多日之前，一位中年女子，在一位朋友的保护下，为了咨询拜访了我，并诉说了其状态。她在45岁-50岁之间，保养地相当好，显然仍未结束她的女性成年期。她的焦虑状态发作之诱因是与上一任丈夫的离婚；但是根据她的解释，在咨询了她所在的郊区里的一个年轻男医生之后，这种焦虑急剧增加，因为他告诉她其焦虑的原因是缺乏性满足。他说她无法忍受丧失了与丈夫的性生活，因此只用三种方法能让她恢复健康——要么回到丈夫身边，要么找个情人，或者自慰。从那时起，她就确信自己无法被治愈，因为她不能回到丈夫身边，同时对于她的道德感和感而言，其他两种选择是令人反感的。然而，她来找我，因为这位医生说这是一种因我而产生的新发现， 所以她只有来问我以便确认他的说法，并且我应该会告诉她除此之外没有其他真相。陪伴她的这位朋友，是一位更老的、干瘪的并且看起来不太健康的女人。她当时恳请我向这位病人担保那个医生弄错了；这不太可能是正确的，因为她自己就守寡多年，却仍免受焦虑之苦而保持体面。
我将不再详述这次访问给我带来的窘境，而是反过来考虑那位将这名女士送到我这来的医生的行为。不过，首先让我们将一种也许并非多余的保留意见记在心里——确实我希望如此。多年的经验已教会我——正如它们也可以教会别人一样——不要立即将病人，尤其是对其医生的叙述当真。无论神经病学家使用哪种治疗方法，他不仅容易成为病人的诸多敌意之对象，而且有时他使自身听任于承受其神经质病人投射出的欲望——这些欲望是被埋葬的受压抑的欲望。相比于在其他医生那里，这样的谴责在任何地方都不能更容易地找到凭证。这是令人忧郁的却也相当重要的事实。
因此我有理由认为这位女士会对她的医生的说法做出一个带有倾向性的歪曲解释， 并且有理由认为对于这个与我素不相识的人而言，将我对“野蛮”精神分析的评论与此事关联起来是有失公允的。 但这样一来也许我能使其他人免于伤害其病人。
所以，让我们假设她的医生的说法确如这位女士所报告的那样。 每个人都将立即提出这样的批评：如果一名医生认为必须要与一个女人讨论性欲问题，那么对此他需要一定技巧并保持分寸。遵照这样的要求与执行某种精神分析的技术规则相一致。此外，这位医生并不清楚许多精神分析的科学理论或者误解了它们，因而显得他几乎没有深入地理解其本质及目的。
让我们从后者开始，即科学性的错误。这位医生给她的劝告清楚地显示了他从何种意义上来理解“性欲生活”一词——在通俗意义上，也就是说在性需要中，除了对产生性高潮和排出性物质的性交或类似行为的需求之外，别无其他。然而他无法不觉察到精神分析通常都因将性欲的概念延伸于正常范围之外而招致批评。这是无可非议的；我不会在这里讨论它被当做一种批评是否正当。在精神分析中性欲的概念包含更多内容；它既低于亦高于其通俗意义。从遗传学角度来看此种延伸是合情合理的；我们将所有起源于原始性冲动的柔情活动都看做是属于性欲生活的，即便当那些冲动相对于其原初目标已受到抑制或者已将这种目的交换成非性目的之时。为此，我们更偏爱于谈及精神性欲，从而强调了在性欲生活中精神因素不应被忽视或低估。 我们所使用的“性欲”一词与德语中“lieben”(爱…)这个词具有同样的广泛意义。我们在早就知道满足的精神缺失及其伴随的结果可以在不乏正常性交的情况下存在；正如作为治疗家我们总将这点铭记于心：未满足的性倾向（其替代满足存在于我们与之抗争的神经症状中）通常只能在性交或其他性行为中找到极其不足的出路。
任何不具备此种精神性欲观点的人都无权引证这些精神分析式的观点——关于性欲的病因重要性的观点。通过只强调性欲中的身体因素，无疑会使问题大大简化，但他必须独自承担其行为之责任。
在这名医生的劝告背后可以看到第二种且同样粗俗的误解。
确实，精神分析提出性满足的缺失会导致神经性的失调。但是难道除此之外它就未涉足其他吗？是不是当它宣布神经性症状起因于两种力量间的冲突时——一方面是来自力比多的力量（一般来说它已经显得过度了），另一方面是对性欲的抵制或极为严苛的压抑力量——它的教学因太过复杂而被忽视了呢？没有哪一个记住这第二个但绝非次要因素的人能依旧认为对于神经症痛苦而言性满足本身构成了一种具有普遍可靠性的治疗方法。事实上，那些人中的大多数要么在其实际境况中，要么大体上是不能获得满足的。倘若他们可以，倘若他们没有其内心的抵抗，即便没有医生的建议，冲动本身的力量将会为他们指出满足的道路。 因此，这样的被假设性地提供给这位女士的医疗建议能产生什么好处呢？
即使它可能被科学性地证明为合理的，对她而言这也并不是可付诸实践的建议。如果她不存在对手淫或私通的抵抗，那么她当然早就采用了这些措施。然而是不是这位医生认为一个年过四十的女人不知道可以找情人，或者说他是否高估了自己的影响力甚至于认为在没有医生批准的情况下她决不敢跨出这一步？
这一切都似乎非常清楚，然而必须承认的是存在着一个通常会令我们难以做出判断的因素。有些被我们称作现实神经症的神经质状态，比如典型的神经衰弱和纯粹的焦虑神经症，很明显取决于性欲生活中的身体因素，然而我们仍未能清晰地描述精神因素与压抑在其中所起的作用。在这些个案中，很自然医生首先应当考虑某种“现实”疗法以及在病人的身体性欲活动中产生某种改变，同时如果他的诊断是正确的，那么他极有理由这么做。求助于这位年轻医生的女士主要抱怨了焦虑状态，因此他很可能假定她患有焦虑神经症；这样的诊断不能只基于症状的名字；还必须要知道焦虑神经症构成了哪些征兆，要能够将它与其他同样表现出焦虑的病理状态区别开来。我的感觉是这名女士患有癔症性焦虑，这样的疾病分类的整体价值，完全可以得到证明，且体现于它指明了一种不同的病因学与疗法之中。在这个个案中任何考虑到癔症性焦虑之可能性的人都不至于陷入忽略了精神因素的错误中，不至于陷入这名医生提出这三种措施时所犯的错误中。
说来也怪，这名所谓的精神分析家所提出的三种选择没有给精神分析留下任何空间！表面上看起来这名女士只能通过回到丈夫身边、自慰或找到情人的方式来治愈自己的焦虑。那么，被我视为治疗焦虑状态的主要疗法将何去何从？
这把我们带向这些技术性的错误。我们可以从被断言的个案中医生的作法里发现它们。这是一种废弃已久的观念，即从表面现象出发所得的观念，认为病人遭受一种无知之苦，假如有人通过给予他相关知识（关于他的疾病与生活的因果、关于其经历等等的知识）来去除这种无知，那么他必定康复。然而这种病理因素不是他本身的无知，而是在其内在抵抗中的无知之根源。正是这些抵抗首先创造了这种无知，并且现在它们仍然维持着它。治疗的任务在于与这些抵抗斗争。告知病人他所不知道的东西是因为他压抑了它，仅是治疗的必要性的预备措施之一。倘若关于的知识对于病人的重要性就像缺乏精神分析经验的人们所想象的那样，那么听讲座或阅读就足以治愈他。然而这些措施对神经性疾病的症状所产生的影响就如同在饥荒年代发放菜单对饥饿所起的作用一样。这种比喻甚至比其直接的适用性要走得更远；因为告诉病人他的无意识经常导致其冲突的激化与问题的恶化。
然而，由于精神分析不能免除给予这类知识，所以在满足如下的两个条件之前它并不主张这么做。首先，经过准备，病人自己已邻近被他压抑的内容，其次，他必须已经对医生形成了一种充分的情感（转移），而他与医生的情感关系可使无经验的逃避变得不可能。
只有当这些条件已具备时，才有可能认识并制服导致压抑与无知的抵抗。因此，精神分析的干预绝对需要一个相当长的与病人建立联系的时期。就技术层面而言，这些在第一次会谈时通过唐突地将已经被医生发现的秘密告知于他的方式来“突袭”他的尝试，是令人厌恶的。由于激起病人对医生的强烈敌意并且切断了他与进一步所产生的影响之间的关系，它们通常都为自身带来惩罚。
除了这些以外， 有时有人可能会产生错误的猜测，也有人从来不处于发现全部真理的位置中。精神分析提供这些明确的规则来取代难以确定的且被当成某种特殊天赋的“医学识别力”。
因此，对于一个医生，只知道精神分析的一些研究结果是不够的；如果他希望自己的医疗手法被精神分析观点所指导，他还必须使自己熟悉其技术。这种技术却不能获知于书本，并且当然它也不能在没有牺牲时间、劳动及成功的情况下被发现。和其他医学技术一样，可以从已经对之精通的人那里学到它。因而，这涉及到对“被我当成这些评论之出发点的那件事情”做出评价而言的某种意义问题，因为我并不认识给这位女士提供如此的建议的医生，也从来没有听过他的名字。
