c. 1916 | Vienna

Making a Diagnosis

Sigmund Freud provides an introduction to psychoanalysis.

Ladies and gentlemen: I cannot tell how much knowledge about psychoanalysis each one of you has already acquired from what you have read or from hearsay. But the wording of my prospectus—“Elementary Introduction to Psycho-analysis”—obliges me to treat you as though you knew nothing and stood in need of some preliminary information.

Psychoanalysis is a procedure for the medical treatment of neurotic patients. And here I can at once give you an instance of how in this field a number of things take place in a different way—often indeed in an opposite way—from what they do elsewhere in medical practice. When elsewhere we introduce a patient to a medical technique which is new to him, we usually minimize its inconveniences and give him confident assurance of the success of the treatment. I think we are justified in this, since by doing so we are increasing the probability of success. But when we take a neurotic patient into psychoanalytic treatment, we act differently. We point out the difficulties of the method to him, its long duration, the efforts and sacrifices it calls for; as regards its success, we tell him we cannot promise it with certainty, that it depends on his own conduct, his understanding, his adaptability, and his perseverance.

The whole trend of your previous education and all your habits of thought are inevitably bound to make you opponents of psychoanalysis. In medical training you are accustomed to see things. You see an anatomical preparation, the precipitate of a chemical reaction, the shortening of a muscle as a result of the stimulation of its nerves. Later on, patients are demonstrated before your senses—the symptoms of their illness, the products of the pathological process, and even in many cases the agent of the disease in isolation. In the surgical departments you are witnesses of the active measurements taken to bring help to patients, and you may yourselves attempt to put them into effect. Even in psychiatry the demonstration of patients with their altered facial expressions, their mode of speech and their behavior, affords you plenty of observations which leave a deep impression on you. Thus a medical teacher plays in the main the part of a leader and interpreter who accompanies you through a museum, while you gain a direct contact with the objects exhibited and feel yourselves convinced of the existence of the new facts through your own perception.

In psychoanalysis, alas, everything is different. Nothing takes place in a psychoanalytic treatment but an interchange of words between the patient and the analyst. The patient talks, tells of his past experiences and present impressions, complains, confesses to his wishes and his emotional impulses. The doctor listens, tries to direct the patient’s processes of thought, exhorts, forces his attention in certain directions, gives him explanations and observes the reactions of understanding or rejection which he in this way provokes in him. The uninstructed relatives of our patients, who are only impressed by visible and tangible things—preferably by actions of the sort that are to be witnessed at the cinema—never fail to express their doubts whether “anything can be done about the illness by mere talking.” That, of course, is both a shortsighted and an inconsistent line of thought. These are the same people who are so certain that patients are “simply imagining” their symptoms. Words were originally magic, and to this day words have retained much of their ancient magical power. By words one person can make another blissfully happy or drive him to despair, by words the teacher conveys his knowledge to his pupils, by words the orator carries his audience with him and determines their judgments and decisions. Words provoke affects and are in general the means of mutual influence among men. Thus we shall not depreciate the use of words in psychotherapy, and we shall be pleased if we can listen to the words that pass between the analyst and his patient.

A miracle drug is any drug that will do what the label says it will do.

—Eric Hodgins, 1964

Psychoanalysis is not to be blamed for a difficulty in your relation to it; I must make you yourselves responsible for it, ladies and gentlemen, at least insofar as you have been students of medicine. Your earlier education has given a particular direction to your thinking, which leads far away from psychoanalysis. You have been trained to find an anatomical basis for the functions of the organism and their disorders, to explain them chemically and physically, and to view them biologically. But no portion of your interest has been directed to psychic life, in which, after all, the achievement of this marvelously complex organism reaches its peak. For that reason psychological modes of thought have remained foreign to you. You have grown accustomed to regarding them with suspicion, denying them the attribute of being scientific, and handing them over to laymen, poets, natural philosophers, and mystics. This limitation is without doubt detrimental to your medical activity, since, as is the rule in all human relationships, your patients will begin by presenting you with their mental facade, and I fear that you will be obliged as a punishment to leave a part of the therapeutic influence you are seeking to the lay practitioners, nature curers, and mystics whom you so much despise.

