Class _J1_P 17^ Book. ^QEXRrGHT DEPOSITV Nervous aod Mental Disease Monograph Series No. 26 The Technique of Psychoanalysis By SMITH ELY JELLIFFE, M.D. Nervous and Mental Disease Publisbing Ceinpany New York and Washington, D. C, 1918 Monograph Nos. 2, 3, 6,S,tQ out of Ptint Nervous and Mental Disease Monograph Series Edited by fl SMITH ELY JELLIFFE, M.D. WILLIAM A. WHITE, M.D. No. I. Outlines of irsychiatry. (Sixth Edition, 1918.) By WM. A. WHITE- M.D., Price $3.00.- A clearly written and concise presentation of psychiatry, especially adapted for' use in teaching and in public institutions for mental diseases. No. 4. Selected Papers on Hysteria and Other Psychoneuroses. (Second Edition, 1912.) By PROF. SIGMUND FREUD, M.D., Price $2.50. A selection of some of the more important of Freud's writings. No. 5. Wassermann Serum Reaction in Psychiatry. By FELIX PLAUT, M.D., Price $2.00. 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Nervous and Mental Disease Monograph Series No. 26 The '1)1^ Technique of Psychoanalysis BY SMITH ELY JELLIFFE, M.D. iiJ^ # NEW YORK AND WASHINGTON NERVOUS AND MENTAL DISEASE PUBLISHING COMPANY 1918 %y NERVOUS AND MENTAL DISEASE MONOGRAPH SERIES ^D Edited by Drs. SMITH ELY JELLIFFE and WM. A. WHITE Numbers Issued 'y; 4f< z. Outlines of Psychiatry. (5th Edition.) $3.00. By Dr. William A. White. a. Studies in Paranoia. (Out of Print.) By Drs. N. Gierlich and M. Friedman. 3 . The Psychology of Dementia Praecox. ( Out of Print) . By Dr. C. G. Jung. 4. Selected Papers on Hysteria and other Psychoneuroses . (2d Edition.) $2.50. By Prof. Sigmund Freud. 5. TheWassermannSerum Diagnosis in Psychiatry $2.00. By Dr. Felix Plant. 6. Epidemic Poliomyelitis. NewYork, 1907. ( Outof Print) . 7. Three Contributions to Sexual Theory. (2d Ed.) $2.00. By Prof. Sigmund Freud. 8. Mental Mechanisms $2.00. By Dr. Wm. A. White. (Out of Print). 9. Studies in Psychiatry. $2.00. New York Psychiatrical Society. 10. Handbook of Mental Examination Methods. $2.00. (Out of Print.) By Shepherd Ivory Franz. 11. The Theory of Schizophrenic Negativism $0.60. By Professor E. Bleuler. 12. Cerebellar Functions. $3.00. By Dr. Andre-Thomas. 13. History of Prison Psychoses. $1.25. By Drs. P. Nitsche and K. Wilmanns. 14. General Paresis. $3.00. By Prof. E. Kraepelin* 15. Dreams and M3rths. $1.00. By Dr. Karl Abraham. 16. Poliomyelitis. $3.00. Dr. I. Wickmann. 17. Freud's Theories of the Neuroses. $2.00. Dr. E. Hitschmann. 18. The Myth of the Birth of the Hero. $1.00. Dr. Otto Rank. 19. The Theory of Psychoanalysis. $1.50. (Outof Print). Dr. C. G. Jung. 20. Vagotonia. $1.00. (2nd Edition). By Drs. Eppinger and Hess. . 21. Wishfulfillment and Symbolism in Fairy Tales. $1.00. By Dr. Ricklin. 22. The Dream Problem. By Dr. A. E. Maeder. $0.60. 23. The Significance of Psychoanalysis for the Mental Sciences. $1.50. By Dr. 0. Rank and D. H. Sachs. 24. Organ Inferiority and its Psychical Compensation. By Dr. Alfred Adler. $1.50. 25. The History of the Psychoanalytic Movement. $0.60. By Prof. S. Freud. 26. Technique of Psychoanalysis. $1.50. By Dr. Smith Ely Jelliffe. Copyright, 19 18, by Nervous and Mental Disease Publishing Company 3617 loth St., N. W., Washington, D. C. ©CI.A494564 The new era printing company Lancaster. Pa. APR 12 1818 J* ;4. J) I TABLE OF CONTENTS Preface v Introduction vii Chapter I. The Material to be Analyzed. What not to Analyze i Chapter II. The Literature, Sources and History of Psy- choanalysis 21 Chapter HI. Opening of the Analysis. The General Sit- uations and Preliminary Formulations 28 Chapter IV. The CEdipus Hypothesis as a Psychological Measuring Unit. Its Evolution and Final Stabilization as a Social Force 49 Chapter V. Transference and its Dynamics the Basis of Social Integration and the Lever in Psychoanalysis .... 66 Chapter VI. Transference and Resistance. Opposing yet Identical Mechanisms. Practical Signs 87 Chapter VII. Overcoming the Conflicts. Socialization of the Personality. The Use of the Dream in Handling the Dynamics of the Transference-Resistance 128 Index 161 111 PREFACE " Not in his goals but in his transitions man is great, and the truest state of mind rested in, becomes false." [Chinese Proverb.] The traveller in a foreign land who keeps to the main highway needs no guide. He does not even have to know the language of the country for a judiciously distributed pour boire will put him in touch with all the more common requirements of his sur- roundings. With his Baedeker in hand, he may even wander about in strange surroundings oblivious to the unknown claque about him and return to his haven of safety with an outline of the topog- raphy of the city, its bricks and mortar, and possibly its trolley cars. But were he to go into the by-ways, were he to reach out for an understanding of the rich life that is actually being lived about him, he is more or less shut off, and deaf and dumb must needs grope about if without knowledge of the language of the country. The doctor of medicine is in some such a position — his un- explored countries come to him, however, he does not go to them. His Baedekers — Gray, Osier, and perhaps a rich library, fur- nishing the details of many