Kurt R. Eissler
One cannot avoid appraising the present state of psychoanalysis as than one of a crisis. Whether one considers this crisis as the of over-abundant but valid research into a variety of directions, or whether one considers it the result of a progressive deterioration of scientific standards, may depend on the optimism or the pessimism of the observer. But either way, we feel it necessary to attempt the evaluation of the situation in at least one aspect of psychoanalysis.
It might have been anticipated that Freud’s death would usher in a long period of “working through” of his findings in view of the wealth of unfinished research left to posterity. But, on the contrary, it seems at present as if the great progress psychology owes him had to be first undone before at some later time it will perhaps be permanently integrated. Freud (1914c [see 1938, p. 943]) wrote in his History of the Psychoanalytic Movement that in earlier years he thought science would take no notice of his discoveries, until decades later somebody would rediscover “the same, now untimely things.” After reading Alexander’s and French’s book on Psychoanalytic Therapy (1946), the first part of Freud’s assumption sounds like a prophesy. This book carries the crisis which hitherto had mainly affected the field of theory, into psychoanalytic practice and questions the very foundation of what has been the common ground of therapeutic endeavors, in spite of all disagreements among analysts in other respects. Alexander divides the development of psychoanalytic therapy into five periods: cathartic hypnosis, waking suggestion, free association, transference neurosis, and emotional re-education. Alexander concedes his admiration for the great progress psychoanalytic therapy made throughout these five phases mainly under the guidance of Freud. But he is certain that the transformation of the initial “one-act drama” as it took place in catharsis, “into a procedure aimed at achieving permanent changes in the ego’s functional capacity by a slowly progressing emotional training” (Alexander, French et al., 1946, p. 18) has not yet been completed. According to him, the present technique is still tainted by the impurities of earlier developmental phases. Hence, “the main purpose of this book is to hasten this transformation and to encourage the development of more pertinent forms of psychotherapy” (ibid., p. 18). However, I believe that if the new technique as evolved by Alexander and French, with the collaboration of the Staff of the Chicago Institute for Psychoanalysis, were accepted as valid by the main centers of psychoanalytic research, this would force us to mark the beginning of a sixth phase in the development of psychoanalytic therapy. Yet I doubt that the future historian of psychoanalysis would be able to discover in. this sixth phase “the immanent logic of the developmental laws of a science” (Alexander, 1925a, p. 114), which after all, connect subsequent phases of scientific: development. Indeed, should it happen that the psychoanalytic technique were re-oriented along the lines presented in this book the development of that technique would have made a most inorganic turn, more or less disconnected with the preceding phases. Alexander’s and French’s book will be a challenge to those who still believe that Freud in Ms theories of the human mind and, his technique of investigation and therapy laid the foundation not only for a scientific psychology but also created an instrument with which to liberate the individual from the shackles of his ancestors and of his society. Alexander’s and French’s book d deviates so far from the great potentialities inherent in Freud’s work that it deserves a detailed discussion which, however, would require a treatise lengthier than the original. It is the curse of error that even under optimal conditions at least two statements are necessary to disprove the fallacy of one.
B. DEFINITION OF NEUROSIS
It may be appropriate to begin by scrutinizing Alexander’s definition of neurosis. He gives two which are not identical and I shall limit myself to the discussion of the following: “Psychoneurosis” writes Alexander, “is a failure of the individual to deal successfully with a given situation, a failure to find socially acceptable gratification for subjective needs under given circumstances” (Alexander, French et al., 1946, p. 8). This definition pertains essentially to the relationship of an individual to success and gratification. If a person is successful and feels gratified the condition according to this definition, precludes the existence of a neurosis; likewise, if a person fails and feels dissatisfied, these are the two factors of significance which indicate a neurotic condition. It is easy to accumulate evidence disproving Alexander’s definition. It is only necessary to quote the clinically well-known type of neurotic who provides himself with “socially acceptable gratification” by daydreams or an illusion of future gratifications which docs not interfere with his successful dealings with external reality or which might even spur his efforts towards success. The large group of neurotics, such as many compulsives whose symptoms make them fit into certain social patterns will adduce further clinical evidence that Alexander’s definition is untenable. Besides, failure and dissatisfaction are not indices of a neurosis. A humanitarian who aims at the elimination of hunger or child labor or capital punishment will fail and will be unable “to find socially acceptable gratification” for his needs, without, being a neurotic. This is not the place to analyze the relationship between neurosis, failure, and subjective frustration; but this much may be said, namely, that a neurosis is only one of the possible reactions to a failure or a frustration. If a person fails to gratify his hostility, but masters it, he is no neurotic; but if he displaces it or develops anxiety as a defense, then he may suffer from a neurotic symptom. There are two remarkable features in Alexander’s definition. The first one is its exclusively behavioristic viewpoint. The conditions of satiation and success are, in the last analysis, behavioristic terms. It will be seen that Alexander’s and his co-workers’ new technique can only be accepted on the basis of a behaviorism which was misapplied in this instance. Neurosis is a concept of psychology pertaining to ego reactions under the impact of a conflict. Alexander’s definition which dispenses with the concept of conflict does not belong in the realm of psychology if psychology is defined in terms of Freud’s structural and dynamic aspects [Footnote 1: It is of interest to compare Alexander’s new behavioristic definition with an earlier definition: “Every psychoneurosis is an attempt at autoplastic mastering of instinct… The attempted auto-plastic and regressive mastering of instinct relieves one part of the system only and leads to fresh tension in another part” (Alexander, 1925b, p. 16, italics by Alexander). The interesting question of whether Alexander adapted his new technique to a new theory or vice versa can be only a matter of conjecture. The reader will agree, however, when he familiarizes himself with the new technique that Alexander did not predict the future correctly when he wrote in the same paper that “the dissolution of the super-ego is and will continue to be the task of all future psychoanalytic therapy” (Alexander, 1925b, p. 32)]. Alexander’s behavioristic approach becomes even clearer in his elaboration of that definition. He believes that “when the situation demands greater powers of integration than the ego possesses, a neurosis develops” (Alexander, French et al., 1946, p. 8). Thus Alexander reduces Freud’s dynamic concept of neurosis to the balance of merely two groups of forces (one external and one internal); this balance barely suffices to explain the mechanisms of flight or primitive aggression; it is by no means, clinically justifiable to reduce the etiology of a neurosis to so narrow a scope. Only by breaking with Freud’s genetic aspect (which break is indicated in the authors’ theory and practice) could Alexander reach the conclusion that a neurosis may develop independently of a specific past, and be derived from the balance of forces at one point of the patient’s life. His reasoning that “acute neurotic states may occur in persons whose ego has always functioned well in the past” (ibid., p. 8) cannot be accepted unless demonstrated by extensive case histories. And moreover what is meant by an ego that has always functioned well? Alexander states that with every patient he looks for that time in the patient’s life when he started to refuse to grow up. Any regressive material which the patient reports which antedates this point, Alexander considers a resistance and not a further penetration into the origin of the neurosis (ibid., p. 29). This static conception of the neurosis as starting at a certain point in time is the result of measuring the “well functioning of the ego” only in terms of external compliance with reality situations.
As early as 1908 Freud demonstrated the slow growth of and the many preparatory steps towards a manifest neurosis; this pre-clinical phase occurs much earlier than the time when the dysfunction of the ego makes its appearance. Only in the course of an extensive genetic investigation, i.e., in a prolonged psychoanalysis, can it be determined when and where those factors originated which resulted in the ego’s dysfunction. Alexander’s behavioristic approach, which considers the ego’s dysfunction the point of departure of the neurosis, and the genetic aspect, which considers the dysfunction the result of a disturbed development appear to be irreconcilable [Footnote 2: Hartmann’s and Kris’ (1945) essay on the genetic approach in psychoanalysis make it unnecessary to pursue Alexander’s disregard of the genetic approach in detail. Only two arguments in Alexander’s reasoning against the etiological importance of childhood neurosis may be mentioned here. One is that “neurotic tendencies lie latent in every person” (Alexander, French et al., 1946, p. 8) and the other “that the patient is, suffering not so much from his memories as from his incapacity to deal with his actual problems of the moment” (ibid., p. 22). The first argument does not present anything new and since childhood neuroses are nearly ubiquitous in our society it rather confirms than disproves Freud’s etiological concept. The second argument is not stringent. It seems to me that it does not sufficiently discriminate between symptoms and causes. It is as though one were to say of a patient suffering from active tuberculosis that ht is not laboring under an infection incurred years ago but is affected by the present cold weather. When Alexander writes: “The past events have of course prepared the way for his (the patient’s) present difficulties, but then every person’s reactions are dependent upon behaviour patterns formed in the past” (ibid., p. 22), I think that he gives indirectly greater support to Freud’s theory than to his own]. It seems that Alexander disregarded certain methodological principles. In order to conclude with any certainty that “a large number of the cases reported in this study” do not have the typical neurotic history (infantile neurosis) (Alexander, French et al., 1946, p. 10), he should have checked the reliability of the tools be applied in his investigation. The expectation of ascertaining the presence or absence of an infantile neurosis after two interviews with a 51-year-old scientist (ibid., p. 146) dots not seem warranted; the same holds true after 26 interviews over a I0-week period in the instance of a 42-year-old patient. Unless Alexander has developed some new and truly revolutionizing methods of psychological exploration to which be does not refer, it makes it doubtful that he established the prerequisites for reaching this conclusion. A person trained in the methodology of science knows the pitfalls of statements referring to the presence or absence of something that is not directly accessible to the crude working of our sense organs. Psychoanalysis has provided the basic investigatory rules which ought to be followed in order to safeguard the reliability of conclusions. When a scientist disregards these rules without replacing them by others more reliable the results of his research are open to doubt. The second point I wish to mention is that of the coincidence of Alexander’s definition with popular views. Our age postulates happiness and success as the essentials of mental health. To consider failure and frustration as manifestations of disease is to follow a tendentious argument which expresses the popular view that happiness and success are in themselves fundamental goals of life; this view denies the reality of ananke. In fact, the authors describe most of their therapeutic successes in terms of the degrees of happiness and success of their patients and they never scrutinize the psychological structure underlying those conditions. In his acceptance of the thesis that man’s childhood is a period of happiness comparable to a Garden of Eden (Alexander, 1942, p. 191; Alexander, French et al., 1946, p. 34), Alexander allies himself with another popular view and thereby denies the gap which has hitherto existed between psychoanalytic discoveries and popular opinions concerning the human mind. It is not apparent from. Alexander’s publications on what clinical evidence he bases his view concerning the happiness of childhood, a time which we know to be fraught with conflict, anguish, and tragedy. It is necessary to stress this thesis here, lest the reader gain the impression that a discussion of a definition of a neurosis is merely an academic question. Far from being merely academic quibbling, a mistake in the definition of basic concepts must lead the investigator to a commensurate failure in his clinical approach and in his understanding of the essence of man, his plight, and his destiny.
C. TRANSFERENCE AND TRANSFERENCE NEUROSIS
Even in his early papers on hysteria Freud mentioned the great importance of the patient’s relationship to the analyst in the therapy of the neuroses.
Later he demonstrated the supreme and unique position which transference, holds in psychoanalysis and any psychotherapy when he published the case history of a patient whom he had treated in 1899 (Freud, 1901). Transference became the central problem of psychoanalytic therapy. The authors, mainly Alexander, French, and Weiss devote a considerable part of their theoretical contributions to a discussion of the transference. Their writings are partly concerned with a critique of the way transference has been handled up to now, and partly with the evolution of an allegedly new technique. According to the authors, it is mainly due to an inappropriate handling of transference that many psychoanalytic treatments hive been interminable or otherwise unsuccessful if the development of a transference neurosis [Footnote 3: The authors call transference neurosis that psychological configuration which is the result of the absorption of the original neurosis by the patient’s emotional relationship to the therapist] can be prevented or if the development of the transference is mastered, planned, and kept on a level of appropriate intensity, then, so the authors claim, long delays will be avoided, the success of treatment go deeper, and the patient’s emotional participation will be more intensive than it would be in standard psychoanalysis [Footnote 4: It is not quite clear, as will be seen in the following, what the authors mean by the term standard psychoanalysis. To say they meant the technique as applied by those psychoanalysts who rightly or wrongly follow the main trend as initiated by Freud is not correct because the authors claim that their technique really achieves the goals Freud had in mind. Hence, they probably referred to an assumed statistical average. Since the majority of analysts, at least, claim to accept the basic rules of technique as laid down by Freud, I will take the liberty of referring mainly to Freud’s writings when presenting the technique of “Standard psychoanalysis.”]. The way the authors proceed in practice will be discussed in the section devoted to their case histories. Inasmuch as their writings comprise some unwarranted claims, it will be necessary to report them in some detail. It is especially Weiss who makes some statements which impress me as untenable, e.g., he believes that the “transference neurosis, in all negative as well as positive aspects was encouraged” (Alexander, French et al., 1946, p. 42). Weiss does not give any reference, hence, I do not know for certain whether or not such advice might not have been: given occasionally by analysts. But undoubtedly such a technique was disapproved by Freud who as early as 1914, wrote that he could not imagine any more “nonsensical proceeding” (Freud, 1914b, p. 380) than that which encourages transference. And in Analysis Terminable and Interminable (Freud, 1937a, p. 386) in a different context he again opposed the same technique. It is well known that deliberate encouragement of transference creates a chaotic analytic situation by virtue of its confusing effect on the patient. Weiss continues: “Until very recently, indeed, the belief was widespread among psychoanalysts that such a complete transference neurosis was unavoidable, that every improvement in the emotional life of a patient could be achieved only by solving his neurotic fixations as they were displaced onto the analyst” (Alexander, French et al., 1946, p. 42).
On what grounds does Weiss make such claims? Certainly there has been agreement among analysts that only under certain conditions does a transference neurosis become manifest, and that it often requires skill and experience to bring it to the fore, and that mistakes, made by the analyst, may quickly lead to its camouflage. Nor has it ever been claimed that “every improvement in the emotional life of a patient” be based on a solution of the transference relationship. It is well known that a wide range both of events and of therapies might achieve an improvement in a patient’s emotional life, a point repeatedly stressed by Freud. Is Weiss here perhaps referring to Freud’s opinion that the successful analysis of symptoms (after they have been absorbed by the transference relationship) offers the best available guarantee for a permanent structural change in the patient’s personality? Weiss further believes that:
…this laissez-faire attitude toward the relationship of the patient to the analyst became greatly modified. Today, even in the standard psychoanalysis, it is recognized that the transference relationship can and must be controlled in certain situations. Psychoanalysts found that the transference neurosis could be used by a patient as resistance to insight (Alexander, French et al., 1946, p. 42).
