those in front of a branch milk station. He now enters an empty waiting room which is, moreover, most modestly furnished, and he is disappointed. He must demand reparation from the physician for the wasted respect that he had tendered him, and so he omits to close the door between the reception room and the office. By this, he means to say to the physician: "Oh, well, there is no one here anyway, and probably no one will come as long as I am here." He would also be quite unmannerly and supercilious during the consultation if his presumption were not at once restrained by a sharp reminder.

You will find nothing in the analysis of this little symptomatic act which was not previously known to you. That is to say, it asserts that this act is not accidental, but has a motive, a meaning, a purpose, that it has its assignable connections psychologically, and that it serves as a small indication of a more important psychological process. But above all it implies that the process thus intimated is not known to the consciousness of the individual in whom it takes place, for none of the patients who left the two doors open would have admitted that they meant by this omission to show me their contempt. Some could probably recall a slight sense of disappointment at entering an empty waiting room, but the connection between this impression and the symptomatic act which followed—of these, his consciousness was surely not aware.

Now let us place, side by side with this small analysis of a symptomatic act, an observation on a pathological case. I choose one which is fresh in my mind and which can also be described with relative brevity. A certain measure of minuteness of detail is unavoidable in any such account.

A young officer, home on a short leave of absence, asked me to see his mother-in-law who, in spite of the happiest circumstances, was embittering her own and her people's existence by a senseless idea. I am introduced to a well preserved lady of fifty-three with pleasant, simple manners, who gives the following account without any hesitation: She is most happily married and lives in the country with her husband, who operates a large factory. She cannot say enough for the kind thoughtfulness of her husband. They had married for love thirty years ago, and since then there had never been a shadow, a quarrel or cause for jealousy. Now, even though her two children are well married, the husband and father does not yet want to retire, from a feeling of duty. A year ago there happened the incredible thing, incomprehensible to herself as well. She gave complete credence to an anonymous letter which accused her excellent husband of having an affair with a young girl—and since then her happiness is destroyed. The more detailed circumstances were somewhat as follows: She had a chambermaid with whom she had perhaps too often discussed intimate matters. This girl pursued another young woman with positively malicious enmity because the latter had progressed so much further in life, despite the fact that she was of no better origin. Instead of going into domestic service, the girl had obtained a business training, had entered the factory and in consequence of the short-handedness due to the drafting of the clerks into the army had advanced to a good position. She now lives in the factory itself, meets all the gentlemen socially, and is even addressed as "Miss." The girl who had remained behind in life was of course ready to speak all possible evil of her one-time schoolmate. One day our patient and her chambermaid were talking of an old gentleman who had been visiting at the house, and of whom it was known that he did not live with his wife, but kept another woman as his mistress. She does not know how it happened that she suddenly remarked, "That would be the most awful thing that could happen to me, if I should ever hear that my good husband also had a mistress." The next day she received an anonymous letter through the mail which, in a disguised handwriting, carried this very communication which she had conjured up. She concluded—it seems justifiably—that the letter was the handiwork of her malignant chambermaid, for the letter named as the husband's mistress the self-same woman whom the maid persecuted with her hatred. Our patient, in spite of the fact that she immediately saw through the intrigue and had seen enough in her town to know how little credence such cowardly denunciations deserve, was nevertheless at once prostrated by the letter. She became dreadfully excited and promptly sent for her husband in order to heap the bitterest reproaches upon him. Her husband laughingly denied the accusation and did the best that could be done. He called in the family physician, who was as well the doctor in attendance at the factory, and the latter added his efforts to quiet the unhappy woman. Their further procedure was also entirely reasonable. The chambermaid was dismissed, but the pretended rival was not. Since then, the patient claims she has repeatedly so far calmed herself as no longer to believe the contents of the anonymous letter, but this relief was neither thoroughgoing nor lasting. It was enough to hear the name of the young lady spoken or to meet her on the street in order to precipitate a new attack of suspicion, pain and reproach.

This, now, is the case history of this good woman. It does not need much psychiatric experience to understand that her portrayal of her own case was, if anything, rather too mild in contrast to other nervous patients. The picture, we say, was dissimulated; in reality she had never overcome her belief in the accusation of the anonymous letter.

