On the sociogenesis of the psychoanalytic

setting

Abram de Swaan

The Ratschlixge (1), or "Recommendations to Physicians Prac

tising Psycho-analysis" by Sigmund Freud/ contain a perfectly
clear and rather complete design for the practice of psycho
analysis and a sociologist will find in these brief writings
a blueprint for the novel profession of psychotherapist. Yet
these four articles, so easily accessible to the uninitiated
reader, are relatively unknown outside the circle of psycho
analytic practicians (2 ) and never were the subject of socio
logical inquiry.
From the beginning of this century sociologists in Europe and
the United States have studied F r e u d s works, but they were
mostly interested in his grand ideas, his general views on
human psychology and, foremost, in Freud's aDplication of his
theories to social p r o b l e m s , (3) or, on the other hand, in the
application of psychoanalytic ideas in the design of sociolo
gical research and analy s i s . (4) Although the relations between
Freud's thought and his own remained mostly implicit, Norbert
Elias in Ubev den Pvozess dev Zivilisation (1936) brought
about an early and very thorough osmosis of psychoanalytic
thinking into sociological anal y s i s : (5)
"Es braucht dabei kaum gesagt zu werden, aber es mag hier einmal
ausdrucklich hervorgehoben sein* wieviel diese Untersuchung den
vorausgehenden Forschungen Freuds und der psycho-analytischen Schule verdankt. Die Beziehungen sind fur jeden Kenner des psycho-ana
lytischen Schrifttums klar, und es schien unnotig, an einzelnen
Punkten darauf hinzuweisen, zumal sich das nicht ohne ausfuhrlichere Auseinandersetzung hatte tun lassen. Die nicht unbetrachtlichen
Unterschiede zviscben dem ganzen Ansatz Freuds und dem der vorliegenden Untersuchung sind ebenfalls hier explicite nicht hervorge
hoben vorden, besonders da sich vielleicht uber sie nach einiger
Diskussion ohne allzugrosze Schwierigkeiten ein Einverstandnis her! stellen liesze."
Another area of confluence between psychoanalysis and the so
cial sciences occurred with the adoption of sociological and
ctnthropologica 1 concepts in psycho-analysis, initiated and
continued by Freud in Totem and Taboo (1912-1913), Group Psy
chology and Analysis of the Ego (1921) , Civilization and its
Discontents (1930), and Moses and Monotheism (1939).

381

In those eighty years the field of psychoanalysis in sociolo

gy has been enormously extended, and so has, to a lesser ex
tent, that of sociology in psychoanalysis,(7) but there re
mains a surprising scarcity of sociology of psychoanalysis,
and a complete absence of psychoanalysis c/sociology.(8 )
Yet, Freudian analysis has become one of the great intellec
tual currents of this century (9) and the study of this de
velopment
rightfully belongs to the sociological domain. One
important course of research would concern the emergence, de
velopment and distribution of psychoanalytic ideas: a socio
logy of psychoanalytic k n o w l e d g e ; (1 0 ) another line of inquiry
would follow the ways in which people ccme to experience and
express their troubles in psychoanalytic terms and even may
come to consider themselves as "suitable cases for treatment".
(11) A third path of investigation would trace the develop
ment of the psychoanalytic movement and profession from the
early days in Vienna to the ongoing establishment of a psycho
therapeutic profession with all its ramifications.(12) The
last approach deserves heuristic precedence: both the profes
sional and intellectual body of psychoanalytic ideas and the
layman's notions about symptoms and complexes are best under
stood in the context of the early cercle (13) and the later
psychoanalytic community where they originated and evolved.
(14) To this purpose it is necessary to investigate the con
crete, daily, practical aspects of the psychoanalytic trade,
what is usually called the "psychoanalytic setting" as it was
first described and prescribed in Freud's Ratschlage of 1912,
and to trace back its origins in the therapeutic practice of
Freud's, and preceding, days.
The subject of this inquiry is the gradual adoption by Freud
in the years 1886-1912 of certain practices that, taken to
gether, became the ways of the psychoanalytic craft, and a
craft it was in the exercise of which Freud madehis great
psychological discoveries. For a sociologist, however, the
psychoanalytic setting itself, .understood here as a particu
lar, novel, form of interaction, which constituted the social
matrix from which sprang the body of psychoanalytic knowledge,
represents as great an invention as any other Freud made.
This paper is devoted to the elaboration and justification of
this contention. It may be summarized in the following four
propositions:
1. The psychoanalytic setting was in many respects a continu
ation of recently emerging customs in general medical oractice.
2 . It was, however, a purified practice, in the sense that all
forms of interaction (or other occurrences) that could
serve as an alternative explanation of the contributions of
the patient were, as far as possible, and in principle,
eliminated, analogous to a natural science experiment in