在医学技术的运用中，我的朋友、我的同时与我都不会同意以这种方式来声称专利权。但是面对内在于可被预见为“野蛮”精神分析的实践给病人及精神分析事业带来的危险，我们别无他法。在1910年的春天，我们建立了国际精神分析协会，通过公布他们的名字，成员们都向它表明自己的忠诚，以便拒绝为那些并不属于我们却把自己的医疗方法称作精神分析的人的所作所为负责。因为事实上这类“野蛮”分析家对精神分析事业的伤害要远大于对病人的损害。我经常发现，如此不得体的方法最终导致治愈，即便一开始它会使病人的情况恶化。尽管不是一直这样，但经常如此。当他充分地辱骂了医生并感觉足够多地远离了他的影响时，他的症状让步了，或者他决定采取一些顺道性地通往治愈的步骤。于是最终的改善自行产生，或者被归功于由病人之后所求助的其他医生所实施的某种完全无足轻重的治疗。在这位已让我们得知其对医生有所怨言的女士的情况中，我可以说，尽管如此，相比于某些被高度尊重的权威会告诉她她所患的是“血管舒缩神经症”而言，“野蛮”精神分析对她则更有帮助。他迫使她去注意自己问题的真正原因，或者说朝向那个方向，并且不顾她的一切反对，他这样的干预并非不会产生某种有利的结果。但是他给自己带来伤害，并且由于他们自然产生的情感性抵抗，他助长了病人对精神分析方法的偏见。而这是能够避免的。
| DURING my consultation hours some days ago an elderly woman called on me accompanied by a protecting friend and complained of states of anxiety. She was in the latter half of her fortieth year, quite well preserved and seemingly had not yet reached her menopause. The separation from her last husband was supposed to have been the cause of her disease, but according to her statement the anxiety had considerably increased since she had consulted a young physician in her suburban town. He explained to her that the cause of her anxiety lay in her sexual demands; that she could not dispense with sexual relations and that for that reason she had only three roads to health—either to return to her husband, to take a lover or to gratify herself. Since that time she became convinced that she was incurable as she did not wish to return to her husband and her moral and religious feelings were against the other two measures. She came to me because the physician had told her that this was a new viewpoint for which I was responsible and urged her to come to me for corroboration of the definite assertions. Her friend, a still older, embittered and unhealthy looking woman, then adjured me to assure the patient that this physician had been mistaken. She insisted that his statement could not be true for she herself had been a widow for many years and remained respectable without suffering from states of anxiety. | |
| I shall not dwell upon the delicate situation into which I was placed by this visit but I shall explain the conduct of the colleague who had sent me this patient. First, I wish to advise caution which is perhaps—or let us hope—not superfluous. Experience of many years has taught me—as it could teach everyone else—not to accept readily as true that which patients, particularly nervous ones, relate in regard to their physician. No matter what the treatment is the neurologist not only becomes the target for the manifold hostile feelings of the patient, but through a form of projection he must also occasionally be willing to assume responsibility for the patient’s secret repressed wishes and it is a sad but significant fact that such thrusts find nowhere more ready credence than among other physicians. | |
| I have, therefore, the right to hope that during the consultation the woman had given me a purposive distorted report of her physician’s utterances and that I would be doing an injustice to one who was unknown to me if I based my observations concerning “wild” psychoanalysis on this particular case. However, in doing this I may be able to restrain others from doing injustice to their patients. | |
| Let us therefore assume that the physician advised exactly what the patient reported. Everyone will then justly criticize that when a physician finds it necessary to discuss the theme of sexuality with a woman he should do it with tact and delicacy. However, these requirements are only a part of certain technical rules of psychoanalysis. Besides the physician has misconstrued or misunderstood a number of scientific theories of psychoanalysis and thereby proven how little he has advanced towards the understanding of its essentials and objects. | |
