This is the only text in which Freud details the actual practice of psychoanalysis without dwelling on the details of the interprative aparatus. It was for a textbok (thus in third person) on obsessional neurosis published by Leopold Loewenfeld (though it is also availible in the Standard Edition of the Collected Works).

FREUD'S PSYCHO-ANALYTIC PROCEDURE

(1904)

FREUD'S PSYCHO-ANALYTIC PROCEDURE

The particular psychotherapeutic procedure which Freud practises and describes as 'psycho-analysis' is an outgrowth of what was known as the 'cathartic' method and was discussed by him in collaboration with Josef Breuer in their Studies on Hysteria (1895). This cathartic therapy was a discovery of Breuer's, and was first used by him some ten years earlier in the successful treatment of a hysterical woman patient, in the course of which he obtained an insight into the pathogenesis of her symptoms. As the result of a personal suggestion from Breuer, Freud revived this procedure and tested it on a considerable number of patients.

  The cathartic method of treatment presupposed that the patient could be hypnotized, and was based on the widening of consciousness that occurs under hypnosis. Its aim was the removal of the pathological symptoms, and it achieved this by inducing the patient to return to the psychical state in which the symptom had appeared for the first time. When this was done, there emerged in the hypnotized patient's mind memories, thoughts and impulses which had previously dropped out of his consciousness; and, as soon as he had related these to the physician, to the accompaniment of intense expressions of emotion, the symptom was overcome and its return prevented. This experience, which could be regularly repeated, was taken by the authors in their joint paper to signify that the symptom takes the place of suppressed processes which have not reached consciousness, that is, that it represents a transformation ('conversion') of these processes. They explained the therapeutic effectiveness of their treatment as due to the discharge of what had previously been, as it were, 'strangulated' affect attaching to the suppressed mental acts ( 'abreaction'). But in practice the simple schematic outline of the therapeutic operation was almost always complicated by the circumstance that it was not a single ('traumatic') impression, but in most cases a series of impressions - not easily scanned - which had participated in the creation of the symptom.

  The main characteristic of the cathartic method, in contrast to all other methods used in psychotherapy, consists in the fact that its therapeutic efficacy does not lie in The expectation is rather that the symptoms will disappear automatically as soon as the operation, based on certain hypotheses concerning the psychical mechanism, succeeds in diverting the course of mental processes from their previous channel, which found an outlet in the formation of the symptom.

  The changes which Freud introduced in Breuer's cathartic method of treatment were at first changes in technique; these, however, led to new findings and have finally necessitated a different though not contradictory conception of the therapeutic process.

  The cathartic method had already renounced suggestion; Freud went a step further and gave up hypnosis as well. At the present time he treats his patients as follows. Without exerting my other kind of influence, he invites them to lie down in a comfortable attitude on a sofa, while he himself sits on a chair behind them outside their field of vision. He does not even ask them to close their eyes, and avoids touching them in any way, as well as any other procedure which might be reminiscent of hypnosis. The session thus proceeds like a conversation between two people equally awake, but one of whom is spared every muscular exertion and every distracting sensory impression which might divert his attention from his own mental activity.

  Since, as we all know, it depends upon the choice of the patient whether he can be hypnotized or not, no matter what the skill of the physician may be, and since a large number of neurotic patients cannot be hypnotized by any means whatever, it followed that with the abandonment of hypnosis the applicability of the treatment was assured to an unlimited number of patients. On the other hand, the widening of consciousness, which had supplied the physician with precisely the psychical material of memories and images by the help of which the transformation of the symptoms and the liberation of the affects was accomplished, was now missing. Unless a substitute could be produced for this missing element, any therapeutic effect was out of the question.

  Freud found such a substitute - and a completely satisfactory one - in the 'associations' of his patients; that is, in the involuntary thoughts (most frequently regarded as disturbing elements and therefore ordinarily pushed aside) which so often break across the continuity of a consecutive narrative.

  In order to secure these ideas and associations he asks the patient to 'let himself go' in what he says, 'as you would do in a conversation in which you were rambling on quite disconnectedly and at random'. Before he asks them for a detailed account of their case history he insists that they must include in it whatever comes into their heads, even if they think it unimportant or irrelevant or nonsensical; he lays special stress on their not any thought or idea from their story because to relate it would be embarrassing or distressing to them. In the course of collecting this material of otherwise neglected ideas Freud made the observations which became the determining factor of his entire theory. Gaps appear in the patient's memory even while he narrates his case: actual occurrences are forgotten, the chronological order is confused, or causal connections are broken, with unintelligible results. No neurotic case history is without amnesia of some kind or other. If the patient is urged to fill these gaps in his memory by an increased application of attention, it is noticed that all the ideas which occur to him are pushed back by every possible critical expedient, until at last he feels positive discomfort when the memory really returns. From this experience Freud concludes that the amnesias are the result of a process which he calls 'repression' and the motive for which he finds in feelings of unpleasure. The psychical forces which have brought about this repression can also be detected, according to him, in the 'resistance' which operates against the recovery of the lost memories.

  The factor of resistance has become one of the corner-stones of his theory. The ideas which are normally pushed aside on every sort of excuse - such as those mentioned above - are regarded by him as derivatives of the repressed psychical phenomena (thoughts and impulses), distorted owing to the resistance against their reproduction. Ideas which are normally pushed aside on every sort of excuse - such as those mentioned above - are regarded by him as   derivatives of the repressed psychical phenomena  (thoughts and impulses), distorted owing to the resistance against their reproduction.