It is safe to say that at least since 1912 when Freud published The Dynamics of the Transference (Freud, 1912a) no responsible analyst has adopted a laissez-faire attitude toward the transference phenomenon. “Even” in standard psychoanalysis, the transference relationship must be controlled not only in certain, but in all situations. Moreover as early as 1912 Freud pointed out that a transference neurosis is a resistance to insight. Perusal of the psychoanalytic literature will show that the control of transference, combating transfer resistance, prevention or constructive use of acting out have been the central problems of psychoanalytic technique. Nowadays, Weiss claims, “the growth of the transference relationship” is, restricted “to those facets of the transference neurosis which reflected the conflict, avoiding a more extensive transference neurosis which would have been more difficult to resolve” (Alexander, French et al., 1946, p. 43). Quite apart from the fact that it is difficult to assume symptoms of a transference neurosis which do not reflect facets of a conflict I do not see why the difficulty of a task militates against its fulfillment.
Furthermore, Weiss tries to disprove the technical validity of the present theory of transference by referring to the possible unsuitability of the analyst’s person as an object of transference. “Far that particular patient’s particular emotions,” writes Weiss, “he may not represent the person in the patient’s past about whom his emotional disturbance is centered” (Alexander, French et al., 1946, p. 43). With few exceptions clinical experience does not confirm Weiss’ claim. In the vast majority of instances it is most impressive to observe, assuming that an appropriate technique has been applied, how far from the analyst’s real personality transference will go. But Weiss’ argument offers evidence that, he is discussing something that is different from what Freud meant by transference. What he calls the analyst’s suitability as transference object is merely a factor which may even clinically impede the patient from recognizing transference as such. This confusion is demonstrated by his belief, that a woman whose conflict centered around her relationship to an older sister and who was successfully treated by him “should logically have been sent to a woman far treatment” (Alexander, French et al., 1946, p. 48). It has been pointed out (Bibring, 1936) that a real likeness between a person of emotional importance in the patient’s past and the analyst may create insuperable difficulties in the course of treatment. In terms of Freud’s viewpoint we would have expected that a patient whose main conflict involved her older sister would respond more readily and successfully to an analysis conducted by a man than to one conducted by a woman her senior.
The following quotation may demonstrate what Weiss believes to be part of a new technique which promises “briefer methods… and an even more subtle manipulation of the transference relationship itself” (Alexander, French et al., 1946, p. 43):
We use the positive attitude of the patient toward the therapist to establish rapport and to keep the curative process in motion. When negative or hostile feelings appear, we do not ignore them but deal with them in a way to keep the patient from becoming so fearful that the process is blocked and the procedure prolonged. Likewise, when positive feelings become too intense, we must handle them lest the patient develop such a dependence on the therapist that he wishes never to give it up (Alexander, French et al., 1946, p. 44).
While this expresses succinctly some of the points of psychoanalytic technique as it has been practiced in the last 30 years, we cannot see in what way these points contribute to a significant shortening of therapy.
French describes three possible reactions of patients to therapy. They may utilize treatment rationally they may show frank resistance reactions such as direct anger about an unpleasant interpretation, or they may develop a transference neurosis (Alexander, French et al., 1946, p. 75).
French’s description of rational utilization of treatment sounds rather like a theoretical construction than a report based on clinical reality. If it should ever happen that a patient behaves in the way French describes, namely, that he listens to what the therapist has to say and uses it successfully for adjustment without traces of resistance or acting out, I would doubt that this was performed on a rational basis, but would think of various pathological mechanisms which might result in behavior that stems rational only from the viewpoint of society. Analysis of the patient subsequent to his “cure” would decide which mechanism alleviated the patients symptom.
But more important is what French says about transference neurosis. To him it is a secondary camouflage of direct resistance reactions. He writes “one of the most frequent causes of a transference neurosis is the need to hide or cloak… frank resistance reactions” (Alexander, French et al., 1946, p. 78). Furthermore he divorces frank resistance reactions from transference neurosis , and believes them to be irrational only insofar as the neurosis is-irrational. Since the therapist is a real threat to the patient because of his interference with the patient’s accustomed defenses, a frank, undisguised resistance can, be considered normal (ibid., p. 77). He gives a clinical example from an analysis which I wish to report extensively because it lends itself to the presentation of some arguments against his theory. I shall permit myself to add a modicum of further construction to French’s report. He discusses
…the case of an attractive young woman who spent the greater part of one analytic interview talking in glowing terms of a minister with whom she was closely associated in church work. She concluded by remarking that it sounded as though she were in love with the minister. The therapist quietly agreed that she must indeed be in love with him, and the rest of the hour was, spent in friendly discussion of the problem created by the fact that the minister was married. Two days later this patient had a violent temper tantrum; when she was seen by the analyst (before her anger had subsided), she was quite unaware of the cause of her outburst (Alexander, French et al., 1946, p. 76).
French considers the temper tantrum. of the patient a natural and inevitable reaction to the previous interpretation. It is difficult to accept French’s opinion without further proof. His explanation neither accounts for the delay in reaction, nor for the occurrence of anger. Another patient in a similar situation might react with a-depression. But French’s example becomes of greater importance when he adds that the patient’s “attachment to a married man was quite incompatible with her conscience, reinforced as it was by her religious training” (Alexander, French et al., 1946, p. 76). Hence, it can be safely concluded that it was something unusual for the patient to develop such feelings toward a married man. When it is further stated that “she had thought of her feelings for the minister in terms of her pleasure in working with him professionally” (ibid., p. 76), it seems evident that this description is also valid for a patients feelings about her therapist and therefore raises the question to what extent the episode with the minister might have been a displacement from the therapeutic situation to external reality, an acting out or a provocation to arouse the therapist’s jealousy or, an attempt at seduction. Certainly, only French can decide whether this assumption is valid, but I think that his example rather tends to show that the distinction between frank resistance reactions and transference neurosis will prove to be artificial in the majority of clinical instances.
If frank resistance reactions are isolated and take out of the context in which they occurred, as French did in his example, they can be used to justify his classification. If, however, they are viewed within the context of a longitudinal section of the detailed life history and. of a cross-section of the present total situation, more frequently than not, those direct resistance reactions will be recognized as part and parcel of a transference neurosis.
That most of the transference neuroses are camouflages of direct resistance reactions to interpretations is not probable. Transference neuroses frequently begin before any interpretations have been given. Nor are their manifestations restricted to the analytic situation. They appear in hypnotic: treatment, in mass phenomena, and in everyday life. If we view all these manifestations collectively it becomes quite probable that French has prematurely discarded Freud’s theory that transference is simultaneously a resistance and a resurgence of archaic psychic reality.
Furthermore, it seems that the authors were prone to disregard transference phenomena where they might actually have occurred. Weiss censures analysts who interpret every dream of ‘ the patient as a transference dream. “Whether or not he appeared, the analyst was found behind some figure the dream. has produced” (Alexander, French et al., 1946, p. 42), complains Weiss. If this is intended to mean that only if the analyst’s person appears in the manifest content of a dream can it be considered a transference dream some important elements of the patient’s transference must have escaped Weiss’ attention. But French’s concept of a transference neurosis is incompatible with his careful advice as how “to damp down the patient’s tendency to develop an unwieldy transference neurosis” (ibid., p. 85). If patients really have such “tendencies,” then his theory that secondary camouflage of direct resistance is the most frequent cause of a transference neurosis, becomes quite inconsistent. French attributes considerable importance to that tendency and he takes analysts to task because they apply a technique which, at least in their minds, throws the transference neurosis into strong relief. French discusses the patient’s difficulty of reality testing in a therapeutic situation in which “the analyst” (in this instance not the therapist) “suppresses his own, personality as much as possible . . . and tries not to permit himself to become angry when he is insulted or to be pleased when the patient becomes fond of him” (Alexander, French et al., 1946, p. 84). He further refers to “the impression of unreality that the standard technique ‘fosters.” He believes that by such “undermining the patient’s capacity for reality testing, we make it much more difficult for the patient’s ego to participate in the effort to gain insight” (ibid., p. 85). If reality testing is facilitated the transference neurosis will not be unwieldy. After such a description of the standard technique, let us learn what “the modern attitude” (ibid., p. 86 f.) would be. We hear: ‘The therapist” (this time not the analyst) “should not aim to be a blank-screen” but should try to the patient at his ease” by behaving in accordance with the patient’s expectations. He should do this by asking the patient “to give an account of his problem and of the circumstances leading up to it.” He should “accept the patient’s own view of his problem.” In case the patient believes he suffers from organic illness this possibility should be investigated objectively; evidence for the patient’s beliefs should be sought. “We also tentatively treat the patient as a normal and rational human being and we continue to do so except when the patient himself proves the contrary.” French continues to enumerate the advantages of such a technique. His description of the modern attitude is disappointing. Years ago, Fenichel (1941) pointed out the possible misunderstanding involved in the concept of the analyst as a screen and I surmise that most analysts are alert to this hazard. I surmise that most analysts, without considering it a modern attitude, do what French suggests such as asking a patient to account for his problems and establishing evidence of an organic illness. In so doing they only differ from. French in his paternalistic attitude of tentatively” treating the patient as normal and rational. Another reservation might be necessary regarding French’s advice to behave in accordance with the patient’s expectation. If French implies the use of Weiss’ technique of varying the scene “to suit the occasion” be lays himself open to severe criticism. Weiss suits the occasion by sitting behind the desk in one instance, by smoking a cigarette with the patient in another, or he sits near the patient “in the manner of a drawing room or beside him on the couch in an even less formal fashion” (Alexander, French et al., 1946, p. 53). Less formal than on a couch in the drawing room? If that does not lead to a transference neurosis the patient must be inhibited indeed!
In may judgment French did not give a correct presentation of the standard technique. Besides the unwarranted description of the analyst as a person who suppresses his personality and tries not to become angry which is contrary to all and everything that Freud taught and described as the prerequisites in the analysts personality (Freud, 1912b), French misapplies, in my estimation, the concept of reality testing in the therapeutic situation in which everything must be done to enable the patient to test his own psychic reality. French presents a subtle argument which at first sight seems to devaluate an important psychoanalytic therapeutic tool. He believes that the patient’s capacity for reality testing is actually undermined by “the aura of mystery resulting from the analyst’s strangely impersonal behavior” (Alexander, French et al., 1946, p. 85). The misunderstanding underlying this view becomes comprehensible when French states that %n the psychotherapy of children and adolescents the therapist abandons this impersonal attitude for one of warm and sympathetic interest” (ibid., p. 84 f.). The psychotherapy of adolescents is too complex a problem to be discussed here, but what concerns child analysis the change of technique as compared with that of adults is due to the clinical experience that children do not develop transference neuroses in the sense adult neurotics do. Yet it is more important that French assumes an inherent incompatibility between an impersonal attitude and one of warm and sympathetic interest. I think it has ever been impossible to analyze a patient by whatever technique unless the analyst possessed and showed a warm and sympathetic interest in his patients. If the necessity and beneficent effect of such attitudes really were a discovery of recent origin I do not see how patients could have been successfully treated in the past and I wonder what attitude French showed before he acquired the “modern” attitude. Likewise an “appeal to the patient’s good judgment and work in cooperation with the patient’s own ego” has been an old standby of standard technique (Freud, 1915-17, pp. 374-389). If the psychoanalytic situation is properly explained to the patient, the patient’s maximum of possible cooperation is made available. On the road to achieve that cooperation the patient can gain some exceedingly important information on conflicts in his ego of which he had not been aware. It is not advisable unless specific facets of the individual patient involve too great a risk, e.g., in borderline cases, to help the patient camouflage conflicts by establishing familiarity. “The impression of unreality” that the analyst’s alleged impersonal behavior “tends to make-especially upon an unsophisticated patient” (Alexander, French et al., 1946, p. 84) [Footnote 5: In my experience it is usually the sophisticated, not to say over-sophisticated, patient who initially complains about feelings of unreality]. impressed me as one of the principal opportunities to unravel fundamental ego attitudes towards reality, but never as a newly created piece of psychopathology in reaction to the peculiarities of the psychoanalytic situation as French seems to believe. The impression of unreality may disappear surprisingly quickly, in my experience, if “the patient is put at his case,” but then may never return again to the detriment of the patient’s analysis. Acting in accordance with the patient’s expectation unless the patients ego is weakened to such a degree as to be incapacitated for bearing up under the strain of the analytic situation, will not in general provide him with the best opportunity of becoming familiar with his psychic reality. A careful study of the authors’ case reports will show that the authors did not adduce any evidence of their patients having made progress in their capacity. to test psychic reality though they might have left treatment with a considerably changed facade al their personality make-up. As will be seen, the authors pursue therapeutic goals which are quite different from those Freud had in mind and, hence, their comparison with Freud’s technique, is, not relevant and challenges critique.
Alexander’s theory of transference and resistance reduces itself to the patient’s unwillingness to grapple with his real problems in life. The following two quotations will familiarize the reader with the frame of reference into which Alexander tries to press that fundamental issue. “Regressive material” writes Alexander in connection with the transference neurosis, “is a sign not of the depth of the analysis but of the extent of the strategic withdrawal of the ego-a neurotic withdrawal from a difficult life situation. back to childhood longings for dependence gratifiable only in fantasy” (Alexander, French et al., 1946, p. 29) and further: “The transference neurosis comes to serve the purpose of the original neurosis: withdrawal from real participation in life” (ibid., p. 33). Historically it is of interest to note that Alexander’s frame of reference has narrowed down in this context to the two concepts with which Alfred Adler tried to explain the totality of the psychopathology of the neuroses.
D. THE GOAL OF THERAPY AND PLANNING THERAPY
The authors elaborate extensively on the goals of therapy and the necessity of making a therapeutic plan for each patient. The authors were right in demanding that psychotherapy be based on a plan like all other rational activity. Alexander (Alexander, French et al., 1946, pp. 102-106) gives a rather long list of what decisions should be made at the outset of therapy; will it be a supportive or an uncovering therapy; will the patient come far daily or weekly interviews; should a change of external conditions in the patient’s life be attempted; should the development of transference relationship be encouraged or limited; what will the limits of the therapeutic goal be? French devotes a chapter to “Planning Psychotherapy” (ibid., pp. 107-131). But before going into details I believe we must decide on a fundamental issue which the authors have not sufficiently stressed, namely, the problem of structural changes of personality. Freud described the goal of psychoanalysis in various ways such as that of removing resistances or making unconscious material conscious or of filling out the amnesic gaps in the patient’s memory (Freud, 1914a p. 367, 1915-17 pp. 390-403). The most comprehensive formulation refers to the transformation of id into ego (Freud, 1932, p. 112).