| Let us begin with the latter—the scientific errors. The physician’s advice clearly shows in what sense he grasps the “sexual life.” He grasps it in the popular sense—namely, that under sexual demands nothing else is understood except the need for coitus or its analogy, the processes causing the orgasm or the ejaculation of the sexual product. But it could not have remained unknown to the physician that psychoanalysis was wont to be reproached for extending the idea of the sexual far beyond its usual limits. The fact is correct, though whether it is just to apply it as a reproach will not be discussed here. In psychoanalysis the idea of the sexual has a much greater compass; both above and below it far exceeds the popular sense. This extension justifies itself genetically; we also ascribe to the “sexual life “all manifestations of tender feelings which originated from the source of primitive sexual emotions, even if those emotions experience inhibition in their original sexual aim or have substituted this aim by another no longer sexual. We, therefore, also prefer to speak of psychosexuality, thus laying stress on the fact that the psychic factor of the sexual life should neither be overlooked nor underestimated. We use the word “sexuality” in the same broad sense as the word “love” in the English language. We have also known for a long time that lack of psychic gratification with all its consequences may exist where there is no lack of normal sexual intercourse, and as therapeutists we always remember that only a small proportion of the ungratified sexual strivings whose substitutive gratification in the form of nervous symptoms we are trying to combat, can be done away with through coitus and other sexual acts. | |
| Whoever does not share this conception of psychosexuality has no right to refer to the doctrines of psychoanalysis in which the etiological meaning of sexuality is dealt with. To be sure he has simplified the problem for himself by the exclusive emphasis of the somatic factor of sexuality, but he alone should be responsible for his action. | |
| Still a second and equally serious misunderstanding is obvious from the advice of the physician. | |
| It is true that psychoanalysis specifies that the lack of sexual gratification is the cause of nervous affliction, but does it not say more? Should one leave aside as too complicated the fact that it teaches that nervous symptoms result from a conflict between two forces, a libido (mostly of excessive growth), and an all too strong sexual rejection or repression? Whoever does not forget the second factor, which was not actually assigned to second rank, can never believe that sexual gratification as such is a universally reliable remedy for the complaints of the neurotic. A great many of these persons are incapable of obtaining gratification under the given conditions or under any conditions. If they were capable of it and had they not their inner resistances the force of the impulse would point out the way to gratification, even without the advice of the physician. What then is the use of such advice as the physician ostensibly gave this woman? | |
| Even if it were justified scientifically it would nevertheless be unfeasible for her. If she had no inner resistances against onanism or against an intrigue she would long since have grasped one of these means. Or does the physician think that a woman of over forty years knows nothing of the possibility of taking a paramour, or does he so greatly overestimate his influence as to believe that without medical approval she could never decide on such a step? | |
