Freud - Complete Works (421 page)

On Beginning The Treatment

2482

   Doctors lend support to these
fond hopes. Even the informed among them often fail to estimate
properly the severity of nervous disorders. A friend and colleague
of mine, to whose great credit I account it that after several
decades of scientific work on other principles he became converted
to the merits of psycho-analysis, once wrote to me: ‘What we
need is a short, convenient, out-patient treatment for obsessional
neurosis.’ I could not supply him with it and felt ashamed;
so I tried to excuse myself with the remark that specialists in
internal diseases, too, would probably be very glad of a treatment
for tuberculosis or carcinoma which combined these advantages.

   To speak more plainly,
psycho-analysis is always a matter of long periods of time, of half
a year or whole years - of longer periods than the patient expects.
It is therefore our duty to tell the patient this before he finally
decides upon the treatment. I consider it altogether more
honourable, and also more expedient, to draw his attention -
without trying to frighten him off, but at the very beginning - to
the difficulties and sacrifices which analytic treatment involves,
and in this way to deprive him of any right to say later on that he
has been inveigled into a treatment whose extent and implications
he did not realize. A patient who lets himself be dissuaded by this
information would in any case have shown himself unsuitable later
on. It is a good thing to institute a selection of this kind before
the beginning of the treatment. With the progress of understanding
among patients the number of those who successfully meet this first
test increases.

   I do not bind patients to
continue the treatment for a certain length of time; I allow each
one to break off whenever he likes. But I do not hide it from him
that if the treatment is stopped after only a small amount of work
has been done it will not be successful and may easily, like an
unfinished operation, leave him in an unsatisfactory state. In the
early years of my psycho-analytic practice I used to have the
greatest difficulty in prevailing on my patients to continue their
analysis. This difficulty has long since been shifted, and I now
have to take the greatest pains to induce them to give it up.

On Beginning The Treatment

2483

   To shorten analytic treatment is
a justifiable wish, and its fulfilment, as we shall learn, is being
attempted along various lines. Unfortunately, it is opposed by a
very important factor, namely, the slowness with which deep-going
changes in the mind are accomplished - in the last resort, no
doubt, the ‘timelessness’ of our unconscious processes.
When patients are faced with the difficulty of the great
expenditure of time required for analysis they not infrequently
manage to propose a way out of it. They divide up their ailments
and describe some as unbearable, and others as secondary, and then
say: ‘If only you will relieve me from this one (for
instance, a headache or a particular fear) I can deal with the
other one on my own in my ordinary life.’ In doing this,
however, they over-estimate the selective power of analysis. The
analyst is certainly able to do a great deal, but he cannot
determine beforehand exactly what results he will effect. He sets
in motion a process, that of the resolving of existing repressions.
He can supervise this process, further it, remove obstacles in its
way, and he can undoubtedly vitiate much of it. But on the whole,
once begun, it goes its own way and does not allow either the
direction it takes or the order in which it picks up its points to
be prescribed for it. The analyst’s power over the symptoms
of the disease may thus be compared to male sexual potency. A man
can, it is true, beget a whole child, but even the strongest man
cannot create in the female organism a head alone or an arm or a
leg; he cannot even prescribe the child’s sex. He, too, only
sets in motion a highly complicated process, determined by events
in the remote past, which ends with the severance of the child from
its mother. A neurosis as well has the character of an organism.
Its component manifestations are not independent of one another;
they condition one another and give one another mutual support. A
person suffers from one neurosis only, never from several which
have accidentally met together in a single individual. The patient
freed, according to his wish, from his one unendurable symptom
might easily find that a symptom which had previously been
negligible had now increased and grown unendurable. The analyst who
wishes the treatment to owe its success as little as possible to
its elements of suggestion (i.e. to the transference) will do well
to refrain from making use of even the trace of selective influence
upon the results of the therapy which may perhaps be open to him.
The patients who are bound to be most welcome to him are those who
ask him to give them complete health, in so far as that is
attainable, and who place as much time at his disposal as is
necessary for the process of recovery. Such favourable conditions
as these are, of course, to be looked for in only a few cases.

