In the past few years, psychoanalysts have been debating among themselves the problem of cure—what it means, how often and to what degree it is achieved, how one may know it has been achieved. Lillian Blumberg here reviews some of this recent discussion, as it is reflected in the professional literature.

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In 1892 a woman, since known as Elisabeth v. R., was treated for hysterical lameness by a young Viennese physician. Maladies of this type, which were more common in the past century than now, had usually failed to respond to medical treatment. Elisabeth v. R.’s case, however, was memorable because her doctor, Sigmund Freud, cured her by causing her to remember certain long forgotten childhood experiences. The method by which he effected this he called psychoanalysis. Psychoanalysis was first applied exclusively to afflictions similar to Elisabeth v. R.’s, and because it literally succeeded in causing the lame to walk and the blind to see, it attracted worldwide attention.

However, when Freud applied psychoanalysis to other types of neurotic illness he discovered that the technique he had used with such success in the case of conversion hysteria—as the type of hysteria leading to localized physical symptoms is called—did not necessarily relieve other neurotic symptoms. Not that Freud felt that the disappearance of symptoms was of itself a sure sign of cure; neurotic symptoms can be hidden, he recognized, or new symptoms substituted for old, while the illness itself remains unchecked. How much less, then, could the conscientious physician say he had obtained a cure if even the original symptoms failed to clear up, as was often the case.

Faced often by unsatisfactory therapeutic results, Freud changed his technique for handling patients. He shifted from the analysis of symptoms to the analysis of total character. He expected that psychoanalytic theory would eventually be developed to the point where psychoanalytic treatment could be successfully applied to all mental illnesses. It seems clear that he regarded success in clinical application as the most important means of establishing the truth of his theory, and as necessary before psychoanalysis could speak with the authority of a full-fledged science.

The common belief that Freud did not value psychoanalysis primarily as a technique of cure is correct only for the last decades of his life, when he became occupied with the more speculative aspects of his theory. In the early days of psychoanalysis he considered the alleviation of human anguish to be of paramount importance. In 1910 he wrote: “Psychoanalytic therapy was created through and for the treatment of patients permanently unfitted for life, and its great triumph has been that by its measures a satisfactorily large number of them have been rendered permanently fit for existence.” But then the disappointing results of his treatment and later turns of theory led him to despair of the possibility of radically changing what he came to believe was man’s essential irrationality.

Yet if psychoanalytic ideas today permeate every area of culture, they owe much of their credit to Freud’s first dramatic cures, not to his theories as such. Psychoanalysis holds public attention not primarily as an explanation of human behavior, or as an aid in the interpretation of literature, but because it offers itself, above all, as a technique for the relief of human suffering. The question of cure therefore becomes central. But how is one to make any judgment here, without knowing what determines when a patient is cured? And this basic, prior question still remains unanswered.

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Today many patients who come under psychoanalytic treatment do not show such obviously pathological symptoms as hysterical paralysis. They suffer variously from vague fears and anxieties, feelings of failure and of being unloved, sexual impotence, addictions, periods of depression, restlessness, despair, general malaise, and emotional apathy. After several years of psychoanalysis they may have remembered many childhood experiences, understood the effect of parents, siblings, friends, upon their development, be able to decipher the unconscious meaning of their dreams, and better understand the behavior of associates. But despite the fact that they may have achieved reasonably complete intellectual insight into the nature of their illnesses, patients often retain the symptoms that led them to the analyst’s couch. Thus, despite the prestige psychoanalysis enjoys as a psychiatric treatment, any guarantee of its clinical success is still problematic.

Psychoanalysts themselves are worried about this, more worried perhaps than their patients. In January 1948, the Boston Psychoanalytic Society and Insititute held the first meeting in this country to consider means of investigating the efficacy of psychoanalysis. The report of these discussions is contained in the orthodox Freudian 1949 Yearbook of Psychoanalysis (New York, International Universities Press, 317 pp., $7.50). In 1941, Dr. Clarence Oberndorf (who had proposed the topic of the Boston conference) sent a questionnaire to twenty-four leading American analysts, all of whom had had more than twenty years of experience. The eighteen replies he received, he writes in the Yearbook, were “. . . very disconcerting. There was nothing upon which they agreed, not in the type of case best suited for analysis, nor the method of termination, nor results, nor how many patients were helped through analysis to avoid serious mental illness. This . . . added to the already great confusion concerning technique and type of case to which psychoanalysis should be applied.”