382

which all variables are controlled so that the resulting

process may be explained in terms of the agens and reagens
alone.
3. T h e recently developed practice of office consultation ap-/ peared to Freud and his contemporaries to be a form of in
teraction-devoid of all exchanges and other events that
... did not immediately serve the business to be transacted:
a. "social null-situation" .
4. In;the Ratschldge Freud proposes two - complementary groundrules, rules of behavior for the analysand and the
an a l y s t : the rule of free association and the rule of ab stinence. These rules constitute the very essence of psy
choanalytic practice and transform the office consultation
' into' an entirely new interactional category which must
-V
count as Freud's greatest sociological invention.
The remainder of this paper is devoted to a justification of
these propositions from historical evidence and from material
in Freud's works, especially the early technical works, first
among them the Ratsehi'dge.
In the eighteenhundredeighties, when Freud established his
neurological practice, the medical profession was being trans
formed b y a succession of scientific discoveries and thera
peutic inventions It; was the heroic epoch of medicine of
Koch or Pasteur and, yet, very few quick and surefire cures
existed at the time. In neurology, Freud's speciality, a num
ber of innovations were being introduced, practically all of
them abandoned as ineffective at present: E r b s electrotherapie, Faradization, W e i r-Mitchell's rest cure etcet e r a ; (15)
the young Freud tried his hand at all of t h e m , (16) including
the older- therapies such as massages, v a p o u r s , p u r g e s , and
b a t h s , and a l s o , hypnosis, which, especially in France, was
coming back into respectability.(17) One of the unintended
consequences of the introduction of new therapies and the ap
plication of all sorts of instruments was that-physicians
found it even harder to travel to see their patients, even as
roads and. vehicles were being i m p r o v e d . (18) The tools of their
trade h a d .become too heavy and too bulky to carry along in a
carriage, let alone on horseback along country r o a d s .
Many of the new treatments could only be administered in the
doctor's^office or even in a clinic. Also, as physicians had
more remedies at their disposal, their services came in greater and more urgent demand among sufferers. It became more
necessary-that doctors could be found every day at a fixed
place and a t an appointed hour. Moreover, once doctors were
widely known to achieve cures, their prestige grew among their
fellow-citizens. But in the early nineteenth century the doc
tor is rpictured and described as a man on the go, a man about
tpwn: (19)

383

Je haufiger der Arzt auf der Strasze gesehen wurde, urn so groszer
schien seine Klientel, je groszer die Klientel, fur um so tiichtiger und beliebter gait der Arzt."
In those early days that was the way to win patients,
cording to a satirist of the t i m e s : (2 0 )

or, ac

"Fahre inuner in der Stadt herum, venn es dir auch anfanglich an

Patienten fehlt, als hattest Du viel zu tun*"
Initially, if the physician received at home, it was during
his A u d i e m s t u n d e for the poor who could not afford to pay
the doctor's visit, and for the maids and valets of the rich
who came to describe their patrons' illnesses and to take back
counsel and medicine, often without the doctor ever seeing the
patient himself. These arrangements changed in the course of
the nineteenth century under the influences mentioned of new
inventions and the prestige gained with these remedies, and,
in a broader perspective, with the rise of the professions in
general, the improvement of university education, the imposi
tion of standards of practice, and through the relative in
crease of bourgeois occupations in general.
As early as 1829 a doctor Hahnemann was receiving his patienb,
regardless of their worldly s t a t u s , in consultation t o r some
five office hours a d a y . (21)
"Ik unsere edle Zeit zu sparen und unserer Wurde nichts zu vergeben, diirfen wir bei keinem chronisch Kranken, und ware er ein
Fiirst, wenn er (nicht) (22) zu uns in Haus koxamen kann, Besuche
machen* Nur ein akuten, bettlagerigen Kranken miissen wir besuchen.
Wer von denen die umher gehen konnen, nicht Hath bei Ihnen im
Hause suchen will, kann vegbleiben, anders geht's nicht,"
Clearly, it is a matter of both efficiency (edle Zeit) and
prestige (Wurde)} and, interestingly enough, the differentia
tion among home and office consultation is no longer between
poor and rich, but between scientific, medical categories,
between chronic and acute, bed-ridden patients; "und ware er
ein Fiirst : The standards of the profession should cut right
across the boundaries of rank. But Hahnemann, known for his
arrogance (as a medical practitioner), was ahead of his col
leagues and found little imitation for some time to c o m e . (23)
Erst seit der Mitte des 19 . Jahrhunderts burgerte sich die
Sprechstunde im Hause des Arztes mehr und mehr ein; von den siebziger Jahren an wurde sie, wie die Dissertation von Ingrid Vieler
zeigte, in der heutigen Form gebrauchlich. Hoch 1 8 9 6 riet allerdings der Berliner Jacob Wolff in seinem Buch iiber den praktischen
Arzt und seinen Beruf dem Anfanger, zunachst keine bestimmten
Sprechstunden an2 usetzen, erst spater konnte er sich einen solchen
Luxus leisten."
The Luxus of an office hour was apparently reserved for those
physicians who had achieved the individual reDutation and
prestige that would make patients come no them, rather than

384

them visit their patients. It is a fair speculation that the

developments in Austria, and especially in Vienna, were simi
lar and roughly synchronous to those in German cities, docu
mented here.
Dr. Sigmund Freud, Privatdozent Neuropathologie, opened his
practice on Eastern Sunday 1886,(24) having recently returne
from his studies with Charcot in Paris and from a brief visit
to Berlin. F r e u d s first years in practice form one of the
least accessible episodes in his life, since the rich corre
spondence with Martha Bernays ceased upon the final reunifi
cation of the couple with their marriage in September 1886*
The equally informative correspondence with Freud's friend
Fliess, on the other hand, went off to a slow start, warming
up only gra d u a l l y . (25) No famous and gifted people came yet to
visit Freud so that their published recollections could enlighten later generations. Freud's biographers are preoccupied
with a different theme during the same period: the reception
of Freud's ideas on hysteria in the Viennese Society of Phy
sicians. (26) After a few months at the Rathausstrasze Freud
moved to an appartment in the Imperial Memorial House. About
the arrangements there little is k n o w n , (27) but already in
1891 the family settled at 19, Berggasse where Freud would
live and work until 1938, in 1907 moving his working quarters
from the ground floor to the first floor where the family
dwelt at the other side of the l a n ding.(28)
Many descriptions of Freud in his work surroundings have been
produced by visiting authors and colleagues, but each time^
that a sociologist would wish such a witness to stoop, be it
only for a moment, to more mundane recollections about eti
quette, financial arrangements, times and schedules, or ser
vants, the writer is struck by another spark of genius, a
flash of insight which, indeed, deserves priority.
The premises at Berggasse where Freud set up^practice have
variously been described as "une maison de mediocre apparence
dans un quartier perdu de Vienne" (A. Bre t o n ) (49) and a
large apartment in one of the best residential quarters in
V i e n n a . " (30) But according to the judgment of a fellowViennese contemporary, a "pupil and friend', Hanns Sachs, it
was "in a quiet and respectable, if not exactly distinguished,
neighbourhood."(31)
Freud's working quarters consisted of three rooms and an ante
room: a waiting room, a study, housing the famous antique col
lection, which could be entered through the consultation room
wh e r e Freud received his pati e n t s . (32) At first very few pa
tients came to see Freud, paying patients even less. Freud s
ffciend and mentor, Joseph Breuer, had advised him at the start
bfP.tiis practice 11to take low fees, treat a good many people
jjE&tis, and count on earning five gulden a day for the first
i/ears." (33) Three times a week Freud worked as director of
the neurological department at the Institute of Children's

