The patient, judging his phantasies from the standpoint of his reason, regards them as valueless and senseless; but, in reality, the phantasies have their great influence on the patient because they are of great importance. They are old, sunken treasures, which can only be recovered by a diver, that is, the patients, contrary to their wont, must now pay an active attention to their inner life. Where they formerly dreamed, they must now think, consciously and intentionally. This new way of thinking about himself has about as much resemblance to the patient’s former mental condition as a diver has to a drowning man. The earlier joy in indulgence has now become a purpose and an aim—that is, has become work. The patient, assisted by the physician, occupies himself with his phantasies, not to lose himself therein, but to uproot them, piece by piece, and to bring them into daylight. He thus reaches an objective standpoint towards his inner life, and everything he formerly loathed and feared is now considered consciously. This contains the basis of the whole psychoanalytic therapy. In consequence of his illness, the patient stood, partially or totally, outside of real life. Consequently he neglected many of his life’s duties, either in regard to social work or to the ordinary daily tasks. If he wishes to be well, he must return to the fulfilment of his particular obligations. Let me say, by way of caution, that we are not to understand by such “duties,” some general ethical postulates, but duties towards himself. Nor does this mean that they are eo ipso egoistic interests, since we are social beings as well, a matter too easily forgotten by individualists. An ordinary person will feel very much more comfortable sharing a common virtue than possessing an individual vice, even if the latter is a very seductive one. They must be already neurotic, or otherwise extraordinary people who can be deluded by such particular interests. The neurotic fled from his duties and his libido withdrew, at least partly, from the tasks imposed by real life. In consequence, the libido became introverted and directed towards an inner life. The libido followed the path of regression: to a large extent phantasies replaced reality, because the patient refused to overcome certain real difficulties. Unconsciously the neurotic patient prefers—and very often consciously too—his dreams and phantasies to reality. To bring him back to real life and to the fulfilment of its necessary duties, the analysis proceeds along the same false path of regression which has been taken by his libido; so that the beginning of psychoanalysis looks as if it were supporting the morbid tendencies of the patient. But psychoanalysis follows these phantasies, these wrong paths, in order to restore the libido, which is the valuable part of the phantasies, to the conscious self and to the duties of the moment. This can only be done by bringing the phantasies into the light of day, and along with them the libido bound up with them. We might leave these unconscious phantasies to their shadowy existence, if no libido were attached to them. It is unavoidable that the patient, feeling himself at the beginning of analysis confirmed in his regressive tendencies, leads his analytical interest, amid increasing resistances, down to the depths of the shadowy world. We can easily understand that any physician who is a normal person experiences the greatest resistance towards the thoroughly morbid, regressive tendency of the patient, since he feels quite certain that this tendency is pathological. And this all the more because, as physician, he believes he is right in refusing to give heed to his patient’s phantasies. It is quite conceivable that the physician feels a repulsion towards this tendency; it is undoubtedly repugnant to see how a person is completely given up to such phantasies, finding only himself of any importance and never ceasing to admire or despise himself. The esthetic sense of normal people has, as a rule, little pleasure in neurotic phantasies, even if it does not find them absolutely repulsive. The psychoanalyst must put aside such esthetic judgment, just as every physician must, who really tries to help his patients. He may not fear any dirty work. Of course there are a great many patients physically ill, who, without undergoing an exact examination or local treatment, do recover by the use of general physical, dietetic, or suggestive means. Severe cases can, however, only be helped by a more exact examination and therapy, based on a profound knowledge of the illness. Our psychotherapeutic methods hitherto have been like these general measures. In slight cases they did no harm; on the contrary, they were often of great service. But for a great many patients these measures have proved inadequate. If they really can be helped, it will be by psychoanalysis, which is not to say that psychoanalysis is a universal panacea. Such a sneer proceeds only from ill-natured criticism. We know very well that psychoanalysis fails in many cases. As everybody knows, we shall never be able to cure all illnesses.
This “diving” work of analysis brings dirty matter piecemeal out of the slime, which must then be cleansed before we can tell its value. The dirty phantasies are valueless and are thrown aside, but the libido actuating them is of value and this, after cleansing, becomes serviceable again. To the psychoanalyst, as to every specialist, it will sometimes seem that the phantasies have also a value of their own, and not only by reason of the libido linked with them. But their value is not, in the first instance, for the patient. For the physician, these phantasies have a scientific value, just as if is of special interest to the surgeon to know whether the pus contained staphylococci or streptococci. To the patient it is all the same, and for him, it is better that the doctor conceal his scientific interest, in order not to tempt him to have greater pleasure than necessary in his phantasies. The etiological importance which is attached to these phantasies, incorrectly, to my mind, explains why so much room is given up in psychoanalytic literature to the extensive discussion of the various sexual phantasies. Once if is known that absolutely nothing is impossible in the sphere of sexual phantasy, the former estimate of these phantasies will disappear, and therewith the endeavor to discover in them an etiological import. Nor will the most extended discussion of these cases ever be able to exhaust this sphere.