| All this seems very clear and still it must be admitted that there is one factor which often hinders the passing of sentence. Some of the nervous affections, the so-called actual neuroses, such as the typical neurasthenia and the pure anxiety neuroses, apparently depend on the somatic factor of the sexual life, while we have not yet any definite conception concerning the rôle played in them by the psychic factors and the repression. In such cases it is natural for the physician to have in view, first of all, an actual therapy, an alteration of the somatic sexual activity and he would be fully justified in so doing were his diagnosis correct. The woman who consulted this young physician complained above all of states of anxiety. He thus probably concluded that she was suffering from anxiety neurosis and felt justified in recommending her a somatic therapy. Again a convenient misunderstanding! He who suffers from anxiety does not necessarily have an anxiety neurosis. This diagnosis is not to be derived from the name. One must know what manifestations constitute anxiety neurosis and how to differentiate them from other morbid states which are also manifested through fear. According to my impression the woman in question suffered from an anxiety hysteria and the whole as well as the full value of such nosographic distinctions lies in the fact that they point to a different etiology and a different therapy. Whoever has in mind the possibility of such an anxiety hysteria would not have failed to neglect the psychic factors as shown in the alternative advice of the physician. | |
| Strangely enough in the therapeutic alternative of this supposed psychoanalyst there is no place left for psychoanalysis. This woman could be freed of her anxiety only were she to return to her husband, or gratify herself by resorting to onanism, or to a paramour. And where would the analytical treatment enter which is the principal remedy in states of anxiety? | |
| We thus come to the technical errors which we recognize in the procedure of the physician in the admitted case. It is easy to refer it to ignorance. It is a conception long since combated, based on a most superficial judgment, that the patient suffers from a lack of knowledge and when this ignorance is removed through enlightenment (concerning the causative relation of his illness with his life, regarding his childhood experiences, etc.) he must become well. It is not this lack of knowledge in itself that is the pathogenic motive, but the determination of this ignorance by inner resistances which first called forth this ignorance and still supports it. The task of the therapy lies in the combating of these resistances. To impart that which the patient does not know because he has repressed it is only one of the necessary preparations for the therapy. If the knowledge of the unconscious were as important to the patient as the inexperienced psychoanalyst believes the cure would be effected if the patient attended lectures or read books on the subject. But these measures have just as much influence on the symptoms of nervous complaints as the distribution of menus has on hunger during a famine. The comparison is useful even beyond its original application, as the imparting of the unconscious to the patient regularly has the result of sharpening his conflict and of exaggerating his complaints. | |
| But as the psychoanalysis cannot dispense with such information it dictates that it should be imparted only after the two following conditions have been fulfilled. First, after the patient has through preparation, himself come into the surrounding of his repression; and secondly, after he has become so attached to the physician (transference) that his feeling toward the latter would make the newer flight impossible. | |