complicated structures — lead him through the more frequented paths of disease processes, but, like the real traveller he not infrequently finds himself lost in unexplored territory. A new language strikes his ear at every specialistic frontier that he would pass; a rich and apparently hopeless terminology has to be mastered if he would travel in new fields, and if he would know what is going on over the boundary he must make it a part of himself. It is of no service to him to rationalize his indolence by calling this speech new-fangled, absurd or unnecessary. To shut his eyes and ears to these new languages, refusing to learn them, only hampers himself, and the stream of active intelligence goes on, leaving him in an eddy of his own isolation. Words are only tools to be used to cut into the facts of nature, so that fellow workers, through mutual understanding, can make a concerted effort and clear a pathway into the secrets of life. The simplest act of reflection will show that the more complex the situation, the greater will be the confusion of new tongues and the greater will be the need for the construction of new Vi PREFACE tools — words — to aid the explorer. This is why the problems connected with the study of mental activities have so rich a terminology and one constantly undergoing evolution. Bones, tendons, muscles, intestines, hearts, lungs, have been much alike for countless centuries, and have modified little in their structures, but the nervous system, an active, changing master-spirit in evolution, is constantly reaching out in its attempt to grasp the infinite. Even the simplest aboriginal inhabitants of an Australian village are giants in mental development when compared to the earliest products of the age of man. Historical retrospect can but imperfectly reconstruct the stages of primitive culture, but the connecting links between aboriginal and modern races are there. The ethnologist, the archeologist, the anthropologist, the student of language, of customs, of laws, of religions has a rich material, and already the data available for the understanding of the development of civilization and of culture surrounds the stu- dent of human nature in bewildering profusion. The races of the twentieth century are partakers in this heritage of a bountiful past and the individual of to-day is its product. To completely understand him entails a knowledge of the principal gifts of this inheritance, and he who would grasp the innermost causes that sway the human mind must be able to reconstruct the stages through which that mind has come in its development from primitive culture to modern conditions. " What are we," queries Bergson, " in fact what is our character if not the condensation of the history that we have lived from our birth — nay even before our birth, since we bring with us prenatal dispositions?" "Doubtless we think with only a small part of our past, but it is with our entire past, including the original bent of our soul, that we desire, will, and act." These " prenatal dispositions," this " original bent of our soul " are a part of the inheritance of which we speak. Everything in human life, individual as well as social, has then its historical background, its origin, its life history and thus its adequate work- ing interpretation. Nothing is trivial, nothing is fortuitous. Psychoanalysis outlines the task of interpreting human motives from this point of view. How; it will be my privilege to more fully set forth. "While we sit still we are never the wiser; but going into the river, and moving up and down, is the way to discover its depths and its shallows." Bacon. INTRODUCTION The present series of articles is planned for the beginner in psychoanalysis. They therefore will contain little that the trained analyst does not already know. If because of their simplistic character they prove of service to the neophyte my purpose will have been accomplished. At the outset it seems desirable to give a general outline of what psychoanalysis is. For this a bare definition will not suffice. The word itself is almost as indicative as such a definition might reasonably hope to be. Psychoanalysis is primarily to be consid- ered as a method. As such, it seeks to establish a knowledge of the development of individual human motives. Just as a chemical analysis serves to determine the ultimate composition of this or that substance present in nature, so psychoanalysis has for its task the unravelling of the ultimate causes of this or that mani- festation of human conduct. Psychoanalysis then is merely a tool, just as chemical analysis is a tool — both are methodological disciplines working with different facts of nature, each seeking to determine ultimates in their respective spheres; the former deal- ing with data of that portion of the nervous system functioning to adapt the individual and the race to reality, the latter working with the inorganic and organic substances making up a large portion of that reality. Not to extend this particular analogy too unduly, it may be added that inasmuch as chemical analysis is restricted only in its choice of material, so psychoanalysis need have no barrier for