Freud has outlined a set of rules far various phases of “structural psychotherapy” in his technical writings. He never insisted that all those rules are to be strictly followed. He considered only a few of them indispensable, such as the advice not to take notes during the analytic interview. Every analyst is entitled to change those technical suggestions in accordance with his experience if he can demonstrate clinically that his innovation will lead to a structural change of the patient’s personality. Experience proved that Freud’s technique did not lead to success in the case of schizophrenics and delinquents. Hug-Hellmuth, Anna Freud, and Melanie Klein did the same for the analysis of children. However far these rules may have departed from Freud’s original technique, all of them have one thing in common, namely, a high probability that the technique as outlined by its innovators is necessary far a structural change in the respective 4inical syndrome or age group. Hence, it can be said that any technique whether it uses a couch or not, whether it requires daily or infrequent interviews, is a psychoanalytic therapy if by use of valid psychotherapeutic tools it aims at, or results in, structural changes of the personality [Footnote 6: The stress on valid psychotherapeutic tools has become necessary since Freeman’s performance of lobotomies in psychoneurotics. This operation unquestionably results in structural personality changes (cf. Freeman & Watts, 1942)]. A psychotherapeutic method may relieve a patient permanently from a symptom; it may make him happy and successful; its effect may gain the applause of the patient’s family and society, yet if it does not effect a structural change, it is divorced from psychoanalysis although the therapist might have applied psychoanalytic theories in his therapeutic technique. I even would go so far as to claim that if another therapist had failed in previous treatment of the same patient, but can prove that the technique applied promised a reasonable chance of effecting a structural change in the patient, then he may claim to have used psychoanalytic methods. We may say, perhaps, that he misapplied it or that be was wrong in his clinical judgment in endeavoring to achieve a structural change, but his method was true psychoanalysis. Proof of the reasonableness of this point involves some additional remarks in order to avoid misunderstandings. First of all, a distinction between structural change and change of content must be made. This distinction is historically and clinically justified. Historically, psychoanalysis started out as a therapy aiming at structural changes even before the theoretical foundation of the therapy had reached a comprehensive concept of structure. Freud has repeatedly and unmistakably expressed the view that a psychotherapy which “cures” a patient,: by any other means cannot be regarded as psychoanalysis. Notwithstanding all the marked disagreements among analysts on technical questions, the goal of structural change has been common to them.
Furthermore the difference between structural change and change of content is significant enough to warrant distinctive terms to designate techniques aiming at the one or the other. A structural change, as it is meant here, is an internal’ change which leads to mastery. It is a change performed in and on the ego in respect to extending its area of capacity mainly by the elimination of certain defense mechanisms. A change of content is a rechanneling of energy based on displacement, or new repressions, or on an exchange of illusions, or the building up of magical beliefs, or on imitation. A clinical example of this is the change of a spendthrift to a, miser; a metamorphosis, which is not too difficult to achieve. Both attitudes are based on a pathological attitude towards money. The result of being a miser is socially more acceptable and less detrimental to the individual than that of the spendthrift, but from the structural viewpoint the patient remains the same. It is of paramount importance to keep in mind that extensive changes of content are possible without changes of structure. This can be proved by overwhelming clinical evidence. Structural changes are painful to the person whereas changes of content usually are gratifying though they might be initiated by a short period of anguish. A patient, as can be regularly observed, is ready to accept extensive changes of content in order to evade a structural change.
I admit that even with the greatest caution it is a very difficult clinical task to ascertain a structural change and it may happen more frequently than not that an assumed structural change turns out later to have been a change of content only [Footnote 7: Sharpe (1937) has presented clinical evidence of a change in dream structure as an index of recovery. I believe, however, no reliable measure for the “sincerity” of dreams has yet been found and, in my opinion, the degree to which the dream is accessible to secondary purposes comparable to mechanisms such as flight into health might have been underestimated though I readily admit that some analysts clinically more experienced than I, might be capable of using dream structures as reliable indices of recovery]. Furthermore, it is easier to determine in negative terms rather than in positive what theoretically a structural change is. As will be discussed later the authors have in my opinion not reported one instance of structural change and therefore should not have called their book psychoanalytic therapy although they used psychoanalytic knowledge in planning their therapeutic procedures [Footnote 8: Somehow the authors must have been aware of this state of affairs because with the exception of one (Benedek) they call themselves, in general, therapists. In one instance the term analyst is used in a deprecatory sense when French, describing a faulty technique, writes: “With this aura of mystery surrounding him, the analyst… tries to behave in accordance with his professional ideal…” (Alexander, French et al., 1946, p. 84) but two pages later when explaining in contradistinction the correct technique, he writes: “The therapist should therefore explain the reasons for any procedure…”. In his opinion, do analysts make mistakes and therapists use the correct technique? In view of the authors’ own distinction between analyst and therapist it is not quite understandable why Alexander insists upon regarding “all of the work set forth in this book as ‘psychoanalytic”‘ (ibid., p. vii)]. The decision to induce structural changes or change of content is of primary importance in planning psychotherapy because there is usually only one road open to structural changes whereas there are several to the achievement of changes of content. Therefore the technique aimed at change of content can be more flexible than that aimed at a structural change. I will call the former “magic” psychotherapy and the latter “rational”. There are various ways of magic, but there is only one ratio. I feel entitled to designate the two groups of techniques in this way because they show the characteristics associated with these terms. In rational psychotherapy there are no secrets between the analyst and the patient. As soon as a truth becomes evident to the analyst he shares his knowledge with the patient. Though in most instances this principle cannot be carried out ideally it remains a latent goal in psychoanalytic technique. The relief of the symptom is not the primary concern of the analyst, but the change of the psychic reality underlying a symptom is. Magic psychotherapy is always secretive and does not let the patient share the maximum possible knowledge and it h primarily interested in the relief of symptoms. The authors are explicit on this point. They claim that it is of importance only for the therapist to know the dynamics and to understand the genetic history of the patient. Based on that knowledge he bas to devise a therapy which will enable the patient to deal with his reality problems successfully in the shortest possible time. If that successful dealing withstands the impact of time, i.e., if it is permanent, the goal of their therapy is achieved. Indeed, if a symptom disappears and does not return a therapist satisfied with magic is content. In ideal rational psychotherapy the relief of symptoms may even be sacrificed in favor of maintaining the goal of structural changes [Footnote 9: Cf. Freud (1922, footnote p. 72): “…It (the therapeutic success) depends principally on the intensity of the sense of guilt; there is often no counteracting force of similar strength which the treatment can put in motion against it. Perhaps it may depend, too, on whether the personality of the analyst allows of the patient’s putting him in the place of his ego-ideal, and this involves a temptation for the analyst to play the part of the prophet, savior, and redeemer to the patient. Since the rules of analysis are diametrically opposed to the physician’s making use of his personality in any such manner, it must be honestly confessed that here we have another limitation to the effectiveness of analysis; after all, analysis does not set out to abolish the possibility of morbid reactions, but to give the patient’s ego freedom, to choose one way or the other.”], whereas in magic psychotherapy that problem can never arise.
It was exceedingly interesting to me to notice that French emphasized in his passages on reality testing the place of anachronism, Le, that the patient’s present reactions are in accordance with old patterns. There is a dearth of references to the more fundamental and genetically older principle of reality testing, namely, the individual’s acquisition of the faculty of distinguishing what is external and what is internal of the psychobiological organism [Footnote 10: Cf. Freud (1915, p. 62): “The apperceptive substance of the living organism will thus have found in the efficacy of its muscular activity a means of discriminating between ‘outer’ and ‘inner?”]. In every psychopathological disturbance the primary disturbance concerns that function of the reality principle. It may be of importance to mention in this context that Schilder and Waelder both suggest that magic is based on the lack of enforcement of that very function of the reality principle. Therefore I surmise that there might be a causal nexus between the authors’ ‘ neglect of that side of reality-testing and the technique they felt obliged, to apply. Be this as it may, a few statements are encountered which reflect opinions barely disguising magic.
When Weiss writes that “the therapist may choose to refer to the infantile neurosis in his interpretations and thus encourage a dependent transference relationship” (Alexander, French et al., 1946, p. 52) or further “to treat the patient as a dependent helpless person by even the slightest intimation will encourage the development of a dependent neurotic transference relationship” (ibid., p. 53) [Footnote 11: Weiss certainly must have been aware that Grotjahn (Alexander, French et al., 1946, p. 167) “repeatedly expressed his sympathy with the patient in having had to grow up in such an atmosphere” (viz. the patient’s parents were psychotic) thus treating him as a dependent helpless person, without causing all the enumerated evil effects.] or when French claims that “by focusing interest on the infantile neurosis we tend to favor the compulsive repetition of memories from the past to the detriment of the reality-testing function” (Alexander, French et al., 1946, p. 88), then the authors act as if words produced the event. This, however, comes close to an exquisitely magic superstition. Why the interpretation of the childhood neurosis must lead to a dependent transfer relationship or why interest in that structure must lead to its repetition is not made clear by the authors. Up to now it was generally assumed that interpretation of the infantile neurosis might give the patient an ability to master the repetitious compulsion which had pervaded his life history before his ego had learned to take cognizance of it.
The technical innovations the authors introduce and the objections to be raised against their recommendations must be viewed from the aspect of the differences between rational and magic therapy. French supposes that there are two main principles of therapeutic approach: adaptation of the patients environment to his needs or modification of the patient’s personality structure “in order to bring it into harmony with the requirements of his environment” (Alexander, French et al., 1946, p. 132). This general outline of therapeutic possibilities, valid as it may be for the vast majority of present psychotherapeutic procedures, means a definite break with the basic tenets of psychoanalysis as it has been formulated up to now. The change of environment which apparently is considered by French as a therapeutic tool on equal level with that aiming at “modifications” of the personality structure is no etiologic therapy at all but at best can result only in a symptomatic: improvement. French knows that of course, since he discusses in the same section the relief patients might obtain by supportive treatment. He counteracts the argument that results thus obtained are “transference cures” by pointing out the frequent permanent effect following such therapy. It is important to notice that French speaks of improvement of adjustment in connection with such results and thus seems to share Alexander’s behavioristic viewpoint of, evaluating the patient’s personality on the basis of outward behavior without raising the question of what the corresponding change of personality, if any, might be. Change of environment, beneficial as it may be in a great number of clinical instances is a typical device of magic therapy. It is an historical outgrowth of earlier customs of pilgrimage; it is a device supporting the patient’s resistance insofar as it confirms his cherished belief that he is facing not an internal conflict but an external one; it offers a wishfulfillment as a compensation for impending displeasure; it further encourages the patient’s desire for the feeling of magic omnipotence. Although it is frequently the only resort available to mitigate the patient’s suffering, it is essentially beyond the compass of rational psychotherapy in the sense of psychoanalysis.
The second therapeutic approach, namely, that of personality modification for the purpose of establishing harmony between personality structure and environment, seems to attack the problem in a way closer to traditional psychoanalysis, but reveals to an even larger degree the extent to which the authors have discarded rational therapy. The psychotherapeutic approach is no longer viewed as an aspect of the existing internal conflict, but exclusively from the angle of the demand of external reality. Here the new technique reaches the level of modern shock therapy and French could just as well have repeated Freeman’s statement concerning the goal of his therapy that, “it: comes down to a question of which deviation interferes less with his (the patient’s) social adjustment” (Freeman & Watts, 1945, p. 739).
Here it is no longer the goal of therapy to give the patient’s ego the greatest possible access to conflicts, but to confine therapy to the area of accidental collisions between the patient and society. The therapist no longer needs to worry about the liberation of the ego, but, with the demands of society in mind, to restrict his activity merely to the narrow limits of the patient’s present conflict. “We should center the patient’s attention rather upon his real present problems” writes French (Alexander, French et al., 1946, p. 88). The past apparently is not real, only the present. Again French sides with the resistance of the patients. It is just that of which most of them try to convince the analyst, namely, that their trouble is a conflict with external reality. But what is the effect of this approach? It puts a premium on camouflaging the real issue of the internal conflict in favor of acceptance of a small sector of external reality in behavioristic terms. Although French discusses one side of rational therapy (ibid., pp. 136-140) the example he describes in the section on modification of behavior patterns represents unmitigated magic psychotherapy. He chooses the technique he believes necessary in cases of asthma and stresses the beneficial effect of confession:
The effect of such a therapy is, of course, at first merely symptomatic. By confessing what is disturbing him the patient gets relief for a time from his asthma attacks. Often, however, symptomatic relief of this kind tends gradually to diminish the deep underlying insecurity and dependence of the patient (Alexander, French et al., 1946, p. 136).
Here we meet not only in the term confession a time-honored magic device but also an entire procedure calculated to grant a wishfulfillment without insight, in the hope that this will make a superficial symptom disappear. “The purpose of interpretation in such cases is to help the patient to confess rather than to clarify motives” (Alexander, French et al., 1946, p. 136).
Every magic procedure collapses when the subject turns against the dispensor of the charm with hostility. Hence the authors give advice on how to avoid such an embarrassing event. Weiss proclaims: “Hostile attitudes toward the analyst, moreover, are often a needless complication of therapy. When the object of such a neurotic attitude can be a person in the patient’s daily life, this complication is removed and the therapy thereby shortened” (Alexander, French et al., 1946, p. 46). French is aware that this may bring serious damage to the patient (ibid., p. 81) and therefore he recommends a more refined technique:
Hostile impulses are evidence of frustration and frustration is a sign of an unsolved problem. If the problem can be solved, then frustration will cease and the resultant hostile impulses should disappear. By digging in behind hostile impulses to the problems that gave rise to them, therefore, it is often possible to eliminate the hostile impulses without at any time focusing the patient’s attention directly upon them… (Alexander, French et al., 1946, p. 131).
What is meant by “digging in behind hostile impulses” is demonstrated by French’s reference to Gerard’s case report of a patient suffering from peptic ulcer and examination anxiety (Alexander, French et al., 1946, pp. 244-254). The technique applied was to enable the patient to satisfy dependent cravings without his pride being hurt. This was done by inducing the patient’s wife to gratify his cravings for dependence, “to give him sympathy and extra tenderness” and by getting the patient’s physician to cooperate in letting the patient (a medical student) “examine and plan the treatment for some ulcer patients” (ibid., p. 250). Needless to say that the therapeutic effect was excellent as in nearly all cases reported, and the patient lost his examination fear, went on a regular diet, lost his abdominal pain, and when last heard of, had settled down as a physician in a middle-sized town with his three-months-old son. Although it is challenging to speculate why techniques of such kind have such miraculous effects, I want to mention only the extent to which the patient is kept in the dark concerning the true nature of his problems; to what extent, further, he is induced by wislifulfillments to act in a socially successful way. All this is part and parcel of magic psychotherapy which in this instance does not make its appearance in crude forms but uses some valid psychological. findings to suit its purpose (cf. Glover, 1931).
