PRINCIPLES OF PRACTICAL PSYCHOTHERAPY

Psychotherapy is a domain of the healing art which has developed and acquired a certain independence only within the last fifty years. Views in this field have changed and become differentiated in a great variety of ways, and the mass of experience accumulated has given rise to all sorts of different interpretations. The reason for this lies in the fact that psychotherapy is not the simple, straightforward method people at first believed it to be, but, as has gradually become clear, a kind of dialectical process, a dialogue or discussion between two persons. Dialectic was originally the art of conversation among the ancient philosophers, but very early became the term for the process of creating new syntheses. A person is a psychic system which, when it affects another person, enters into reciprocal reaction with another psychic system. This, perhaps the most modern, formulation of the psychotherapeutic relation between physician and patient is clearly very far removed from the original view that psychotherapy was a method which anybody could apply in stereotyped fashion in order to reach the desired result. It was not the needs of speculation which prompted this unsuspected and, I might well say, unwelcome widening of the horizon, but the hard facts of reality. In the first place, it was probably the fact that one had to admit the possibility of different interpretations of the observed material. Hence there grew up various schools with diametrically opposed views. I would remind you of the Liébeault-Bernheim French method of suggestion therapy, rééducation de la volonté; Babinski's "persuasion"; Dubois' "rational psychic orthopedics"; Freud's psychoanalysis, with its emphasis on sexuality and the unconscious; Adler's educational method, with its emphasis on power-drives and conscious fictions; Schultz's autogenic training—to name only the better known methods. Each of them rests on special psychological assumptions and produces special psychological results; comparison between them is difficult and often well-nigh impossible. Consequently it was quite natural that the champions of any one point of view should, in order to simplify matters, treat the opinions of the others as erroneous. Objective appraisal of the facts shows, however, that each of these methods and theories is justified up to a point, since each can boast not only of certain successes but of psychological data that largely prove its particular assumption. Thus we are faced in psychotherapy with a situation comparable with that in modern physics where, for instance, there are two contradictory theories of light. And just as physics does not find this contradiction unbridgeable, so the existence of many possible standpoints in psychology should not give grounds for assuming that the contradictions are irreconcilable and the various views merely subjective and therefore incommensurable. Contradictions in a department of science merely indicate that its subject displays characteristics which at present can be grasped only by means of antinomies—witness the wave theory and the corpuscular theory of light. Now the psyche is infinitely more complicated than light; hence a great number of antinomies is required to describe the nature of the psyche satisfactorily. One of the fundamental antinomies is the statement that psyche depends on body and body depends on psyche. There are clear proofs for both sides of this antinomy, so that an objective judgment cannot give more weight to thesis or to antithesis. The existence of valid contradictions shows that the object of investigation presents the inquiring mind with exceptional difficulties, as a result of which only relatively valid statements can be made, at least for the time being. That is to say, the statement is valid only in so far as it indicates what kind of psychic system Ave are investigating. Hence we arrive at the dialectical formulation which tells us precisely that psychic influence is the reciprocal reaction of two psychic systems. Since the individuality of the psychic system is infinitely variable, there must be an infinite variety of relatively valid statements. But if individuality were absolute in its particularity, if one individual were totally different from every other individual, then psychology would be impossible as a science, for it would consist in an insoluble chaos of subjective opinions. Individuality, however, is only relative, the complement of human conformity or likeness; and therefore it is possible to make statements of general validity, i.e., scientific statements. These statements relate only to those parts of the psychic system which do in fact conform, i.e., are amenable to comparison and statistically measurable; they do not relate to that part of the system which is individual and unique. The second fundamental antinomy in psychology therefore runs: the individual signifies nothing in comparison with the universal, and the universal signifies nothing in comparison with the individual. There are, as we all know, no universal elephants, only individual elephants. But if a generality, a constant plurality, of elephants did not exist, a single individual elephant would be exceedingly improbable.

2 These logical reflections may appear somewhat remote from our theme. But in so far as they are the outcome of previous psychological experience, they yield practical conclusions of no little importance. When, as a psychotherapist, I set myself up as a medical authority over my patient and on that account claim to know something about his individuality, or to be able to make valid statements about it, I am only demonstrating my lack of criticism, for I am in no position to judge the whole of the personality before me. I cannot say anything valid about him except in so far as he approximates to the "universal man." But since all life is to be found only in individual form, and I myself can assert of another individuality only what I find in my own, I am in constant danger either of doing violence to the other person or of succumbing to his influence. If I wish to treat another individual psychologically at all, I must for better or worse give up all pretensions to superior knowledge, all authority and desire to influence. I must perforce adopt a dialectical procedure consisting in a comparison of our mutual findings. But this becomes possible only if I give the other person a chance to play his hand to the full, unhampered by my assumptions. In this way his system is geared to mine and acts upon it; my reaction is the only thing with which I as an individual can legitimately confront my patient.

