The problem of lay-analyses

“But the physicians! It seems I am really unable to bring you to the main point of our conversation. You are continually evading me. After all, the question before us is whether physicians should be given the exclusive right to employ psychoanalysis, that is, after they have fulfilled certain conditions, if you should insist upon such. According to your own statement, the majority of ‘quacks,’ dabbling with psychoanalysis, does not consist of physicians. You also admit that the greatest number of your disciples and followers are physicians. I have heard that these do not share your point of view, in regard to lay-analyses.

“Of course, it is to be expected that your disciples agree with you in the question of sufficient training. Just the same, they hold the laymen should be excluded from the practice of psychoanalysis. Is that really the case? And if so, how do you account for it?”

You are correctly informed. Not all, but a great number of my medically trained collaborators do not side with me in this matter, but insist that psychoanalytical treatment of neurotics be exclusively reserved for physicians. From this, you may gather that even within the limits of our own camps, there prevails a difference of opinion. Although my point of view is very well known, the divergence of opinion in matters of lay-analyses, in no way interferes with an otherwise splendid harmony.

How to explain this position of some of my disciples?

I am not so sure, but I assume that professional pride is behind it. You see, their process of development has been different from mine. That they find themselves somewhat isolated from their colleagues, is still annoying them. They would like to be considered, by the profession as a whole, as members in good standing, so to say. Thus, in order to win the tolerance of their Æsculapian brothers, they are willing to make a sacrifice, whose value is apparently not clear to them.

Of course, I may be wrong here. To assume that fear of competition is dictating their position, would not only amount to suspecting them of a low motive, but also condemn them for a peculiar shortsightedness. After all, as long as they are ready to initiate colleagues into psychoanalysis, it can be of no importance to them whether they will have to share prospective patients with them, or with laymen.

Probably, there is something else to be considered. They may be impressed by certain features which, in the practice of psychoanalysis assure the physician of an unquestionable advantage over the layman.

“There you are:—‘Assure the advantage’! At last, you admit this advantage! I should think this admission settles our argument.”

I admit this advantage. Perhaps by doing so I shall prove to you that I am not as passionately deluded as you think. I postponed mentioning these conditions, because in airing them, additional theoretical discussion is necessary.

“What are you driving at now?”

There is first the question of diagnosis. Before admitting a patient, suffering from nervous disturbances, to psychoanalytical treatment, one naturally desires to have as much assurance as possible that this therapy is suitable in that particular case, that is, that the patient has a good chance of being benefited by psychoanalysis. This can only be the case, if he is actually suffering from neurosis.

“I should think that would be easily ascertained, by the symptoms he complains about.”

You are putting your finger just on the point, where new complications may arise. It is not always possible to be perfectly sure of such a case. The patient, in spite of displaying all the visible symptoms of neurosis, may actually be suffering from something else. The incipient stage of a mental disease, for example, or the beginning of a process destroying his brain. To distinguish between such symptoms is not always easy or possible. Responsibility for such a decision must naturally be assumed by the physician alone. And as mentioned before, it is not so easy for him. For the longest time, an ailment may appear absolutely harmless, until finally manifesting its malignant character. Nervous people, as a rule, fear that they may be on the road to some mental disease.

Assumed that a physician has not correctly diagnosed a case, or has been unable to discover its true nature, nothing has been lost, no damage has been done. Analytical treatment, although not doing any harm to the patient, would have been superfluous in such a case. It might have given any number of people a chance to lay the blame for the unfortunate development of the case at the door of psychoanalysis. Unjustly so, to be sure, but such a likelihood should be avoided nevertheless.

“That sounds hopeless. It apparently tears out, by the very roots, everything you told me about the nature and development of a neurosis.”

Not at all. It only strengthens the fact that neurotics are a nuisance and a dilemma for all parties concerned, including the psychoanalysts. I may be able to alleviate your new apprehensions if I make myself clearer. Probably it would be more correct to say of such cases, as we now have under discussion, that they actually present neuroses. However, these neuroses are not psychic but rather somatic, that is, they do not originate from the soul, but rather from the body. Do you understand me?

