analysis terminable and interminable(1937c)
I
Experience has taught us that psycho-analytic therapy - the freeing of someone from his neurotic symptoms, inhibitions and abnormalities of character - is a time-consuming business. Hence, from the very first, attempts have been made to shorten the duration of analyses. Such endeavours required no justification; they could claim to be based on the strongest considerations of reason and expediency. But there was probably still at work in them as well some trace of the impatient contempt with which the medical science of an earlier day regarded the neuroses as being uncalled-for consequences of invisible injuries. If it had now become necessary to attend to them, they should at least be disposed of as quickly as possible.
A particularly energetic attempt in this direction was made by Otto Rank, following upon his book, The Trauma of Birth (1924). He supposed that the true source of neurosis was the act of birth, since this involves the possibility of a child’s ‘primal fixation’ to his mother not being surmounted but persisting as a ‘primal repression’. Rank hoped that if this primal trauma were dealt with by a subsequent analysis the whole neurosis would be got rid of.
Thus this one small piece of analytic work would save the necessity for all the rest. And a few months should be enough to accomplish this. It cannot be disputed that Rank’s argument was bold and ingenious; but it did not stand the test of critical examination. Moreover, it was a child of its time, conceived under the stress of the contrast between the post-war misery of Europe and the ‘prosperity’ of America, and designed to adapt the tempo of analytic therapy to the haste of American life.
We have not heard much about what the implementation of Rank’s plan has done for cases of sickness. Probably not more than if the fire-brigade, called to deal with a house that had been set on fire by an overturned oil-lamp, contented themselves with removing the lamp from the room in which the blaze had started. No doubt a considerable shortening of the brigade’s activities would be effected by this means. The theory and practice of Rank’s experiment are now things of the past - no less than American ‘prosperity’ itself.
I myself had adopted another way of speeding up an analytic treatment even before the war. At that time I had taken on the case of a young Russian, a man spoilt by wealth, who had come to Vienna in a state of complete helplessness, accompanied by a private doctor and an attendant.1
In the course of a few years it was possible to give him back a large amount of his independence, to awaken his interest in life and to adjust his relations to the people most important to him. But there progress came to a stop.
We advanced no further in clearing up the neurosis of his childhood, on which his later illness was based, and it was obvious that the patient found his present position highly comfortable and had no wish to take any step forward which would bring him nearer to the end of his treatment. It was a case of the treatment inhibiting itself: it was in danger of failing as a result of its - partial - success.
In this predicament I resorted to the heroic measure of fixing a time limit for the analysis. At the beginning of a year’s work I informed the patient that the coming year was to be the last one of his treatment, no matter what he achieved in the time still left to him.
At first he did not believe me, but once he was convinced that I was in deadly earnest, the desired change set in. His resistances shrank up, and in these last months of his treatment he was able to reproduce all the memories and to discover all the connections which seemed necessary for understanding his early neurosis and mastering his present one. When he left me in the midsummer of 1914, with as little suspicion as the rest of us of what lay so shortly ahead, I believed that his cure was radical and permanent
See my paper published with the patient’s consent, ‘From the History of an Infantile Neurosis’ (1918b). It contains no detailed account of the young man’s adult illness, which is touched on only when its connection with his infantile neurosis absolutely requires it.
In a footnote added to this patient’s case history in 1923, I have already reported that I was mistaken. When, towards the end of the war, he returned to Vienna, a refugee and destitute, I had to help him to master a part of the transference which had not been resolved.
This was accomplished in a few months, and I was able to end my footnote with the statement that ‘since then the patient has felt normal and has behaved unexceptionably, in spite of the war having robbed him of his home, his possessions, and all his family relationships’.
Fifteen years have passed since then without disproving the truth of this verdict; but certain reservations have become necessary. The patient has stayed on in Vienna and has kept a place in society, if a humble one.
But several times during this period his good state of health has been interrupted by attacks of illness which could only be construed as offshoots of his perennial neurosis. Thanks to the skill of one of my pupils, Dr. Ruth Mack Brunswick, a short course of treatment has on each occasion brought these conditions to an end. I hope that Dr. Mack Brunswick herself will shortly report on the circumstances.
Some of these attacks were still concerned with residual portions of the transference; and, where this was so, short-lived though they were, they showed a distinctly paranoid character.
In other attacks, however, the pathogenic material consisted of pieces of the patient’s childhood history, which had not come to light while I was analysing him and which now came away - the comparison is unavoidable - like sutures after an operation, or small fragments of necrotic bone. I have found the history of this patient’s recovery scarcely less interesting than that of his illness.
I have subsequently employed this fixing of a time-limit in other cases as well, and I have also taken the experiences of other analysts into account. There can be only one verdict about the value of this blackmailing device: it is effective provided that one hits the right time for it. But it cannot guarantee to accomplish the task completely.
