ON BEGINNING THE TREATMENT (FURTHER RECOMMENDATIONS ON THE TECHNIQUE OF PSYCHO-ANALYSIS I) - (1913)
Anyone who hopes to learn the noble game of chess from book will soon discover that only the openings and end-games admit of an exhaustive systematic presentation and that the infinite variety of moves which develop after the opening defy any such description. This gap in instruction can only be filled by a diligent study of games fought out by masters. The rules which can be laid down for the practice of psycho-analytic treatment are subject to similar limitations.
In what follows I shall endeavour to collect together for the use of practising analysts some of the rules for the beginning of the treatment. Among them there are some which may seem to be petty details, as, indeed, they are. Their justification is that they are simply rules of the game which acquire their importance from their relation to the general plan of the game. I think I am well-advised, however, to call these rules ‘recommendations’ and not to claim any unconditional acceptance for them. The extraordinary diversity of the psychical constellations concerned, the plasticity of all mental processes and the wealth of determining factors oppose any mechanization of the technique; and they bring it about that a course of action that is as a rule justified may at times prove ineffective, whilst one that is usually mistaken may once in a while lead to the desired end. These circumstances, however, do not prevent us from laying down a procedure for the physician which is effective on the average.
Some years ago I set out the most important indications for selecting patients1 and I shall therefore not repeat them here. They have in the meantime been approved by other psycho-analysts. But I may add that since then I have made it my habit, when I know little about a patient, only to take him on at first provisionally, for a period of one to two weeks. If one breaks off within this period one spares the patient the distressing impression of an attempted cure having failed. One has only been undertaking a ‘sounding’ in order to get to know the case and to decide whether it is a suitable one for psycho-analysis. No other kind of preliminary examination but this procedure is at our disposal; the most lengthy discussions and questionings in ordinary consultations would offer no substitute. This preliminary experiment, however, is itself the beginning of a psycho-analysis and must conform to its rules. There may perhaps be this distinction made, that in it one lets the patient do nearly all the talking and explains nothing more than what is absolutely necessary to get him to go on with what he is saying.
1 ‘On Psychotherapy’ (1905a).8
There are also diagnostic reasons for beginning the treatment with a trial period of this sort lasting for one or two weeks. Often enough, when one sees a neurosis with hysterical or obsessional symptoms, which is not excessively marked and has not been in existence for long - just the type of case, that is, that one would regard as suitable for treatment - one has to, reckon with the possibility that it may be a preliminary stage of what is known as dementia praecox (‘schizophrenia’, in Bleuler’s terminology; ‘paraphrenia’, as I have proposed to call it), and that sooner or later it will show a well-marked picture of that affection. I do not agree that it is always possible to make the distinction so easily. I am aware that there are psychiatrists who hesitate less often in their differential diagnosis, but I have become convinced that just as often they make mistakes. To make a mistake, moreover, is of far greater moment for the psycho-analyst than it is for the clinical psychiatrist, as he is called. For the latter is not attempting to do anything that will be of use, whichever kind of case it may be. He merely runs the risk of making a theoretical mistake, and his diagnosis is of no more than academic interest. Where the psycho-analyst is concerned, however, if the case is unfavourable he has committed a practical error; he has been responsible for wasted expenditure and has discredited his method of treatment. He cannot fulfil his promise of cure if the patient is suffering, not from hysteria or obsessional neurosis, but from paraphrenia, and he therefore has particularly strong motives for avoiding mistakes in diagnosis. In an experimental treatment of a few weeks he will often observe suspicious signs which may determine him not to pursue the attempt any further. Unfortunately I cannot assert that an attempt of this kind always enables us to arrive at a certain decision; it is only one wise precaution the more.1
9 Lengthy preliminary discussions before the beginning of the analytic treatment, previous treatment by another method and also previous acquaintance between the doctor and the patient who is to be analysed, have special disadvantageous consequences for which one must be prepared. They result in the patient’s meeting the doctor with a transference attitude which is already established and which the doctor must first slowly uncover instead of having the opportunity to observe the growth and development of the transference from the outset. In this way the patient gains a temporary start upon us which we do not willingly grant him in the treatment.