I am not unaware of the excuse that we have to accept for this defect in your education. No philosophical auxiliary science exists which could be made of service for your medical purposes. Neither speculative philosophy, nor descriptive psychology, nor what is called experimental psychology (which is closely allied to the physiology of the sense organs), as they are taught in the universities, are in a position to tell you anything serviceable of the relation between body and mind or to provide you with the key to an understanding of possible disturbances of the mental functions. It is true that psychiatry, as a part of medicine, sets about describing the metal disorders it observes and collecting them into clinical entities; but at favorable moments the psychiatrists themselves have doubts of whether their purely descriptive hypotheses deserve the name of a science. Nothing is known of the origin, the mechanism, or the mutual relations of the symptoms of which these clinical entities are composed. There are either no observable changes in the anatomical organ of the mind to correspond to them, or changes which throw no light upon them. These mental disorders are only accessible to therapeutic influence when they can be recognized as subsidiary effects of what is otherwise an organic illness.

This is the gap which psychoanalysis seeks to fill. It tries to give psychiatry its missing psychological foundation. It hopes to discover the common ground on the basis of which the convergence of physical and mental disorder will become intelligible. Psychoanalysis must keep itself free from any hypothesis that is alien to it, whether of an anatomical, chemical, or physiological kind, and must operate entirely with purely psychological auxiliary ideas—and for that very reason, I fear, it will seem strange to you.

Two of the hypotheses of psychoanalysis are an insult to the entire world and have earned its dislike. The first of these unpopular assertions made by psychoanalysis declares that mental processes are in themselves unconscious and that of all mental life it is only certain individual acts and portions that are conscious. In saying this, it has from the start frivolously forfeited the sympathy of every friend of sober scientific thought, and laid itself open to the suspicion of being a fantastic esoteric doctrine eager to make mysteries, and fish in troubled waters. Yet I can assure you that the hypothesis of there being unconscious mental processes paves the way to a decisive new orientation in the world and in science.

The second thesis, which psychoanalysis puts forward as one of its findings, is an assertion that instinctual impulses which can only be described as sexual, both in the narrower and wider sense of the word, play an extremely large and never hitherto appreciated part in the causation of nervous and mental diseases. It asserts further that these same sexual impulses also make contributions that must not be underestimated to the highest cultural, artistic, and social creations of the human spirit.

Achilles binding Patroclus’ wounds, from a kylix by the Sosias Painter, c. 500 BC. Altes Museum, Berlin, Germany.

Achilles binding Patroclus’ wounds, from a kylix by the Sosias Painter, c. 500 BC. Altes Museum, Berlin, Germany. 

In my experience antipathy to this outcome of psychoanalytic research is the most important source of resistance with which it has met. Would you like to hear how we explain that fact? We believe that civilization has been created under the pressure of the exigencies of life at the cost of satisfaction of the instincts; and we believe that civilization is to a large extent being constantly created anew, since each individual who makes a fresh entry into human society repeats this sacrifice of instinctual satisfaction for the benefit of the whole community. Among the instinctual forces which are put to this use, the sexual impulses play an important part; in this process they are sublimated—that is to say, they are diverted from the sexual aims and directed to others that are socially higher and no longer sexual. But this arrangement is unstable; the sexual instincts are imperfectly tamed, and in the case of every individual who is supposed to join in the work of civilization, there is a risk that his sexual instincts may refuse to be put to that use. Society believes that no greater threat to its civilization could arise than if the sexual instincts were to be liberated and returned to their original aims. For this reason society does not wish to be reminded of this precarious portion of its foundations. It has no interest in the recognition of the strength of the sexual instincts or in the demonstration of the importance of sexual life to the individual. On the contrary, with an educational aim in view, it has set about diverting attention from that whole field of ideas. That is why it will not tolerate this outcome of psychoanalytic research and far prefers to stamp it as something aesthetically repulsive and morally reprehensible, or as something dangerous. But objections of this sort are ineffective against what claims to be an objective outcome of a piece of scientific work, if the contradiction is to come into the open it must be restated in intellectual terms. Now it is inherent in human nature to have an inclination to consider a thing untrue if one does not like it, and after that it is easy to find arguments against it. Thus society makes what is disagreeable into what is untrue. It disputes the truths of psychoanalysis with logical and factual arguments, but these arise from emotional sources, and it maintains these objections as prejudices against every attempt to counter them.

We, however, ladies and gentlemen, can claim that in asserting this controversial thesis we have had no tendentious aim in view. We have merely wished to give expression to a matter of fact which we believe we have established by our painstaking labors. We claim too the right to reject without qualification any interference by practical considerations in scientific work, even before we have inquired whether the fear which seeks to impose these considerations on us is justified or not.


Sigmund Freud

From The Introductory Lectures on Psychoanalysis. Freud as a small boy moved with his family in 1860 to Vienna, where he remained until the Nazi annexation of Austria in 1938. Appointed a lecturer in neuropathology at the city’s university in 1885, Freud was an early enthusiast of cocaine, observing that while under the influence “one senses an increase of self-control.” He died in London at the age of eighty-three in 1939.