Our methods of psychotherapy should logically depend upon the opinion we hold of the nature of the illnesses concerned and of the 'modus operandi' of the therapeutic process. Our advance in knowledge of mental 'disease' is gradually revealing that this term is only a figure of speech, and that these morbid conditions are really distortions and dissatisfactions of the love life (i.e. social maladaptations which in severe cases involve failure of Interest). Experience of the War Neuroses created a widespread impression that hysterical conversion-symptoms and anxiety were due to more or less definite environmental traumata and shocks. It was then supposed that these painful and terrifying memories, as it were, became 'encapsulated' in the mind by repressions, and that the task of the physician was merely to uncover and discharge the feeling attached to these psychic 'foreign bodies' (complexes). Such a conception attributed prime importance to the physician's knowledge of the patient's unconscious thought. Logically then, it encouraged the hope that by improved means of investigation, whether by symbol-interpretation or by induction of specially responsive states of mind in the patient (e.g. hypnotism or even drugs), or by surprising or 'tricking' the defences by word-association, the skilled physician could accelerate the therapeutic process indefinitely.
Such a hope has proved illusory. 'The progress of psycho-pathology has revealed that the psychopathies of wartime differ from those we meet in peace in, among other ways, one vitally significant circumstance. In war the traumatic factor was adult fear of death and injury, and perhaps horror and discomfort at the conditions of life. In peace the 'traumata' are infantile anxieties and resentments, whose nature and origin have been completely repressed. Both types of neuroses alike have the function of defence or escape, but the latter represents a complete, life-long, maladjustment to life which has been able, however, to fulfil important defensive and compensatory functions in the patient's life. As we see it now, the social separation-anxiety, which is the main drive alike of psychopathy and of culture-evolution, forced the hysteric soldier back to the trenches in Flanders, while the very same factor pins the hysteric invalid to her bed. This predominant factor in pathogenesis (i.e. separation-anxiety, which is displacing sex traumata even in the psycho-analytic etiologies) was our main ally in treating the war neuroses but it is our main enemy in the treatment of those of peace. In the former case the separation-anxiety helped us to overcome the pathogenically insignificant fear of bodily death; in the latter, our task is to induce the patient to lay aside her age-old defences against the infantile dread of isolation, and to find an adequate substitute in adult love and interest-companionship.
Perhaps I appear to state dogmatically what should be supported by argument; but an examination of the various extinct and extant theories of psychotherapy will show that the trend and present consensus of opinion supports the view that psychopathy is a disturbance in the love life. There are some nine or ten theories of therapy that are worth considering. Most of these represent an aspect of the truth, and their changing vogue will perhaps help us to discover the essential process which all are trying to achieve.
We can dismiss at the very beginning such static and intellectual conceptions of cure as a process of 'increase of insight', 'removal of gaps in memory', etc., or even 're-integration', if the latter conception is intended in a structural or intellectual sense. Therapy deals not with ideas and their logical arrangement, but with free emotion of an unpleasant character or with its inhibition-effects such as loss of interest, seclusiveness, substitution of fantasy-gratification for reality, paralysis, etc. Although I have suggested a classification of psychopathy into two groups, one predominantly expressing morbid (socially unsuitable) wishes or ideals and another representing their corresponding frustrations, I regard frustration, with its consequent anxiety and bate, as the root cause of both alike. Re-integration therefore means no more than the removal of anxiety barriers, and so does not well express the essence of psychotherapy.
The earliest psycho-analytic conception of the mechanism of cure, that of Catharsis or Abreaction, was that already referred to as dominating our treatment of the war neuroses, namely the uncovering of a traumatic, unconscious memory or fantasy and the discharge of the affect of this Complex', which was imagined to be pent up by repressive fear. Somewhat akin to this mechanistic conception of psychic illness and its 'cure' is the idea that we must increase the patient's tolerance or diminish his censorship of the evil, sexual impulses which were at one time imagined as the main content of the unconscious system. The neurotic was held to be morally hyper-aesthetic, and contact with the broadminded analysts de-sensitized, or, as many disapproving lay writers held, demoralized him to the required extent. Needless to say such a theory of therapy was never approved by serious analysts, though it was popular with rebel temperaments who embraced analysis for anti-social reasons, conscious and unconscious.