French points out what complications might follow if duodenal ulcer patients are made aware of their intensive hostile feelings. He may be right or wrong with such warning. It may turn out that it is impossible to apply rational therapy to a certain clinical group. A therapeutically ambitious physician might, therefore, relinquish the narrow pathway of rational therapy and apply magic. There certainly is no objection to such procedure; but it is not permissible to describe magic therapy in terms as if it concerned rational therapy. It is more in keeping with valid scientific thinking to admit that here the point might have been reached at which a real change of the ego is impossible, where the patient’s personality structure is permanently injured and the therapist’s goal is reduced to palliative measures. But in French’s own words it appears not to be impossible to give such patients more than a palliative. He says: “A number of analyses of duodenal ulcer cases have succeeded in giving marked relief to the gastrointestinal symptoms, but have resulted in substituting in its place a reaction of the type… which bas proved very difficult to treat” (Alexander, French et al., 1946, p. 130). “Very difficult to treat” concerns a demand put on the analyst, but does not indicate a definite limitation on the patient’s side.
The magic attitude underlying the new technique which, however, is presented in terms of reason, provides the authors with a feeling of knowledge close to omniscience which is far beyond the limitations that still burden mental science. French describes the situation of the analyst in the first few hours when be becomes familiar with the patient’s problem and, life history in terms of the following comparison: “The analyst during this period may be compared to a traveler standing on top of a hill overlooking the country through which he is about to journey. At this time it may be possible for him to see his whole anticipated journey in perspective” (Alexander, French et al., 1946, p. 109).
Freud’s early description, however, of the same period of treatment may still be valid. He wrote: “This first account may be compared to an unnavigable river whose stream is at one moment choked by masses of rock and at another, divided and lost among shallows and sandbanks” (Freud, 1901). A feeling of power derived from magic omniscience seems expressed in Johnson’s comment on the cure of a case of bronchial asthma in 36 interviews. She states: “This case illustrates… a therapy… which accomplished an actual analysis of the conflict because the therapist already knew the dynamic structure of the asthmatic syndrome… it is believed that a real ego change was achieved in this case… since the therapist bad the advantage of knowing the fundamental dynamic constellation in asthma cases as worked out in earlier research…” (Alexander, French et al., 1946, p. 303 f.; italics by Johnson).
The authors enjoy an enviable optimism. Limitations to knowledge or to possible achievements of psychotherapy are scarcely mentioned; Johnson even goes so far as to give the impression that our present knowledge of asthma is sufficient for all practical purposes.
True magic is usually colorful and appealing to the emotions; rational procedures appear drab and monotonous, and only the discerning eye perceives how rational procedures adjust to the peculiarities of the reality situation. Alexander believes that psychoanalysis has not-adapted its technique to the diversity of cases and that its “therapeutic tool is rigidly fixed and the patients made to conform” (Alexander, French et al., 1946, p. 25). He evidently bases that impression on the fact that most patients are treated daily while lying on a couch. Alexander does not mention that the treatment of a hysteria or of a compulsive neurosis proceeds on entirely different lines; his impression of monotony or rigidity in psychoanalytic technique results from his keeping his eye fixed on the paraphernalia. The naive observer might believe that painting is a monotonous procedure because one always uses brushes and pigments [Footnote 12: Cf. Sharpe (1937, p. 124): “The nuances of technique, when the analyst is attuned to his material, will arise in response to the particular medium in which he works.”].
In view of their acceptance of magic techniques, it is quite understandable that the authors do not esteem too highly the importance of using insight as a tool in their psychotherapeutic technique. Alexander attributes to “corrective emotional experiences necessary to break up the old reaction pattern” the highest therapeutic value above “emotional discharge, insight and a thorough assimilation of the significance of the recovered unconscious material” (Alexander, French et al., 1946, p. 26). French postulates emotional readjustment as the goal of therapy, not insight (ibid., p. 126). “In many cases it is not a matter of insight stimulating or forcing the patient to an emotional reorientation, but rather one in which a very considerable preliminary emotional readjustment is necessary before insight is possible at all” (ibid., p. 127), writes he. He describes a case in which the therapist decreased the patient’s anxiety by supportive therapy and then concludes: “By thus diminishing her anxiety, we hope to make it possible for her spontaneously to face the realities of her situation” (ibid., p. 127). This clearly expresses the secondary value put on insight, and hence, on interpretation. The therapist hopes that an emotional change which he has induced not by interpretation but by an understanding attitude, will produce insight by chance. The reader must really gain the impression that insight is connected with considerable danger. Three pages are devoted to “complications resulting from attempts to force insight” (Alexander, French et al., 1946, pp. 128-130), and we read that “therapists who have been fascinated by psychoanalysis but who have not yet had much practical experience… often tremendously over-value the therapeutic efficacy of insight” which “is expected to cure the patient as though it were a magic wand” (ibid., p. 128).
It may help in clarifying this problem if the use of the term “goal” is made more precise. After having established emotional readjustment and not insight as the goal of therapy, I was astonished to read of a technique in which the main therapeutic goal was “either of giving the patient emotional support or of making it possible for him to confess…” (Alexander, French et al., 1946, p. 136). Evidently the unqualified use of the word goal here burdens the discussion. A differentiation of goals and means is necessary. Emotional support is a psychotherapeutic tool just as is interpretation but the latter leads to insight if it is integrated by the patient. I think that greater stringency in keeping tools and goals apart would make the difference between psychoanalysis and the new psychotherapy clearer. Most analysts will agree that an ego which has attained mastery over previously unconscious parts of the personality will have no difficulty in its emotional and social adjustment. Mastery without insight is inconceivable in the adult; but this by no means claims that adjustment is possible only by insight. To induce adjustment – a secondary goal to the analyst – is not too difficult in many clinical instances.
By postulating adjustment as the main goal, and by “centering the patient’s attention upon his real present problems… and…. upon the motives for irrational reactions in the present” (Alexander, French et al., 1946, p. 88), French narrows the scope of psychotherapy. In this context I wish to refer the reader to Alexander’s (1927) description of the resistance an ego presents against knowledge of its unconscious part and, further, to the importance he attributed to the analysis of those resistances (Alexander, 1927, pp. 4-6). When French stresses the trust and confidence a patient must have in his physician before an unwelcome interpretation should be given, he emphasizes a point of minor importance. The main issue is the ego’s resistance to the interpretation of its defensive setup which can be successfully combatted only by giving the patient insight into that part of his personality. French rightly stresses the preparatory work necessary before giving certain interpretations but he fails in his presentation to describe the exact nature of that preparatory work which is a series of minute interpretative steps centering on that secondary resistance to acknowledgment of the main conflicts which Alexander has described in the reference just quoted. If French advocates avoidance of that analytic work by the establishment of certain positive feelings in the patient towards the physician, then he is bringing magic devices into play. This might be done or avoided depending on whether the physician wants his patient to achieve mastery or whether he limits his intention to the inducement of adjustment. Insight may be achieved by a variety of means, the main one of which is still interpretation. It may be that many analysts, even after prolonged practical experience, handle interpretation and insight like magic tools. It would not be surprising, since the products of rational thinking more frequently. than not, themselves acquire magical meaning to the majority. Railroads, electricity, and the persistently quoted atomic bomb are subjectively magic instruments to most of us, but that does not preclude their objective rational meaning and their possible efficiency in mankind’s battle for survival. The persistent attempt which pervades the book to “debunk” insight is a significant result of the victory of magic over rational psychotherapy.
Alexander even goes so far in his distrust of rational therapy as to contend that psychoanalysis must necessarily fail with a patient who seeks therapy because of psychogenic physical distress, if that patient is convinced of the organic nature of his disease. He writes:
If this man were to be treated by the standard psychoanalytic method the analyst would assume an understanding but impersonal attitude, waiting for the transference neurosis to develop and offering little or no suggestion or direction. As a result, the patient might easily transfer onto the analyst all the conflictful emotions from his past life and tend to become one of the “interminable” cases… or, conversely, he might become disgusted with the entire therapeutic situation, feel that lie was not receiving active help, and flee treatment after two or three interviews (Alexander, French et al., 1946, p. 55) [Footnote 13: I can think of other effects psychoanalysis might have on such a patient and have observed them in practice. Alexander himself must have once upon a time been more successful in the application of standard psychoanalysis since he wrote in an earlier publication: “Often it requires a substantial bit of psychoanalytic work to rob the patient of his conviction that there is an organic basis for his illness” (Alexander, 1927, p. 36)].
Some of the new technical advice presented can be understood only in the light of the distrust of insight harbored by the authors. A device introduced by Alexander, and accepted by, the rest of the authors insofar as they make reference to it, is the staggering of interviews, i.e., varying the weekly or monthly number of interviews and sometimes interspersing long periods of interruptions [Footnote 14: These periods extended from one to eighteen months (Alexander, French et al., 1946, p. 36)] before discontinuing treatment. The beneficial effect of the device, as claimed by the authors, is varied and significant and the scope of technical problems allegedly solved by it is so broad that I, too, was inclined to think of a magic wand. The advantage of manipulating interview frequency is often presented by referring to the damage done by a technique of daily interviews. Such a technique “tends, in general, to gratify the patient’s dependent needs more than is desirable”; prevents the patient from becoming aware o£ his needs for dependency; exercises “a seductive influence on a patient’s regressive and procrastinating tendencies” (Alexander, French et al., 1946, p. 28) ; “makes the analysis emotionally less penetrating”; “tends to reduce the patient’s emotional participation in the therapy” (ibid., p. 30) “may, in some cases, make the patient too dependent on the therapist and thus actually aggravate the difficulties of therapy” (ibid., p. 141).
On the other hand proper manipulation of frequency of interviews will achieve the right emotional level, avoid regressions, facilitate a natural termination of analysis, prevent dependence of the patient on the analyst, etc. It is difficult to discuss here all the claims the authors make in favor of that device and to repudiate their unfavorable comments on Freud’s technique of daily interviews. Yet insofar as the very core of the psychoanalytic situation is misrepresented, discussion should follow. It cannot be conceded that the analytical situation of daily interviews per se involves any regular emotional reactions in patients. Their emotional reactions depend on their individualities and the analyst’s technique. Since 1938 Alexander has emphasized the factor of dependence not only in connection with daily therapeutic interviews but also in connection with almost all problems of clinical psychiatry. It would be of interest to find out by questionnaires if his experience is confirmed by that of other analysts. Do so many patients really become dependent on their analysts to such an extent that termination of the analysis becomes a problem of such seriousness as to require, manipulation by tools other than those of, classic analytic therapy? My own experience and what I have heard from others tends to indicate that the problems of inducing the patient to continue his treatment and to accept the fact that there is still unresolved psychopathology present are encountered at least as frequently. It seems reasonable to raise the question whether the importance which Alexander assigns to dependence reactions was the outgrowth of the way he applied the classical technique. He interprets the patient’s dependence on the analyst as a regression to a happy, gratifying archaic condition. Is it conceivable that: it is the content of the interpretation which makes it ineffective in “weaning” the patient from the analyst? May it be possible to reduce the number of strong and unmanageable dependence reactions in patients if dependence on the analyst is interpreted as transference resistance? Dependence is not a primary entity; it has a great variety of meanings and must be dissolved into its components in order to be understood. More frequently than not it is a reaction formation against hostility and against an inflated desire to be independent. Furthermore, is it not possible that a majority of strong and unmanageable dependency reactions occur if the classical technique has been inappropriately applied in the early phases of treatment?
It is of historical interest to quote Alexander’s opinion on that matter 20 years ago: “The resistance to giving up the analytic situation, which, moreover, has many prototypes besides the biological separation at birth, such, for example, as weaning, learning to walk, leaving the parental home, etc., must with all its objective – motives become conscious” (Alexander, 1927, p. 48). I wonder what clinical experience made Alexander change his former opinion that dependency reactions to the analyst are transference resistances. French writes: “He (the patient) may find the therapeutic relationship seductive and therefore disturbing in that it stimulates erotic impulses within him. In such cases, too frequent interviews may complicate the therapy, especially, if the therapist fails to interpret and discuss the conflicts arising out of this erotic transference” (Alexander, French et al., 1946, p. 142). This reminds me of a surgeon who warns against surgery because if it is performed under . unhygienic: conditions, it will harm a patient, Yet French continues: “In more severe cases, this reaction to the therapy as a dangerous seduction may result in very undesirable consequences even if it is interpreted” (ibid., p. 142). Interpreted as what-as a reaction to the therapy? The question arises again to what extent the authors’ unhappy experiences with the technique of daily interviews might have been due to improper handling of that magic wand, interpretation. I think the authors should have published the report of one of their analyses including a report on the interpretations given to convince the reader of the correctness of their objections. But even assuming that the authors applied ah the knowledge accumulated up to now and, further, that they conducted the analyses of their patients correctly, it is significant how they solved the problems they met. They do not take the attitude that more knowledge is necessary for their patients, they do not request that better understanding of dependency reactions is required in order to combat them successfully but they proclaim. that here the analytic situation per se has found a limit, or causes, so to speak, a sickness and has to be discarded. Whatever the patient’s specific reactions to the analytic situation may be, they must be viewed as significant data concerning his personality structure. They enrich in every instance the analyst’s and the patient’s knowledge. This aspect has not been sufficiently stressed by the authors and therefore I believe they made the short circuit of making the analytic situation per se responsible and of shifting to an a-rational psychotherapeutic device where rational therapy is still in its full right.
It may be that the staggering of interviews will affect the patient’s behavior as the authors describe it. Nevertheless, it is not evident from their reports that this technical device worked to the patient’s benefit. After a reduction of the number of interviews, we hear, the patient becomes aware of the extent of his dependency. But did the authors then switch back to daily interviews in order to make him understand the origin of his dependency reaction? Nothing of the kind. If the patient acted as if he were independent it was a gratifying success in* the auth6rs’ estimation. Quite generally, I think, the authors underestimate the magic component in the human mind. I have noticed in some patients of mine that after discontinuance of the treatment due to external factors, they established a situation in which they continued to owe me a small amount of money. , Notwithstanding the aggressive ‘component of that behavior, I surmise that it served the purpose of establishing a persistent bond between them and Me. It amounts to the maintenance of the illusion that they did not really separate from me. Such a fantasy of magic content might enable them to behave outwardly in a seemingly mature way. From the psychoanalytic viewpoint, however, the treatment was a failure in spite of a possible success in terms of standards of social adaptation. Certainly if Alexander “weam” his patients by interspersing longer and longer periods between interviews, he nourishes certain magic fantasies in the patient although he might convert actual dependency into phantasied dependency and apparent external independence. The patient might be ready to bear the burden of responsibility ii the compensation in the form of even short lasting reliance on the admired therapist looms on the horizon, however distant. From the viewpoint of a rational therapy, however, this is a therapeutic failure.