“I do. But I am at a loss to connect all this with the psychological aspect.”

That can easily be done, if only complications of the living substance are sufficiently taken into consideration. What was the inherent feature of a neurosis? That the “I,” constituting the very essence of the soul, so to speak, developed and improved by the influence of the outer world, proved unable to fulfill its mediating functions between the “It” and reality; that the “I,” on account of its weakness, shirked its duties in regard to the “It,” thus incurring repressions from which it suffers. It is because such weakness of the “I” regularly takes place in all of us in childhood that events of our tender years exert such great importance in later life.

In the few years of our childhood, we have to cover the enormous distance of development from primitive man of the Stone Age to civilized man of today. In addition to this tremendous burden, the child has to ward off the urges of an early sexuality. Small wonder, then, that our “I” takes recourse to repressions, thus exposing itself to childhood neuroses, the effects of which in turn furnish the disposition for nervous disturbances in more mature years.

Everything now depends upon how the growing up individual will be treated by fate. If life is too hard, the divergence between urges and the opposition of reality too great, the “I” may remain unsuccessful in its endeavors to mediate between the two. This is the more probable, the more the “I” is encroached upon by such infantile dispositions as it may have acquired in tender years. Thus, the process of repression is repeated; urges tear themselves free from the sovereignty of the “I” to gain, by way of regression, a substitute for the gratification they crave, while the poor “I” has become helplessly neurotic.

Let us hold on firmly to this: that the most important, the pivotal point in the whole situation, so to speak, is the relative strength of the “I” in all its phases. It is easy, then, to complete our whole etiological survey, that is our endeavor to assign causes to the phenomena observed. We already know the normal causes for nervousness to be the infantile weakness of the “I,” the checking of early sexual urges, and the influence of chance episodes in our childhood.

But is there no possibility that there are also some other contributory factors, antedating childhood? For example, an inborn strength and unruliness of those urges which constitute the “It,” presenting right from the very start a task much too difficult for the “I”? Or could a certain weakness, existing for reasons unknown, in the development of the “I” be held responsible? Of course, all these possibilities will exert an etiological importance, in some cases of surpassing value.

The specific driving power of the “It” must always be taken into consideration, and wherever it is developed to an excessive degree, there are only meagre chances for a successful application of our therapy. Of the reasons that block the development of the “I,” we still know too little to account for such cases of neurosis which arise on a constitutional basis. It may be assumed that neurosis hardly ever develops unless there are constitutional or congenital factors increasing the possibility for such a condition. However, if it is correct that the relative weakness of the “I” is the deciding factor for the development of neuroses, then it would also appear possible that later, physical disturbances may result in a neurosis provided it also results in a weakening of the “I.”

This happens only too frequently. Such a physical disturbance may aim at the “It,” intensifying its urges to an extent where the “I” is not able to cope with them any more. As an example for such developments, the changes induced in woman by the disturbances of menstruation and menopause could perhaps be drawn upon. Other reasons that may weaken the “I” are general physical disturbances, organic diseases of the central nervous system. All of these may result in interference with those sources from which the soul apparatus draws its strength, to lead, in turn, to an encroachment of its more delicate functions, which are necessary to maintain unimpaired the whole “I” organization. In all these cases, neurosis presents about the same picture. However, while manifesting the same psychological mechanism, neuroses develop on the basis of a multifarious, frequently highly complicated etiology; that is, they arise from a great number of various causes.

“That suits me better. At last you have spoken like a physician. And now I am waiting for you to admit that so complicated a condition as a neurosis should only be treated by a physician.”

I am afraid you are expecting too much. What we have just discussed belonged in the realm of pathology. Psychoanalysis, however, is a therapeutical process. I admit, no, I even insist, that a physician should first diagnose each and every case where psychoanalysis seems applicable. Fortunately, the greater number of neuroses are of a psychical nature and not pathologically induced. As soon as the physician has ascertained this, he may safely leave the treatment to the lay-analyst. We have always followed this procedure within our analytical societies. Thanks to this close coöperation between the medically trained and non-trained members, errors almost never occur.