iifseiaSes of his acquaintance Kassowitz. He held an office

385

hour {Ovdinationsstunde) daily from two to three p . m . , seeing

patients that were often referred to him by friendly col
leagues , such as Nothnagel, and, foremost, Breuer:(34) "In
die Ordination die beiden alten Patienten von Breuer, sonst
nichts. Ich habe in der Regel funf Personen in der Ordination:
die zwei zum Elektrisieren, einen Gratis, einen Schnorrer und
einen - Schadchen. /matchmaker/" Freud applied the stock in
trade remedies of the neurological profession, but he gradual
ly became known as a specialist in hypnosis with an interest
in hysteria. He had, after all studied with Charcot, lectured
on the subject of hysteria, translated and edited works by
Charcot (35) and B e r n h e i m , (36) and made a visit to the clinic
of Bernheim and Liebault at Nancy in 1889.(37) Gradually,
patients "with disorders that had resisted all attempts at
organic treatment and that were thought to be of psychic ori
gin" (38) were being referred to Freud.
In tracing the development of the psychoanalytic setting it
is significant that Freud received very few of these patients
at his office and usually went to see them, where they stayed.
Apparently, he considered this a matter of no importance, if
he considered it at all, since he rarely even mentions where
the treatment of a patient took place. In the earliest ca&e
study (1892), the reader finds him making visits to the homes
of his hysterical patients: "far from being welcomed as a
saviour in the hour of need, it was obious that I was being
received with a bad grace and that I could not count on the
patient having much confidence in m e . " (39) In the Studies on
Hysteria (1895) Freud visits most of his patients at their
homes, in nursing homes or clinics, but at least one is re
ceived in office consultation: Lucy R, "came to visit me from
time to time in my consulting h o u r s . " (40), and so, apparently
did Rosalie H . : "One day the patient came for her session."
(41) Daily visits (42) to homes or clinics seem to have been
the normal pattern in the early nineties. Thus, a turning
point in the treatment of Elisabeth von R. occurred when
during the session she overheard her brother-in-law in the
adjoining room, but the reader is left to guess that this
disturbance happened in the patient's h o u s e . (43) Consultation
in clinics and rest homes sometimes took place at the bedside,
but, especially in later years, it also happened in a special
treatment room or office on the premises. In 1910, when the
Wolf-Man, began his treatment, it all apparently still was a
matter of convenience, be it,at that time of Freud's conve
nience: (44)
Freud told us he found my case suitable for psychoanalytic
treatment, but that he was at present so busy that he could not
immediately take any new patients. However, we might make a com
promise. He was visiting a patient every day in the Cottage Sana
torium, and following this visit he would begin my treatment there,
if I agreed to spend a few weeks in the sanatorium."

386

k -.fe^Viwebks later the Wolf-Man began to be received for

treatment.at the Berggasse office.
Dne'mhy speculate about the reasons that brought Freud and
his;:;'pat.ients together in his office, rather than at their
homes fvorl elsewhere. It certainly was not a matter of equipm e n ^ ^ l i f ^ i c u l t to be carried around, as in other medical
s-^eci^l^e's. Freud gave up the use of one implement after antyt^eriiajbi ;<fina 1 ly abandoned all manipulations. But saving
11
;.the time and the effort of moving hither and tither
tve- been a great relief for a man with F r e u d s schedule
yered a working day from nine a.m. until after mid'yj Among late nineteenth century medical men practice
,if-ice instead of home visits was also connected with
tU -professiona1 reputation, a "Luxus" one could afford
established one s n a m e , and an arrangement t h a t ,
.jf;-enhanced one's prestige: (46) "Grafe und Barone hiilndfin seiner A n t i chambre." This reputational aspect of
.nges in Freud's practice will be discussed in a later
But-fbpemost in this transition to home practice must have
beehytiie necessity of physical and social seclusion and of
constant: surroundings: the office setting greatly increased
ossibility of controlling the scene of the treatment..
.eSopment of Freud's therapeutic procedure was one of
abandonment of almost everything that reminded of
3/iiechnique, and, finally, of all manipulation and
instruction, but one: the fundamental rule of free asLDht In
of the J
first five
years or so Freud
Jill the
UA1C course
CVUi
w
w J
jflbhe standard neurological therapies, maintaining only
Ires until at least 1910.(47) He turned to hypnotic suggestipii:. in December 1887,(48) but with this technique, also,
h-lsfi&yplution was toward doing less and less, omitting suggbbtibnVfor the simple instruction to concentrate and rememvherythe ^circumstances under which the patient's complaints
first a p p e a r e d . (49) In the following years Freud gradually
forsook the attempt to induce hypnosis, partly because of the
imperviousness of some patients, partly because he found it
tiresome-,, and also becatise he discovered he could do without:
"When, therefore, my first attempt did not lead to somnabu'lism or to a degree of hypnosis involving marked physical
c h a n g e s , I ostensibly dropped hypnosis and only used concen
tration. "(50) In this "pressing technique" Freud proceeded as
f ollows :(51)
1 ;placed my band on the patient's forehead or took her head be
tween my hands and said: 'You will think of it under the pressure
of ay hand. At the moment at which I relax my pressure you will
se?e ^something in front of you or something will come into your
heidb Catch hold of it. It will be what we are looking for. - Well
what'have you seen or what has occurred to you?' -- Eventually
I grew so confident that, if patients answered 'I see nothing or
iwAtVii vifr Vi0 or
* T
H S S tll3_S 3,5 S.T1 lEffDOSSl^

