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CHAPTER V

PSYCHO-ANALYSIS IN PSYCHOTHERAPY

BY ERNEST JONES, M.D., M.R.C.P. (LOND.)

London

THE evolution of psychotherapy, like that of all other modes of treatment, is marked by an ever-increasing precision in method and an ever-deepening comprehension of the conditions to which it is applicable. Progress in these two respects must always go hand in hand, for the moment therapeutics becomes divorced from pathology and diagnosis it leaves its scientific basis and stands in danger of approximating to that medical charlatanery which it is the highest interest of our profession to resist. The two studies are peculiarly interwoven in the case of the psycho-analytic form of psychotherapy, for, as I shall presently indicate, treatment is here carried out by simultaneously laying bare and remedying the pathological mechanisms at the basis of the malady. From this point of view we can discern two stages in the development of any new method of treatment, and these I can best illustrate by a reference to more familiar methods, for instance the operations of trephining or of laparotomy. When the possibility of these operations was first realized we saw the first stage in development, in which, namely, they were regarded merely as an adjunct to the therapeutic armamentarium, and were applied in the relief of conditions that were already well known and studied on established pathological lines. The second stage arose when, through the repeated performance of such operations, conditions that could be relieved by them came to be studied anew, fresh aspects of pathology opened up, and questions of precise diagnosis that had previously been academic problems of trivial interest now became urgent matters of life and death. A moment's reflection on the history of appendicitis will remind you of how little we knew of the pathology, the diagnosis, or even the existence of the affection until the surgeon's knife showed that it could be cured. We might, in fact, paraphrase the motto underlying British Imperialistic policy, to wit, that trade follows the flag, and say that in medicine diagnosis follows treatment.

Now in psychotherapy most of the medical world is at present only entering on the first stage. That the medical world of America will definitely enter on this stage as a prelude to further advancement will, I trust, be one of the results of this present symposium. In this stage we clearly recognize that we have secured a new therapeutic weapon of the utmost value, which we may describe as the capacity to alleviate certain complaints by purely mental measures, in other words as psychotherapy in its broadest sense. Our attitude towards the nature of these complaints, however, remains in this stage substantially the same as it was when they were treated only by physical remedies. Hence we may see the strange picture of a physician removing by verbal suggestion a symptom which he considers is produced by a toxin circulating in the blood. However, a thoughtful person who employs any form of psychotherapy soon realizes that a symptom which can be removed by mental measures is in all probability of a mental nature. It may parenthetically be remarked that he further realizes how the suffering endured by the patient, so far from being unreal, is all the more dreadful and formidable for having a mental and not a physical origin. A non-appreciation of this important fact is still all too common. Only recently an article appeared in one of the leading medical journals in which the writer remarked: “In this manner I hope that we will always be able to trick a malingerer or hysterical subject into betraying the falsity of his claim.” This attitude, though rarely in such an outspoken form, is frequently implied in medical writings, and cannot be too strongly condemned. Apart from yielding an inkling of the mental nature of various disorders, the first stage in the evolution of psychotherapy is characterized by an indeterminate attitude towards the origin and pathogenesis of them. The older conceptions have begun to dissolve, but the knowledge won by the new method of treatment has not yet been formulated. Psychotherapy is in this stage employed in a quite empiric way, and the physician either does not concern himself with the intrinsic modus operandi of his treatment, or else offers explanations of it which are so superficial as to be of little scientific value.

Psycho-analysis represents the second stage in the evolution of psychotherapy. Here a deeper insight is sought into the essential nature and origin of the morbid phenomena with a view to obtaining a fuller understanding of the aims of treatment and so to achieving a greater precision in the application of it. The psychoanalytic method we owe almost completely to the genius of Professor Freud of Vienna, who in the past sixteen years has wrought it into an elaborate science of which I can here give only the most summary outline. The method is based on the knowledge that the symptoms present in the psycho-neuroses owe their origin to a conflict between two groups of ideas or mental processes which cannot be brought into harmony with each other. One complex of mental processes is for some reason or other of such a kind as to be inacceptable to the main body of the personality. The personality fails to assimilate it, will have nothing to do with it, tries to forget it, to submerge it, to repress it. The repressed complex then takes on an automatic existence, and acts as an irritating foreign body in the same way as any physical foreign body that has not been absorbed. From this point of view we may define the pathology of the psychoneuroses as a defect in assimilation.