On the contrary, we may be sure that, while part of the material will become accessible under the pressure of the threat, another part will be kept back and thus become buried, as it were, and lost to our therapeutic efforts.
For once the analyst has fixed the time-limit he cannot extend it; otherwise the patient would lose all faith in him. The most obvious way out would be for the patient to continue his treatment with another analyst, although we know that such a change will involve a fresh loss of time and abandoning fruits of work already done. Nor can any general rule be laid down as to the right time for resorting to this forcible technical device; the decision must be left to the analyst’s tact. A miscalculation cannot be rectified. The saying that a lion only springs once must apply here.
The discussion of the technical problem of how to accelerate the slow progress of an analysis leads us to another, more deeply interesting question: is there such a thing as a natural end to an analysis -
is there any possibility at all of bringing an analysis to such an end? To judge by the common talk of analysts it would seem to be so, for we often hear them say, when they are deploring or excusing the recognized imperfections of some fellow-mortal: ‘His analysis was not finished’ or ‘he was never analysed to the end.’
We must first of all decide what is meant by the ambiguous phrase ‘the end of an analysis’. From a practical standpoint it is easy to answer. An analysis is ended when the analyst and the patient cease to meet each other for the analytic session.
This happens when two conditions have been approximately fulfilled: first, that the patient shall no longer be suffering from his symptoms and shall have overcome his anxieties and his inhibitions; and secondly, that the analyst shall judge that so much repressed material has been made conscious, so much that was unintelligible has been explained, and so much internal resistance conquered, that there is no need to fear a repetition of the pathological processes concerned. If one is prevented by external difficulties from reaching this goal, it is better to speak of an incomplete analysis rather than of an unfinished one.
The other meaning of the ‘end’ of an analysis is much more ambitious. In this sense of it, what we are asking is whether the analyst has had such a far-reaching influence on the patient that no further change could be expected to take place in him if his analysis were continued. It is as though it were possible by means of analysis to attain to a level of absolute psychical normality - a level, moreover, which we could feel confident would be able to remain stable, as though, perhaps, we had succeeded in resolving every one of the patient’s repressions and in filling in all the gaps in his memory. We may first consult our experience to enquire whether such things do in fact happen, and then turn to our theory to discover whether there is any possibility of their happening.
Every analyst will have treated a few cases which have had this gratifying outcome. He has succeeded in clearing up the patient’s neurotic disturbance, and it has not returned and has not been replaced by any other such disturbance. Nor are we without some insight into the determinants of these successes.
The patient’s ego had not been noticeably altered and the aetiology of his disturbance had been essentially traumatic. The aetiology of every neurotic disturbance is, after all, a mixed one. It is a question either of the instincts being excessively strong - that is to say, recalcitrant to taming by the ego - or of the effects of early (i.e. premature) traumas which the immature ego was unable to master.
As a rule there is a combination of both factors, the constitutional and the accidental. The stronger the constitutional factor, the more readily will a trauma lead to a fixation and leave behind a developmental disturbance; the stronger the trauma, the more certainly will its injurious effects become manifest even when the instinctual situation is normal.
There is no doubt that an aetiology of the traumatic sort offers by far the more favourable field for analysis. Only when a case is a predominantly traumatic one will analysis succeed in doing what it is so superlatively able to do; only then will it, thanks to having strengthened the patient’s ego, succeed in replacing by a correct solution the inadequate decision made in his early life.
Only in such cases can one speak of an analysis having been definitively ended. In them, analysis has done all that it should and does not need to be continued. It is true that, if the patient who has been restored in this way never produces another disorder calling for analysis, we do not know how much his immunity may not be due to a kind fate which has spared him ordeals that are too severe.
A constitutional strength of instinct and an unfavourable alteration of the ego acquired in its defensive struggle in the sense of its being dislocated and restricted - these are the factors which are prejudicial to the effectiveness of analysis and which may make its duration interminable.
One is tempted to make the first factor - strength of instinct - responsible as well for the emergence of the second - the alteration of the ego; but it seems that the latter too has an aetiology of its own. And, indeed, it must be admitted that our knowledge of these matters is as yet insufficient.
They are only now becoming the subject of analytic study. In this field the interest of analysts seems to me to be quite wrongly directed. Instead of an enquiry into how a cure by analysis comes about (a matter which I think has been sufficiently elucidated) the question should be asked of what are the obstacles that stand in the way of such a cure.
This brings me to two problems which arise directly out of analytic practice, as I hope to show by the following examples. A certain man, who had himself practised analysis with great success, came to the conclusion that his relations both to men and women - to the men who were his competitors and to the woman whom he loved - were nevertheless not free from neurotic impediments; and he therefore made himself the subject of an analysis by someone else whom he regarded as superior to himself.