387

bility and could assure them that they had certainly become aware
of what was wanted but had refused to believe that was so and had
rejected it. -- I turned out to be invariably right. The patients
had not yet learned to relax their critical faculty."
This pressing technique/ in its turn, was abandoned probably
some time before 1900.(52) Patients would still be invited
to lie down and shut their eyes and even this latter request
was left out shortly after 1900.(53) Only the supine position
on the couch was left over from the neurological and hypnotic
origins of the treatment, when, in 1903, Freud wrote about
his procedure: (54)
At the present time he treats his patients as follows: without ex
erting any other kind of influence he invites them to recline in a
comfortable position on a couch, while he himself is seated on a
chair behind them outside their field of vision. He does not ask
them to close their eyes and avoids touching them as well as any
other form of procedure which might remind them of hypnosis. The
consultation thus proceeds like a conversation between two equally
wakeful persons, one of whom is spared every muscular exertion and
every distracting sensory impression which might draw his attention
from his own mental activity.
The transition from hypnosis to cathartic method and from
there to the psychoanalytic procedure represents a gradual
elimination of activities, be it manipulations or instructions,
on Freud's part. They were abandoned as ineffective and su
p erfl u o u s , but they also conflicted with the emerging para
digm of the psychoanalytic setting; whatever the patients did
or said during the session had to be understood from their
own psychical conflicts and should not in any way be influ
enced, or even appear to be influenced by the therapist and
his surroundings: "without exerting any other kind of influ
ence , avoids touching", "is spared every muscular exertion
and every distracting sensory impression." Thus the psycho
analytic encounter was brought to the constancy and seclusion
of the consultation room and its choreography reduced to
well-nigh z e r o .
Before broaching the subject of the complementary pair of
groundrules of free association and abstinence, it may be
useful to trace some other lines of development -in the psy
choanalytic setting in their connection with common medical
practice in F r e u d s time: arrangements concerning money, time,
discretion and acquaintance, each time demonstrating the
underlying evolution toward a social "null-situation".
In his writings Freud assumes an uncompromising position on
matters of money, which not only underlines the distinction
between psychoanalytic practice versus pastoral and charita
ble care, but also represents a break with the medical tra
dition of honorary fees from the rich and gratis treatment of
the poor. Money matters ought to be dealt with right at the
beginning of the treatment, a fee set, to be paid regularly,

388

and no exemptions allowed. This simple and strict arrange

ment is justified, apart from the obvious necessity to earn
a living, with the observation "that money matters are treat
ed by civilized people in the same way as sexual matters
with the same inconsistency, prudishness and hypocrisy. (55)
The psychoanalyst should counter this tendency: "He shows
them that he himself has cast off false shame on these top
ics, by voluntarily telling them the price at which he values
his t i m e ."(56)
This stance in matters of payment may not have been unique,
or even uncommon in Freud's time, but it appeared to him
quite controversial: "This is of course not the usual prac
tice of neurologists or other physicians in our European
cities. But the psycho-analyst may put himself in the posi
tion of a surgeon, who is frank and expensive because he has
at his disposal methods of treatment which can be of use."
(57) As a matter of fact, Freud's attitude in this respect
also constituted a departure from the customs among hypnotizers and m a g n e t i z e r s . His senior contemporary Lifibault
treated his patients without remuneration, having already
assembled a small fortune in earlier occupations.
La plupart des magnetiseurs qui 1 'avaient precede, a 1 'exception
de Mesmer, n etaient pas mSdecins de profession; leur activite psychothSrapique etait pour eux secondaire et ils n en
attendaient pas de profits m a t e r i e l s ."(58)
Such feelings of "inconsistency, prudishness and hypocrisy"
among "civilized people" (Kulturmensahen) were expressed very
vividly more than a century earlier by a medical professor
from Tubingen, D.W.G. P l o u q u e t :(59)
"Eine Belohnung, ein Stuk geld von Hand zu Hand zu empfangen, so gewiss es such Bczahl ung oinor Sehuld, und koin Geschenk ist., hat doch
iminer etwas ZuriicKstosendes, etwas Undelicates an sich, iiber welches
mancher Arzt sein ganzes Leben hindurch sich nicht ganz binwegsetzen kann, iimaer erregt es ein Ar^. widriger, beschamender Empfindung."
It is not fitting to bring up the subject of payment, nor
very wise: "Die freywillige Geber bringen oft mehr als die
Taxe besagt", often "nicht in Gelde, sondern mit Kostbarkeit e n . " (60)
Almost half a century later the embarassment has not diminish
ed at all: "haben wir eins noch zu besprechen, von dem wir
lieber schweigen mochten ... vom Lohne des Arztes ..."(61)
Dr.. B. Liehrsch summarizes his financial advice in Die wahre
Lebenspolitik des Arztes fur alle Verhaltnisse (1842) thus:
"In'alien Fallen der Bezahlung muss der Arzt den Anstand
wahrert/den sein Stand, der kein Handwerkerstand ist, erfordprb."(62) The last words present a clue to the motives
for this embarassment. To demand quid pro quo payment at set
rates would make the doctor similar to a craftsman, who was
lower in status, but apparently the distance was not enough