3 These considerations of principle produce in the psychotherapist a very definite attitude which, in all cases of individual treatment, seems to me to be absolutely necessary because it alone is scientifically responsible. Any deviation from this attitude amounts to therapy by suggestion, the kind of therapy whose main principle is: "The individual signifies nothing in comparison with the universal." Suggestion therapy includes all methods that arrogate to themselves, and apply, a knowledge or an interpretation of other individualities. Equally it includes all strictly technical methods, because these invariably assume that all individuals are alike. To the extent that the insignificance of the individual is a truth, suggestive methods, technical procedures, and theorems in any shape or form are entirely capable of success and guarantee results with the universal man —as for instance, Christian Science, mental healing, faith cures, remedial training, medical and religious techniques, and countless other isms. Even political movements can, not without justice, claim to be psychotherapy in the grand manner. The outbreak of war cured many a compulsion neurosis, and from time immemorial certain miraculous localities have caused neurotic states to disappear; similarly, popular movements both large and small can exert a curative influence on the individual.

4 This fact finds the simplest and most nearly perfect expression in the primitive idea of "mana." Mana is a universal medicinal or healing power which renders men, animals, and plants fruitful and endows chieftain and medicine-man with magical strength. Mana, as Lehmann has shown, is identified with anything "extraordinarily potent," or simply with anything impressive. On the primitive level anything impressive is therefore "medicine." Since it is notorious that a hundred intelligent heads massed together make one big fathead, virtues and endowments are essentially the hallmarks of the individual and not of the universal man. The masses always incline to herd psychology, hence they are easily stampeded; and to mob psychology, hence their witless brutality and hysterical emotionalism. The universal man has the characteristics of a savage and must therefore be treated with technical methods. It is in fact bad practice to treat collective man with anything other than "technically correct" methods, i.e., those collectively recognized and believed to be effective. In this sense the old hypnotism or the still older animal magnetism achieved, in principle, just as much as a technically irreproachable modern analysis, or for that matter the amulets of the primitive medicine-man. It all depends on the method the therapist happens to believe in. His belief is what does the trick. If he really believes, then he will do his utmost for the sufferer with seriousness and perseverance, and this freely given effort and devotion will have a curative effect—up to the level of collective man's mentality. But the limits are fixed by the "individual-universal" antinomy.

5 This antinomy constitutes a psychological as well as a philosophical criterion, since there are countless people who are not only collective in all essentials but are fired by a quite peculiar ambition to be nothing but collective. This accords with all the current trends in education which like to regard individuality and lawlessness as synonymous. On this plane anything individual is rated inferior and is repressed. In the corresponding neuroses individual contents and tendencies appear as psychological poisons. There is also, as we know, an overestimation of individuality based on the rule that "the universal signifies nothing in comparison with the individual." Thus, from the psychological (not the clinical) point of view, we can divide the psychoneuroses into two main groups: the one comprising collective people with underdeveloped individuality, the other individualists with atrophied collective adaptation. The therapeutic attitude differs accordingly, for it is abundantly clear that a neurotic individualist can only be cured by recognizing the collective man in himself—hence the need for collective adaptation. It is therefore right to bring him down to the level of collective truth. On the other hand, psychotherapists are familiar with the collectively adapted person who has everything and does everything that could reasonably be required as a guarantee of health, but yet is ill. It would be a bad mistake, which is nevertheless very often committed, to normalize such a person and try to bring him down to the collective level. In certain cases all possibility of individual development is thereby destroyed.

6 Since individuality, as we stressed in our introductory argument, is absolutely unique, unpredictable, and uninterpretable, in these cases the therapist must abandon all his preconceptions and techniques and confine himself to a purely dialectical procedure, adopting the attitude that shuns all methods.

7 You will have noticed that I began by presenting the dialectical procedure as the latest phase of psychotherapeutic development. I must now correct myself and put this procedure in the right perspective: it is not so much an elaboration of previous theories and practices as a complete abandonment of them in favour of the most unbiased attitude possible. In other words, the therapist is no longer the agent of treatment but a fellow participant in a process of individual development.