There is enough truth in the idea, however, to warrant closer examination, for the reduction of the patient's intolerance could be construed in either of two ways. Firstly, the aim of cathartic treatment might be expressed by this imaginary verbal reassurance by the physician to patient, 'these evil thoughts and wishes are not really bad after all. Sex is only bad for children; that is why it is hidden by adults from them. Now you are grown up and permitted to wish these things.' We might name this type of therapy 'initiation'. On the other hand the physician's attitude might be represented by this imaginary speech. 'Of course you (patient) are bad - if you call sex bad; we all are bad in this sense. We are merely hypocrites; and goodness is an illusion.' This might be called Disillusionment Therapy, yet, even here, in practice we establish a fellowship of sorts with the patient. This latter (alternative) meaning of analytic 'demoralization' is implicit in Freud's Metapsychology and in his social and ethnological writings, such as 'The Future of an Illusion' and his recent letter to Einstein on 'Why War?' We see it again in Dr Eder's dictum 'We are born mad. We acquire morality and become stupid and unhappy. Then we die.' As I will try to show in a later chapter, this Freudian pessimism and aggressive-ness has its roots in the author's pre-oedipal separation-anxiety and rage, and has no real relationship to his clinical work. On this supposition only, it appears to me, can we account for the unscientific nature and development of the Freudian General Theory of Mind and for the curious fact that psychoanalytic theory and practice are so far divorced from each other that not only does theory not influence therapy but it is even unable to explain it.
We reject then (in common with all Psycho-analysts) the idea that a mere counter-attack upon social restrictions, idealisms, and censorships, and the demonstration of the 'hypocrisy' of our traditional convention really relieves neurosis except by substituting for it cynicism and revolt. The rebel is not 'free'; it does the patient no good to bring others down to his level, since it leaves him still without any sense of belonging to and with others without any sense of 'acceptance' or common purpose in life; in other words it leaves him as lonely and aimless as before. Even on the first interpretation of 'de-moralization' (namely as the demonstration of a dual idealism, one for adults and one for children respectively) we do not get very far. ‘Enlightenment' and 'initiation' have, however, a momentary good effect, and as this element of treatment promises quick results (as well as for un-conscious reasons) a theory of cure and corresponding technique of this sort makes a wide appeal.
Summing up these earlier ideas about psychotherapy, we can distinguish:
1. Those methods which, broadly speaking, represent a flight from feeling into intellectual or philosophical 'solutions'. 'Explanations', 'insight', 'recovery of memories', 'occupation and distraction', etc., all work in this manner, as also do the very popular and prevalent theories which assure us that the trouble is all due to some morbid bodily condition. The advantage (?) of all these methods is that they save the therapist from the difficulty of under-standing his patient and spare him the pain of sympathizing with the patient's distress. They preserve his tenderness-taboo.
2. If the therapist's own security does not depend on neurotic 'flight' from feeling and he is therefore not impelled to an 'affective' flight from the patient, be may approach the latter in the role of parent armed with authority and a 'patronizing' love. On this line a whole range of techniques is open, called 'persuasion', suggestion, hypnosis, 'confession and absolution', etc., all aiming at the encouragement or moral coercion of the patient into 'normal' ways of thinking and acting. By such methods we disregard the illness, repress its symptoms, and seek to reassure the patient. These methods are criticized on the ground of their ineffectiveness in dealing with the deeper sources of guilt and anxiety and because they do not assist the patient to grow up.
3. From the beginning the Freudian approach showed more interest in and sympathy with the patient than either of the above, and more curiosity about what was actually wrong with him. The earlier analytic theories of therapy, such as 'catharsis', 'freeing of the libido', etc., along with the outlook upon life characteristic of the metapsychology and the social philosophy of psycho-analysis, seem to me to present the therapist as 'siding with' the patient's desire for freedom and enjoyment against the tyranny of social environment and cruelty of life generally. The effect of such an approach is tacitly to offer the patient the sympathy and companionship of joint revolt and suffering, and of course this is to some extent reassuring to him. To the love-shy and love-starved patient a systematic denial of the existence of any love but bodily gratification must be comforting. We cannot wish for the non-existent, so that here again the analyst's tenderness-taboo is preserved.