its activities. It is not a method limited solely to the solution of problems of psychopathology any more than chemical analysis is confined to the study of pathological human substances. All of the questions arising in relation to psychological activities may be investigated by the psychoanalytic method. It seems to me desirable in this place to clearly emphasize the fact that in psychoanalysis we are dealing solely with a method for gaining data since one frequently hears the statement that psychoanalysis is nonsense. A method, or a tool, is not nonsense. Chemical analysis is not nonsense, although bad quantitative or qualitative chemical methods may lead to false or nonsensical results. The individual chemist may be badly trained in his vii Vlll INTRODUCTION methods and be a poor chemist. This does not invalidate the methods of chemistry. Again certain substances may be so com- plex in their structure as to defy even the best chemical methods at separation and identification ; this argues only for the compar- ative crudity of the known analytic resources. It can readily be conceded in an analogous sense that the psychoanalytic methods now developed may be comparatively crude, but this only sup- plies a motive for their betterment rather than an argument as to their falsity. The crudities of those social instruments, the law and medicine, are known to all men, but only the sick egoist argues to do away with all law and all medicine. Those healthy nervous systems capable of adaptation to the realities of nature are endeavoring to improve law and medicine. They seek to minimize their crudities and make them better instruments for the obtaining of human happiness. In this, as well as in many another task, the methods of psychoanalysis are destined to play an enormous role in the near future. In this place, I can only indicate some of the fields of activity in which psychoanalysis, as a method, has already rendered im- portant service, leaving for future consideration, when I hope to present a summary of the development of the method, the more complete statement of its spheres of operation. It is chiefly in the realms of psychopathology that psycho- analysis first showed its value ; those chapters in medicine devoted to the study of the neuroses and psychoneuroses having been entirely remodelled by its application. In a similar manner the understanding of certain of the psychoses, particularly schizo- phrenia (dementia prsecox), paranoia, and the manic-depressive group, is undergoing marked transformations as a result of the psychoanalytic methods. That large chapter of alcoholism which is not an object of interest to medicine alone, but enters into almost every sphere of human life, is having most penetrating and far-reaching light thrown upon it by the students of the psycho- analytic school. A new science and application of pedagogy are being reared upon the data obtained by psychoanalysis, as witness the masterly work of Pfister recently published and made the forerunner of an important series of works on pedagogy under the leadership of Meumann and Messmer. The students of history, anthropology, ethics, religion, philos- INTRODUCTION IX ophy and art are beginning to feel the value of the material ob- tained by the methods of psychoanalysis, and already a shift of position with better generalizations is making itself apparent.^ It is not my purpose, however, to sketch any such ambitious program in these pages. I shall content myself with the rudi- ments, and shall deal more particularly with simple medical prob- lems ; with such as are met with by the average practitioner, or those that come more directly to the student of nervous diseases. I believe that every sincere practitioner can practise psycho- analysis just as he can practise surgery. In the latter case, with a fundamental knowledge of bacteriology he may cut just as far as his anatomical knowledge and experience permit him. He may limit himself to minor surgery, or he may attempt more difficult and complicated operations. So with the methods of psychoanaly- sis, if the practitioner will make an earnest attempt to understand them, he will be enabled to be of enormous service even when only using the simplest fundamentals. There are numerous sick individuals who do not need a complex analysis, because they have not developed a complex neurosis. Such can be relieved or cured by the application of the rudiments of psychoanalysis. This is particularly true in the pedagogic field working with develop- ing children. On the other hand, it is important for the general practitioner to know that the complicated cases need a more complete grasp of the methods, just as an operation upon the brain requires more than a general knowledge of the princi- ples of minor surgery. The statement that we are dealing solely with a method, how- ever, is incomplete — it is necessary to ask what is the method in- tended to do ? and furthermore why is a special method needed ? It has already been said that by psychoanalysis one seeks to establish a knowledge of the causes for human behavior, that all of the psychical activities may be investigated by its means, and