It is generally agreed that certain mental disorders such as schizophrenia, manic depressive psychosis, psychopathy, and others, do not respond favorably to the psychoanalytic method; for both theoretical and practical reasons psychoanalysts disagree among themselves as to whether or not such cases should be accepted for treatment. When, either for experimental purposes or inadvertently—because of mistakes in the original diagnosis—such cases are treated by psychoanalysis, it is more or less expected that the results will be unfavorable. Obviously, to evaluate psychoanalysis on the basis of its success with a category of cases that psychoanalysis itself is not sure it can treat would be unfair and fruitless. Judgments of psychoanalysis should be based on the types of cases traditionally considered best suited to its treatment. However, failures with even such types of cases at the hands of classical psychoanalysis occur frequently enough to be a source of dismay to psychoanalysts—as Dr. Oberndorf, who writes with honesty and clarity, himself admits:

The failure of such cases to respond offers the greatest challenge to the method. Many of these are cases where the neurosis may be fairly well limited, such as compulsive handwashing or fear of death, and yet after from three to five years of analysis, the patient is still thoroughly incapacitated. The psychoanalytic treatment over this period may have been given by the same or several successive analysts.

I have reported one such case where a mixed neurosis had existed in a forty-year-old man from the age of six years. The mechanisms were so characteristic of compulsion neurosis that they had been used as typically illustrative before a class of students at a psychoanalytic institute. He had been treated psychoanalytically by four competent analysts before he came to me, his fifth analyst, and discontinued at the end of about a year and a half without improvement, for I had failed as had my predecessors.

Unsatisfactory results with this category of cases is a principal source of discomfiture and chagrin to the analyst and may arouse doubts as to the adequacy of the psychoanalytic method.

A difficulty that arises in attempting an estimate of the success of psychoanalysis lies in the fact that a statistical survey indicating the approximate percentages of successful and unsuccessful analyses has never been made in this country. One of the reasons for this—aside from the technical complexities such a project would involve—is that psychoanalysts are not, as pointed out earlier, agreed as to what they mean by “cure.” According to Dr. Oberndorf: “It is difficult to establish criteria of what constitutes a satisfactory result with psychoanalysis. . . . No investigation exists which proves that long deep analysis conducted according to the orthodox technique produces more lasting results in any form of neurosis.”

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The term “cure” itself, indicating a transfer from one sharply defined state to another, is somewhat inappropriate when used in psychoanalysis. For one of Freud’s major contributions to psychiatry was the conception that “normal” and “abnormal” are but quantitative extremes of human behavior, rather than separate and antithetical categories; there are no distinct boundaries between what is normal and what is abnormal, but only shadings. Since Freud’s time it has become a psychiatric custom to use, instead of the term “cure,” which implies a qualitative change from abnormal to normal, the more accurate expression “improvement,” which only implies a quantitative change from being sick to being less sick. (Today the term “cure” is loosely used as a synonym for “improvement” in the technical journals, although still often used in its older sense in popular psychiatric literature.) “Cure” is most legitimately used in its older meaning in reference to specific symptoms, e.g., the patient was cured of his nail-biting.

But even the term “improvement,” while more precise than “cure,” remains ambiguous; there are conflicting opinions in psychiatry, generally, as well as in the more specialized practice of psychoanalysis, as to what should be considered adequate criteria of successful “improvement.” Dr. Oberndorf asks whether an estimate of results should be based on the patient’s own subjective evaluation, or on the doctor’s presumably more objective judgment; whether or not relief of symptoms should be accepted as a criterion of improvement, and if so, what degree of alleviation of symptoms should be accepted as evidence of improvement. He cites as an example of the latter difficulty the fact that some analysts may consider that they have achieved clinical success if a homosexual patient becomes adjusted to the fact of his homosexuality and accepts it, while other analysts may believe that cure is not achieved until homosexual patients become heterosexual (unfortunately this is rarely accomplished). In the case of Elisabeth v. R., Freud felt that the fact that his patient eventually got married was an even broader indication of cure than the fact that he had cleared up her lameness. Dr. Lawrence Kubie, in another contribution to the Boston symposium, points out that an evaluation of the degree of success attained “must be made against an estimate of what would have happened to the patient if the illness had been allowed to run its course.” But it seems obvious that such an estimate would be difficult to make, and at best only a guess. For instance, if the patient shows no improvement at all, would he have got worse without treatment, remained the same, or improved? If he improves with treatment, might he not also have improved without it? (“Spontaneous improvement” is far from being unknown in psychiatry.) If he gets worse, would he have deteriorated more rapidly without treatment, remained the same, or improved? And how much time should elapse before estimates are made?