There is another emergency when the analyst has to invite the assistance of a physician. It is possible that, in the course of psychoanalytical treatment, symptoms—mostly of physical nature—appear which may either be part of the neurosis, or else manifestations of independent, organic disturbances. Here, the decision must once more be left to the physician.

“From all this, there follows that the analysts, even during the analysis, cannot dispense with the physician. This is another argument against lay-analyses.”

No, this possibility cannot be drawn upon as an argument against lay-analyses, because in an analogous case the medically trained analyst would not proceed any differently.

“I do not understand that.”

There is a rule that even a medically trained analyst, running across such dubious symptoms in the course of the treatment, is not to depend on his own judgment, but to consult some colleague, preferably a specialist of internal diseases.

“Why this rule, apparently so superfluous?”

This rule is not superfluous at all. There are several reasons for it. In the first place, it is hard to combine organic and psychical treatment. In the second place, the particular condition of transference frequently prevailing in analyses may make it inadvisable for the analyst to subject his patient to physical examination. In the third place, there are all the reasons in the world for the analyst to doubt his own opinion, inasmuch as he is so intensely interested in the psychical aspects of the case.

“I now understand your position towards lay-analyses. You insist that there must be lay-analysts. However, as you have to admit their insufficiency for the task, you compile everything that could serve to excuse them, and make things in general easier for them. To be frank with you, I cannot understand why we should have lay-analysts at all, inasmuch as they would never be more than second-class therapeutists. This need not include those few laymen who have already received their training, but institutes for psychological training should not accept laymen any more.”

I would assent to all this, if I could be shown that such restrictions would benefit all parties interested. You will admit that these interests are tri-fold:—There is the interest of the patient, the interest of the physicians, and last but not least, the interest of science which, in turn, includes the interest of all patients of the future. Let us investigate these three points.

It does not matter whether the patient be analysed by a physician or a layman, as long as any danger of mistaking his condition is excluded by being properly examined by a physician before the beginning of the treatment, or re-examined as soon as developments, in the course of the analysis, make this advisable. It is much more important for the patient that the analyst possesses those personal qualities which invite full confidence, and that he has that knowledge and experience which alone qualify him to apply psychoanalysis. To some people, it may seem that it might undermine the authority of the analyst to have his patient know that he is no physician and must obtain the advice of a medically trained expert in certain matters. However, although we have never kept a patient in the dark, as to the qualifications of an analyst, we have come to the conclusion that the patients have no prejudice against a non-medically trained analyst; they are only too glad to accept the benefits of treatment, wherever they offer themselves—a fact resented by the medical profession for the longest time.

It also must be considered that analysts, practising today, are men and women with academic training and degrees, pedagogues, of great experience and impressive personality. The analysis, to which all candidates of psychoanalytical institutes are required to submit, is the best means of testing their personal suitability for the performance of so exerting an activity as an analysis presents.

In reference to the interest of the physicians, I do not believe that medicine has anything to gain by annexing psychoanalysis. Today, medical training requires five years, with almost a whole sixth year taken up with examinations. Ever so often, new demands in regard to training are made with which the young student must comply, if his medical education is to be considered adequate. Generally speaking, while it is difficult today to enter the medical profession, the practice of medicine is neither very satisfactory nor very advantageous. And as soon as the undoubtedly justified necessity is realized that the physician be also informed of the psychological aspects of diseases, thus including in medical training a partial preparation for psychoanalysis, there would follow an extension of the medical curriculum and a corresponding extension of the period of training. I do not know how physicians would like such a development, arising from the monopoly they claim on psychoanalysis. But these demands would then have to be fulfilled and at a time when, in general, the material aspects of those strata of society which contribute the greatest contingent to the medical profession, are such that young physicians must establish a practice, as soon as possible.

However, the medical profession may not intend to include preparation for psychoanalysis into the medical curriculum proper. The general opinion may be that it is much more practical for the young physician to acquire psychoanalytical knowledge only after having completed his medical education. It may be said that such a procedure would not involve any actual loss of time, inasmuch as a young man under thirty never gains that confidence of patients which is an indispensable condition for benefiting a patient psychoanalytically. Of course, it could be said that a young physician, too, who has just won his diploma, cannot command too much respect, as regards his opinion of the physical ailments of his patients, and that the young analyst could very well utilize his time, by working in a psychological clinic, under the supervision of an experienced practitioner.