that it deals with data of the psychic life in its function of adaptation to reality. It thus seeks to establish a basis for the understand- ing of human conduct. Such broad statements, however, are entirely too general, especially for the purposes I have in mind in these pages. We shall limit them here more particularly to the individual principles of human behavior, especially in their application to definite med- ^The Significance of Psychoanalysis for the Mental Sciences. Nerv- ous and Mental Disease Monograph Series, No. 23, edited by White and Jelliffe, New York and Washington. X INTRODUCTION ical situations. The psychoanalytic methods which will be here outlined then will bear solely upon practical medical problems con- fined within comparatively narrow bounds. We intend to learn by them why certain symptoms of disease come into being, and what the meaning of these symptoms is for the individual's adaptation. We may then be in a position to properly estimate the modus operandi of the disorders under discussion and may possibly eliminate or modify them for the benefit of the sick in- individual. And why is a special method needed? This latter question can only be answered completely after a more extended review of the situations which are to be analyzed. It can be stated here broadly that medicine had not been able to satisfactorily explain the import of many so-called nervous symptoms. The hypotheses were inadequate. Many, in fact most of them, proceeded along lines of chemical analogy. Pituita, black humors, perverted chemism, faulty metabolism, auto-intoxication, indicanuria, etc., these are links in a long his- torical chain of such interpretations, the incompleteness and un- satisfactoriness of which have been demonstrated for thousands of years. Such interpretative formulae might attempt to ex- plain why an individual with an incipient schizophrenia, for instance, should believe that it was absolutely necessary for her when going up a pair of stairs " to go three steps and then stop or else suffer from constipation.'' They would say that it was due to gastro-intestinal fermentation, possibly a parathyroid hyperactiv- ity, or a deficiency of hypophysis secretion. For the sake of discussion it may be admitted that possibly such a disease as schizophrenia may arise from one or other of these or analo- gous metabolic disturbances, but even so wherein does this knowl- edge aid in an understanding of the " three steps or constipation " symptom ? Perhaps the symptom is meaningless and neither needs nor can obtain an explanation. This attitude of mind can be under- stood. It is very old. It has fostered the type of organic ex- planation just mentioned. On the basis of the nonsense of the symptom a still more nonsensical interpretation is given. But let it be assumed that the symptom means something, that it is as real as a dyspnea, and arises from necessary psychical antecedents, then at once it becomes apparent that ''auto-intoxication, per- verted metabolism," etc., are of no value as explanations ; they must be abandoned. INTRODUCTION XI This is all preparatory to saying that the content of an idea, a psychological fact, can never be explained on the basis of per- verted chemism, and that every idea, for we shall deal with ideas — mental facts — has a basis which is as absolutely determined as any other reality of nature. This fundamental postulate that every psychological fact is a bit of nature with definite laws is the reason why a new method of investigation had to be found. The chemical, bacteriological, pathological laboratories had shown their sterility in this par- ticular field of enquiry. Even recognizing this bankruptcy, so to speak, of organic ex- planations for psychological phenomena it may be further recalled that academic psychology has been far from being a promising guiding principle. There have been a number of reasons for this, but two psychological tendencies, which had received the official sanction of the schools, may be touched upon since the psycho- analytic method has shown their inadequacy for its particular problems. For many years official psychology was limited to the so-called physiological psychology. This was practically little more than a detailed physiology of the special sense organs. Its study de- veloped a mass of information relative to the receptors and the conducting mechanisms of the special sense organs, facts of great importance, but of little applicability in getting at explanations for human conduct. Another important attitude of psychology was its insistence upon what it was pleased to call its " norms." The famous dictum that the abnormal in mental life could only be understood from a study of the normal has been one of the chief obstacles to progress. Such an attitude of mind could only have come from the labora- tory worker unacquainted with the progress made in the empirical biological sciences. For here the great advances in knowledge have come from the pathological side. The normal has been built up out of the pathological. Hence, when Freud, rejecting all of the dicta of the official and reigning schools of thought, con- structed his