| Only through the fulfillment of these conditions does it become possible to recognize and master the resistances which have led to repression and ignorance. Hence a psychoanalytical procedure assumes from the beginning a longer contact with the patient; and attempts to surprise the patient by brusquely imparting to him his secrets guessed by the physician during his first consultation hour are technical errors which usually avenge themselves by the doctor’s incurring the cordial enmity of the patient which thus cuts off every future influence. | |
| We shall leave out of consideration the fact that one sometimes advises wrongly and that one is never in a position to guess everything. By the aid of these unequivocal technical rules psychoanalysis replaces the demand of the vague “medical tact” in which one looks for a special endowment. | |
| It is therefore not enough that the physician should know some of the results of psychoanalysis, but he must also be well versed in its technique if he wishes to guide his medical actions by psychoanalytic viewpoints. This technique can not yet be learned from books and to acquire it through one’s self requires great sacrifices of time, effort and success. Like other medical techniques it is best learned from those who have already mastered it. It is therefore certainly not a matter of indifference for the criticism of the case on which I base my remarks, that I do not know nor have I ever heard the name of the physician who is supposed to have given such advice. | |
| It is neither agreeable to me nor to my friends and co-workers to monopolize in such manner the claim to the practice of a medical technique. But in view of the dangers which may be anticipated from the practice of “wild” psychoanalysis for the patients as well as for the subject of psychoanalysis, no other course was left to us. In the spring of 1910 we founded an international psychoanalytic society, in order to be able to disclaim responsibility for the acts of all who do not belong to us and who call their medical practice “psychoanalysis.” For as a matter of fact such wild analysts do more harm to the subject than to the individual patient. It has often been my experience that such an awkward procedure, even if it at first caused an aggravation of the symptoms, has nevertheless achieved a cure in the end. Not always, but quite often. After the patient has railed against the physician long enough and feels himself far enough removed from his influence his symptoms abate, or he decides to take a step which leads to the road of recovery. The final improvement is then supposed to have come “of itself,” or is attributed to the most indifferent treatment of the physician who treated the patient last. As for the case of the women who complained against the physician we have heard, I should say that the wild psychoanalyst had nevertheless done more for his patient than any eminent authority who would have told her that she was suffering from a “vasomotor neurosis.” He forced her attention to, or near, the real cause of her illness, and in spite of the patient’s opposition this intervention will not remain without favorable results. He harmed himself, however, and helped to increase the prejudices against the activity of the psychoanalysts, which arise in the patients as a consequence of comprehensible affective resistances. And this can be avoided. |