It seems to me that the aforementioned demand amounts to a waste of energy which, in view of economic conditions, does not seem justified. Although analytical training invades the field of medical training, it neither includes this training, nor is included by it. If a psychoanalytical college were to be organized, which today may strike one as being a fantastic idea, the curriculum of this institution would have to include much of what is taught in medical schools. Aside from the Psychology of the Depths, which would naturally always be the main subject taught, Biology would have to be included in the course, and Science of Sex would also be one of the major subjects. In addition, adequate instruction would have to be given on such disturbances which belong in the realm of Psychiatry. Psychoanalytical training would have to include a number of subjects which have no connection with medicine, and never enter the physician’s practice, such as History of Civilization, Mythology, Psychology of Religion, and Literature. Without being well acquainted with these subjects, the analyst will be unable to grasp the problems that will face him in the course of his practice.

Most of the subjects, however, belonging to medical training, will not be of any use to him and although all this knowledge is highly valuable for those who need it, it would not assist the analyst to understand a neurotic condition nor to alleviate it. In case the objection is made here that specialists in other fields of medical endeavor, also do not need all the details they acquire in the course of their training, it must be said that such a case could not be considered analogous. For many branches of medicine, such facts as, for example, Pathology presents, are of great importance. The analyst, however, reaches out for a variety of experiences, with different phenomena, underlying different laws. Although philosophy may succeed in bridging the chasm between body and soul, as far as our own experience is concerned, this chasm, nevertheless, exists, presenting itself in an especially striking light, as regards our practical endeavors.

It seems unjust and impractical to force a person to take a roundabout route via medical training, if this person be bent upon relieving another individual from the agonies of a phobia or a fixed idea. Moreover, such a procedure would be ineffective, as long as psychoanalysis in general is not suppressed.

Just imagine that somewhere in the country, there is a certain mountain top that can be reached by two different roads, the one being short and straight, and the other long and winding. An attempt is made to block the short road by a “no-trespass” sign. There is some chance of this sign being respected, if the short road is steep and difficult to climb, whereas the long road is easy to travel. However, if the detour should be the more difficult road, you can easily surmise how little the trespassing sign would be respected.

I am very much afraid it will be just as difficult to force the laymen to study medicine, as it is for me to induce physicians to study psychoanalysis. Human nature is like that.

“If you are correct in your assumption that analytical treatment cannot be administered without a special training, but that on the other hand the medical curriculum could not bear the burden of psychoanalytical training, and that medical knowledge, to the greatest extent, is superfluous for the analyst, how will we ever achieve the ideal medical personality, the physician who can cope with all the demands of his profession?”

I am unable to foresee how to solve these difficulties, and I do not feel called upon to make any suggestions. I only perceive two things clearly: firstly, that the analysis seems to constitute a dilemma, but certainly the neurotic is also a dilemma; secondly, that for the time being, all interests would be served if physicians resolve to tolerate a class of therapeutists who will relieve them of the arduous treatment of those tremendously frequent psychical neuroses, in addition benefiting the patients by remaining in constant contact with them.

“Is that your last word in reference to the problem of lay-analyses, or is there something else?”

There is a third interest to be considered:—that of science. Although what I have to say in that respect may not mean much to you, it nevertheless means a good deal to me.

We do not consider it advisable that psychoanalysis be swallowed up by medicine, finally to be shelved in a text-book of psychiatry, under the chapter heading of Therapy, together with such other treatments as Hypnotic Suggestion, Auto Suggestion, Persuasion which, due to lack of knowledge, were indebted for their short lives to the indolence and ignorance of the broad masses. Psychoanalysis deserves a better fate, which, let us hope, it will really attain.

