Psychoanalysis may be undertaken either for the purpose of gaining insight into underlying mental mechanisms of normal or abnormal conduct, or for a therapeutic purpose. If for the latter, it is important to bear in mind that not all cases can be materially benefited by this method of treatment. Psychoanalysis should not be attempted with patients of low cultural status, or in cases of marked mental deficiency, psychoses of established chronicity, or those arising on an organic basis. Old age, grave character defects, and unwillingness to be cured are among other conditions constituting obstacles to successful psychoanalytic treatment. Psychoneuroses and mild or remittent psychoses, occurring in intelligent, educated, and sincere persons are most hopeful as regards results to be derived from psychoanalytic treatment.
Inasmuch as psychoanalysis is undertaken in cases in which symptoms are assumed to be actuated by complexes that are submerged in the region of the unconscious by reason of being charged with painful affect, the physician must be prepared to meet with more or less determined resistance to his probing. To overcome this resistance it is necessary, while becoming acquainted with the patient, in the course of history taking and physical examination, and before the work of psychoanalysis proper is begun, to inspire the patient with friendliness, respect, confidence, hopefulness, and, above all, a certain intimacy which might be likened to that of, say, parent and child.
1 E. Bleuler. Autistic Thinking. Amer. Journ. of Insanity, Special Number, Vol. LXIX, 1913.
Some such relationship between physician and patient has always been instinctively understood to be desirable even where it is merely a question of the patient submitting to a surgical procedure, a dietetic regime, or a course of medication. In cases requiring psychoanalysis it is an indispensable condition. In older psychotherapy it was known as rapport. Psychoanalysts speak of it as transference (of affection).
In the growth of such a relationship the patient's feeling toward the physician may become one of sexual love. Under such circumstances the physician "must neither drive away tlie transference nor must he return it. He must firmly grasp the phenomenon as a temporary manifestation belonging only to the period of treatment, which must be led back to its unconscious sources, an instrument which will thus serve to bring into consciousness the most hidden part of the patient's love life in order to obtain mastery over it. There must be enough permission granted to the love to allow the patient to feel herself sufficiently secure to produce all the stipulations, phantasies and characteristics of her erotic desires, which lead the way into their infantile sources." "The situation as far as the physician is concerned is simply an inevitable part of the treatment for which he must assume the responsibility as for any other professional confidence and trust, a responsibility that is only increased by the ready willingness of the patient. Technical as well as ethical motives determine his responsibility and strengthen his appreciation of the therapeutic value of this situation.
The love is to be freed from its infantile fixations, not in order to be expended in the course of the treatment but to be preserved for the demands of real life for which the treatment is preparing the patient." l
In psychoanalytic work considerable use has been made of word-association tests.2 The technique of such a test is described in Appendix VI, of this Manual. In the main, however, the work of psychoanalysis - whether in the study of psychoneurotic symptoms or of dreams - consists in a procedure described by Freud as follows:
"A certain psychic preparation of the patient is necessary. The double effort is made with him, to stimulate his attention for his psychic perceptions and to eliminate the critique with which he is ordinarily in the habit of viewing the thoughts which come to the surface in him. For the purpose of self-observation with concentrated attention, it is advantageous that the patient occupy a restful position and close his eyes; he must be explicitly commanded to resign the critique of the thought formations which he perceives. He must be told further that the success of the psychoanalysis depends upon his noticing and telling everything that passes through his mind, and that he must not allow himself to suppress one idea because it seems to him unimportant or irrelevant to the subject, or another because it seems nonsensical. He must maintain impartiality towards his ideas; for it would be owing to just this critique if he were unsuccessful in finding the desired solution of the dream, the obsession, or the like."
"I have noticed in the course of my psychoanalytic work that the state of mind of a man in contemplation is entirely different from that of a man who is observing his psychic processes. In contemplation there is a greater play of psychic action than in the most attentive self-observation; this is also shown by the tense attitude and wrinkled brow of contemplation, in contrast with the restful features of self-observation. In both cases, there must be concentration of attention, but, besides this, in contemplation one exercises a critique, in consequence of which he rejects some of the ideas which he has perceived, and cuts short others, so that he does not follow the trains of thought which they would open; toward still other thoughts he may act in such a manner that they do not become conscious at all - that is to say, they are suppressed before they are perceived. In self-observation, on the other hand, one has only the task of suppressing the critique; if he succeeds in this, an unlimited number of ideas, which otherwise would have been impossible for him to grasp, come to his consciousness.
With the aid of this material, newly secured for the purpose of self-observation, the interpretation of pathological ideas, as well as of dream images, can be accomplished."
1S. Freud. Bemerkungen u. d. Uebertragungsliebe. Int. Zeit. f. Aerzt. Psa., Vol. Ill, No. 1, 1915. Quoted by S. E. Jelliffe. The Technique of Psychoanalysis. New York, 1918.
2 C. G. Jung. Diagnostische Assoziationsstudien. Vol. I, 1906, Vol. II, 1910. - E. Jones. The Practical Value of the Word-Association Method in the Treatment of Psychoneuroses. Rev. of Neurol, and Psychiatry, Nov., 1910.
"The suspension thus required of the critique for these apparently ' freely rising ' ideas, which is here demanded and which is usually exercised on them, is not easy for some persons. The ' undesired ideas ' are in the habit of starting the most violent resistance, which seeks to prevent them from coming to the surface."