  The greater the resistance, the greater is the distortion. The value of these unintentional thoughts for the purposes of therapeutic technique lies in this relation of theirs to the repressed psychical material. If one possesses a procedure which makes it possible to arrive at the repressed material from the associations, at the distorted material from the distortions, then what was formerly unconscious in mental life can be made accessible to consciousness even without hypnosis.

  Freud has developed on this basis an art of interpretation which takes on the task of, as it were, extracting the pure metal of the repressed thoughts from the ore of the unintentional ideas. This work of interpretation is applied not only to the patient's ideas but also to his dreams, which open up the most direct approach to a knowledge of the unconscious, to his unintentional as well as to his purposeless actions (symptomatic acts) and to the blunders he makes in everyday life (slips of the tongue, bungled actions, and so on). The details of this technique of interpretation or translation have not yet been published by Freud. According to indications he has given, they comprise a number of rules, reached empirically, of how the unconscious material may be reconstructed from the associations, directions on how to know what it means when the patient's ideas cease to flow, and experiences of the most important typical resistances that arise in the course of such treatments. A bulky volume called The Interpretation of Dreams, published by Freud in 1900, may be regarded as the forerunner of an initiation into his technique.

  From these remarks on the technique of the psycho-analytic method the conclusion might be drawn that its inventor has given himself needless trouble and has made a mistake in abandoning the less complicated hypnotic mode of procedure. However, in the first place, the technique of psycho-analysis is much easier in practice, when once one has learnt it, than any description of it would indicate; and, secondly, there is no other way which leads to the desired goal, so that the hard road is still the shortest one to travel. The objection to hypnosis is that it conceals the resistance and for that reason has obstructed the physician's insight into the play of psychical forces. Hypnosis does not do away with the resistance but only evades it and therefore yields only incomplete information and transitory therapeutic success.

  The task which the psycho-analytic method seeks to perform may be formulated in different ways, which are, however, in their essence equivalent. It may, for instance, be stated thus: the task of the treatment is to remove the amnesias. When all gaps in memory have been filled in, all the enigmatic products of mental life elucidated, the continuance and even a renewal of the morbid condition are made impossible. Or the formula may be expressed in this fashion: all repressions must be undone. The mental condition is then the same as one in which all amnesias have been removed. Another formulation reaches further: the task consists in making the unconscious accessible to consciousness, which is done by overcoming the resistances. But it must be remembered that an ideal condition such as this is not present even in the normal, and further that it is only rarely possible to carry the treatment to a point approaching it. Just as health and sickness are not different from each other in essence but are only separated by a quantitative line of demarcation which can be determined in practice, so the aim of the treatment will never be anything else but the practical recovery of the patient, the restoration of his ability to lead an active life and of his capacity for enjoyment. In a treatment which is incomplete or in which success is not perfect, one may at any rate achieve a considerable improvement in the general mental condition, while the symptoms (though now of smaller importance to the patient) may continue to exist without stamping him as a sick man.

  The therapeutic procedure remains the same, apart from insignificant modifications, for all the various clinical pictures that may be presented in hysteria, and all forms of obsessional neurosis. This does not imply, however, that it can have an unlimited application. The nature of the psycho-analytic method involves indications and contra-indications with respect to the person to be treated as well as with respect to the clinical picture. Chronic cases of psychoneuroses without any very violent or dangerous symptoms are the most favourable ones for psycho-analysis: thus in the first place every species of obsessional neurosis, obsessive thinking and acting, and cases of hysteria in which phobias and aboulias play the most important part; further, all somatic expressions of hysteria whenever they do not, as in anorexia, require the physician to attend promptly to the speedy removal of symptoms. In acute cases of hysteria it will be necessary to wait for a calmer stage; in all cases where nervous exhaustion dominates the clinical picture a treatment which in itself demands effort, brings only slow improvement and for a time cannot take the persistence of the symptoms into account, will have to be avoided.

  Various qualifications are required of anyone who is to be beneficially affected by psycho-analysis. To begin with, he must be capable of a psychically normal condition; during periods of confusion or melancholic depression nothing can be accomplished even in cases of hysteria. Furthermore, a certain measure of natural intelligence and ethical development are to be required of him; if the physician has to deal with a worthless character, he soon loses the interest which makes it possible for him to enter profoundly into the patient's mental life. Deep-rooted malformations of character, traits of an actually degenerate constitution, show themselves during treatment as sources of a resistance that can scarcely be overcome. In this respect the constitution of the patient sets a general limit to the curative effect of psychotherapy. If the patient's age is in the neighbourhood of the fifties the conditions for psycho-analysis become unfavourable. The mass of psychical material is then no longer manageable; the time required for recovery is too long; and the ability to undo psychical processes begins to grow weaker.

  In spite of all these limitations, the number of persons suitable for psycho-analytic treatment is extraordinarily large and the extension which has come to our therapeutic powers from this method is, according to Freud, very considerable. Freud requires long periods, six months to three years, for an effective treatment; yet he informs us that up to the present, owing to various circumstances which can easily be guessed, he has for the most part been in a position to try his treatment only on very severe cases: patients have come to him after many years of illness, completely incapacitated for life, and, after being disappointed by all kinds of treatments, have had recourse as a last resort to a method which is novel and has been greeted with many doubts. In cases of less severe illness the duration of the treatment might well be much shorter, and very great advantage in the direction of future prevention might be achieved.