Every case is theoretically inexhaustible. But in general the production of phantasies ceases after a time. Naturally, we must not conclude from this that the possibility of creating phantasies is exhausted, but the cessation in their production only means that there is then no more libido on the path of regression. The end of the regressive movement is reached as soon as the libido takes hold of the present real duties of life, and is used to solve those problems. But there are cases, and these not a few, where the patient continues longer than usual to produce endless phantastic manifestations, either from his own pleasure in them or from certain false expectations on the part of the doctor. Such a mistake is especially easy for beginners, since, blinded by the present psychoanalytical discussion, they keep their interest fixed on these phantasies, because they seem to possess etiological significance. They are therefore constantly at pains to fish up phantasies of early childhood, vainly hoping to find thus the solution of the neurotic difficulties. They do not see that the solution lies in action, and in the fulfilment of certain necessary duties of life. It will be objected that the neurosis is entirely due to the incapacity of the patient to carry out these very demands of life, and that therapy by the analysis of the unconscious ought to enable him to do so, or at least, give him means to do so. The objection put in this way is perfectly valid, but we have to add that it is only so when the patient is really conscious of the duties he has to fulfil, not only academically, in their general theoretical outlines but in their most minute details. It is characteristic for neurotic people to be wanting in this knowledge, although, because of their intelligence, they are well aware of the general duties of life, and struggle, perhaps only too hard, to fulfil the prescriptions of current morality. But the much more important duties which he ought to fulfil towards himself are to a great extent unknown to the neurotic; sometimes even they are not known at all. It is not enough, therefore, to follow the patient blindfold on the path of regression, and to push him by an inopportune etiological interest back into his infantile phantasies. I have often heard from patients, with whom the psychoanalytic treatment has come to a standstill: “The doctor believes I must have somewhere some infantile trauma, or an infantile phantasy which I am still repressing.” Apart from the cases where this supposition was really true, I have seen cases in which the stoppage was caused by the fact that the libido, hauled up by the analysis, sank back into the depths again for want of employment. This was due to the physician’s attention being directed entirely to the infantile phantasies, and his failing therefore to see what duties of the moment the patient had to fulfil. The consequence was that the libido brought forth by analysis always sank back again, as no opportunity for further activity was found.
There are many patients who, on their own account, discover their life-tasks and abandon the production of regressive phantasies pretty soon, because they prefer to live in reality, rather than in their phantasies. It is a pity that this cannot be said of all patients. A good many of them forsake for a long time, or even forever, the fulfilment of their life-tasks, and prefer their idle neurotic dreaming. I must again emphasize that we do not understand by “dreaming” always a conscious phenomenon.
In accordance with these facts and these views, the character of psychoanalysis has changed during the course of time. If the first stage of psychoanalysis was perhaps a kind of surgery, which would remove from the mind of the patient the foreign body, the “blocked” affect, the later form has been a kind of historical method, which tries to investigate carefully the genesis of the neurosis, down to its smallest details, and to reduce it to its earliest origins.
The Conception of Transference
This last method has unmistakably been due to strong scientific interest, the traces of which are clearly seen in the delineations of cases so far. Thanks to this, Freud was also able to discover wherein lay the therapeutical effect of psychoanalysis. Whilst formerly this was sought in the discharge of the traumatic affect, it was now seen that the phantasies produced were especially associated with the personality of the physician. Freud calls this process transference (“Uebertragung”), owing to the fact that the images of the parents (“imagines”) are henceforth transferred to the physician, along with the infantile attitude of mind adopted towards the parents. The transference does not arise solely in the intellectual sphere, but the libido bound up with the phantasy is transferred, together with the phantasy itself, to the personality of the physician, so that the physician replaces the parents to a certain extent. All the apparently sexual phantasies which have been connected with the parents are now connected with the physician, and the less this is realized by the patient, the more he will be unconsciously bound to his physician. This recognition is in many ways of prime importance.
This process has an important biological value for the patient. The less libido he gives to reality, the more exaggerated will be his phantasies, and the more he will be cut off from the world. Typical of neurotic people is their attitude of disharmony towards reality, that is, their diminished capacity for adaptation. Through the transference to the physician, a bridge is built, across which the patient can get away from his family, into reality. In other words, he can emerge from his infantile environment into the world of grown-up people, for here the physician stands for a part of the extra-familial world. But on the other hand, this transference is a powerful hindrance to the progress of treatment, for the patient assimilates the personality of the physician as if he did stand for father or mother, and not for a part of the extra-familial world. If the patient could acquire the image of the physician as a part of the non-infantile world, he would gain a considerable advantage. But transference has the opposite effect; hence the whole advantage of the new acquisition is neutralized. The more the patient succeeds in regarding his doctor as he does any other individual, the more he is able to consider himself objectively, the greater becomes the advantage of transference. The less he is able to consider his doctor in this way, the more the physician is assimilated with the father, the less is the advantage of the transference and the greater will be its harm. The familial environment of the patient has only become increased by an additional personality assimilated to his parents. The patient himself is, as before, still in his childish surroundings, and therefore maintains his infantile attitude of mind. In this manner, all the advantages of transference can be lost.
There are patients who follow the analysis with the greatest interest without making the slightest improvement, remaining extraordinarily productive in phantasies, although the whole development of their neurosis, even to the smallest details, has been brought to light. A physician under the influence of the historical view might be thus easily thrown into confusion, and would have to ask himself: What is there in this case still to be analyzed? Those are just the cases of which I spoke before, where it is no longer a matter of the analysis of the historical material, but we have now to face a practical problem, the overcoming of the inadequate infantile attitude of mind. Of course, the historical analysis would show repeatedly that the patient had a childish attitude towards his physician, but it would not bring us any solution of the question how that attitude could be changed. To a certain extent, this serious disadvantage of transference is found in every case. Gradually it has been proved that this part of psychoanalysis is, considered from a scientific standpoint, extraordinarily interesting and of great value, but in its practical aspect, of less importance than that which has now to follow, namely, the analysis of the transference.