389

to prevent anxiety. "Unwillkurlich stellt man durch ein solches Faktum seine Kunst dem Handwerk gleich."(63) Thus, the
sociologist will proceed to explain this consistent and rath
er intense embarrassment on financial matters in the nine
teenth century medical profession in terms of status anxie
ties, whereas a psychoanalytical explanation might proceed
in terms of the,symbolic connotations of money, for example:
(64)

vities pf those days someone who received a fee for services

performed risked to be assimilated with the lower ranks of
craftsmen and laborers, but there existed at the same time a
moral hierarchy in which dutiful, self-sacrificing, lifesaving effort made a man the better of his social superiors
w h o were receivers of his care. This reversal of values, in
whichvan
gain is foresaken for a less apparent, often
secret or even unconscious glory, is called a (moral) masoch
istic manoeuvre in psychoanalytic psychology.(70) And, in
a sense, this was what the professional attitude towards mon
ey around mid-century entailed: by insisting on prompt and
proper payment doctors risked to become assimilated in status
With:lower occupations: by waving their claims they could
prevent this status diminution and attempt to place them
selves outside the prevailing status hierarchy, implicitly
placing themselves in a different, moral status hierarchy.
This had to be done tacitly, as it does not fit the benefac
tor's position to loudly claim it for oneself. All this fits
t h ^ m o r a l masochistic stance: surrender of obvious, immediate
benefits for the sake of some unspeakable and often unthinkable^iantasy of glory. Doctors, for example in written manu
als, supported one another in this stance with so many words
and within the profession expressed their fantasy of moral
g lory.(71) And, in the long run, this abnegating stance ser
v e d ^ doctor's reputation, earned him patients, and ended in
rewarding him also materially.

"-- for faeces were the first gift that an infant could make,
something he could part with out of love for whoever was looking
after him. After this, corresponding exactly to analogous changes
of meaning that occur in linguistic development, this ancient in
terest in faeces is transformed into the high valuation of gold
and money "
Of course, no psychoanalyst would proceed to produce an ex
planation in these terms in abstvocto, but he might use these
connotations as a search strategy in the given context of a
p a t i e n t s productions or of an autobiographical fragment.(65)
One is reminded of Elias' remarks on "Sociology and Psychia
try" : (66)
"The difficulty is that, as in other similar cases, each group
of scientific specialists regards its own type of explanation as
exhaustive and exclusive. --- In a sense the two groups "become
involved in a competitive struggle, each attempting to reduce the
other's explanation to its own as the more fundamental type. -Each may feel that the other group threatens its own professional
and theoretical autonomy."
But the apparent gap between the different explanations may
be bridged in this case by looking somewhat closer to the
doctors' embarassments: Liersch exclaims "wie sollte da ein
Geschenk an Pretiosen oder Geld ein passendes Equivalent
sein, (67) compared to the life-saving efforts of the ever
ready physician. "Der Arzt hat Re o h t , Lohn zu fordern; darum
nehme er selbst die grossten Gaben nicht mit beschamten und
kriechende Danke a n . " (68) The doctor is entitled to payment
for his services and even though asking for his fee or accept
ing gifts might appear to reduce his status, in the direction
of a craftsman, at the same time none of this is true compen
sation for the life-bringing gifts he himself has bestowed
upon his pati e n t s : (69)
"The wealthy "by no means discharge in full their obligations to
the Physician, who attends upon them in all their sickness with
unwearied fidelity, when they pay him for his attendance. They
owe to him the affection of a true friendship, and the gratitude
due to something more than a professional performance of duty in
their behalf. ' 1

William Hooker, writing around 1850, completes the reversal

in this quotation: it may be true that in the status s e n s i t i -

390

In the course of the nineteenth century the prestige of the

profession as a whole is enhanced, among other reasons, be
cause; of the increase in therapeutic possibilities. But withit the medical profession doctors must each one of them build
a;'reputation for themselves in which moral grandeur plays a
diminishing role, but technical competence comes to count for
more ;and m o r e .
Again, it was Hahnemann who pioneered a more consistent and
direct approach: "Sie miissen sich auch, wenn der Kranke zu
Ihnen ins Haus kommt, jedesmal gleich ihr Honorar fur Bemuhung auszahlen lassen.
"(72) But Hahnemann, who thought so
highly of his "edle Kunst" may not have been so afraid anymore
to be- compared with a cobbler or a blacksmith. Yet, the great
increase, in status of the medical profession relative to
otheir.: occupations probably eased the status anxieties of doc
tors :as medical men, but it did not solve for each one of
.them.- the problem of achieving a reputation in competition with
his c olleagues. At first when the profession in its entirety
based its claims on an elevated self-denying stance, this
conpetition for a reputation within the profession forced in
dividual physicians to be as abnegating as their next col
league. In the long run, each one of them and the profession
in its entirety stood to gain from maintaining a social dis
tance from craftsmen in terms of prestige, social privileges
and \lso remuneration. And looking at medical customs from