8 I would not like it to be supposed that these discoveries dropped straight into our laps. They too have their history. Although I was the first to demand that the analyst should himself be analysed, we are largely indebted to Freud for the invaluable discovery that analysts too have their complexes and consequently one or two blind spots which act as so many prejudices. The psychotherapist gained this insight in cases where it was no longer possible for him to interpret or to guide the patient from on high or ex cathedra, regardless of his own personality, but was forced to admit that his personal idiosyncrasies or special attitude hindered the patient's recovery. When one possesses no very clear idea about something, because one is unwilling to admit it to oneself, one tries to hide it from the patient as well, obviously to his very great disadvantage. The demand that the analyst must be analysed culminates in the idea of a dialectical procedure, where the therapist enters into relationship with another psychic system both as questioner and answerer. No longer is he the superior wise man, judge, and counsellor; he is a fellow participant who finds himself involved in the dialectical process just as deeply as the so-called patient.

9 The dialectical procedure has another source, too, and that is the multiple significance of symbolic contents. Silberer distinguishes between the psychoanalytic and the anagogic interpretation, while I distinguish between the analytical-reductive and the synthetic-hermeneutic interpretation. I will explain what I mean by instancing the so-called infantile fixation on the parental imago, one of the richest sources of symbolic contents. The analytical-reductive view asserts that interest ("libido ") streams back regressively to infantile reminiscences and there "fixates"—if indeed it has ever freed itself from them. The synthetic or anagogic view, on the contrary, asserts that certain parts of the personality which are capable of development are in an infantile state, as though still in the womb. Both interpretations can be shown to be correct. We might almost say that they amount virtually to the same thing. But it makes an enormous difference in practice whether we interpret something regressively or progressively. It is no easy matter to decide aright in a given case. Generally we feel rather uncertain on this point. The discovery that there are essential contents of an indubitably equivocal nature has thrown suspicion on the airy application of theories and techniques, and thus helped to range the dialectical procedure alongside the subtler or cruder suggestion methods.

10 The depth-dimension which Freud has added to the problems of psychotherapy must logically lead sooner or later to the conclusion that any final understanding between doctor and patient is bound to include the personality of the doctor. The old hypnotists and Bernheim with his suggestion therapy were well enough aware that the healing effect depended firstly on the "rapport"—in Freud's terminology, "transference"— and secondly on the persuasive and penetrative powers of the doctor's personality. In the doctor-patient relationship, as Ave have said, two psychic systems interact, and therefore any deeper insight into the psychotherapeutic process will infallibly reach the conclusion that in the last analysis, since individuality is a fact not to be ignored, the relationship must be dialectical.

11 It is now perfectly clear that this realization involves a very considerable shift of standpoint compared with the older forms of psychotherapy. In order to avoid misunderstandings, let me say at once that this shift is certainly not meant to condemn the existing methods as incorrect, superfluous, or obsolete. The more deeply we penetrate the nature of the psyche, the more the conviction grows upon us that the diversity, the multidimensionality of human nature requires the greatest variety of standpoints and methods in order to satisfy the variety of psychic dispositions. It is therefore pointless to subject a simple soul who lacks nothing but a dose of common sense to a complicated analysis of his impulses, much less expose him to the bewildering subtleties of psychological dialectic. It is equally obvious that with complex and highly intelligent people we shall get nowhere by employing well-intentioned advice, suggestions, and other efforts to convert them to some kind of system. In such cases the best thing the doctor can do is lay aside his whole apparatus of methods and theories and trust to luck that his personality will be steadfast enough to act as a signpost for the patient. At the same time he must give serious consideration to the possibility that in intelligence, sensibility, range and depth the patient's personality is superior to his own. But in all circumstances the prime rule of dialectical procedure is that the individuality of the sufferer has the same value, the same right to exist, as that of the doctor, and consequently that every development in the patient is to be regarded as valid, unless of course it corrects itself of its own accord. Inasmuch as a man is merely collective, he can be changed by suggestion to the point of becoming—or seeming to become—different from what he was before. But inasmuch as he is an individual he can only become what he is and always was. To the extent that "cure" means turning a sick man into a healthy one, cure is change. Wherever this is possible, where it does not demand too great a sacrifice of personality, we should change the sick man therapeutically. But when a patient realizes that cure through change would mean too great a sacrifice, then the doctor can, indeed he should, give up any wish to change or cure. He must either refuse to treat the patient or risk the dialectical procedure. This is of more frequent occurrence than one might think. In my own practice I always have a fair number of highly cultivated and intelligent people of marked individuality who, on ethical grounds, would vehemently resist any serious attempt to change them. In all such cases the doctor must leave the individual way to healing open, and then the cure will bring about no alteration of personality but will be the process we call "individuation," in which the patient becomes what he really is. If the worst comes to the worst, he will even put up with his neurosis, once he has understood the meaning of his illness. More than one patient has admitted to me that he has learned to accept his neurotic symptoms with gratitude, because, like a barometer, they invariably told him when and where he was straying from his individual path, and also whether he had let important things remain unconscious.