Let me illustrate my meaning with a concrete instance. A man conceives an attraction toward the wife of a near friend or relative, and in his imagination perhaps plays with the thought of what might happen were the friend to meet with a fatal accident. If he honestly faces his wish and realizes its nature he will instantly see that, though possibly a perfectly natural one, it is of such a kind that for social and ethical reasons it must obviously be suppressed. If he adopts this healthy attitude he will probably think no more about the matter except in the most harmless way. The wish-complex is here assimilated by the main body of the personality. If on the other hand he regards the mere possibility of entertaining such a wish as a sin and a sign of the most desperate iniquity he may refuse to own up to himself that he has ever felt it, even momentarily; whenever the thought occurs to him he endeavors to put it from him, to get away from it, in other words to repress (‘verdrängen’) it. The complex here is not assimilated, it therefore continues to act, and the more the man strives to escape from it, the more hauntingly does it torment him. He has now become the prey to a fixed idea which is out of his control, and which evinces its independence by appearing irregularly whether he wills it or not. In actual practice we never meet with cases so simple as this, but the instance will serve to illustrate the notion I am trying to convey, namely that certain mental processes, particularly strivings, desires, and impulses, if they are not absorbed in the main stream of the personality are apt to manifest an independent activity out of control of the will. This activity is usually of a low order, of an automatic and almost reflex kind, and- if I may be allowed to use the term in a clinical and non-philosophic sense—it is generally an unconscious activity, that is to say it operates without the subject's being aware of it.

As I have just said, matters are not so simple in practice, and what actually happens is that the activity of the repressed complex is manifested not directly but indirectly in some distorted form that is often hard to recognize. In the above example, for instance, the subject might have counterbalanced his real attitude towards his friend by developing an exaggerated solicitude for his welfare, and have shown great concern and dread whenever the friend ran the slightest risk of accident or danger. Again, an abnormally strong emotion might be evoked by anything accidentally associated with the persons in question, a condition that Professor Morton Prince described some ten years ago under the name of “association neurosis.” This distortion in the manifestation of the activity of the mental complex is often exceedingly involved, and one of the main difficulties in the psycho-analytic method is the unravelling of the confused end-product, which clinically we call a symptom. The psychological mechanisms by means of which the distortion is brought about are very intricate, so that in the time allotted it would be impossible for me to describe them. They have been worked out with great accuracy and detail by Freud and Jung, and an exact study of them is essential to the use of the psycho-analytic method.

Investigation on the lines presently to be indicated discloses the fact that every psycho-neurotic symptom is to be regarded as the symbolic expression of a submerged mental complex of the nature of a wish. The wish itself on account of its unacceptable nature is concealed, and the symptom arises as a compromise between it and the repressing force exerted by the main personality. The stream of feeling that characterizes the wish is dammed up, it can find no direct outlet, and so flows into some abnormal direction. The metaphor of “side-tracking” is, I believe, used in American psychiatric circles to indicate this process. In more technical phraseology we may say that the affect of the original complex is inhibited, and so becomes transposed on to an indifferent mental process. This indifferent mental process has now become invested with the strength of feeling that properly belongs to the original complex, and so may be said to replace the complex. Thus arises what Professor Adolf Meyer calls a substitution neurosis, in which an abnormal outlet has been found for a pent-up affective process. The outlet may be in a purely mental direction, in which case we have such a symptom as a phobia, or towards various bodily processes, a condition that Freud calls conversion-hysteria, in which case we have such symptoms as a tremor or a paralysis. In the symptom the patient obtains a certain unconscious gratification of the repressed wish, and this means of obtaining the gratification, however perverse and abnormal it may be, is still the only means possible to the patient under the circumstances. This fact explains the obstinacy with which such a patient may instinctively cling to his symptoms, and is one of the causes of the resistance that the physician encounters when trying to remove these. I need hardly remind you that this obstinacy is often erroneously interpreted even by physicians as indicating mere wilful perversity, a mistake that does not conduce to success in treatment. Not only does the observer commonly fail to understand the significance of the symptom, but the patient himself has no knowledge of its meaning or origin. In fact, enabling the patient to discover and appreciate the significance of the mental process that manifests itself as a symptom is the central aim of the psychoanalytic method.

