Selected papers on hysteria and other psychoneuroses

by Sigmund Freud

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 suitable 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 explanations concerning this cathartic or analytic method of psychotherapy.

(a) I notice that this method is often mistaken for the hypnotic 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 exists between the suggestive 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 levare, 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 understanding. I have so early given up the technique of suggestion, 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 against the recovery, and which alone can give us an understanding of their behavior in life.

(b) It seems to me that a very widespread mistake among my colleagues is the idea that the technique of the investigation for 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 I 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 undertake a “psychoanalysis” with a hysterical woman. I am convinced that he would not entrust him with the examination of an extirpated tumor without previously assuring himself that he is acquainted with the histological technique. Likewise I am informed 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, therefore, 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 occasions I can not help but think 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.)

(c) You will have surmised from some of my observations 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 and 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 therapeutic method in grave and in the gravest of cases only; my material at first consisted of patients who tried everything unsuccessfully, 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 gratifying number of such, permanently capacitated. Against this success all expense is insignificant. We can not conceal from ourselves 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 contraindications of this treatment. However, I will attempt to discuss with you a few points:

1. 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 individual associated with the manifestations of degeneration. The analytic psychotherapy is therefore no procedure for the treatment 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 themselves to it by order of their relatives. The characteristic feature upon which the usefulness of the psychoanalytic treatment depends, 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 procedures, 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 psychoses.

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 increased. The earliest age limit is to be individually determined; youthful persons, even before puberty, are excellent subjects for influence.