On Beginning The Treatment

2484

   The next point that must be
decided at the beginning of the treatment is the one of money, of
the doctor’s fee. An analyst does not dispute that money is
to be regarded in the first instance as a medium for
self-preservation and for obtaining power; but he maintains that,
besides this, powerful sexual factors are involved in the value set
upon it. He can point out the money matters are treated by
civilized people in the same way as sexual matters - with the same
inconsistency, prudishness and hypocrisy. The analyst is therefore
determined from the first not to fall in with this attitude, but,
in his dealings with his patients, to treat of money matters with
the same matter-of-course frankness to which he wishes to educate
them in things relating to sexual life. He shows them that he
himself has cast off false shame on these topics, by voluntarily
telling them the price at which he values his time. Ordinary good
sense cautions him, furthermore, not to allow large sums of money
to accumulate, but to ask for payment at fairly short regular
intervals - monthly, perhaps. (It is a familiar fact that the value
of the treatment is not enhanced in the patient’s eyes if a
very low fee is asked.) This is, of course, not the usual practice
of nerve specialists or other physicians in our European society.
But the psycho-analyst may put himself in the position of a
surgeon, who is frank and expensive because he has at his disposal
methods of treatment which can be of use. It seems to me more
respectable and ethically less objectionable to acknowledge
one’s actual claims and needs rather than, as is still the
practice among physicians, to act the part of the disinterested
philanthropist - a position which one is not, in fact, able to
fill, with the result that one is secretly aggrieved, or complains
aloud, at the lack of consideration and the desire for exploitation
evinced by one’s patients. In fixing his fee the analyst must
also allow for the fact that, hard as he may work, he can never
earn as much as other medical specialists.

On Beginning The Treatment

2485

   For the same reason he should
also refrain from giving treatment free, and make no exceptions to
this in favour of his colleagues or their families. This last
recommendation will seem to offend against professional amenities.
It must be remembered, however, that a gratuitous treatment means
much more to a psycho-analyst than to any other medical man; it
means the sacrifice of a considerable portion - an eighth or a
seventh part, perhaps - of the working time available to him for
earning his living, over a period of many months. A second free
treatment carried on at the same time would already deprive him of
a quarter or a third of his earning capacity, and this would be
comparable to the damage inflicted by a severe accident.

   The question then arises whether
the advantage gained by the patient would not to some extent
counterbalance the sacrifice made by the physician. I may venture
to form a judgement about this, since for ten years or so I set
aside one hour a day, and sometimes two, for gratuitous treatments,
because I wanted, in order to find my way about in the neuroses, to
work in the face of as little resistance as possible. The
advantages I sought by this means were not forthcoming. Free
treatment enormously increases some of a neurotic’s
resistances - in young women, for instance, the temptation which is
inherent in their transference-relation, and in young men, their
opposition to an obligation to feel grateful, an opposition which
arises from their father-complex and which presents one of the most
troublesome hindrances to the acceptance of medical help. The
absence of the regulating effect offered by the payment of a fee to
the doctor makes itself very painfully felt; the whole relationship
is removed from the real world, and the patient is deprived of a
strong motive for endeavouring to bring the treatment to an
end.

On Beginning The Treatment

2486

   One may be very far from the
ascetic view of money as a curse and yet regret that analytic
therapy is almost inaccessible to poor people, both for external
and internal reasons. Little can be done to remedy this. Perhaps
there is truth in the widespread belief that those who are forced
by necessity to a life of hard toil are less easily overtaken by
neurosis. But on the other hand experience shows without a doubt
that when once a poor man has produced a neurosis it is only with
difficulty that he lets it be taken from him. It renders him too
good a service in the struggle for existence; the secondary gain
from illness which it brings him is much too important. He now
claims by right of his neurosis the pity which the world has
refused to his material distress, and he can now absolve himself
from the obligation of combating his poverty by working. Anyone
therefore who tries to deal with the neurosis of a poor person by
psychotherapy usually discovers that what is here required of him
is a practical therapy of a very different kind - the kind which,
according to our local tradition, used to be dispensed by the
Emperor Joseph II. Naturally, one does occasionally come across
deserving people who are helpless from no fault of their own, in
whom unpaid treatment does not meet with any of the obstacles that
I have mentioned and in whom it leads to excellent results.