391

the viewpoint of gaining and maintaining a reputation, the

seigneurial codes in financial matters become suddenly quite
entrepreneurial themselves: in order to obtain patients, so
as to prove his moral, and later on his technical qualities
and thus achieve a reputation and win a clientele in compe
tition with other practitioners in the same service area, a
doctor had to provide at first gratis or low-fee treatments.
The Ploucquet and Liehrsch manuals may be read in their en
tirety as guides for the conquest of a reputation by the os
tentatious display of moral character, of kindness and em
pathy, readiness, reliability, discretion, chastity, knowledgeability etcetera. The "other-directedness" of this ad
vice is sometimes s t r i k i n g : (73) "In den Augen des Publikums
sind Sie wenig oder nichts, w enn Sie keine Bibliothek haben."
The young doctor was instructed in the display of modesty to
wards more established or senior colleagues, and of arrogance
toward the lower ranks of the helping professions, surgeons
and midwives. From these manuals the early nineteenth century
doctor emerges as an entrepreneur who invested in his reputa
tion at the cost of some material reward in the short run.(74)
detailing the techniques whereby the individual could ingratiate
himself with others, warning against the kind of behavior uh?ch
others found offensive, with all of these counsels dedicated to
the end of inducing others to ar.si.sL in one's campaign for wealth
and social prestige."
Norbert Elias in his study of courtly society in France com
pared the ongoing evaluation of the courtiers' social posi
tion to a stock exchange: "Auch in ihm bildeten sich in einer
aktuell gegenwartigen Gesellschaft wechselnde Meinungen iiiber
Werte." And he continues to explain that such a configuration
as the French court carried with it a specific type of ratio
nality: (75)
Wie jeder Typ der Rationalitat, bildet sich auch dieser in Ver
bindung mit ganz bestiramten Zwangen zur Selbstkontrolle der eigenen Affekte heraus. Eine gesellschaftliche Figuration, innerhalb
deren ein relativ hohes Masz ari Umforraung der Fremdzwange in
Selbstzvange stattfindet, ist ein stehende Bedingung fur die Produktion von Verhaltensformen, auf deren unterscheidende Merkmale
man durch den Begriff der "Rationalitat" hinzuveisen sucht. Die
Komplementarbegriff "Rationalitat" und "Irrationalitat" beziehen
sich dann auf den relativen Anteil von kurzfristigeren Affekten
und/angfristigeren gedanklichen Hodellen der beobachtbaren Realitatszusammenhange an der individuellen Verhaltenssteuerung."
Elias points out that the courtly type of rationality implied
the acceptance of a loss of financial opportunities (Chancen)
for the sake of a gain in opportunities for status and pres
tige. (76)
*
"Was im hofischen Sinne ais "rational" und "ivalistisch" erscbien,
war dementsprechend im berufsburgerlichen "irrational" und "unre-

392

alistisch". Beiden gemeinsam war die Steuerung des Verhaltens im

Hinblick auf Machtchancen, wie man sie jeweils verstand, also
eitspreckend der geweiligen Figuration der Menschen."
This approach would also allow to understand some of the con
tradiciions in the customs and actions of professionals es
tablished in private practice. Their first concern is with
the establishment of a reputation, formerly of moral excel
lence, increasingly of technical competence, both as end in
itself, and because of the opportunities it affords for finan
cial rewards and personal prestige. The social constellation
in which professionals in private practice find themselves
also imposes upon them a specific type of "reputational" ra
tionality .
The great discoveries of the latter part of the nineteenth
century, some of which Freud himself contributed, secured a
great relative gain in status for the medical profession in
its entirety. Until the advent, however, of large scale, pub
lic or semi-public medical insurance schemes which assured
doctors a steady income and a fair share of patients, the
competition for reputation within the profession went on al
most unmitigated.(77) And, thus, Freud began his practice as
part of a social configuration in which he had to make a name
for himself if he wished to survive as a doctor, or even as
\ middle class family man, at all. This is the context in
v.hich Breuer's benevolent advice quoted above, must be read.
Freud, as a psychological innovator and an original moralist,
succeeded in conquering for himself an almost uniquely large
margin of free movement within Viennese professional society,
even turning some adverse conditions in his favor, but he
could only achieve this as part of a social configuration in
which, as a man without independent means (78) and, maybe, as
a J e w , (79) he had to build himself a reputation in the short
est time possible. The prospects appeared gloomy: "Since
there was nothing to live on for such a stretch of time Freud
concluded he would have to emigrate after six months, but
Breue*' thought there was no hope in that either unless he
went as a waiter." (80)
A university c a r e e r offering insufficient reward to maintain
a family, in order to survive there were only two avenues:
accepting the referrals (81) and the financial aid of a few
friendly, senior colleagues, and, making a great discovery as
>a;i$hb;rtbut to fame. Freud travelled both. The keen observer
had. discerned some of the tactics of the reputation game, the
mpiailst avoidedthe dilemma by creating his own v e r s i o n : (82)
"Freud observed that all these men /Viennese colleagues? had a
:certain characteristic 'manner1, so that he had better decide to
"idopt one also. He chose to exploit his native tendency to jp'.rightness and honesty: he would make a 'mannerism' of that, and
the various people would have to get used to it. If he didn't
succeed, at least he would not have lowered himself."