The latest theories and techniques of analysis represent, however, a franker approach to fellowship and the therapeutic employment of love. The play-analysis of children combines the companionship of a friendly playfellow with the insight, equanimity, wisdom, and strength of a parent, giving to the child at one and the same time a sense of freedom and sense of security. Even the reductive method of analysis, as will be seen, 'exhibits' far more love than is usually admitted, in the sense of a responsiveness which is unwearying, tolerant, and even appreciative, insighted, and alert. A true and full companionship of interest is offered to the patient, which in all therapeutically essential respects reconstitutes the primary interest-relationship of mother and baby in baby and its affairs.
Though the physician may not actually respond emotionally to the patient's emotions in unison or in harmony, he shows by his understanding and insight that he too has suffered these experiences, so that there is a 'fellowship of suffering' established. Ferenczi's 'Active-therapy' represents a protest against the more extreme ideals of 'passive' technique, and Barbara Low apparently refers to these errors in speaking of the analyst's dangerous attempt 'to maintain the fiction of immunity from emotion'. A one-sided, unresponsive, love-relationship must evoke anxiety and cannot be curative. I suggest that the patient is entangled into this dependency by the analyst's insight and sympathetic interest, which seem to promise real (parental) love and that the physician's subsequent reserve and aloofness forces the love-needing patient into an abject surrender, pleading, protesting, and self-revealing. This is utilized for the exhaustive examination of ancient grievances, anxieties, and rages connected with frustrated social needs of childhood. I further suggest that the 'overcoming of resistances' is therapeutically effective not because of the wishes so released for future gratification, but because of the removal of the threats and sanctions which bad inhibited them and which continue to produce anxiety and resentment; that is to say recovery is essentially a social reconciliation. This appears to me to be the use of anxiety.
I fully accept Ferenczi's dictum 'The physician's love heals the patient', the nature of the love being understood as a feeling-interest responsiveness - not a goal-inhibited sexuality. The cure would then appear to be restoration of that social confidence which is the basis of interest, and the removal of the privation-anxiety which is the main disturber of the sex appetite. If tenderness or love were goal-inhibited sexuality as Freud holds, then it should itself be anxiety-ridden and could not therefore form a therapeutic agent. Further, as I have pointed out, it is itself rigorously inhibited although it is not offensive to social feeling as are jealousy, incest-guilt, etc. So I conclude that the essential process in psychotherapy is to offer the patient the means of re-establishing free 'feeling-interest' relationships with his social environment in the person of the analyst (to begin with). The latter thus replays the original role of the mother in becoming the starting-point of a broadening circle of anxiety-free relationships - that is to say of relationships where feelings need not be inhibited or repelled (this does not refer to conscious control) and where interest responses are equally free.
This is the foundation of companionship; so that the role of psychotherapy appears to be the restoration 'of the patient to full membership of society, to a feeling-interest integration with other minds, a rapport in which the patient can express himself in 'the confidence of evoking agreeable response and in which he feels himself able to respond agreeably to the overtures of others. Expression, as I have said, is not merely evacuation or 'detensioning', though Freud often speaks of it in this sense. I regard it as complete only when a response has been evoked and appreciated. Of course the patient, by degrees and according to his capacity, must be led out of the companionship of expressed emotion to that of Interest and Speech. He must grow up, and so some response must be given to him in psychotherapy, or anxiety and not care will result, as actually happens occasionally.
If I am right in the above representation of Psychotherapeutic processes, then we can discern the factor common to them all - the quest for a basis of companionship with the patient. Even in the first group - the flight from feeling - the therapist seeks to share with the patient his own neurotic defences, and establishes a fellowship of interest (meanings, ideas, etc.) in lieu of that of 'feeling' which neither can tolerate. The second aims at the secure, authoritative rapport of parent and child; the third mode of therapy establishes a conspiracy or fellowship of suffering while the later analytic group of 'techniques' almost explicitly 'exhibit' love, even while theoretically denying its existence. Here is a progressive approach to the position upheld in this book, but how is it that the social nature of the process is not more frankly admitted, cultivated, and studied?
In spite of the complex and abstract evasions (by certain psycho-analytic teachers) of the issue which Ferenczi put in a nutshell, we conclude that the development of psychotherapy is demonstrating in ever clearer fashion the reality and importance of that 'love' whose nature and origin this book is intended to explore.