psychoanalytic method upon pathological data, he followed the path of experience in the other biological sciences, and by avoiding the sterile psychology of that fatuous nonentity the "normal mind" founded a method of great value. No previously existing system of thought could properly form a working hypothesis to explain why for this or that individual Xll INTRODUCTION it was necessary for the patient to "go up three steps or else be constipated," or other analogous symptoms which will occur to the reader and which are found in abundance in all pathological cases, be they hysterias, or compulsion neuroses, phobias, schizo- phrenias, or what not. The medical historian, acquainted with the various hypotheses, can see the thread of truth that runs through all of them. Each new century has brought better and better explanations, but it was only when, towards the Charcot era, a definite parting with struc- tural concepts took place, that psychopathology gained a definite right to state to the student of academic psychology that it had to be reckoned with, and that previously existing systems of thought, even philosophies, would prove inadequate if the patho- logical data of medical science in the psychological sphere were neglected. A method, therefore, which would bring together and unite into a genetic or dynamic concept these data of psychopathology was much to be desired. It saw its earliest systematic beginning in the days of Charcot but it remained for Freud to forge the tools of psychoanalysis, and make them of value for every stu- dent of psychical phenomena. That same historian viewing human endeavor in its search of the absolute must realize that psychoanalysis, like other tools that homo faher has constructed, will undergo changes and develop- ments. The very facts of nature that it reveals will cause it to be modified, and if it remain sufficiently plastic, it too can evolve. It is no part of the present program to follow any dogmatic presentation, but I would remind the reader that a simple state- ment of the outlines of the psychoanalytic methods inclines towards a certain amount of positivism which I would gladly avoid if it were possible. THE TECHNIQUE OF PSYCHOANALYSIS. CHAPTER I The Material to be Analyzed. What Patients not to Analyze " There is no vice," says Rochefoucault, " that is not better than the means taken to conceal it." A change of heart has taken place in many quarters of the medical profession with reference to the so-called functional man- ifestations of the nervous system. The neurotic is no longer to be jeered at and made fun of. "Truth from (their) lips prevails with double sway, and fools who come to mock remain to pray." That multitude of patients who "have nothing the matter with them " has commenced to be seen in its true colors. The mem- bers of that much greater multitude who have " so many things the matter with them," and who, as Dejerine very pointedly re- marks, make up at least half of the practice of most physicians, will soon be seen, not in the light of sufferers in this or that or- ganic realm, but as having psychogenic illness, which make them sufferers just as truly as those with "nothing the matter with them." When these truths become the universal heritage of the profession then the medical iconoclasts and jeerers, such as the likes of Pliny, Moliere and Bernard Shaw, will have lost an at- tribute of their vocation and can devote their energies to con- structive rather than destructive criticism. At the present time, however, medicine needs the quips of Shaw to accent its many fads and foibles. The first requirement of the analyst then is a sympathetic attitude towards his material. To pooh-pooh a symptom as " nonsense," as " imagination," as " silly," as " make believe," or "malingering" is an assumption which has no value from the standpoint of the understanding of the symptom. Such an ap- proach to mental problems is rather an index of the naivete and indolence of the assumer. These universal human attributes must be reckoned with and overcome. Thus the analyst becomes a 2 THE TECHNIQUE OF PSYCHOANALYSIS good listener. This listening does not mean the turning of an indulgent ear to the plaints of the sufferer, but a comprehending and grasping curiosity that counts " nothing as trivial, nothing as fortuitous." The analyst must hunger for information about the patient's ills, being ever on guard against formulating interpreta- tions before the returns are all in. All this takes time ! In an opening Dialogue between Philopiro, a physician, and Misomedon, his patient, written by a Dr. B. Mandeville^ some two hundred and fifty years ago, I find the following. Misomedon: I have sent for you. Doctor, to consult you about a distemper, of which I am well assured I shall never be cured. Philopiro: Whatever your case may be. Sir, it is a great Mis- fortune you entertain so ill an Opinion of it; but I hope, your Disease may prove less desperate than your Fears represent it. Misomedon: It is neither better nor worse than I tell you, and what I say, is what I am convinced of by Reason, and not a sug- gestion of my Fears : But you think, perhaps, I'm a Madman, to send for a Physician, when I know beforehand that he can do me no good. Truly, Doctor, I am not far from it: But first of all are you in haste, pray? Philopiro: Not in great haste. Sir. Misomedon: I am glad of that, for most of your Profession either are, or at least pretend to be in a great hurry. But tho' you are at leisure. Can you hear a Man talk for half an hour together, and, perhaps, not always to the purpose, without in- terrupting him? For I have a great deal to say to you, several Questions to ask you, and know I shall be very tedious ; but if you can bear with me I'll consider your Trouble, and pay you for your Time, and Patience both. Can you stay an Hour? Philopiro: Yes, Sir, or longer, if there be occasion." 