A short historical remark will be appropriate here. The authors try to justify some of their innovations by reference to Freud’s advice on the technique of phobias. As is well known, Freud pointed out that patients suffering from phobias, who discontinued exposing themselves to the phobic situation prior to the beginning of treatment, must be requested at the appropriate time to undergo the dreaded situation voluntarily. This is necessary to carry the treatment into the pathogenic layer of the personality. Hence it is not quite correct historically when French writes:
Frequent interviews may, in some cases, make the patient too dependent on the therapist and thus actually aggravate the difficulties of therapy. In illustration of. this principle, consider the therapeutic problem in many cases of phobia. Freud pointed out many years ago that such patients tend to become fixated upon their analytic treatment and are with difficulty induced to end it (Alexander, French et al., 1946, p. 141).
Freud did not attribute the difficulty to a specific impact of the analytic situation on the patient; this can be easily seen from his reference to a symptomatic condition which existed prior to the onset of the patient’s analytic treatment.
To avoid misunderstandings it should be emphasized that the authors do not explicitly deny the importance of structural changes at any point of their writings [Footnote 15: It is interesting to observe how terms such as “dynamic” and “structural” have become mere slogans. It is further surprising how sparingly Freud (1899) has used the word “dynamic” even in his Seventh Chapter of the Interpretation of Dreams in which the human personality has so far found its most dynamic presentation. It is noteworthy from the historical viewpoint to compare the present-day attitude with Wernicke’s pride in having achieved a “mechanical” theory of the psychoses though an intelligent reading of his Lectures will convince one that Wernicke’s theories were most dynamic. Today no author would dare to boast of the mechanical nature of his theory. It seems that authors nowadays insist on the dynamism of their views, believing that the use of such an epithet proves the correctness of their theories]. The authors, however, correlated the changes of behavior which they bad observed in their patients in the course of therapy, to structural changes without further inquiry into the background which might have supported the modification of their patients’ behavior patterns. Since detailed childhood histories of most of their patients were unknown to the’ authors they even did not know whether the variation of behavior pattern observed during and after the treatment might not have been due to further regression.
How far some of the authors’ theoretical purposes deviate from their practice may be seen in Alexander’s professed goal to hasten the transformation of psychoanalysis into a procedure that will achieve permanent changes in the ego by “a slowly progressing emotional training” (Alexander, French et al., 1946, p. 18) and the readiness with which he uses the word recovery in connection with therapeutic results even if based only on one interview (ibid., p. 163). The emotional training in that one interview conducted by Grotjahn, concerned a physician, a refugee, 45 years old, suffering “from an intense depression resulting from extreme irritation with his son.” In the one and only consultation the patient realized “that life would be easier now if his son and wife were not with him,” “that the demands of his son were really not exaggerated but seemed so because he himself felt insecure…”, that “he felt guilty and responsible” and that his son’s behavior was justified.
But this success achieved in one interview was not enough. Besides the marked relief of an intense depression, the therapist dispensed with permanent help in making the patient “adjust his way of working to the American style of life.” This was achieved by the advice that the patient should have “an office outside the home” (Alexander, French et al., 1946, p. 156). Even the most ardent believer in the efficacy of social work would not dare to use the terms adjustment and recovery with reference to such simple manipulation of the environment.
It is of interest to note that Alexander was initially troubled by doubt in the genuineness of rapid therapeutic results. When for the first time be “cured” a patient with the new technique he still “thought that probably this was one of those ‘flights into health’ sometimes observed in psychoanalyses” (Alexander, French et al., 1946, p. 153). Yet he later brushed that possibility aside because his observations “no longer permitted such a complacent explanation” (ibid., p. 153). Evidently in order not to be complacent he abstained from any further thought about that most insidious resistance which manifests itself by flight into health, and which constitutes one of the exceedingly difficult tasks of therapy.
E. CORRECTIVE EMOTIONAL EXPERIENCES
Alexander introduces a term of which it is difficult to determine whether it is just a new name for a well-known fact or whether it describes a new therapeutic principle. In two previous papers, Alexander (1935, 1944) found it appropriate to describe the process of psychoanalytic therapy with three concepts; namely, emotional discharge, insight, and working through or integration. This time he adds a fourth; namely, the corrective emotional experience. He subordinates the importance of the three other concepts to the fourth (Alexander, French et al., 1946, p. 26). What do corrective emotional experiences mean in Alexander’s presentation of therapy?
The patient has an opportunity to display his old conflicts in the transference relationship. The analyst assumes a different attitude from that of the patient’s parents. Alexander writes:
…the analyst’s objective, understanding attitude allows the patient to deal differently with his emotional reactions and thus to make a new settlement of the old problem. The old pattern was an attempt at adaptation on the part of the child to parental behavior. When one link (the parental response) in this interpersonal relationship is changed through the medium of the therapist, the patients reaction becomes pointless…
…the therapeutic significance of the differences between the original conflict situation and the present therapeutic situation is often overlooked. And in just this difference lies the secret of the therapeutic value of the analytic procedure (Alexander, French et al., 1946, p. 67).
Alexander, no doubt, emphasizes an important point in psychoanalytic technique. To what extent that point has been overlooked, I do not know, but I fear that Alexander over-emphasizes a point of importance to suit the requirements of his technique. His conclusion is that the analyst should “provide, by his own attitude, the new experiences necessary to produce therapeutic results” (Alexander, French et al., 1946, p. 67). We shall see later in a clinical instance how he proceeds in practice. At this point, it should be emphasized that in certain phases of the psychotherapy of schizophrenics, delinquents, alcoholics, addicts, and probably of very severe neurotics the consistent pursuit of such a technique becomes a necessity during certain phases of their treatment.
On the other hand, I believe that Alexander in his frequent references to the failure of insight to produce personality changes, clearly limits the concept of insight to intellectual insight. Freud pointed out in early writings that intellectual insight is inefficient and wasted in any therapeutic effort. Whenever Freud uses the word “insight” he refers to a psychological act pertaining to or having its effect on all structures of the personality, including the emotional sphere. . Insight bas been used in most analytical writings in the meaning Freud attributed to that concept. Alexander’s depreciation of intellectual insight is unnecessary.
It might become easier to understand what Alexander means by the concept of corrective emotional experience when we discuss the literary example of Jean Valjean, the hero of Victor Hugo’s (1862) Les Misérables, which Alexander quotes as a paradigma. It might be of interest to point out that it is often difficult to interpret Hugo’s novels psychologically in view of political tendencies and social theories underlying his artistic productions. Les Misérables was written under the assumption that crime is a reaction to social conditions. A far-reaching social philosophy was expressed in that literary masterpiece which cannot be classified only as a psychological novel but also as a tendentious program. Furthermore, Les Misérables was written in the romantic period of French literature with its predilection for complicated plots, and it is not discernible to what extent certain events were introduced for the sake of plot construction or for the purpose of presenting human nature. Certainly, Hugo is quite different from Dostoevsky who “lived” in the progress of his novels and did not anticipate what turn the vicissitudes of his heroes would take. But let us do the best we can with Jean Valjean’s conversion. Alexander refers to the Christian, forgiving way Monsigneur Bienvenu, the bishop, treated a crime committed by Jean Valjean. That hardened criminal was taken by complete surprise because he had never before experienced human kindness. A few hours later he committed a less severe violation of law against a young boy. While committing that violation, and shortly thereafter, he underwent an emotional storm, the effect of which induced him to commence a new kind of social life, a, true antithesis of his past. He. changed from a criminal to a very saintly man. It is not quite clear from Alexander’s presentation whether he considers Jean’s reaction to the bishop’s kindness or Jean’s following misdemeanor, or both, the corrective emotional experience. According to Alexander, the effect the bishop’s kindness had on Jean is “anything but novel.” Alexander believes that Jean’s subsequent behavior, when robbing the young boy, was significant of Hugo’s “dynamic perception.” However, Jeans’ regression to criminal behavior is explained by Alexander as the “recrudescence of the symptom” before it can be-given up; hence, it does not fit exactly into the concept of a corrective emotional experience. As far as I can see, Alexander’s new concept may mean an exclusively emotional turmoil which results in a change of behavior as described in the life of many saints, the most famous of which is the miraculous metamorphosis of Saul to Paul. Moreover, to return to Alexander’s clinical example, I want to say that Jean’s delinquent behavior against the young boy was, introduced by Hugo possibly for the sake of keeping Jean in the state of a hunted criminal without which detail the following complications of the novel would have been impossible. But be that as it may, let us take Jean Valjean as a test case of the efficacy of “corrective emotional experiences.” Let us see what his fate was after that emotional revolution had taken place in his life. It becomes evident that he had not changed, in the , sense psychoanalysis aims to achieve through changes of structure. First of all, the dichotomy he faces after his conversion; namely, of either becoming an angel or a monster, is no good omen. The reference to the necessity of becoming better than the bishop especially indicates that only an exchange of indices has taken place. The underlying mechanism can be thus described: “Since I have been the worst of criminals, I must now become saintlier than the saintliest man I have met so far.” Actually, Jean never became free from the bishop. All the rest of his life he competed with his “therapist,” so to speak. Even on his deathbed, he asked whether he merited the bishop’s approval or not. But likewise, he never got rid of his past. This is beautifully expressed in Jean’s comparison of a cloister in which he lived for many years, and the galleys whence he came. Actually he loves no one but a child, Cosette. His goodness to other people is performed on an intellectual level according to a plan with little inner participation. The only person to whom he develops a strong positive emotional attachment is the child of a woman whose life he bad indirectly and inadvertently destroyed. Again the feeling of guilt and the character. of reaction formation are quite conspicuous. In all his kindness and apparent unselfishness towards the child, the psychopathology is only barely disguised. When Cosette later falls in love with Marius, Valjean’s selfish manipulation of Cosette becomes very evident and he is thrown into a deep conflict. When he becomes aware that his fight to eliminate his competitor has been lost, he again applies the outwardly unselfish attitude and saves Marius’ life. But he does it with hatred in his heart according to Hugos own words, and after Cosettes and Marius’ wedding, he withdraws entirely from life, confesses to Cosette’s lover that he was an ex-convict and purposely makes him believe that he has continued his criminal career, thus endangering the happiness of the newlyweds.
Alexander could not have chosen a better example than that of jean Valjean to demonstrate the shortcomings and limitations of corrective emotional experiences. They might induce a person to shift from one extreme to another, but they do not effect structural changes and do not lead to integration.
The corrective emotional experience is the main tool used in magic psychotherapy. It is the spell which the magician spreads over his subject. Hugo’s description of Valjean’s conversion is one example among thousands of old Magic: beliefs. Hatred is combatted by goodness. Drought is changed to rain by the sorcerer’s sprinkling of the field. He gives nature an example of what should happen. Although magic is shattered by the unalterable laws of physics and biology, the human mind does react to magic: and a criminal therefore might be induced to discharge his destructiveness in repeated charitable acts, although it would not change his psychic reality. Society only evaluates behavior and does not care about motivations. But psychoanalysts should never make themselves the puppets of society and accept superficial behavior patterns as indices of psychic reality.
Alexander’s reference to Aichhorn’s technique of the therapy of delinquents is not justified since Aichhorn’s basic tenet is that neither punitive severity nor friendliness and kindness are the proper tools for the treatment of delinquents. Friendliness and kindness might be necessary during the preparatory treatment phase when the main goal of establishing an adequate transference relationship dominates all the steps in the therapeutic process. In order to make a delinquent analyzable, certainly magic psychotherapy is not only indicated but absolutely necessary. This likewise holds true for certain phases in the psychotherapy of schizophrenics. It is particularly Aichhorn who emphasized the shortcomings of a therapy which would stop after having reached a stage in which the delinquent ceases to show the symptoms of- his original disorder. It was a true therapeutic triumph and a great contribution to society when he could prove that the delinquent after having undergone a series of “correctional emotional experiences” (in the terminology of Alexander), became capable of’ enduring rational therapy resulting in structural changes. The stage of rehabilitation as described by Hugo and accepted by Alexander as a cure was well known to the pre-Freudian epoch of psychology. It was just Freud’s supreme achievement that he lifted the “level of intended personality change” far above that which bad been conceived possible or which even had been previously known. The authors’ attempts to undo that achievement by recasting it into a pre-Freudian mould is regrettable.
It is only logical in view of Alexander’s position that he assumes recovered memories to be mere indicators of the progress of treatment and that he denies their importance in terms of a structural change. Clinical evidence disproves h is assertions. Hypnotic treatment which leaves the structure of the ego fairly untouched can rearrange the dynamic equilibrium of the personality by one-sided drainage of pent-up energy bound in repressed memory systems. Recovery of memories alone, were it possible, certainly can never fulfill the requirements of rational therapy, but it is an integral factor in giving the ego mastery. Alexander’s devaluation of the genetic approach is necessary in order to devaluate insight and interpretation and to make the transference relationship, per se, the central therapeutic tool. If the patient became cognizant of the history of his transference relationship, the magic spell would dissolve and all the hard and prolonged work required in rational therapy would become incumbent.
F. HISTORICAL REMARKS
Alexander tries to fit his technical approach into the history of psychoanalysis. He claims Ferenczi and Rank as the spiritual godfathers of his innovation. Alexander refers to Ferenczi’s and Rank’s principle that the patient can be cured without recollecting his past (Alexander, French et al., 1946, p. 22). He believes that his own work “is a continuation and realization of ideas first proposed” by those authors. “They advocated an emphasis upon emotional experience instead of intellectual genetic understanding of the sources of the patient’s symptoms. They held that emotional experience should replace the search for memories ‘and intellectual reconstruction” (ibid., p. 23). Thus Alexander most favorably reviews The Development of Psycho-Analysis (Ferenczi & Rank, 1924) in 1946, emphasizing an essential difference between standard psychoanalysis and his own new technical approach.
I do not know if the reader is familiar with the ancient Greek story of the man who borrowed a pot and returned it to its owner in a damaged condition. When sued, he defended himself by claiming that firstly he had never borrowed the pot, secondly, the pot was damaged when he borrowed it, and thirdly, it was undamaged when he returned it to its owner. ‘ I was reminded of that story when I reviewed what Alexander wrote about the same book in the course of little more than two decades. When he reviewed that book in 1925 (Alexander, 1925a), he emphasized that insofar as it contained correct statements, it did not say anything new; when discussing the problem of psychoanalytic technique in 1935 (Alexander, 1935), he emphasized that Ferenczi and Rank were wrong because “obviously the ego’s integrating function is neglected, together with the corresponding technical device, the working through” and he summarily claims that Ferenczi’s and Ranks technique “can be classified as abreaction therapies (Alexander, 1935, p. 597). Strangely enough, in 1946 Alexander wants to free psychoanalysis of hidden remnants of abreaction therapy by means of a technique which, in his own words, historically developed out of a technique he had called an abreaction therapy, 10 years previously. In 1946 Ferenczi is heralded as representing a constructive reaction to dissatisfaction with psychoanalytic technique.