Now what position does a psychiatrist take toward such a case? We already know what he would do in the case of the symptomatic act of the patient who does not close the doors to the waiting room. He declares it an accident without psychological interest, with which he need not concern himself. But this attitude cannot be maintained toward the pathological case of the jealous woman. The symptomatic act seems no great matter, but the symptom itself claims attention by reason of its gravity. It is bound up with intense subjective suffering while objectively it threatens to break up a home; therefore its claim to psychiatric interest cannot be put aside. The first endeavor of the psychiatrist is to characterize the symptom by some distinctive feature. The idea with which this woman torments herself cannot in itself be called nonsensical, for it does happen that elderly married men have affairs with young girls. But there is something else about it that is nonsensical and incredible. The patient has no reason beyond the declaration in the anonymous letter to believe that her tender and faithful husband belongs to this sort of married men, otherwise not uncommon. She knows that this letter in itself carries no proof; she can satisfactorily explain its origin; therefore she ought to be able to persuade herself that she has no reason to be jealous. Indeed she does this, but in spite of it she suffers every bit as much as she would if she acknowledged this jealousy as fully justified. We are agreed to call ideas of this sort, which are inaccessible to arguments based on logic or on facts, "obsessions." Thus the good lady suffers from an "obsession of jealousy" that is surely a distinctive characterization for this pathological case.

Having reached this first certainty, our psychiatric interest will have become aroused. If we cannot do away with a delusion by taking reality into account, it can hardly have arisen from reality. But the delusion, what is its origin? There are delusions of the most widely varied content. Why is it that in our case the content should be jealousy? In what types of persons are obsessions liable to occur, and, in particular, obsessions of jealousy? We would like to turn to the psychiatrist with such questions, but here he leaves us in the lurch. There is only one of our queries which he heeds. He will examine the family history of this woman and perhaps will give us the answer: "The people who develop obsessions are those in whose families similar and other psychic disturbances have repeatedly occurred." In other words, if this lady develops an obsession she does so because she was predisposed to it by reason of her heredity. That is certainly something, but is it all that we want to know? Is it all that was effective in causing this breakdown? Shall we be content to assume that it is immaterial, accidental and inexplicable why the obsession of jealousy develops rather than any other? And may we also accept this sentence about the dominance of the influence of heredity in its negative meaning, that is, that no matter what experiences came to this human being she was predestined to develop some kind of obsession? You will want to know why scientific psychiatry will give no further explanation. And I reply, "He is a rascal who gives more than he owns." The psychiatrist does not know of any path that leads him further in the explanation of such a case. He must content himself with the diagnosis and a prognosis which, despite a wealth of experience, is uncertain.

Yet, can psychoanalysis do more at this point? Indeed yes! I hope to show you that even in so inaccessible a case as this it can discover something which makes the further understanding possible. May I ask you first to note the apparently insignificant fact that the patient actually provoked the anonymous letter which now supports her delusion. The day before, she announces to the intriguing chambermaid that if her husband were to have an affair with a young girl it would be the worst misfortune that could befall her. By so doing she really gave the maid the idea of sending her the anonymous letter. The obsession thus attains a certain independence from the letter; it existed in the patient beforehand—perhaps as a dread; or was it a wish? Consider, moreover, these additional details yielded by an analysis of only two hours. The patient was indeed most helpful when, after telling her story, she was urged to communicate her further thoughts, ideas and recollections. She declared that nothing came to her mind, that she had already told everything. After two hours the undertaking had really to be given up because she announced that she already felt cured and was sure that the morbid idea would not return. Of course, she said this because of this resistance and her fear of continuing the analysis. In these two hours, however, she had let fall certain remarks which made possible definite interpretation, indeed made it incontestable; and this interpretation throws a clear light on the origin of her obsession of jealousy. Namely, she herself was very much infatuated with a certain young man, the very same son-in-law upon whose urging she had come to consult me professionally. She knew nothing of this infatuation, or at least only a very little. Because of the existing relationship, it was very easy for this infatuation to masquerade under the guise of harmless tenderness. With all our further experience it is not difficult to feel our way toward an understanding of the psychic life of this honest woman and good mother. Such an infatuation, a monstrous, impossible thing, could not be allowed to become conscious. But it continued to exist and unconsciously exerted a heavy pressure. Something had to happen, some sort of relief had to be found and the mechanism of displacement which so constantly takes part in the origin of obsessional jealousy offered the most immediate mitigation. If not only she, old woman that she was, was in love with a young man but if also her old husband had an affair with a young girl, then she would be freed from the voice of her conscience which accused her of infidelity. The phantasy of her husband's infidelity was thus like a cooling salve on her burning wound. Of her own love she never became conscious, but the reflection of it, which would bring her such advantages, now became compulsive, obsessional and conscious. Naturally all arguments directed against the obsession were of no avail since they were directed only to the reflection, and not to the original force to which it owed its strength and which, unimpeachable, lay buried in the unconscious.

Let us now piece together these fragments to see what a short and impeded psychoanalysis can nevertheless contribute to the understanding of this case. It is assumed of course that our inquiries were carefully conducted, a point which I cannot at this place submit to your judgment. In the first place, the obsession becomes no longer nonsensical nor incomprehensible, it is full of meaning, well motivated and an integral part of the patient's emotional experience. Secondly, it is a necessary reaction toward an unconscious psychological process, revealed in other ways, and it is to this very circumstance that it owes its obsessional nature, that is, its resistance to arguments based on logic or fact. In itself the obsession is something wished for, a kind of consolation. Finally, the experiences underlying the condition are such as unmistakably determine an obsession of jealousy and no other. You will also recognize the part played by the two important analogies in the analysis of the symptomatic act with reference to its meaning and intent and also to its relation to an unconscious factor in the situation.