1' From which it may be seen that in 1685 as well as today, the " physician has failed to understand these patients, and has neglected to give time to their study. If the physician is unwilling to utilize a great deal of time he can never make an analysis. j| Sympathetic insight, intense work in obtaining many state- ments of what are facts to the patient, ofttimes with innumer- able apparently trivial and unimportant details, and time are the primary factors in the opening of an analysis. ^ " A Treatise of the Hypochondriack and Hysterick Diseases in Three Dialogues." London, 1685. MATERIAL TO BE ANALYZED 3 This outline is a commonplace to the trained analyst, but I am here writing for the beginner, who wishes to obtain a working knowledge of a method. No other attitude of mind will bring any useful results. A beginner in chemistry who does not believe there is anything in the atomic theory, that H2SO4 as a symbol for something is nonsense, and that the two sides of a chemical equa- tion convey no information as to what is going on in a chemical reaction is not likely to become a chemist and much less a com- petent authority on chemical problems. Still another situation is in need of emphasis before we ap- proach the patient. This is the subject of diagnosis. The young student is prone to pin his faith to names. They seem very definite to him. Hence he always seeks the diagnosis, and can then "consult an authority" or "read it in a book." He is prone to shut the book before him, the patient, and read what somebody else says about something he knows nothing about, i. e., this particular problem. The diagnosis of the mental side of the problem is an absolutely negligible matter for the opening of an analysis. One's object is to find out what is going on in the • patient's mind. The interest should be concentrated on the cor- rect ascertaining of the symptoms and on processes^ not on names. All diagnoses, it hardly seems necessary to say, are purely artificial • creations for social purposes. They represent useful generaliza- tions for subsequent comparison and discussion with others later on in one's investigations. The attitude of mind that feels that its task has been accomplished when the patient is labelled — hysteria, compulsion neurosis, neurasthenia, etc. — will never grasp nor comprehend the living process going on within the patient. All enquiry stops when one dogmatizes at a diagnosis. The beginning student, therefore, should thrust the idea of the mental diagnosis aside for the more vital problems of getting the facts. Naturally the physical diagnosis, if there is one, is another ques- tion which will be taken up. Mental Facts. — In obtaining the initial history of a patient, one's attitude should be an absolutely impartial and uncritical one. One should avoid all leading questions, and, in the words of Misomedon, one must be willing, yes anxious, "to hear a man talk for half an hour together, and, perhaps not always to the purpose, without interrupting him." This "talk" may be hastily jotted down, or written in short- hand, or an effort made to remember it as one sees fit, which detail will be discussed later. 4 THE TECHNIQUE OF PSYCHOANALYSIS If one is not certain regarding a detail, the patient should be asked to repeat, or explain further, or try to make it absolutely certain just what he means by the statement made. Thus, a patient says " everything must be clear." (Just what do you mean; give me an example. )2 "Why under the bed must be clear; the bed must be clear; the closet must be clear." (How?) "Why I must spread newspapers under the bed, then I can see that it is clear. I must roll up the sheets, and the mattress, and then I am sure that it is clear. I put white papers in the closet and am sure it is clear." (Why?) " Because I must make it clear that there is nothing there. No Booey (negro) element there." This may be as far as such a line of enquiry will take one for the time being, or one goes on to another symptom. In a very short time the analyst experiences the pleasant sensation that the patient feels that some one is really trying to understand what is going on in his mind.