I regret that Alexander’s early review of Ferenczi’s and Rank’s book is not available in English [Footnote 16: The quotations from Alexander’s book review are my own translation]. In 1925 Alexander was still aware that the reproach that analysis neglects emotional experiences in therapy is only possible if Freud’s work is disregarded. It is worthwhile to quote a few sentences from Alexander’s polemic against Ferenczi which sounds today as if Alexander had anticipated a critical review of his own book which he was to write 20 years later. He stated:
The basic thought of… the book appears most succinctly in the authors’ statements that psychoanalysis enters a new phase today, namely, “the phase of emotional experience” (Erlebnisphase), which follows the “intellectual phase” (Erkenntnisphase) of the last few years. According to Ferenczi and Rank the latter consisted partly of a hypertrophy of theoretical research, partly, as concerns therapy, of an overemphasis of knowledge conveyed to the patient during treatment. …I must confess that I am not familiar, especially in what concerns psychoanalytic technique, with a mere “intellectual phase” at least since the time of Freud’s publication of comprehensive papers on technique thirteen years ago. (Alexander, 1925a, p. 115).
To prove this, Alexander quotes from Freud The Dynamics of the Transference (Freud, 1912a) and continues:
The essential content of the whole booklet by Ferenczi and Rank is contained in these sentences by Freud. Ferenczi and Rank have not presented the technical importance of the emotional factor more clearly, more persuasively or more distinctly (viz. than Freud)… A person who might not have taken into account Freud’s discoveries of that time committed a personal mistake, but by no means did he accomplish his therapeutic task in the sense of psychoanalysis. lf anyone should insist on speaking of a phase of emotional experience, then he must date its beginning back to a time thirteen years ago when Freud published the quoted paper and must not let it start with the publication of Ferenczi’s and Rank’s book. (Alexander, 1925a, p. 115).
If only Alexander had re-read his review before publishing his new book, how much confusion could he have saved the students of mental science who are already heavily burdened by the sprouting of secessionistic movements. In his review of 1925, Alexander did not refer to opinions, but to facts, and I do not see how be can reconcile the Alexander of 1925 and of 1946. When he further reprimanded Ferenczi and Rank for having neglected the dissolution of the transference and the working through which “have to accomplish the truly analytic part (das eigentlich Analytische) and by means of which the permanent ego change… is enforced” and then, commits the same mistake 20 years later, the reader might say that possibly, further research has proved those two mechanisms to be of less importance than it might have been believed earlier when Alexander thought that Ferenczi and Rank had “missed the boat.” But in 1925 Alexander wrote that “the greatest pressure which we can exert on the patient in order to induce him to renounce consists of the uncovering of the transference; this process relentlessly progressing and continuously becoming more distinct makes it more and more conflictive and difficult for the patient to play the role of the infant which occurs in the transference at a time when he is an adult. This internal conflict is the most efficacious factor contributing to the dissolution of the transference.” Here Alexander referred to clinical experiences, to facts he must have observed with his own eyes and again an irreconcilable contradiction is met when he claims, 20 years later, that the analytic situation, per se, creates increasing dependence of the patient on the analyst. Alexander did not hesitate to speak of the ambivalent attitude of Ferenczi and Rank towards some parts of analytic therapy (Alexander, 1925a, p. 122), and in turn, he will have to reproach himself today with the same ambivalence he diagnosed in others 20 years ago. I have not expressed my own opinion on Ferenczi’s stupendous work in the foregoing. I only tried to compare the facts reported by Alexander in two different periods of his work. As to Alexander’s claim to have continued Ferenczi’s work, I am convinced that Ferenczi had penetrated far too deeply into the abyss of the human mind to be willing to father an author who adheres to the principle of simple explanations. He writes:
I cannot share the a priori distrust of many scientists for simple formulations. I am prejudiced in a different way: against complicated and obscure attempts at explanation. I am convinced that in nature relations are extremely simple. (Alexander, 1927, p. xvii).
Alexander’s latest book demonstrates anew that he adheres faithfully to this principle. But whoever has bad a chance to take a look at Nature, whether it be the physicist or the biologist, feels confused by the unending maze of unsolvable riddles. Even he who studies the smallest units, such as atoms, recognizes the impenetrability of nature to the searching eye, and notices that each discovery results in larger vistas of unmapped continents. However, Alexander persistently overlooks these new vistas and blissfully returns to old concepts which really appear to be simple in view of more recent discoveries. He repeats an earlier formulation when writing: “It was not until 1930 (Alexander, 1930) that the recovery of memories was demonstrated to be not the cause of therapeutic progress, but its result” (Alexander, French et al., 1946, p. 20). However, careful examination of the Studies in Hysteria will prove that this point was demonstrated as early as 1895. Breuer and Freud (1892-95) wrote:
…although the patient can rid himself of an hysterical symptom only after reproducing and uttering under emotion its causal pathogenic impressions, yet the therapeutic task merely consists in inducing him to do it, and once the task has been accomplished, there remains nothing for the doctor to correct or to abolish. All the contrary suggestions necessary have already been employed during the struggle carried on against the resistance. The case may be compared to the unlocking of a closed door where as soon as the door knob has been pressed downward no other difficulties are encountered in opening the door. (Breuer & Freud, 1892-95, p. 213).
This formulation was correct in terms of the concept of the human mind Freud had developed approximately up to 1900, and coincides by and large with Alexander’s opinions in 1946. But since 1900 it has become evident that there are many memories whose recovery the patient opposes with such strong resistances that analysis must attack the problem from two different directions: by analyzing the resistances and by guessing at the content of the repressed memories. This latter construction will arouse in the patient certain expectations which will facilitate the appearance of the recollections searched for and will reveal to the patient the content against which his resistance is directed. Furthermore, it has become evident that the most important unconscious recollections can never be remembered by the patient because they cannot be put into words and therefore must be reconstructed by the analyst (Freud, 1937b). Anyone who believes that the mere finding of recollections, after the removal of resistances, will end the analyst’s work, has never seriously attempted to obtain an adequate history of a neurotic symptom. Is not the recovery of childhood memories only the initial step in the more important task of interpreting their meaning? Furthermore in compulsive neuroses the patient easily reproduces a fairly complete history of his symptoms including most pertinent childhood memories. Do these memories constitute the result of the therapeutic process or are they not the manifestation of an intensive resistance against the experience of emotions? The extreme simplicity Alexander expects to encounter in nature presupposes a persistent blindness to significant sectors of life. Without that, the laws of psychology will appear at least as complicated as those of the atom.
G. TRIAL INTERPRETATIONS
To continue the discussion of the new technique the reader should be made familiar with another new device; namely, that of trial interpretations, recommended by Alexander mainly for application during the first interview, in order to gauge the strength of the patient’s ego. Alexander evaluates the patient’s reaction to those interpretations in terms of the patient’s capacity for insight, the character and extent of his probable resistance and future cooperation (Alexander, French et al., 1946, p. 98). It is worthwhile to read Alexander’s original report (Alexander, 1944) on an example of that technique. A businessman nearly 60 years old, accompanied by his wife, consulted him because of a recently developed phobia. Alexander quickly found out that that phobia was an excuse for the patient’s reluctance to face his changed status in life due to the weakening of his capacities. Alexander described a series of trial interpretations and their evaluations as follows:
I cautiously began to explain to the patient that his phobia had an emotional and not a physical origin. I immediately met with a massive resistance, he was convinced that the whole condition was a result of his sun stroke. Here I did not get even to first base so I let up another “trial balloon.” I proceeded to intimate tactfully that he might misjudge his partners’ ability to conduct the business without his help. He was adamant in his opinion. Then I began to approach him from another angle and discuss with him the emotional difficulties of retirement in general. I said to him that often a person does not want to realize that he has outgrown his usefulness. The patient became markedly restless. I continued to tell him how difficult it is to cede one’s place to the youth. I added that I was somewhat doubtful concerning the validity of his criticism of his partners. I called his attention to the fact that his statements concerning them were quite contradictory. The more I tried the clearer it became that no matter how tactfully I proceeded it would be impossible to make him see the unpleasant truth… I told him the truth as tactfully as possible, namely, that he could not face the change in his life situation… When I was through, with my appeal the patient jumped up from the chair, and in a shrill voice called out to his wife in the waiting room, “Mamma, let us go home!”… his wife telephoned me a few days later that her husband did not mention any more going down to the office. I think I saved the patient a long analysis and myself a therapeutic failure. Would the patient have shown a somewhat less massive resistance after my first interpretation I would have changed my whole strategy. (Alexander, 1944, p. 330).
This report is of interest among other reasons because of the possible disagreement, on what tact in psychotherapy may mean. The reader is referred to Reiks’ (1935, pp. 102-111) remarks on the topic. Reik rightly stresses the intimate relationship between tact and timing of interpretations, a connection of which Alexander seems to be oblivious [Footnote 17: ‘Ferenczi may have been right when he reproached Alexander for lack of sense for the finer shades of the personality. He wrote: “…his (Alexander’s) susceptibility to shades of difference is not his strongest point…” (Ferenczi, 1926, p. 225)]. I think that Alexander here recommends a technique which everyone must be warned against applying. The patient’s ceasing to demand that he go to his office, as reported by his wife, might have been. the sign of the beginning of a severe depression. A therapist, clinically experienced, would know from the patient’s history and his manifest symptoms that he is not a subject for analysis at all, and that patients of this type require a kind of psychotherapy which may be called “custodial,” i.e., consisting of repeated interviews possibly covering the rest of their lifetime with mild encouragement and strict avoidance of any provocation. A patient whose suffering has reached this degree, should never, when he comes to a physician’s office, be exposed to humiliation. To attempt to decrease the patient’s defenses is to risk a severe deterioration in this type of patient. , I think Alexander could not have chosen a better clinical example to c”vince the reader of the inappropriateness of trial interpretations. We cannot share his optimism that he avoided a therapeutic failure.
H. CASE REPORTS
Alexander demonstrates the principle of flexibility in psychotherapeutic technique in a case of conversion hysteria and severe personality disturbance (Alexander, French et al., 1946, p. 55 f.). It concerns a 42-year-old businessman suffering from uncontrollable jerking motions of the arms. He bad suffered three attacks of unconsciousness several years before. There was the possibility of a focal epilepsy. The patient was an, irritable, intolerant person who bad lost his potency shortly before he started treatment. The treatment consisted of 26 interviews covering a period of 10 weeks. Eleven months after termination of treatment the recovery from all symptoms bad persisted unabated. How did Alexander achieve that remarkable success? In the first interview he reached the conclusion that the patient’s considerable difficulties were the result of the damage he suffered in his youth at the hands of a domineering, tyrannical, narrow-minded, and prohibiting father. The patient had lost a protective mother at the age of 10. After his father’s death, he had succeeded in his attempts to prove his superiority to his father as a businessman, and he enlarged the inherited enterprise considerably. This, however, was the only sector of life in which he was successful. In all human relationships, with his wife, his only son, and his associates, he failed. From the very start of therapy the patient tried to establish a situation in which he could repeat the earlier behavior pattern developed in his relationship to his father. But Alexander counteracted the establishment of rebellion, admiration, or devotion by minutely avoiding any possibility of argument, by minimizing his own contribution and by convincing the patient that “had the patient devoted himself to the profession, it was quite possible he might have become even more expert than the analyst” (Alexander, French et al., 1946, p. 58). This attitude towards the patient was, as far as I can see, the main device by which Alexander precipitated an improvement in the patient’s condition. Rightly, Alexander stresses that the patient’s conflict with his father had not been internalized and that no feeling of guilt had developed about his hostility against the father (Alexander, French et al., 1946, p. 59). That lack of internalization and Alexander’s technique are to be viewed simultaneously and therefore the following comment may be permitted: The patient apparently came for therapy in great tension. Alexander’s behavior was quite opposite from what he expected, but it coincided with an old wish. Alexander provided him. lavishly with wishfulfillments. Since the conflict was not internalized but still concerned an external object the wishfulfillment did not arouse feelings of guilt. As the patient had tried to outdo his father in business matters, he tried to outdo Alexander now in this new field of competition. When Alexander reports that “he himself (the patient) recognized that he could now act as, a father toward his son because he had at last found in the treatment what he had always wanted – understanding and support from a person in authority” (Alexander, French et al., 1946, p. 59), this can only mean that he did not recover from his symptoms because his personality structure bad changed, but because a wish had been fulfilled. It is not the point here to discuss the advisability of such a technique (clinically the success was most brilliant), but it should be emphasized that the recovery was effected by means which are extraneous to psychoanalysis. It is the technique which reminded Freud of the Austrian Emperor Joseph who, in disguise, familiarized himself with the hardships of his subjects and by charitable acts removed the source of their unhappiness.
Alexander speaks of the patient’s utter confusion when he was confronted with a benign authority and he illustrates this by two dreams: one in which the patient made the analyst a despot like the father and another in which “he made the father the benevolent restorer of his potency. In reality the analyst was the benevolent person and the father the tyrant” (Alexander, French et al., 1946, p. 60). I am not inclined to follow Alexander in that evaluation. These two dreams do not refer to any confusion; they indicate that from the viewpoint of psychic reality, father and analyst were on the same plane; they had become identical not by transference, but in accordance with the working of the unconscious in which extremes are branches of the same root (Freud, 1910). Alexander succeeded in dramatizing a picture which was inherent in the patient’s relationship to his father probably from a very early date on. Thus he succeeded in making a reality relationship coincide with an unconscious and repressed relationship. Alexander’s report is not detailed enough to substantiate the conjecture that the patient, during the period of recovery, compulsively pursued a pattern of action just opposite to that by which he was previously dominated. If Alexander had tried to demonstrate that such behavior changes from one extreme to another can be achieved without standard psychoanalysis, he would have met full agreement. But he went further and believed that his technique – taught the patient adult attitudes and “that lie brought the patient to an earlier correction of his neurotic attitude” (Alexander, French et al., 1946, p. 65) than would have been possible with the standard technique. He attacked the psychoanalytic technique at this point and demonstrated all the effects classical psychoanalysis allegedly would have had on this patient. This was quite unnecessary since the patient showed some of the earmarks which, according to Freud, make him ineligible for psychoanalysis anyhow. This certainly does not mean that there are no other techniques which might alleviate the patient’s conscious suffering. But Alexander evidently overlooked the fact that the patient did not really change according to the meaning which psychoanalysts have hitherto given to that word. The patient developed behavior patterns that were more appropriate to the patient’s environment. According to Alexander’s definitions this is one of the main goals of psychotherapy, and thus he feels satisfied with his achievement. Yet those who primarily aim at structural changes, this clinical success admirable as it was will not convince of the insufficiency of the classical technique.