As the Psychology of the Depths, the teaching of the Unconscious, psychoanalysis may prove indispensable to all sciences which deal with the development of human culture, and such of its great achievements as art, religion, and civilized society. Psychoanalysis has already appreciably assisted these sciences in the solution of their problems. But all this is insignificant, compared to what may be achieved through psychoanalysis in the future, when students of History, Psychology of Religion, and Etymology, will avail themselves to the fullest extent of the assistance psychoanalysis will be able to render them.

The employment of psychoanalysis for the treatment of neuroses is only one of its possibilities, and time may yet prove that this is not even the most important of them. At any rate, it would be unfair to sacrifice all other advantages of psychoanalysis, simply because there is just one phase where the application of psychoanalysis encroaches upon the preserves of medicine.

Here another aspect manifests itself which cannot be interfered with, without causing damage. If the representatives of the different sciences should really take up the study of psychoanalysis, to apply it in their own spheres of interest, it would not suffice for them to merely avail themselves of such results as have been recorded in psychoanalytical literature. They will have to come to an understanding of psychoanalysis in the only way possible, that is, by submitting themselves to analysis.

Thus, to the neurotics in need of analysis, a second class of persons would be added: those who undergo analysis for intellectual reasons and who would welcome that intensification of their efficiency which would result incidentally from analysis. To undertake these analyses, a number of analysts would be necessary for whom medical knowledge would be of specially limited importance. However, these instructor-analysts—as they ought to be called—are in need of an especially thorough training, which they can only obtain if they are given opportunities to study interesting and convincing cases. Inasmuch as healthy persons do not feel the necessity and curiosity to be analysed, neurotics would have to be the objects of study for the instructor-analysts. Their study would be guided by expert analysts, with a special eye to their future, non-medical work. Of course, all this necessitates a certain amount of freedom of action, and would not brook petty interference.

Perhaps you do not believe in these strictly theoretical endeavors of psychoanalysis, and are not ready to admit their importance, in connection with the practical side of the problem of lay-analyses. In that case, let me remind you that there is another field for the application of psychoanalysis, outside the hunting ground of the “quack”—a field which physicians will hardly claim as their own. I allude to the application of psychoanalysis to pedagogy.

As soon as a child manifests the first signs of an undesirable development, by being moody, stubborn and inattentive, neither the child specialist nor the school physician will be able to do anything for him; not even when a child shows such clear signs of nervous disturbances as timidity, lack of appetite, vomiting, and sleeplessness. A treatment which combines analytical influence with pedagogic measures and is applied by persons who are not above delving into the child’s own world and who understand how to penetrate the soul life of the child, will succeed not only in dissolving nervous disturbances, but also in reversing incipient traits of character.

The importance which we were forced to attach to apparently unimportant neurotic conditions of children, in view of the fact that they very often serve as a disposition for disturbances in later life, would prove that the analyses of children constitute a splendid means of prophylaxis. Although psychoanalysis still has its enemies, I do not know what means are at their disposal to hinder the activity of a pedagogic analyst, or analytical pedagogue, and I doubt whether this could be done so easily.

To return once more to the problem of the analytical treatment of adults, suffering from nervous disturbances, we have not yet exhausted all points of view. Civilized life of today exerts an almost unbearable pressure, which necessitates corrective measures. Does it seem too fantastic to expect that psychoanalysis, in spite of the many difficulties it encounters, should be called upon to furnish this corrective agent? Maybe some American millionaire will one day donate enough money for the psychoanalytical training of the social workers of his country, thus creating an emergency corps, to fight neurotic conditions brought about by present-day life.

“You mean some sort of a new Salvation Army?”

Why not? After all, our fancy always follows existing patterns. The stream of eager students that will then flood towards Europe, will, of course, have to pass Vienna, because there the development of psychoanalysis may have prematurely died, on account of governmental interference. You smile? I’m not saying this to sway your judgment. I know you don’t believe me, and I surely cannot guarantee that my predictions will come true. But there is one thing I know: it is not at all important what the opinions of individuals and of individual governments may be, in respect to the problem of lay-analyses. All this can only have limited effects. What is really important is that potentialities for the development of psychoanalysis cannot be affected by ordinances and prohibitions.