This critical illumination of his own self had a completely successful result. He married the woman he loved and turned into a friend and teacher of his supposed rivals. Many years passed in this way, during which his relations with his former analyst also remained unclouded.
But then, for no assignable external reason, trouble arose. The man who had been analysed became antagonistic to the analyst and reproached him for having failed to give him a complete analysis. The analyst, he said, ought to have known and to have taken into account the fact that a transference-relation can never be purely positive; he should have given his attention to the possibilities of a negative transference.
The analyst defended himself by saying that, at the time of the analysis, there was no sign of a negative transference. But even if he had failed to observe some very faint signs of it - which was not altogether ruled out, considering the limited horizon of analysis in those early days - it was still doubtful, he thought, whether he would have had the power to activate a topic (or, as we say, a ‘complex’) by merely pointing it out, so long as it was not currently active in the patient himself at the time.
To activate it would certainly have required some unfriendly piece of behaviour in reality on the analyst’s part. Furthermore, he added, not every good relation between an analyst and his subject during and after analysis was to be regarded as a transference; there were also friendly relations which were based on reality and which proved to be viable.
I now pass on to my second example, which raises the same problem. An unmarried woman, no longer young, had been cut off from life since puberty by an inability to walk, owing to severe pains in the legs. Her condition was obviously of a hysterical nature, and it had defied many kinds of treatment. An analysis lasting three-quarters of a year removed the trouble and restored to the patient, an excellent and worthy person, her right to a share in life.
In the years following her recovery she was consistently unfortunate. There were disasters in her family, and financial losses, and, as she grew older, she saw every hope of happiness in love and marriage vanish. But the one-time invalid stood up to all this valiantly and was a support to her family in difficult times. I cannot remember whether it was twelve or fourteen years after the end of her analysis that, owing to profuse haemorrhages, she was obliged to undergo a gynaecological examination.
A myoma was found, which made a complete hysterectomy advisable. From the time of this operation, the woman became ill once more. She fell in love with her surgeon, wallowed in masochistic phantasies about the fearful changes in her inside - phantasies with which she concealed her romance - and proved inaccessible to a further attempt at analysis.
She remained abnormal to the end of her life. The successful analytic treatment took place so long ago that we cannot expect too much from it; it was in the earliest years of my work as an analyst. No doubt the patient’s second illness may have sprung from the same source as her first one which had been successfully overcome: it may have been a different manifestation of the same repressed impulses, which the analysis had only incompletely resolved. But I am inclined to think that, were it not for the new trauma, there would have been no fresh outbreak of neurosis.
These two examples, which have been purposely selected from a large number of similar ones, will suffice to start a discussion of the topics we are considering. The sceptical, the optimistic and the ambitious will take quite different views of them. The first will say that it is now proved that even a successful analytic treatment does not protect the patient, who at the time has been cured, from falling ill later on of another neurosis - for, indeed, of a neurosis derived from the same instinctual root – that is to say, from a recurrence of his old trouble.
The others will consider that this is not proved. They will object that the two examples date from the early days of analysis, twenty and thirty years ago, respectively; and that since then we have acquired deeper insight and wider knowledge, and that our technique has changed in accordance with our new discoveries. To-day, they will say, we may demand and expect that an analytic cure shall prove permanent, or at least that if a patient falls ill again, his new illness shall not turn out to be a revival of his earlier instinctual disturbance, manifesting itself in new forms. Our experience, they will maintain, does not oblige us to restrict so materially the demands that can be made upon our therapeutic method.
My reason for choosing these two examples is, of course, precisely because they lie so far back in the past. It is obvious that the more recent the successful outcome of an analysis is, the less utilizable it is for our discussion, since we have no means of predicting what the later history of the recovery will be. The optimists’ expectations clearly presuppose a number of things which are not precisely self-evident.
They assume, firstly, that there really is a possibility of disposing of an instinctual conflict (or, more correctly, a conflict between the ego and an instinct) definitively and for all time; secondly, that while we are treating someone for one instinctual conflict we can, as it were, inoculate him against the possibility of any other such conflicts; and thirdly, that we have the power, for purposes of prophylaxis, to stir up a pathogenic conflict of this sort which is not betraying itself at the time by any indications, and that it is wise to do so. I throw out these questions without proposing to answer them now. Perhaps it may not be possible at present to give any certain answer to them at all.
Some light may probably be thrown on them by theoretical considerations. But another point has already become clear: if we wish to fulfil the more exacting demands upon analytic therapy, our road will not lead us to, or by way of, a shortening of its duration
http://www.clas.ufl.edu/users/burt/analysis.pdf
www.psychspace.com心理学空间网