393

In later years Freud may have learned that a controversia1

reputation was not necessarily all harmful in a cosmopolitan
centre such as Vienna around the turn of the century. A p
proaching Freud's first years as a practitioner from the per
spective of the social configuration of which he was a part
and that compelled him to achieve a reputation for himself
quickly may explain a great part of his actions without any
referral to his moral or psychic characteristics, such as
his alleged ambition, concern about priority, interest in
money and those other traits that have been the subject of so
many and so acrimonious, essentially moralistic, polemics,
such was the compulsion of this configuration that no one
would have heard of him, had Freud not been up to it, and
this he'understood very clearly: "In wenigen Wochen 1st mein'
ceid - das i c h n o c h nicht einmal behoben habe - zu Ende, und-dann musz es sich ja zeigen, ob ich weiter in Wien leben kanh
oder in Amerika, Australien Oder sonstwo.
Und im Ver- trauen, meine Hoffnung, es in Wien aushalten zu konnen, 1st
sehr klein."(83)
This same, ongoing struggle for a reputation may have impeLtd
some of Freud's followers to present a novel theory cum ther
apy so as to conquer a name for themselves, just as j_t may be
the impelling motive to do so in contemporary psychotherapy
wherever a government arrangement for the payment of psycho
therapeutic treatment is lacking or inaccessible. Careful in
vestigation of the means of existence, the recruitment and
distribution of patients, and the ways of disseminating hew
therapies, could help decide on the validity of this assumpAfter this extensive digression on the financial mores of :
nineteenth century medical men and the necessities and possi
bilities of building a reputation within the medical profes
sion, some insight may have been achieved into the social
compulsions Freud had to cope with and in the implications of
nis own recommendations on the subject of money. It is cer
tainly clear from which entanglements he saved himself and
his p a t i e n t s : (84)
"It seems to me more respectable and ethically less objectionable
to acknowledge onefs actual claims and needs rather than, as is
still the practice among physicians, to act the part of the dis
interested philanthropist - a position which one is not, in fact,
able to fill, with the result that one is secretly aggrieved, or*
complains aloud, at the lack of consideration and the desire for
exploitation evinced by one's patients."
Freud warned in the Ratschlage against taking gratis patients,
even against the custom of treating colleagues or their relaJ eco? en s e* First of all, analytic treatment inolves
the dedication of a considerable portion (an eighth
ir a seventh part, perhaps) of the time available for his
livelihood over a period of several m o n t h s . " (85) Note the

394

brevity of the treatment. There is, however, another reason:

Gratuitous treatment enormously increases many neurotic reIsistknces,---(86) And, thirdly: "the whole relationship re
cedes into an unreal world, and the patient is deprived of a
'successful incentive to exert himself to bring the cure to an
teiidi" (87) Freud mentions that he himself did take gratis paGie'nis during ten years, "an hour daily, and sometimes two,
I & & i t h i s was only "for the purpose of studying the neuroses
iii w s_th the fewest possible h i n d r a n c e s (8 8 ) Nevertheless,
G i s o in later years Freud permitted himself to be exempted
own recommendations and did treat some patients gratis,
'MSBiig' them the Wolf-Man, w hom he even assisted financially
land.otherwise.(89) With paying patients, too, he may J ave
i ^ e ^ f l e s s strict than his Ratschlage suggest, at least until
G ^ 3 | : w h e n he wrote to Breuer to w hom he was indebted: (BU;
r|"Schon seit mehreren Jahren war ich in meiner Wirtschaftsrechnung
aktiv, aber der Hberschusz bestand stets in Ausstanden, wie sie
unsere Profession sich gefallen lassen musz, und die wiederholt
erprobte Schwierigkeit, bares Geld, das man zur Lebensfuhrung
braucht, auch wenn es gedeckt ist, sich leihweise zu verschaffen,
machte mir die Aufnahme der Ruckzahlungen unmoglich. Erst im _
letzten Jahr, welches das beste meiner Praxis war, hat sich e m
solcher Uberschusz im Barem hergestellt, dasz^ich mich dessen
Verminderung um eine gewisse Summe getrauen konnte.
ri' the same letter Freud explains an arrangement he made with
one of his patients: "Mir lag selbst daran, kern Obermasz von
B^hkbarkeit aufkommen zu lassen; andererseits lag es mir rerdas arme Madchen ihrer kleine Habe zu berauben.
These
Co n s i d e r a t i o n s , inspired by therapeutic motives, or so it
^seems, resulted in an agreement which provided for a greatly
l:te&uced fee, to be paid in full only when the young lady
& & u T d have inherited from her mother, then still a l i v e . (91)
Gfibud's attitude in matters of payment shows his firm inten
s i o n both to survive as a practitioner and family man on the
S # hand, and, on the other hand, to sweep aside all those
fi&ostly tacit, partly contradictory, moral and social obliga.lons and restrictions that would result in unmanageable en. tanglements which might interfere with the psychoanalytic
'process. Thus, the psychoanalytic situation was stripped of
.the' trappings which "Kulturmenschen" hitherto had adhered to.
A i r financial complexity was, in principle, reduced to a
' minimum agreement of maximal clarity: prompt monthly payment
at a fixed rate; one further approximation of a social null
Having traced the evolution of physical and finacial arrange
ments in the psychoanalytic setting, the following discussion
of/temporal arrangements and those arrangements that served
isolate the psychoanalytic dyad as much as possible from
interference from the larger social network may be briefer.
HT;n regard to time, I adhere strictly to the principle of