In carrying out this method several procedures may be adopted according to circumstances. The hypnotic state, for instance, may be utilized in the search for forgotten memories. Only a very few of those acquainted with the psycho-analytic method employ this procedure at all extensively, for it has grave disadvantages which I need not here discuss. Personally I employ it only as a rare exception and for special reasons; under certain circumstances, however, it undoubtedly has a legitimate place. The procedure introduced and developed by Freud is the one most generally used, and gives by far the most satisfactory results. It is one of the ways of obtaining what is known in psychology as “free association,” and is carried out by getting the patient to concentrate his mind on a given idea, generally one in relation to a symptom, and asking him to relate in the order of their appearance the various thoughts that come to his mind. It is essential for him to do this quite honestly, and fortunately we have several objective tests of his behavior in this respect. He must suspend his natural tendency to criticize and direct the thoughts flowing in, and must therefore play a purely passive part during this stage. At first he will omit to mention a number of thoughts on the ground that they are apparently irrelevant, unimportant, or nonsensical, and others because they are of a painful or unpleasant nature. After a time, however, the length of which largely depends on his intelligence and sincerity, he acquires the capacity of adopting the non-critical and passive attitude essential to success.

Other means of reaching buried mental complexes may briefly be mentioned. A study of various mannerisms, symptomatic movements and tricks of behavior, and slips of the tongue or pen, often reveals the automatic functioning of some repressed train of thought. The word-reaction association method as developed by Jung is of the highest assistance, particularly in furnishing us with a series of clues to serve as starting points for future analyses. In this method a series of test-words are called out to the patient, who has to respond with the first word or thought thus called to his mind. From a general review of the kind of responses given much can be learned about the mentality of the patient and the type of psychosis present. Further, by noting certain peculiarities in the individual reactions we may discover certain complexes or trains of thought which possess for the patient a high emotional value, and these can then be followed and studied more fully. The peculiarities I refer to are ten or twelve in number. The chief are: undue delay in the time of reaction, failure to respond at all, response by repetition of the test-word, perseveration affecting the succeeding reactions, anomalous clang associations, assimilation of the test-word in an unusual sense, and erroneous reproduction of the reaction when the memory for it is subsequently tested. Last but not least is the analysis of the patient's dreams by means of the special technique introduced by Freud. The study of dreams is in this connection of supreme importance, for of all the means at our disposal it is the one that best enables us to penetrate into and understand the most hidden parts of the mind. No one can have more than an outsider’s notion of the psycho-analytic method who has not thoroughly studied Freud’s Traumdeutung, for in this work he has laid down the technique of his methods, and discussed the principles on which they are based, with a fulness to be found nowhere else in his writings.

By means of the methods just outlined we are enabled to determine the origin of the symptom by retracing the steps along which its pathogenesis proceeded. It is impossible to deal with the underlying complexes, to discharge their pent-up affect, to render them more assimilable by the patient, unless one succeeds in this task and brings them to the full light of day. The symptoms constitute a veiled language in which hidden thoughts and desires find the only means allowed them of coming to expression. We have to get the patient to translate his symptoms into more direct language, and thus to understand and appreciate the origin of them. In so doing we give the patient a deeper insight into the workings of his mind, so that he is enabled to correct abnormal deviations, to overcome internal inhibitions and impediments, and to acquire a more objective standpoint towards the repressed mental complexes, the automatic functioning of which has produced the morbid manifestations. He is in this way able to free his personality from the constraining force of these complexes, and, by taking up an independent attitude towards them, to gain a degree of self-control over his aberrant thoughts and wishes that was previously impossible. The method is thus in almost every respect the reverse of treatment by suggestion, although several would-be critics have naively exposed their ignorance of the subject in maintaining that the successful results are produced by suggestion. In suggestion treatment the physician adds something to the patient’s mind,—confidence, belief, etc.,—and thus makes the patient more dependent on him. The psycho-analytic method does not add; it takes away something, namely inhibition. It enables the patient to disentangle confused mental processes, and, by giving him control over the disharmonies of his mind, leads him to develop a greater measure of self-reliance and independence. The training received by the patient is thus an educative one in the highest sense of the word, for he not only achieves a richer development of will power and self-mastery, but acquires an understanding of his own mind which is of incalculable value for future prophylaxis. He grows both in capacity to know and in ability to do.

The conditions that lend themselves to psycho-analytic treatment comprise practically all forms of psycho-neurosis, the different types of hysteria, the phobias, obsessions, anxiety neuroses, and even certain kinds of sexual perversions. I shall refrain from relating any individual cases, for to do so would be only to weary you with the recital of a list of typical and atypical instances of these various conditions. It is further impossible for me to narrate any single instance of an analysis, for in every case the richness of material is so great that it would take several hours to give even an outline of the main points in the case.