^ It should be the analyst's endeavor, in getting the preliminary history, to listen with great care to the patient's own explanation and not endeavor to correct it. Usually the explanation is a correct one, but it is expressed in terms other than those which the non-analytically trained physician usually employs. If the analyzer does not understand what the patient means, it will be pretty certain that the patient will not understand what the analyzer means should he attempt to explain the symptoms. Until the analyzer has grasped the exact significance of the situa- tion, as the patient sees it, it is nonsense for him to offer an explanation. It is of the highest importance not to explain too much to the patient about his neurosis in the beginning. The detailed reasons for this will appear later. It is, up to this point, only necessary for the analyzer to believe that the patient's ex- planations must have some truth in them. 1 am speaking here of mental explanations, not of the banal 2 Parentheses indicate the analyst's enquiries ; the patient's answer follows. 3 Thus recently while listening very attentively for an hour to the "ravings" (?) of a lunatic, the patient suddenly grasped her ear and repeated " rubber ear, rubber ear, rubber ear." This turned out to mean : (i) You are Hstening to what I am saying, (2) I am listening to what you are saying, and (3) some one else is listening at the keyhole. The patient's husband was listening at the keyhole. MATERIAL TO BE ANALYZED 5 interpretations which include ''too much uric acid," "a bit of nerve tire," " an acid stomach," " floating kidney," " eye strain," etc., which have been suggested. Even the medical explanations — given by the patient — bits of misconstrued physiology and the like, these also should be carefully listened to, not with incredulity and impatience, for the patient has accepted them in good faith usually from a former physician in whom there once was con- fidence. After the first unburdening of the patient's mind takes place the real work of history taking begins. This may have occupied one or two visits. The first task now involves a rigid sorting process. lA complete physical examination is usually necessary. The symptomatology will often determine just how minute the examination must be. It must never be overlooked that physical disturbances may exist side by side with psychical ones. It is not my purpose to discuss the relation of the one to the other in just this place, but I hope to make it clear where a practical division may be made so far as psychoanalysis is concerned. Anybody may be analyzed to his advantage. A patient may be greatly benefited even if his headache be due to a brain tumor, but to take the position that such a procedure would be justifiable for the treatment of the tumor is naturally farcical. It would be on a par with the hypnotist's treatment of a mild emotional excitement due to a syphilitic arteriosclerotic cerebral softening by the metronome, or the internist's treatment of the same by valerian, asafetida or bromides ; for forsooth was it not hysterical ? ) Complicated emotional states due to or accompanied by phys- ical disorder are constantly being met with, and the beginning analyst must be on guard not to overlook such a somatic disorder. On the other hand entirely too much stress may be laid upon the latter and the needs for a mental house cleaning overlooked. Even so profound a disturbance as the ataxia of tabes, with its well-known anatomical substratum, contains, according to as good an observer as Maloney,* a very large psychogenic factor in fear, which reinforces the ataxia and makes many bedridden who could otherwise walk with but little difiiculty. In the domain of gastro-intestinal disturbances one constantly meets with this interrelationship of the physical and psychical. In the great majority of cases, the analyst sees the patient only * Journal of Nervous and Mental Disease, November, 1913. 6 THE TECHNIQUE OF PSYCHOANALYSIS after many months of ineffectual gastro-enteric therapy. Under such circumstances the need for analysis is obvious. Gastroin- testinal references are the most frequent in the psychoneuroses. " Man lives to eat " and probably more interest enters into the average man's gastronomic ceremonials than into any other form of expression. It is not to be wondered at, therefore, that the " stomach " should play such a large part in the neuroses and that such a mass of ignorance and superstition should still be found in all classes of society relative to the nutritive instinct. Extremely primitive and animistic notions concerning the food function and the processes of digestion still hold sway even among physicians. The dietary fads of the latter have been subjects for ridicule and satire for years and not without a certain measure of justification. Concerning these and the general subject of the nutritive instinct more will be said later. Before passing to the consideration of the detailed history of the patient which is necessary from the psychoanalytic standpoint, attention should first be directed to those types of patients who should not be analyzed. What Patients Not to Analyze Perhaps the most important thing for the beginner to know is what not to analyze. Even the trained analyst may find to his distress that he has unwisely started a psychoanalytic procedure to learn later that the method in general will not bring about the hoped for