Such questions are not easy to answer because so many factors enter into both the clinical situation and the patient’s life situation that it is often difficult to know to which specific factor or set of factors clinical changes can be attributed. It would appear that psychoanalysis (and I mean all schools of it) is beset by the same difficulties in achieving clinical success as is the entire field of psychiatry. But if its end results are no better than those attained by the shorter and less expensive methods of standard psychiatry, a serious doubt arises as to whether the financial burden psychoanalysis imposes on the patient is worth it. As a young doctor, Freud believed that the patient should get something for his money; in his Autobiography he wrote, “Anyone who wanted to make a living from the treatment of nervous patients clearly must do something to help them.”

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To speak of “cure” or “improvement” should also imply, it would seem, a fairly clear notion of what is meant by a “normal” personality; but psychoanalysts are as yet far from agreement on what constitutes the “normal personality.” Orthodox Freudians disagree among themselves, and all schools and factions appear to disagree with each other.

Franz Alexander states that psychoanalysis has already demonstrated that it can “modify personality structure,” while Herman Nunberg says that analysis can only bring about relative changes that involve quantitative diíferences; Theodor Reik insists that human nature is unchangeable and civilization doomed because of man’s instinctive, irrational drive toward destruction. (Many psychoanalysts who subscribe to this view nevertheless continue to practice.) The Fromm-Horney school holds that man is inherently good and that cultural rather than biological factors are responsible for neurosis. Marynia Farnham conceives of the normal female personality as being fundamentally passive—a view dismissed by Clara Thompson.

The influence of anthropologists who insist that normality is not a biological concept at all, but only relative to particular cultural patterns, has only added to the confusion. In The Neurotìc Personality of Our Time, Karen Homey wavers between an ideal definition of normal personality and a statistical one based on numerical majorities in specific cultures. (A difficulty of the latter approach is that if everybody in a particular culture has periodic attacks of homicidal mania, then such states would have to be considered normal.) Erich Fromm says that to be normal is to be “productively oriented,” but neglects to say what he means by “productively oriented.” Wilhelm Reich (who no longer considers himself a psychoanalyst) regards the normal personality as one that has attained full “orgastic potency.” (Whether sound or not, this concept of normality is far more elaborate than its appellation would indicate and, unlike most of the others, has specific defining characteristics.)

Perhaps the most astonishing treatment of the problem of normality is that of Dr. Norman Reider, who in a recent issue of the Psychoanalytic Quarterly (1950, No. 1) writes that too much psychiatric knowledge can have adverse effects on individuals, for they then develop conflicts around the psychological implications of their self-knowledge and become worried about whether or not they are “normal.” To Dr. Reider, the concept of normality is “an extension and derivative of the term good,” and becomes a kind of mass illusion. The persistence of symptoms after treatment may then be interpreted as being a necessary and normal state of affairs, for “psychoanalytic literature contains numerous direct and oblique references to the limitations of therapy.” “Normality” thus becomes a myth necessary to ward off anxiety, and further, the popularization of psychiatric ideas, in leading people to expect too much, may result in harmful social consequences.

The one point on which all schools of psychoanalysis seem to agree is that it is easier to ascertain what isn’t normal than what is.

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This vagueness as to the psychoanalytic goal is perhaps the source of the uncertainty of psychoanalysts about when to terminate their treatments. Dr. Alexander says: “The patient does not get up one day from the couch cured. Therefore it is difficult to form an opinion as to when this process should be terminated. . . .” A not uncommon manifestation of the close of a long analysis is “termination jitters” characterized by a sudden relapse on the part of the patient, who had seemed until then to be greatly improved. Wilhelm Stekel was convinced that a long Freudian analysis might even precipitate a latent psychosis, and felt that there was a disproportion between effort and result in the classical technique, (Autobiography, Liveright, 1950). Reich says, similarly: “To put one’s trust in the duration of the treatment makes sense only if and when the analysis is developing. But it is useless to expect success from just waiting.” (Character Analysis, Orgone Institute Press, 1949.)