The results obtained by the treatment, though by no means ideal, are yet very gratifying. They surpass those obtained by simpler methods in two chief respects, namely in permanence and in the prophylactic value they have for the future. Although most symptoms can be removed by other methods, such as hypnotism, yet any one who has devoted much time to the study of these cases knows how great is the tendency to relapse, to recurrence, and to the appearance of fresh groups of symptoms. Mild cases can indeed be not only alleviated but even cured by the simpler psychotherapeutic measures, so that these all have their sphere of usefulness; severe cases, on the other hand, need a more radical treatment, an uprooting of the actual morbid agents. It is easy to understand how this must be so. Hypnotic and other suggestion acts merely by blocking the outward manifestation of the underlying pathogenetic idea. The idea itself persists, because it has not been reached and dealt with, and sooner or later it will again manifest itself either in the same direction or in some fresh one. The analogy of a tubercular, or better still of an actinomycotic abscess occurs to me in this connection. If the suppurating sinus is forcibly plugged then the symptom of discharging pus is removed, but sooner or later the pent-up pus will find a vent in either the same or a fresh direction. Before satisfactory healing can take place the tension must be relieved by instituting free drainage for each pus pocket, and the more thoroughly the focus of the disease is dealt with the better will be the result.

A few words are now necessary on the clinical applicabilities and limitations of the method. It is a method that makes great demands on both physician and patient. Apart from technical knowledge the physician must evidently possess, not only unimpeachable integrity, but also a considerable measure of tact, patience, and sympathetic understanding; without these qualifications he is unlikely to gain the patient's confidence to the requisite degree. The treatment further makes a great call on his time. Freud often finds it necessary to devote to a patient an hour a day for three years, but he acknowledges that the cases sent to him are generally of a very severe nature. In milder cases one can achieve very satisfactory results in a few months, a fact to which I can fully attest from my own experience. The amount of time may appear excessive unless one remembers the hugeness of the task imposed, for in all cases the roots of the trouble go back to early childhood, and important modes of reactions have to be altered which have been fixed and stereotyped for many years. When we consider how much trouble and time frequently has to be expended in the orthopedic straightening of a deformed limb, we should not grudge the same to the far more intricate task of the orthopsychic training of a deformed mind, especially when this results in converting an intolerable existence into a happy life, and a person paralyzed by doubts, fears, and suffering into an active and useful citizen.

The demands made on the patient are no less great. The results of the treatment will vary with the intelligence, courage, honesty, and perseverance he shows. With stupid and quite uneducated patients relatively little can be done, so that happily we can most help those whose value to the world is greatest. Again, age sets a formidable barrier to our efforts. In old age, when the plasticity of the mind is diminished, far less can be done than at an earlier period, and furthermore the time necessary to trace back the erroneous mental reactions through so many years is naturally longer. Still I have had a few fairly satisfactory results even above the age of fifty.

It will be realized that the method is at present not one generally applicable by the practising physician. Not only is the time necessary for the treatment a great hindrance, but also a laborious special training is necessary before the technique of psycho-analysis can be acquired to an adequate extent. It is generally admitted that this demands three years’ incessant practice, a good previous knowledge of neurology being assumed. Here, as elsewhere, therefore, good work exacts arduous labor, and there is no royal road to the art of handling the most intricate and delicate machine we know of, the human mind.

You may now legitimately ask why I have taken up so much of your time in describing a mode of treatment which I acknowledge not many will have the opportunity to learn or to apply. My answer is a twofold one. In the first place I am not one of those who hold that the general physician should be cut off from all advancing knowledge except that which he can immediately apply in his daily work. No physician can apply all methods of diagnosis and treatment but it is surely well that he should at least be aware of the existence of them. I cannot believe that because a country practitioner is not expected to apply the Wassermann test in the diagnosis of syphilis, or to perform excision of the Gasserian ganglion for the relief of trigeminal neuralgia, it is therefore better for him not to know about such methods. In the second place I wish to contribute to the general effect that this symposium must have in bringing home to you in some degree the present unsatisfactory state of medical education so far as psychology is concerned, for this is the main cause of the helplessness of the medical profession against the very maladies that are the triumph of the quack, religious or otherwise. The sooner we honestly face the shameful but undeniable fact that unqualified empirics can relieve distressing affections in cases that have defied medical skill, can produce results where we fail, the sooner will this flagrant lack in our system of education be remedied, and the better will it be for the dignity and honour of the medical profession. While the present state of affairs lasts, in which most physicians are given not five minutes’ training in psychology in the five years of their student life, and in which there is no teacher of clinical psychology in any university or medical school in the country; our profession must submit to being the prey of the charlatan and the mock of the scoffer.