"Most of my patients accomplish it after the first instructions; I myself can do it very perfectly, if I assist the operation by writing dcwn my notions. The amount, in terms of psychic energy, by which the critical activity is in this manner reduced, and by which the intensity of the self-observation may be increased, varies widely according to the subject matter upon which the attention is to be fixed."
"The first step in the application of this procedure now teaches us that not the dream as a whole, but only the parts of its contents separately, may be made the object of our attention. If I ask a patient who is as yet unpracticed: 'What occurs to you in connection with this dream? ' as a rule he is unable to fix upon anything in his psychic field of vision. I must present the dream to him piece by piece, then for every fragment he gives me a series of notions, which may be designated as the ' background thoughts ' of this part of the dream."
"Comments on the dream and seemingly harmless observations about it often serve in the most subtle manner to conceal - although they usually betray - a part of what is dreamed. Thus, for example, when the dreamer says: Here the dream is vague, and the analysis gives an infantile reminiscence of listening to a person cleaning himself after defecation. Another example deserves to be recorded in detail. A young man has a very distinct dream which recalls to him phantasies from his infancy which have remained conscious to him: he was in a summer hotel one evening, he mistook the number of his room, and entered a room in which an elderly lady and her two daughters were undressing to go to bed. He continues: ' Then there are some gaps in the dream; then something is missing; and at the end there was a man in the room who wished to throw me out with whom I had to wrestle.' He endeavored in vain to recall the content and purpose of the boyish fancy to which the dream apparently alludes. But we finally become aware that the required content had already been given in his utterances concerning the indistinct part of the dream. The 'gaps' were the openings in the genitals of the women who were retiring: ' Here something is missing ' describes the chief character of the female genitals.
In those early years he burned with curiosity to see a female genital, and was still inclined to adhere to the infantile sexual theory which attributes a male genital to a woman.'
' If the report of a dream appears to me at first difficult to understand, I request the dreamer to repeat it. This he rarely does in the same words. The passages wherein the expression is changed have become known to me as the weak points of the dream's disguise." "The analysis may start from these points."
"It often happens that in the midst of interpretation work an omitted fragment of the dream suddenly comes to the surface. This part of the dream snatched from forgetfulness is always the most important part. It lies on the shortest road toward the solution of the dream, and for that very reason it was most objectionable to the resistance."
"In general it is doubtful in the interpretation of every element of the dream whether it - (a) is to be regarded as having a negative or a positive sense (relation of opposition); (b) is to be interpreted historically (as a reminiscence); (c) is symbolic; or whether (d) its valuation is to be based upon the sound of its verbal expression. In spite of this manifold signification, it may be said that the representation of the dream activity does not impose upon the translator any greater difficulties than the ancient writers of hieroglyphics imposed upon their readers."
.."The interpretation of a dream cannot always be accomplished in one session; you often feel after following up a concatenation of thoughts, that your working capacity is exhausted; the dream will not tell you anything more on that day; it is then best to break off, and return to the work the following day. Another portion of the dream content then solicits your attention, and you thus find an opening to a new stratum of the dream thoughts. We may call this the ' fractionary ' interpretation of dreams."
"The question whether every dream can be interpreted may be answered in the negative. One must not forget that in the work of interpretation one must cope with the psychic forces which are responsible for the distortion of the dream. Whether one can become master of the inner resistances through his intellectual interest, his capacity for self-control, his psychological knowledge, and his practice in dream interpretation becomes a question of the preponderance of forces. It is always possible to make some progress." l
Cures through psychoanalysis are effected by bringing to light unconscious complexes underlying psychoneurotic symptoms and thus achieving psychic "catharsis." The patient is, of course, not relieved of the external situation which had provoked his symptoms as a diseased form of adjustment, but is helped to a normal, i.e., a more purposeful and more social form of adjustment.
"When I promised my patients help and relief through the cathartic method, I was often obliged to hear the following objections: 'You say, yourself, that my suffering has probably to do with my own relation and destinies. You cannot change any of that. In what manner, then, can you help me? ' To this I could always answer: ' I do not doubt at all that it would be easier for destiny than for me to remove your sufferings, but you will be convinced that much will be gained if we succeed in transforming your hysterical misery into everyday unhappiness, against which you will be better able to defend yourself with a restored nervous system.' " 2
Psychoanalysis in relation to psychoneuroses and psychoses cannot be fully treated in the limited space that is available for it in this Manual. For further study, therefore, the student must be referred to special works.3
1S. Freud. The Interpretation of Dreams. English translation by A. A. Brill. New York, 1916.
2 S. Freud. Selected Papers on Hysteria. English translation by A. A. Brill. New York, 1909.
3 S. Freud. Delusion and Dream. - E. Hitschmann. Freud's Theories of the Neuroses. English translation by C. R. Payne. - H. W. Frink. Neurotic Fears and Obsessions. - C. G. Jung. The Psychology of Dementia Prcecox. English translation by F. Peterson and A. A. Brill, New York, 1909. - A. A. Brill. A Case of Schizophrenia. Amer. Journ. of Insanity, July, 1909. - E. Jones. Psycho-Analytic Notes on a Case of Hypomania. Amer. Journ. of Insanity, Oct., 1909.