It remains to review the rest of the case reports. I shall emphasize some of the points which in my judgment are open to criticism and then proceed to a general appraisal of the new technique.
There are a total of 21 cases reported. One of them is a case of war neurosis, a very special topic which will not be discussed here. The evaluation of the case reports from the point of view of a structural psychology such as Freud’s. psychoanalysis, is difficult, as one gets only occasional glimpses into the pertinent material. Furthermore, the use of some terms is quite different from. psychoanalytic custom, and, hence, the possibility of misunderstandings is great. For example, Gerard uses the term insight in a context which is worth quoting extensively because it demonstrates so very clearly one of the irreconcilable differences between psychoanalysis and the new technique. Gerard gives the following account of the first interview with a 21-year-old sophisticated girl who had recently suffered an outbreak of acute phobias (Alexander, French et al., 1946, p. 237 f.).
In the first interview, the patient was given insight into her hostility toward her mother, with an explanation of how it grew from her mother’s restriction of her independence and self-expression-a result of her mother’s ambitions for her-and from the consequent restrictions of her social life. The therapist discussed with her the fact that all children develop such hostilities toward their parents and showed the patient how, from fear of losing love, she had formed defenses against her own childhood hostility by exaggerated obedience, shyness, and avoidance of tabooed activity. An explanation was given to her of how the conflict had been intensified into severe symptom formation during her first trip away from home, because she was. really deserting her mother in choosing to be with her fiance and yet she was enjoying herself. A hint was also offered her about guilt reactions to any enjoyment because of her training to sacrifice so much for achievement in work. This guilt in turn made her even more dependent upon her mother, the childhood disciplinarian whose presence could protect her from indulging her wishes for pleasure.
These interpretations were followed with a permissive suggestion that she might try to refrain from repressing angry feelings toward her mother when critical thoughts occurred, with an explanation of the naturalness of such feelings in spite of the traditional teaching that one should love one’s parents under all circumstances. It was then suggested that some mild self-indulgence such as lunch with her sorority sisters or an after-class drink in the drugstore with them if she felt the inclination might aid in her recovery, and that she go to classes or begin to study again only when she felt comfortable and wished to. But, in order to protect her from losing prohibitions too rapidly, she was urged not to indulge herself beyond her feeling of comfort.
I quote the report because I was surprised by the indication that a therapist believes that she has imparted insight into one of the most important conflicts of female development in a first interview in which, to boot, the elaborate theories as quoted were showered over a patient who could not possibly have followed that synopsis of modern psychology. Indeed I agree with French, when he so correctly says that it is “almost self-evident… to focus the patient’s attention upon only one problem at a time” (Alexander, French et al., 1946, p. 91). Gerard, however, achieved “excellent results by a treatment which extended over a period of two months” (ibid., p. 234), with 12 interviews and a few follow-up meetings, in spite of a questionable technique, at least in the first interview. Surely when a physician in authority thrusts elaborate theories on a young patient, the patient is necessarily forced to intellectualize the conflict, if any response at all can occur. Intellectualization of a conflict is a potent defense against an acute symptom and, hence, it is understandable that the patient reported in the second interview “that she had begun to feel that she would recover.” I do not want to lead the reader through the intricacies of the ensuing ‘treatment, the therapist’s conversation with the patient’s mother to make her more permissive [Footnote 18: It is noteworthy that as early as 1899 Freud recognized distinctly what kind of specific advice he might give to a patient’s father in order to make the patient’s symptoms stop. He wrote (Freud, 1901, p. 53): “‘But – I added – I hoped he would not let himself be persuaded to do this, for then she (the patient) would have learned what a powerful weapon she had in her hands… Yet if her father refused to give way to her, I was quite sure she would not let herself be deprived of her illness so easily.” This clinical remark illustrates beautifully Freud’s early adherence to an etiological treatment based on his willingness to forego the satisfaction of a quick clinical success. This is all the more remarkable since, as a later quotation from the same paper will demonstrate, Freud was still deeply influenced at that time by concepts of disease structure he had developed during the cathartic period of psychoanalysis.], the third interview in which the patient got insight into the transference relationship and instruction in the facts of life, etc., but I want to point out that there are a number of young women suffering from phobias who react splendidly to therapy if the therapist has the good luck of starting the treatment at a time when the symptom is still in statu nascendi. I particularly remember a patient with a personality make-up similar to Gerard’s case whose phobias disappeared with the administration of bromides and a minimum of psychotherapeutic activity. However, when the acuteness of the symptom had been allayed, and the prerequisites for intensive treatment bad been established, I transferred her to a colleague for standard analytic treatment.
At this point it is necessary to discuss a matter of therapeutic principle. In Alexander’s case there was a patient whose age and history militated against standard analysis. In Gerard’s case, all the prerequisites were present for a successful psychoanalysis. The patient was a young and intelligent person whose personality structure and symptomatology united all the characteristics of a subject who would greatly profit from extensive analysis. No doubt the symptom. for which she sought help could be removed by a variety of therapies. But is this sufficient justification to deprive the patient of the benefits which standard psychoanalysis offers to a young and intelligent person? Clinical experience shows that phobic symptoms ought to be considered a signum mali ominis in terms of the entire life history. Nobody can safely say how this young girl will react under the psychic strain of childbirth, of menopause, or of serious deprivations which might befall her. Clinical experience further shows that psychoanalysis, although not providing the subject with immunity against the development of psychopathological reactions later if exposed to strain, yet considerably decreases the probability of such reactions. It is surprising in how many instances of serious psychogenic disorders such as, e.g., schizophrenias, the history is found of frank phobias which occurred during the years following adolescence. In my experience these phobias which really are prodromal symptoms of the later, often devastating disorder, are particularly prone to vanish and are quite different in this respect from what is called the classic phobia which usually is a rather stubborn disorder defying often even prolonged therapeutic: effort. It is meaningless if Gerard’s patient is reported to have been free. of symptoms three years after termination of the treatment, because an identical sequence of events can be found in patients who never had been treated, prior to the onset of the final disease. Depending on precipitating factors, the time of their occurrence and the ensuing specific clinical symptomatology, a second phase of the disease might pose insuperable difficulties. Are we entitled to deprive a promising young woman of those therapeutic conditions that will grant access-to the optimal means of strengthening the human personality? The situation was entirely different in Johnson’s case (Alexander, French et al., 1946, pp. 293-297), that of a young man, 19 years of age, suffering from an acute depression. This patient evidently was still in the midst of adolescence and his development was impeded by an unsolved conflict concerning the death of his mother when he was three years of age. Johnson brought out a delayed reaction of mourning and thus opened up a new avenue towards maturation. The problem of the psychoanalytic technique applied to adolescents cannot be discussed here, but certainly there is a large number of adolescents who suffer from considerable psychopathology and nevertheless should not be analyzed because they had not yet had sufficient opportunity for experimentation with the world on their own account. If the acute, impediment blocking constructive access to the world has been removed, no further therapy should be instituted, but the patient should be informed of the therapeutic possibilities he ought to use at a later date if need should arise.
The authors’ marked inclination to take their patient’s reports at face value is unusual among analysts. Fuerst offers a good example of the readiness to accept uncritically the patient’s word in a case of frigidity with which he achieved “complete sexual readjustment” by three interviews. A 19-year-old black woman had “completely satisfactory” sexual relations with her husband until a baby was born. An umbilical hernia caused by childbirth apparently injured the pride the patient took in her beauty. This was overlooked by the gynecologist, but “to the psychologically experienced therapist… it was immediately apparent that the patient was extremely self-conscious and disturbed over the deformity of her abdomen” (Alexander, French et al., 1946, p. 160). I wonder if even the most experienced therapist can ascertain in three interviews whether a patient’s sexual relationship has been “completely satisfactory” or whether his therapy has led to a “complete sexual readjustment.” Up to now there has existed the evidently erroneous belief that it takes along time until patients in the course of treatment would discover what their sexual experiences really are, what the phantasies accompanying intercourse are, and to what extent the orgasm may have been achieved on a makeshift basis. All these essential facts necessary to an evaluation of a patient’s sexual life apparently have been unnecessary niceties which can be safely discarded from now on. The same superficiality in clinical judgment is patent in the same author’s contribution to the analysis of character disturbances. A 27-year-old woman was treated successfully with 15 weekly interviews extending over four months, and the reader will no longer be astonished to hear the treatment achieved “a real personality change” comparable to the result of a standard psychoanalysis (Alexander, French et al., 1946, p. 227).
The patient had suffered from deep feelings of inferiority and guilt, obsessive and compulsive manifestations, phobias, and food idiosyncrasies. After the first interview “she was always composed, friendly, and very serious in her attitude toward the therapy.” In the second interview she already “felt like waking up” and said “apparently I have never lived my own life” (Alexander, French et al., 1946, p. 224). The author considered this a manifestation of insight and did not raise the question how such discoveries can be reconciled with a “composed and friendly” attitude. Unless it is to be assumed that such verbiage is mere lip service, you. would expect that a patient’s true discovery that she never had lived her own life would be followed by a modicum of subjectively unpleasant emotions. Nevertheless, Fuerst insists that “the weekly sessions were conducted on a high level of emotional participation, the intensity of treatment consistently greater than in a standard psychoanalysis of daily interviews” (Alexander, French et al., 1946, p. 223). Fuerst should not have considered that piece of submissiveness and obedience which the patient showed throughout the treatment “a high level of emotional participation,” and he should not have praised the intensity of his treatment as being greater than in psychoanalysis because the emotional, level his patient seems to have reached would not be considered adequate for the successful conduct of “standard psychoanalysis.” When the patient said: “Now I realize one can’t have everything. I have learned to be satisfied with what I have” (ibid., p. 227), the author evaluated this as signs of “a more mature attitude.” Yet, Fuerst made it difficult for the patient to express her true feelings. He writes:
Once she displayed a kind of compulsive confusion… and felt as guilty about coming to the therapist as about everything else. The analyst interrupted her, however, and simply remarked that understanding her behavior was more important than complaining. The patient immediately felt better and told him that she had actually been much better and her relationship to her mother had improved greatly. (Alexander, French et al., 1946, p. 226).
This information is important because it may give a clue to what the patient believed understanding to mean. She seemed to have taken the therapist’s interruption as criticism and readily tried to reconcile him by reporting the improvement she had made. The author reported that from then on the patient “became much more free and uninhibited in her attitude. She felt more self-confident and no longer had the need to blame herself for everything” (Alexander, French et al., 1946, p. 226). Might it be possible that the patient had felt intimidated and had stopped talking about her real trouble ?
Nearly all these authors apply a technique of ego evaluation which is open to criticism. When a patient’s symptom disappeared under the influence of their treatment, they assumed that the ego had integrated some constructive experience and they further assumed in view of the rapid improvement that the patient’s ego was strong. I do not believe this conclusion to, be stringent. If a patient discontinues a psychogenic: symptom this might occur for other reasons than integration. It may happen on a predominantly imitative basis, or it might be done in order to win the physicians praise, or it might be precipitated by a fear of losing the physician’s appreciation. I further believe to have observed that, no so infrequently, it is the weak ego that wants to remain in conformity with an appealing frame of reference and therefore is prone to show great ability in shifting its symptomatology to a less accessible area of the personality. It is just that very following up into the less conspicuous sectors of defense that makes psychoanalysis a drawn-out affair. Since the authors accept the disappearance of a symptom as a cure and as the manifestation of a strong ego their therapy certainly required a small number of interviews. Indeed, the weekly intervals between interviews facilitate the camouflage of the patient’s retreat into less conspicuous symptom formations.
The technique most of the authors used can be characterized as highly seductive to the patient: praise, and advice were freely given; the patients, were reassured that their conflicts were natural, that their aggressions were universal. It is a kind of Catholic absolution without punishment. I dare say the patients were bribed into well being. As the authors did not accurately investigate the patients’ defenses but relied on their gross social conduct and their reports of feeling well, I do not think that they have any right to compare their therapeutic results with those of psychoanalysis. The goal of psychoanalysis is placed at an entirely different personality level than the goal of the authors’ technique.
I. GENERAL REMARKS
At this point, I should like to revert to a general discussion. I can only confirm by my own observation the repeated claim of the authors that even severe symptoms tend to disappear in a large number of patients after short. therapy. Though I am, mainly interested in that field of research which is accessible only to standard psychoanalysis, I have applied short psychotherapy to a considerable number of patients during a period of six years. I made the same amazing experience which the authors describe. Patients, suffering from chronic: fatigue, schizoid personalities, acute anxiety states, and a long list of other syndromes, responded to a great variety of techniques ranging from the administration of bromides to simple encouragement or occasional interpretations. I can add now, after familiarization with a larger sector of the population in my Army experience, that there seems to be no therapeutic agent which could not be successfully used for the purpose of improving the patient’s psychogenic displeasure under certain circumstances. There was a vast number of soldiers who reported in their life histories improvements achieved by chiropractors or simply by “some pill a doctor prescribed,” improvements which nevertheless were comparable to those reported by the authors. It should not be forgotten that in this country the desire to fit into the social machine, to act like the rest, is a very strong motivating force in the vast majority of our patients. If only a little chance is offered, I should say, if any chance is offered, it is readily accepted by a large number of patients for the purpose of external adjustment. The average patient docs not want insight into his problems, be does not desire clarification of his standing in the universe, he does not want the enlargement of his ego, but he wants exactly what the authors offered, namely, “social adjustment” in the sense of being able to carry on on the level accepted by the majority. He will gladly react to any magic offered. In the following quotation, Alexander came the nearest to the truth concerning the new therapy which be advocates:
In the course of one interview, the patient may react with violent anxiety, weeping, rage attacks, and all sorts of emotional upheavals together with an acute exacerbation of his symptoms – only to achieve a feeling of tremendous relief before the end of the interview. Such experiences, although curative in effect, are painful; they might be described as benign traumata.