   As far as the middle classes are
concerned, the expense involved in psycho-analysis is excessive
only in appearance. Quite apart from the fact that no comparison is
possible between restored health and efficiency on the one hand and
a moderate financial outlay on the other, when we add up the
unceasing costs of nursing-homes and medical treatment and contrast
them with the increase of efficiency and earning capacity which
results from a successfully completed analysis, we are entitled to
say that the patients have made a good bargain. Nothing in life is
so expensive as illness - and stupidity.

On Beginning The Treatment

2487

   Before I wind up these remarks on
beginning analytic treatment, I must say a word about a certain
ceremonial which concerns the position in which the treatment is
carried out. I hold to the plan of getting the patient to lie on a
sofa while I sit behind him out of his sight. This arrangement has
a historical basis; it is the remnant of the hypnotic method out of
which psycho-analysis was evolved. But it deserves to be maintained
for many reasons. The first is a personal motive, but one which
others may share with me. I cannot put up with being stared at by
other people for eight hours a day (or more). Since, while I am
listening to the patient, I, too, give myself over to the current
of my unconscious thoughts, I do not wish my expressions of face to
give the patient material for interpretations or to influence him
in what he tells me. The patient usually regards being made to
adopt this position as a hardship and rebels against it, especially
if the instinct for looking (scopophilia) plays an important part
in his neurosis. I insist on this procedure, however, for its
purpose and result are to prevent the transference from mingling
with the patient’s associations imperceptibly, to isolate the
transference and to allow it to come forward in due course sharply
defined as a resistance. I know that many analysts work in a
different way, but I do not know whether this deviation is due more
to a craving for doing things differently or to some advantage
which they find they gain by it.

   The conditions of treatment
having been regulated in this manner, the question arises at what
point and with what material is the treatment to begin?

   What the material is with which
one starts the treatment is on the whole a matter of indifference -
whether it is the patient’s life-history or the history of
his illness or his recollections of childhood. But in any case the
patient must be left to do the talking and must be free to choose
at what point he shall begin. We therefore say to him:
‘Before I can say anything to you I must know a great deal
about you; please tell me what you know about yourself.’

On Beginning The Treatment

2488

   The only exception to this is in
regard to the fundamental rule of psycho-analytic technique which
the patient has to observe. This must be imparted to him at the
very beginning: ‘One more thing before you start. What you
tell me must differ in one respect from an ordinary conversation.
Ordinarily you rightly try to keep a connecting thread running
through your remarks and you exclude any intrusive ideas that may
occur to you and any side-issues, so as not to wander too far from
the point. But in this case you must proceed differently. You will
notice that as you relate things various thoughts will occur to you
which you would like to put aside on the ground of certain
criticisms and objections. You will be tempted to say to yourself
that this or that is irrelevant here, or is quite up important, or
nonsensical, so that there is no need to say it. You must never
give in to these criticisms, but must say it in spite of them -
indeed, you must say it precisely
because
you feel an
aversion to doing so. Later on you will find out and learn to
understand the reason for this injunction, which is really the only
one you have to follow. So say whatever goes through your mind. Act
as though, for instance, you were a traveller sitting next to the
window of a railway carriage and describing to someone inside the
carriage the changing views which you see outside. Finally, never
forget that you have promised to be absolutely honest, and never
leave anything out because, for some reason or other, it is
unpleasant to tell it.’¹