The prevailing pessimism in psychoanalytic circles as to the limitations of psychoanalytic treatment is accompanied by an increasing tendency among psychoanalysts to attribute their failures to constitutional or hereditary factors in the patients.

At the Boston conference, Dr. Phyllis Greenacre expressed the opinion that genetic neurotic elements are necessarily present in every individual. An analyst who disregards these elements is little better than a layman who naively believes “that neurosis can be completely cured.” The failure of some analysts to recognize that the possibilities of treatment are limited by genetic factors comes, Dr. Greenacre feels, from “a narcissistic need to seek or to have omnipotence.” Elsewhere in the Yearbook, Dr. H. G. van der Waals says, “The potentialities of psychoanalysis are linked with the occurrence of [environmental] modifications and the possibility of a patient being influenced by psychoanalysis finds a limit where the apparent modification actually is a mutation, i.e., a pathological endowment.” This throws the onus of failure squarely on the shoulders of the patient, who, if he fails to respond to treatment, is pathologically endowed; it ignores the lessons learned from medical history (after all, conversion hysteria was once attributed to constitutional factors until Freud demonstrated otherwise), and also serves to draw attention away from the fact that the inadequacies of psychoanalytic method itself have not yet been sufficiently investigated.

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Why has psychoanalysis failed to fulfill Freud’s early expectation that it would become the most successful of all psychiatric techniques? The answer lies partly in the fact that the development of psychoanalysis, instead of following the path of medical science, duplicates that of general psychology insofar as it showed from the first a tendency to split into “schools,” each of which developed new terminologies and new concepts. Unfortunately, most of the splits were based on theoretical reformulations rather than on practical refinements or improvements of clinical procedures. The relation among the various sects is largely one of mutual suspicion and hostility rather than cooperation, and the fresh insights of one school are only slowly absorbed by the other, generally older, schools, while the late-comers often ignore the gains already made by their predecessors. The privately practicing, eclectic psychiatrist who remains unaffiliated with any particular school has the advantage of being able to draw on the insights of all factions, but he is also likely to suffer from a lack of prestige, since membership in one or another of the various psychoanalytic associations brings one publicity and respectability.

Another reason for the slow development of new clinical techniques derives from a tradition that stems from Freud himself. After he expounded the death-instinct hypothesis, which is based on the supposition that the human organism has a biological drive toward extinction, he became less and less interested in psychoanalysis as therapy and began to regard himself as essentially a research scientist. Since Freud, the dispute between those who hold that the goal of. science should be knowledge for its own sake and those who believe that the ends of science should be to serve man’s needs has raged nowhere more fiercely than in psychoanalysis. One may feel that Freud, and other psychoanalysts, were completely mistaken in considering that their work on psychoanalytic theory made them “scientists”; nevertheless, that is the way they considered (and consider) themselves. And so a major dispute arose over the question of whether the psychoanalyst is primarily a doctor whose first interest is to cure his patient, or whether he is primarily a research worker seeking to implement and expand psychoanalysis as an explanation of human behavior.

Dr. Oberndorf would seem to represent the viewpoint of those psychoanalysts who believe that the responsibility of the psychiatrist as a healer takes precedence over everything else. He writes: “I think I am correct in saying that Freud felt that if suicide were the logical outcome of the patient’s situation, then it is not the physician’s concern as to whether or not he carries it out. As doctors who are trained with the idea of curing people, I think we cannot morally or ethically ignore the idea that life is what they are seeking.” A similar point of view is expressed by Wilhelm Stekel, who writes: “. . . while Freud asks himself what a case offers to science I ask myself what science can offer to a case.” (Freud, like the Bible, can be quoted on all sides of a psychoanalytic issue—in 1909 he would have agreed with Stekel, for he wrote: “. . . a psychoanalysis is not an impartial scientific investigation but a therapeutic measure. Its essence is not to prove anything but merely to alter something.”)

Many psychoanalysts, ` however, do consider the psychoanalyst as first of all, and above all, a research scientist. In another contribution to the symposium, Dr. Phyllis Greenacre says: “It seems to be so simply true as to be elusive that the worker whose goal is the essential verity of his scientific work may in some instances take unnecessary detours of exploration, but by and large will contribute most to the science and to his patients.”