result, i. e., the betterment of the patient. For some patients psychoanalysis is not the method to employ. The psycho- analytic viewpoint however should be held to nevertheless. Experience is rapidly accumulating relative to this matter and it is my purpose to discuss some of the bearings of this ex- perience in the following paragraphs. The what not to analyze is intimately related to the why not analyze and hence they must be discussed at the same time. In most respects there are no rules pertaining to psychoana- lytic methods which do not apply to other methods of investiga- tion utilized in medicine in the large. Being methods dealing more particularly with psychical activities going on in the human organism, which activities are plastic and variable, at first sight the material obtained seems more intangible than that obtained by the use of methods which investigate the workings of nature at other levels, i. e., the reflex and the physico-chemical. To illus- MATERIAL TO BE ANALYZED 7 trate: let it be assumed that certain tests are made to determine the sensory and motor functions of a limb. These modes of examination have revealed paralysis with flaccidity, hypotonus, diminution in electrical response, defect in epicritic discrimina- tion, painful nerve trunks, swollen, boggy skin, mild cyanosis, etc. These results lead one to conclude that the peripheral sen- sory and motor neurons in the affected area are undergoing cer- tain alterations. These the science of neurological medicine summarizes under the broad symbol "neuritis." The facts are tangible, one says, because the symbol, neuritis, can group them and handle them as an entity. Intelligence puts the facts — ap- parently quite definite and determined — together, and draws what it calls a logical conclusion. The beginner in neurology, it is true, may assume that only one thing is represented by the term neuritis, and his query may be how to " treat " neuritis, i. e., a symbol, not a thing. The more ex- perienced neurologist is aware that after all there is no dynamic conception behind the term neuritis — the word only symbolizes a series of results and contains only indirect references to causes — i. €., changes induced in nerve impulse conducting structures (nerves — muscles) by various agents, toxic and mechanical. Enquiry should reach out for a genetic conception, and finds it either in alcoholic, diabetic, typhoid, influenza or other type of poisoning, or in mechanical factors due to a syphilitic menin- gitis in the cervical cord, dura, a spinal cord tumor, an osteo- arthritis of the cervical spine, a cervical rib, etc. Determinism now stands revealed; ignorance is dislodged, and intelligence applies the best possible means, chemical or surgical, to over- come the difficulty. This is called logical. The whole chain of events is based on determinism of facts seen at reflex, i. e., sensori- motor levels of the nervous system. One might find illustration after illustration which on final analysis would be reducible to the single thesis of determinism in the facts of nature at least so far as physico-chemico-vltal combinations of phenomena are concerned. As we have seen, the psychoanalytic method assumes the same postulate, namely determinism, for that category of facts which, so far as we are now able to see, may adequately be grouped under the symbol psychical. The very criteria to be applied in solving the " neuritis " problem, here used as an illustration, are pertinent for psychical situations. If the facts obtained seem intangible, 8 THE TECHNIQUE OF PSYCHOANALYSIS incomprehensible — such terms denote simply our ignorance of the many determinants, i. e., the dynamic factors. There can be no intangibility resident in the facts. To say the facts are incom- prehensible is a rationalization of individual ignorance. Ignorance, however, may be no fault. It becomes so only when the individual permits himself to rationalize it, i. e,, give it a disguise, which effectually blocks him in the utilization of his intelligence, which might otherwise solve the problem in hand. Rationalization, therefore, becomes a Janus faced servant of both ignorance and indolence, permitting neither to recognize the other and thus it proves an aid to inertia, that fundamental property of matter which in our school days was defined as " that property by which a body at rest tends to stay at rest until set in motion." Fortunately, however, for human evolution, Newton's theorem goes on to say that " when set in motion it tends to remain in motion until stopped." Therefore, if one is able to recognize ignorance frankly — is able to avoid rationalizing it, such an indi- vidual may be free to choose his pathway. But then, why do we say there are patients who should not be analyzed? Is this a rationalization of ignorance? Let us examine into this ? Is it impossible, or is it unwise to analyze them? If impossible, why? and is such a permanent or a temporary condition? If unwise, is it (a) Because it will be of no service to them; (&) Are there advantages and disadvantages; (c) Do the disadvantages work (c, i) against the patient, (c, 2) the social body, (c, 3) oneself; (