In this fact is to be found the nucleus of the popular belief that in certain cases of mental disturbance some accidental and powerful experience may suddenly restore mental health. Perhaps this is the psychological explanation of the miracles of the Bible, the cures of Lourdes, indeed the magical cures of all cultures throughout the ages” (Alexander, French et al., 1946, p. 165). [Footnote 19: Cf. Freud (1901, p. 56 f.) : “Destiny has an easier time of it (viz. to combat the motives of illness): it need not concern itself either with the patient’s constitution or with his pathogenic material; it has only to take away a motive for being ill, and the patient is temporarily or perhaps even permanently freed from his illness. How many fewer miraculous cures and spontaneous disappearances of symptoms should we physicians have to register in cases of hysteria, if we were more often given a sight of the human interests which the patient keeps hidden from us. In one case, some stated period of time bas elapsed; in a second, consideration for some other person bas ceased… the whole disorder, which up till then had shown the greatest obstinacy vanishes at a single blow… because it has been deprived of its most powerful motive, one of the uses to which it has been put in the patient’s life.” Cf. another passage in the same paper (Freud, 1901, p. 133), which Alexander could nicely fit into the history of his technique: “…the barrier erected by repression can fall before the onslaught of a violent emotional excitement produced by a real cause; it is possible for a neurosis to be overcome by reality. But we have no general means of calculating through what person or what event such a cure can be effected.” The reader might keep in mind, that these passages were written in 1900 prior to the explicit introduction of the structural aspect into psychoanalysis]
Indeed, Alexander reverts to magical treatment coached -in psychoanalytic phraseology. It is exactly that which Freud had warned against and which he made a supreme effort to keep out of psychoanalysis. It is the unalterable tenet of psychoanalysis to abstain from such magic procedures as it was expressed by Freud in The Ego and the Id (Freud, 1922, footnote 18) when be stated that the role of the prophet or of the savior is incompatible with psychoanalysis and, further, that the task of psychoanalysis cannot be to make pathological reactions impossible but to give the patient’s ego the freedom to choose one way or the other. This does not mean that magical therapy is ill-advised; it only means that a physician using magical therapy should know that he is outside the bounds of psychoanalysis. However, in spite of the great success of Alexander’s technique (close to 600 patients were treated in eight years by him and his staff), he is still far off from the record of Lourdes where up to 1913, 4.445 patients representing about 190 different sicknesses were cured (Bertrin, 1906). Likewise, like the report on Lourdes which does not indicate the proportion of those who sought cure and of those who actually obtained it, Alexander’s book also lacks information on that very point. The willingness and the desire of patients to be cured by magic is astounding; I fear Alexander and his collaborators assumed specific causal correlations between therapy and outward change of behavior in patients in whom an equation of an entirely different order is to be assumed.
Psychoanalysis is in a crisis. That crisis has been mainly limited to theory until now. Alexander’s book initiates a new phase in which that crisis spills over into problems of psychoanalytic technique. I call it a crisis because the disagreement concerns differences which do not grow out of a common frame of reference upon which there is agreement. Disagreement of opinion among analysts, and for that matter among any scientists, may be of two different kinds. The first stems from a lack of a common frame of reference. The other may concern problems which are acceptable as legitimate, but which cannot be clarified at present; they are matters of opinion only. There are some problems of this kind mentioned in Alexander’s and French’s book. For example, French’s advice to make early psychodynamic formulations, to plan the analytic treatment, to scan the possible complications to be expected in the course of therapy-these pertain to questions which might be called legitimate problems. I do not agree with French on those points. I believe that more frequently than not such procedures will lead to intellectualization. Moreover, I believe that in spite of the progress mental science bas made in the last five decades, it is impossible to proceed the way French outlines [Footnote 20: See the very different attitude Reik (1935) takes; Fenichel tries to combine both attitudes (Fenichel, 1941)]. The individual core of the patient is still beyond prediction and when analysis reaches it, it results in a surprise for the analyst also. But I am well aware that French still might be correct on that point. Time and further experience will solve the issue. The points of criticism I tried to raise concern questions I cannot consider legitimate problems of psychoanalytic technique and I surmise that at least some psychoanalysts will agree with me on that score. Hence, I believe the characterization of a crisis is appropriate. If a group of scientists cannot any longer agree on the scope of the problems falling within their range something must have gone wrong and the earlier the problem is outlined succinctly, the better for the scientists. Alexander believes be bas carried to fulfillment the immanent content of psychoanalysis, but I believe that Alexander’s technique is, so to speak, a side branch in that development, an attempt to establish the degree to which psychoanalytic knowledge may lend itself to magic psychotherapy. To be sure, this is a legitimate undertaking per se, but detrimental if done the way Alexander and his group did it. No doubt his new technique will become the standard technique at the Chicago Institute, and what be calls standard technique will be used under exceptional circumstances only. No doubt the new technique will have a great appeal to the majority of workers in the field. It is short, it is less expensive to the patient, it is less painful to him, and it sounds more sensible than the “orthodox” technique. Briefly, it satisfies nearly all of the objections usually raised against psychoanalysis.
I wonder what an historian of psychology will think in one or two hundred years about such a dispute as was presented lien. How will he proceed to uncover the underlying forces effecting the profound cleavage among psychoanalysts who have barely anything in common but their denomination [Footnote 21: Ernest Lewy (1941) has anticipated a pertinent and, to my mind, satisfactory answer to that question. In a more general frame, but referring to a specific historical situation an answer to the question was attempted by Gregory Zilboorg (1944). In regard to the specific disagreement outlined here, I wish to mention a problem with which, as I surmise, nearly every analyst must be familiar from his own experience. The “orthodox” technique imposes some great demands on the analyst’s personality. It involves among other factors a slow progress, a block to motor discharge and, consequently, to the direct discharge of motor energy, an emphasis on the purely mental sphere of human existence; these all entail a certain aloofness to the perceptual-sensual sphere of existence. In order to integrate that technique it is necessary to reach such perfection as to derive from mental activity those pleasures commonly accessible in the kinesthetic sphere. It can be safely assumed that such a degree of sublimation can be achieved only under rare circumstances. It may be worthwhile to speculate as to what degree the new technique protects the therapist from exposure to that very issue. In human affairs the effect of an action frequently betrays the motivation of that action. Cf. Fliess (1942)].
The one group whose opinions I tried to outline will run the risk of being called dogmatic, narrow minded, conservative, overawed by the respect for the genius of Freud, and therefore blinded to see the new light on the horizon. It is quite possible that such judgment will be passed by the future historian and that he will consider me a representative of a group Alexander had described previously as follows:
There is the inert mass of blind followers who uncritically apply the views of an authority, who laboriously have learned the ideas of the master and now desperately defend them from every innovation which would demand new intellectual investment. Since they seldom have judgment or courage for critical evaluation they feel confused and helpless if the critic begins to undermine traditional views and thus shakes their blind belief in the authority, a belief which they so direly need. They therefore dislike the innovator who is capable of emancipating himself from the spell of the master. (Alexander, 1940a, p. 2).
Such opinionated adherence to the tenets inherited from the work of a genius certainly has occurred frequently; after all who is certain enough of the pureness of his desire of finding the truth, to be able to vouch that he is not victimized by that weakness? On the other hand, if it should turn out that Alexander’s new technique has not been a logical step forward in the development of the psychoanalytic technique, the historian will have to turn his investigation towards documentary evidences which might contribute to the explanation of Alexander’s possible mistake.
As far as I can see there are two groups of conditions the historian will have to explore: sociological and subjective. By then the historian will know whether or not Freud was right when making his brief comment that the desire for accelerating the speed of analytic therapy may possibly be correlated to periods of economic prosperity (Freud, 1937a, p. 373). Strangely enough, Alexander dates his interest in a more flexible and briefer technique from the years 1938 and 1939, which coincide fairly well with the beginning of a new wave of economic prosperity. Furthermore, about that time, if I am not mistaken, other analytic groups also began to look around for devices to shorten therapy. Let us hope that the heralded economic depression will have a sobering effect on the present therapeutic fervor.
The historian may know by then whether Freud’s belief, when quoting Anatole France, that the misuse of power might be a stumbling block to objective psychological research, was correct (Freud, 1937a, p. 402). Possibly Freud was quite right in suggesting that every analyst should submit to a personal analysis every five years (Freud, 1937a, p. 402). (I surmise that Freud had in mind an analysis directed by the rules of standard technique.) On the other hand, the historian will have to decide whether that phase of psychoanalysis had been reached which Freud had envisaged when he predicted the alloy of the pure gold of analysis with the copper of direct suggestions which would occur in the application of psychoanalysis to large masses (Freud, 1918).
Furthermore, the future historian may turn for his subjective material to Alexander’s writings to ascertain the background of this therapeutic departure. He will have to investigate to what extent a strong aversion to being a member of a minority group [Footnote 22: See Alexander (1940b, p. 312): “The mentality of a minority group never appealed to him (viz. Alexander)… Minorities always believe that they are chosen people, become suspicious, withdrawing, provocative, and narrow minded.” This horror of being a member of a minority group prevented Alexander, in his formative years, according to his biographical sketch, from joining the psychoanalytic group of his native city. Might it not be possible that such likes or dislikes create some of the disagreements under which psychoanalysis labors at present so direly? After all, psychological facts cannot yet be ascertained with that accuracy which makes’ it increasingly difficult for physicists and biologists to use science as a battleground for their emotions. In this context it may be of interest to quote what Freud himself thought about the possible effect his membership in a minority group may have had on his scientific work. He wrote (Freud, 1924): “It is perhaps not a mere coincidence that a Jew was the first representative of psychoanalysis. In order to avow one’s belief in it, one needed a considerable measure of readiness to bear the fate of isolation when in opposition. The Jew is more familiar with, this fate than is anyone else.” (My own translation.) At least here there seems to have been one instance where membership in a minority lad a wholesome effect on scientific creativity] is conducive to finding the truth in psychological research. Those who shall find new truths concerning the human mind in the present historical epoch will constitute an unpopular minority for a good many years to come, and those who embark on the dangerous voyage of plumbing the depths of the human mind should be aware that there is no glory waiting for them during their lifetime.
The future historian will have to make up his mind on the significance of initial reactions to Freud’s work in those who continue to make psychoanalytic research their life work. He will have to compare the reports of men like Alexander and Sachs, both of whom read Freud’s book on dreams at comparable phases of their mental development. One rejected it as crazy, the other grasped immediately its epochal significance [Footnote 23: Franz Alexander (1940b, p. 310): “The author vaguely remembered that once, years ago, as a medical student be had read Freud’s Interpretation of Dreams… The author returned the book to his father, contemptuously saying, ‘This may not be philosophy, but medicine it is certainly not.’ The book appeared to him crazy”. Hanns Sachs (1944, p. 3): “My first opening of the Traumdeutlung (The Interpretation of Dreams) was the moment of destiny for me – like meeting the ‘femme fatale,’ only with a decidedly more favorable result… When I had finished the book, I had found the one thing worth while for me to live for;…” and further (Sachs, 1944, p. 40 f.): “A book fell in my hands with the fascinating, but bewildering title Traumdeutung. From the first I felt strongly aroused by its outstanding originality and I was excited by the entirely new angle under which many trivial, long-known facts assumed a startling significance. No other scientific book had told me about problems that I, like everyone else, always had before my eyes and yet had never seen or tried to understand. No other book made life seem so strange and no other book had explained its riddles and self-contradictions so fully. I said to myself that these stupendous revelations needed and merited the most complete scrutiny; even if it should in the end turn out that every theory advanced in its pages were wrong, I would not regret the loss of time. I was resolved to spend months or even years if the task should require it.”]. The truth of the old French adage: “On revient toujours a ses premiers amours” has been verified for the neurotic; to what extent it may have validity for the Scientist, will be for the future historian to decide. He will find many other remarkable passages in Alexander’s writings which should facilitate his final evaluation. I want to quote only one of them which I believe to be of importance. When Alexander reviewed the modification of psychoanalysis by one of his colleagues, he tried to depreciate the alleged originality of that author by writing (Alexander, 1940a, p. 4): “Due to a prevailing worship of authority, or perhaps only to an instinctive respect for the sensitiveness of the master, only a few of these more or less widespread modifications were stated explicitly.”
How will the future historian explain the disciple’s claim after the master’s death that the master who bore the weight of spiritual isolation and physical persecution with equanimity could be hurt by the word of truth? By then the historian will know whether it was wise to offer to a civilization already crushingly overburdened by the impact of technology on the individualism of its group members, a substitute for that last island of true individualism which present society possesses in psychoanalysis. Will the historian agree with Alexander concerning the “implications for improving the mental health of the country” (Alexander, French et al., 1946, p. iv) which he assumes to be inherent in his technique, when be finds Alexander’s praise of a maxim “Nothing succeeds like success” (ibid., p. 40) [Footnote 24: Morris (1947, p. 330) discusses the implication the concentration on success had on American civilization which, according to William James, was suffering from “a national disease: ‘the exclusive worship of the bitch-goddess, Success’”] and his belief that “There is no more powerful therapeutic factor than the performance of activities which were formerly neurotically impaired” (Alexander, French et al., 1946, p. 40) [Footnote 25: Compare Alexander of 1946: “The therapist need not wait until the end of treatment, but, at the right moment, should encourage the patient (or even require him) to do those things which he avoided in the past…” (Alexander, French et al., 1946, p. 41), with Alexander of 1925: “Ultimately we free the patient’s ego but from responsibility of self by giving prohibitions or commands. All such activities are but formal if compared with genuine activities which aim at convincing the patient by means of the material gained by analysis…” (Alexander, 1925a, p. 120; my own translation)] or will he register such subjective evaluations as empty reverberations of a society overly concerned with utilitarian values? WRI that historian be utterly confused and not- know weather he is studying a treatise on psychotherapeutics or a primer for Sunday School teachers when he reads (Alexander, French et al., 1946, p. 141): “The therapist must prepare the patient for failures, explaining that they are unavoidable and that the most important thing for him is to be always ready to try new experiments.”
The future of mental science is covered with darkness as is the road of western civilization. Will psychoanalysis as an exact science and as an etiological therapy survive the present witch cauldron? No one knows; but it may be fitting to close with an historical report which will show how ancient is the present dispute. Plutarch reports the following incident the life of Alexander the Great who fell into a melancholic stupor after he had killed his friend Clitus while drunk:
They now brought Callisthenes, the philosopher, who was the near friend of Aristotle, and Anaxarchus of Abdera, to him. Callisthenes used moral language, and gentle and soothing means, hoping to find access for words of reason, and get a hold upon the passion. But Anaxarchus, who had always taken a course of his own in the philosophy, …as soon as he came in, cried aloud, “Is this the Alexander whom the whole world looks to, lying here weeping like a slave, for fear of the censure and reproach of men, to whom he himself ought to be a law and measure of equity, if he would use the right his conquests have given him as supreme lord and governor of all, and not be the victim of a vain and idle opinion? Do not you know,” said he, “that Jupiter is represented to have Justice and Law on each hand of him, to signify that alt the actions of a conqueror are lawful and just?” With these and the like speeches, Anaxarchus indeed allayed the king’s grief, but withal corrupted his character, rendering him more audacious and lawless than he bad been (Plutarch, The Lives of the Noble Grecians and Romans, p. 839).
Callisthenes trying to get “a hold upon the passion” and Anaxarchus introducing on the spur of the moment a corrective emotional experience! We really are in the midst of a modern dispute. Yet Plutarch, the great philosophical describer of human nature, did not permit himself to be blinded by the disappearance of symptoms. He perceived the deterioration of character which was facilitated by Anaxarchus’ clinically dubious procedure.
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