Of course, whether the individual psychoanalyst thinks of himself first as a doctor treating sick people, or as an investigator in the field of human behavior, will depend to a considerable extent on his own personality. Yet, if he does function in the dual capacity of physician and research worker, one wonders whether the course of an individual analysis must not necessarily be affected by this. Many clinical hours could be diverted by a physician pursuing his special research, even though he is also dedicated to effecting a cure. In other areas of medicine a new technique is seldom put into practice without some preliminary laboratory research to determine its effectiveness, and usually the patient is informed beforehand of its experimental nature. Needless to say, the development of psychoanalytic theory is a legitimate and necessary pursuit, yet one must ask whether the immediate patient ought to be required to pay for it. Dr. Kubie believes that research and therapeutic functions ought to be separated. He feels that there is a need for a research institute devoted to the study of both the neurotic process and the psychotherapeutic process. Researchers “must be free from any immediate therapeutic or teaching responsibilities. They must be ‘unfettered’ scientists pursuing unchartered courses to reach unexpected findings.”

We must also consider the nature of this scientific work which sometimes tempts psychoanalysts to slight immediate therapeutic tasks. Much of the “theoretical” writing in the journals today has become a highly abstract metaphysics from which the essence of human emotions has evaporated.¹ Reading it one is often left with the impression that the theoretical preoccupation of psychoanalysts is so strong as to make them oblivious to the immediate human reality of their patients, as well as to the problems of improving clinical procedures.

Dr. Greenacre believes that it would be incorrect to evaluate psychoanalysis on the basis of its clinical success or failure because an emphasis on results would tend not only to deflect interest from psychoanalysis as a science of human behavior, but, paradoxically, might even serve to increase rather than reduce the number of failures. She stresses the dangers inherent in “too great therapeutic zeal” on the part of the analyst and emphasizes that Freud “repeatedly indicated his belief that marked therapeutic zeal . . . was frequently an indication of an underlying sadism.” According to Dr. Greenacre, the analyst’s desire to cure his patient may also come from “personal ambition”—that is, the analyst wants to cure the patient not for the patient’s own sake, but because of an unconscious desire for prestige, or because of the feeling of power he gets from the act of curing. In Dr. Greenacre’s opinion, such unconscious motivations in the analyst have destructive effects on treatment. However, she does not specify the point at which the desire to heal becomes “excessive.” Nor does she—and one cannot but wonder at the omission—consider the possible negative effects of excessive scientific zeal.

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Specific criticism of analytic procedures is often received with hostility by the psychoanalysts themselves, especially those anxious to preserve the sanctity of psychoanalytic theory. For instance, Dr. Oberndorf’s observation that the analyst’s own philosophy and personality can affect the welfare of the patient brought the following comment from Dr. Martin Wangh: “One cannot help but fear that such an argument might lead to psychoanalytic nihilism.” To the layman Dr. Oberndorf’s further suggestion that group seminars should review cases that have been in analysis for over three hundred hours appears eminently sensible.

Dr. Greenacre touches upon another factor that may be responsible for therapeutic failures—namely, the negative feelings of psychoanalysts towards their patients, i.e., the negative counter-transference—and suggests that analysts should not accept patients towards whom they feel a definite antipathy. (Dr. Greenacre presents no theories about the possible unconscious motivations of analysts who persist in accepting patients they don’t like.) Though the phenomenon of counter-transference has been recognized for a long time as a stumbling block to treatment, few investigators have concerned themselves with it. Wilhelm Stekel indirectly recognized that counter-transference was a decisive factor in prognosis. He writes, “I could treat only patients who awakened my interest and with whom I felt sympathetic. . . . I soon dismissed patients who did not appeal to me, or turned them over to my pupils. When the patient bored me it was a torment, and I often had to fight against a strong desire to fall asleep.” Because psychoanalysis depends for its effects on complex emotional interactions between therapist and patient, investigations of counter-transference could well turn up clues leading to the improvement of clinical methods. Sometimes the literature indicates that psychoanalysts are thrown off balance by their patients’ extraordinary ability to probe their (the analysts’) weaknesses; the resulting unfriendly feelings on the part of the analyst are quickly felt by the patient, who then reacts with even stronger negative feelings and resistance to treatment. Some analysts believe they work better with patients whose personality traits strike a responsive chord. Conversely, Stekel has described “analytic scotoma,” i.e., the analyst’s blindness to neurotic characteristics similar to his own.