Naturally, we have not yet answered all the questions which may be put on the basis of this case. Rather the case bristles with further problems of a kind which we have not yet been able to solve in any way, and of others which could not be solved because of the disadvantage of the circumstances under which we were working. For example: why is this happily married woman open to an infatuation for her son-in-law, and why does the relief which could have been obtained in other ways come to her by way of this mirror-image, this projection of her own condition upon her husband? I trust you will not think that it is idle and wanton to open such problems. Already we have much material at our disposal for their possible solution. This woman is in that critical age when her sexual needs undergo a sudden and unwelcome exaggeration. This might in itself be sufficient. In addition, her good and faithful mate may for many years have been lacking in that sufficient sexual capacity which the well-preserved woman needs for her satisfaction. We have learned by experience to know that those very men whose faithfulness is thus placed beyond a doubt are most gentle in their treatment of their wives and unusually forbearing toward their nervous complaints. Furthermore, the fact that it was just the young husband of a daughter who became the object of her abnormal infatuation is by no means insignificant. A strong erotic attachment to the daughter, which in the last analysis leads back to the mother's sexual constitution, will often find a way to live on under such a disguise. May I perhaps remind you in this connection that the relationship between mother and son-in-law has seemed particularly delicate since all time and is one which among primitive peoples gave rise to very powerful taboos and avoidances.[37] It often transgresses our cultural standards positively as well as negatively. I cannot tell you of course which of these three factors were at work in our case; whether two of them only, or whether all of them coöperated, for as you know I did not have the opportunity to continue the analysis beyond two hours.

I realize at this point, ladies and gentlemen, that I have been speaking entirely of things for which your understanding was not prepared. I did this in order to carry through the comparison of psychiatry and psychoanalysis. May I now ask one thing of you? Have you noticed any contradiction between them? Psychiatry does not apply the technical methods of psychoanalysis, and neglects to look for any significance in the content of the obsession. Instead of first seeking out more specific and immediate causes, psychiatry refers us to the very general and remote source—heredity. But does this imply a contradiction, a conflict between them? Do they not rather supplement one another? For does the hereditary factor deny the significance of the experience, is it not rather true that both operate together in the most effective way? You must admit that there is nothing in the nature of psychiatric work which must repudiate psychoanalytic research. Therefore, it is the psychiatrists who oppose psychoanalysis, not psychiatry itself. Psychoanalysis stands in about the same relation to psychiatry as does histology to anatomy. The one studies the outer forms of organs, the other the closer structure of tissues and cells. A contradiction between two types of study, where one simplifies the other, is not easily conceivable. You know that anatomy to-day forms the basis of scientific medicine, but there was a time when the dissection of human corpses to learn the inner structure of the body was as much frowned upon as the practice of psychoanalysis, which seeks to ascertain the inner workings of the human soul, seems proscribed to-day. And presumably a not too distant time will bring us to the realization that a psychiatry which aspires to scientific depth is not possible without a real knowledge of the deeper unconscious processes in the psychic life.

Perhaps this much-attacked psychoanalysis has now found some friends among you who are anxious to see it justify itself as well from another aspect, namely, the therapeutic side. You know that the therapy of psychiatry has hitherto not been able to influence obsessions. Can psychoanalysis perhaps do so, thanks to its insight into the mechanism of these symptoms? No, ladies and gentlemen, it cannot; for the present at least it is just as powerless in the face of these maladies as every other therapy. We can understand what it was that happened within the patient, but we have no means of making the patient himself understand this. In fact, I told you that I could not extend the analysis of the obsession beyond the first steps. Would you therefore assert that analysis is objectionable in such cases because it remains without result? I think not. We have the right, indeed we have the duty to pursue scientific research without regard to an immediate practical effect. Some day, though we do not know when or where, every little scrap of knowledge will have been translated into skill, even into therapeutic skill. If psychoanalysis were as unsuccessful in all other forms of nervous and psychological disease as it is in the case of the obsession, it would nevertheless remain fully justified as an irreplaceable method of scientific research. It is true that we would then not be in a position to practice it, for the human subjects from which we must learn, live and will in their own right; they must have motives of their own in order to assist in the work, but they would deny themselves to us. Therefore let me conclude this session by telling you that there are comprehensive groups of nervous diseases concerning which our better understanding has actually been translated into therapeutic power; moreover, that in disturbances which are most difficult to reach we can under certain conditions secure results which are second to none in the field of internal therapeutics.

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