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Psychoanalytic treatment shows a vast range of possible approaches: to paraphrase Dr. Carl M. Herold (Psychoanalytic Quarterly, 1939, No. 8), it may be anything from Theodor Reik’s “passive divination” of the patient’s repressed thoughts to the “pounding” of his narcissistic defenses (or resistance mechanisms) as practiced by Wilhelm Reich. Dr. Herold believes that any analyst’s particular adaptation of technique is a function of his own character structure and is determined by his own specific ways of handling his aggressive feelings within the clinical situation. Thus, it would be impossible for Reik, say, to employ Reich’s more active method, or for Reich to content himself with Reik’s quieter approach. Most analysts, Dr. Herold feels, fluctuate between the clinical extremes he describes. He says, further, “There is a tacit assumption that every analyst should be able to analyze every patient successfully. If he is not successful there must be something wrong with his technique. I admit that in many cases, even the majority of them, this is true; but in this generalization, the assumption that every analyst should he equally able to handle every case is certainly incorrect. Every experienced analyst recognizes that fact when he has to recommend a patient to a colleague. If he be conscientious, and there is a choice between several colleagues, he weighs carefully which of them is most fit for that particular patient. Such judgment is based mostly on intuition rather than on theoretical deliberations.” (My italics.)

If Dr. Herold is correct, to what extent can one speak of a “classical technique” applied by “orthodox” psychoanalysts? It would appear, rather, that there are as many ways of practicing psychoanalysis as there are psychoanalysts, and the psychoanalytic method itself is a private art rather than a public, scientific discipline. Of course, adherence to an orthodox practice is not in itself necessarily a virtue. Freud once wrote: “There are many ways and means of practicing psychotherapy. All that lead to recovery are good. . . . I consider it quite justifiable to resort to more convenient methods of healing as long as there is any prospect of attaining anything by their means. That, after all, is the only point at issue.” Unfortunately, however, it is almost impossible for an individual patient to tell in advance of treatment what particular kind of psychotherapy will help him most. For instance, if the analyst remains passive he may give the patient too little help. At the other extreme, the patient who is unable to withstand the pressure of an unrelenting attack by the analyst on his protective defenses may be tempted to abandon therapy altogether. A central screening of patients would perhaps provide a more objective means of matching patients with psychoanalysts whose individual methods are best suited to their needs than the present haphazard “shopping around.” Such a procedure has, in fact, been instituted by Reich’s Orgone Institute.

To meet the problem of evaluating therapeutic failures, Dr. Greenacre suggests a uniform filing of case records and an over-all statistical approach. Dr. Kubie continues along these lines by stressing such details as methods of recording data, re-evaluation of psychiatric language, how to write up a diagnosis, etc. “So many elements have to be considered,” he says, “that perhaps it will be possible to carry out such a survey only by codifying the essential data, working it out on punch cards and then observing and recording results over a long period of time.” A statistical survey is, however, unlikely to succeed unless the problem is first clearly stated. Moreover, this emphasis on mechanical details seems to be part of the American mania for fooling around with the tools of scientific research; and there is the danger often that the mechanics of research will bewitch investigators to the point where the object itself is all but forgotten. In the experimental sense of “science,” it is debatable whether psychoanalysis has yet reached the point where statistical evaluations could be useful to it. The chief methodological problem in psychoanalysis is still to determine what the very goal of psychoanalytic treatment is. As Dr. Kubie says: “It is hard to prove a murder when you cannot produce the corpse.”

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In many branches of medicine, successful therapists have much of the artist as well as the scientist. Even in the experimental sciences great hypotheses do not evolve from cards punched on IBM machines but from insights relating apparently unconnected variables. In psychiatry such relations are often felt rather than logically understood, as Otto Fenichel realized when he wrote, “The therapeutic successes that are reported [in connection with psychotics] are not yet sufficiently due to a systematic, scientific consciousness of the necessary modification [of the classical procedure] but rather to the intuitive, therapeutic skill of the respective analysts”; and later in the same volume, “The majority of therapists do not follow any conscious ‘system’ but, rather, their intuition. The doctor guesses, acts parts, changes his behavior according to the patient’s manifest reactions, without understanding them. A good ‘born psychologist’ will succeed, a bad one will fail.” (The Psychoanalytic Theory of Neurosis, Norton, 1945.) The sensitive therapist reacts instinctively to the succession of signals that go back and forth between himself and the patient These warn him when he is in error.

The good clinician sees what actually is before him, not what theoretically should be there. He perceives how the patient reacts in reality and not the way he is supposed to react according to a set of rules. Freud, to judge by his own writing, was rather impatient with his own rules. A therapeutic system hardened into inflexibility is about as useful in a specific clinical situation as an army field manual would be during the establishment of a beachhead. The “bad psychologist” usually suffers from a lack of empathy for which he compensates by applying therapeutic rules mechanically. Descriptions of the way classical psychoanalysis functions are often given in terms of an ideal situation. Such descriptions ignore the fact that what is supposed to happen in theory far too often fails to happen in practice.

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In spite of the fact that the psychoanalysts, in their technical journals, are conservative in their estimates of the success of psychoanalysis, many of them, in their popular texts, continue to oversell the actual achievements of psychoanalysis. Serious writers like Kris, Hartmann, and Loewenstein, who attempt to formulate psychoanalytic concepts with greater clarity and precision, are crowded out of the limelight by the “glamor” analysts, who empty psychoanalytic ideas of their content and misrepresent psychoanalysis itself as a panacea as easy to take as vitamins.

In the process of transplantation from its native Vienna to this country, psychoanalysis has become singularly American in its values and appeal. Concepts such as “adjustment,” “productivity,” “self-realization,” “optimal functioning,” all of which belong to the notion of “the normal personality,” derive from the high premium Americans put on success, getting ahead, conformity, etc., etc. In America even perfection is relative and Americans are constantly preoccupied with improving themselves. And while not everybody can afford to be psychoanalyzed, almost anybody can read about it. For every person who actually enters psychoanalytic treatment there are probably hundreds who read popular psychoanalytic texts and absorb psychoanalytic ideas in garbled fashion. As a result the “wild psychoanalysis” that Freud warned against in 1910 now prevails everywhere.

Meanwhile psychoanalysis has achieved the status of a secular dogma, and its practitioners have become culture heroes held in awe as magical figures. In movies about psychiatry the psychoanalyst can no more be mistaken about human nature than Einstein can be about an equation; in Hollywood a therapeutic failure is inconceivable. Many psychoanalysts, especially when their works are aimed at mass consumption, seem to take this myth about themselves with utter seriousness. A stock scene in a semi-novelized account of a-day-in-the-life-of-apsychoanalyst pictures him alone at his desk brooding over the problems of the world while a shaft of sunlight coming through an open window plays over his head. “I was tired,” says Dr. Ludwig Eidelberg’s fictional analyst; “I looked at the little clock ticking busily on my desk, and saw that soon the long day would be over. Then I could cease being God and Devil, father and mother, and could be myself. Two more hours and I could feel sad or exuberant, angry or friendly, just as I wished.” (Take Oft Your Mask, International Universities Press, 1948.)

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The vast and complex structure of psychoanalytic theory has remained inaccessible to verification according to experimental principles; thus far, such attempts as have been made to bridge the gap between psychoanalysis and experimental psychcology have been, in the main, unsuccessful. Yet, psychoanalysis has immeasurably enriched man’s knowledge of himself and its insights should not be lost in the limbo to which go the fads in which the public has lost interest. There is a real danger that this will happen, because psychoanalysts have been dealing with patients from behind a metaphysical veil too long; human beings are the reality, and not theories about them. In present-day psychoanalysis, theory seems to have become a higher value than the welfare of the patients with whom those same theories are presumably concerned. If psychoanalysis is to fulfill its early promise as a therapeutic method, a retreat to first principles may be necessary even at the cost of surrendering cherished hypotheses. And the attachment to science on the part of the psychoanalysts should come to mean, not elaborate theorizing barely related to observable human behavior, but a more systematic effort to understand just what is being done with patients, its successes and its failures. And this in turn means concern with such basic scientific procedures and processes as systematic observation, full recording, frank discussions of successes and failures, and, where possible, statistical and experimental research.

Dr. Oberndorf says, “Further investigation of the cause for disappointment with the psychoanalytic technique is indicated, for up to the present time no concerted effort has been made by any group of analysts to pool their experiences to this end.” Of course, the task will be difficult. “For,” as Freud said, “it is not so easy to play upon the instrument of the soul.”

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