395

leasing a definite h o u r . " {92) Mention of this strict arrange

ment is immediately followed by a comparison to practitioners
of somewhat lower status, "teachers of music of languages in
good society" and with a reference to medical dignity, it
"may perhaps seem too rigorous in a doctor, or even unworthy
of his profession." It, too is justified by pointing to the
threat to the material existence of the physician that might
follow from patients failing to attend with all sorts of ex
cuses . (93)
"Nothing brings home to one so strongly the significance of the
psychogenic factor in the daily life of men, the frequency of
malingering and the non-existence of chance, as a few years'
practice of psycho-analysis on the strict principle of leasing
by the hour."
Again, with these firm rules, Freud slashed a knot that had
tied up many nineteenth century doctors in status dilemma's
aid reputational calculations:(94)
"Junge Aerzte und Charlatane pflegen meist ihre Besuche abzukurzen, um fur vollbeschaftigt zu gelten; Vielgeschaftigte mussen
dies ohnehin; Andere suchen sich gerade durch langes Aufenthalt
beliebt zu machen."
Usually, Freud worked with a patient six days a week, one
hour a d a y . (95) On the duration of the treatment Freud would
be somewhat reticent, the question "is almost unanswerable".
This is one of the few unspecified clauses in the implicit
treatment contract and it had to be fully explained to the
patient that psychoanalysis always is a matter of long periods
of time: six months, a year, or more. With usual consistency
Freud would not "bind patients to continue the treatment for
a certain length of t i m e ; " (96) The analysis could be broken
off whenever the patient so whished, but Freud would warn
that this might leave him in an "unsatisfactory s t a t e . " (97)
It wo u l d appear that Freud's recommendations on strict and
precise temporal arrangements agreed more with his personal
inclinations than the equally strict presciptions in financial
matters; "The Herr Professor is always s&hv punktZich very
punctual in everything he d o e s . " (98) This punctiliousness
in timing served to manage an extraordinarily busy schedule,
"eight or nine hours of therapeutical or training analysis
make a strenuous day's w o r k . " (99) The evenings were devoted
to the many chores of a researcher, writer and teacher, a
proliferous letter-writer and leader of a gradually expanding
movement with its own journals and publishing houses, and its
variety of managerial bodies.
The psychoanalytic setting thus became gradually defined more
sharply in time and space, divested from anything superfluous,
anything that might introduce ambiguity between analyst and
analysand, anything that might contaminate the situation in
the sense that this element, rather than the patient's own

396

psychic conflicts, might be held accountable for his contri

butions in the analysis. This isolated dyadic encounter has
been called a "social null-situation," analogous to the ex
pression "nu11-hypothesis" and analogous to the conceptual
structure underlying a natural science experiment: since all
relevant variables, except the independent variable - the
patient himself - are controlled, whatever occurs in the ex
periment may be explained on the basis of this remaining fac
tor, the patient reproducing his own psychic conflicts. Note
that this argument refers to the conceptual structure under
lying the psychoanalytic setting and in no way to what goes
on between the couple engaged in the interaction of analysis.
This conceptual approach also requires the elimination of all
remaining direct and indirect relationships between analyst
and analysand, but for the one analytic dyad. Formerly, doc
tors had practised a certain reservation in the intercourse
with patients, their relatives and acquaintances, and had set
themselves high standards of discretion, especially in matters
pertaining to venereal diseases and gynaecological afflic
tions .
"Die Stille Brust des Arztes ist oft ein Grab, in das man Abgeschiedenes versenkt." Therefore: "Vsvsahwisgenheit ist eine
der ersten Pflichten des A r z t e s ."(100) This oldest of medical
obligations weighed very heavily with Freud: "Mit den Neurotikern schliessen wir also den vertrag: voile Aufrichtigkeit
gegen strenge D iskretion."(101) For the medical audience ad
dressed in the Recommendations the matter went almost without
saying. It must have been so much common place that even the
i nn-keepers daughter in the Alp hotel, Katharine, trustfully
began her confession on the mountain top with: "You can say
anything to a doctor, I s u p p o s e ."(102) Yet, Freud learned at
an early point in his career that even the closest relatives
must be excluded, no matter whether communications could pos
sibly clarify matters. He conscientiously reports an incident
at the end of the treatment of Elisabeth von R., after he had
discussed with the mother an infatuation on the part of his
patient: "She was indignant with me /Freud? for having betray
ed her secret. She was entirely inaccessible, and the treat
ment had been a complete failure," the mother reported about
the daughter; Freud, though, maintained his confidence in the
result of his ef f o r t s .{103) Concerning the limitation of in
tercourse with the patient and his kin there is no medical
tradition comparable to the heritage of discretion. Yet, ear
ly nineteenth century handbooks do warn physicians to be
.guarded in their relations with female patie n t s : (104)
"Schon das, was man blose Calanterie nennt, den Hof macben, das
Handkussen u.s.w. kann den noch unverheuratheten Arzt in grosse
Verlegenheiten bringen. Das Frauenzimmer, noch mehr aber die
Mutter, halt dies alles fur ernsthafte, auf Heurath abzielende
Liebeserklarungen, und, wenn diese hernach nicht erfolgen, entsteht gewohnlich Hass und schadenbringende Verfolgung -- Bey

397

verbeuratheten Frauenzimmer aber, wo die allegemeine Mode er nicht

mit sich bringt, oder dekt, entstehet Verdacht anderer Art
"
And Liehrsch, almost half a century later warns: "Im Umgang
mit Damen muss der Arzt besonders vorsichtig sein --- Viele
sehen in dem Arzt bestandig einen Courmacher, Oder wunschen
es we n i g s t e n s ."(105) Clearly, the phenomenon of transference
love had been recognized widely and for a long time, e v e n " i n ;
the much less frequent and less intimate contacts between phy
sicians and their female c l i e n t s .(106) But this affect, which
had chased Breuer from Anna O.'s house, had not been under- .
stood. It was Freud's soup de genie to turn this familiar sub
ject of embarassment and jokes into the very vehicle of ther
apy. This, however, necessitated some strict rules of conduct
which Freud had to discover on his own and through trial and
error. In the Studies on Hysteria the reader finds him en
gaging freely in social intercourse with his p a tients,(107)
staying at Frau Emmy von N.'s country h o u s e , (108) or - be it
stealthily - visiting a ball where Elisabeth von R. whirls
past in a lively d a n c e . (109)
Of course, since for some time Freud was the only psychoana
lyst, and for many years the analyst of all other analysts,
he himself had to be exempt from this r u l e . (110) Stone spec
ulates that Freud also was "already groping for a solution"
to the problem of terminating the transference, when inviting
a patient to supper in the final stage of the analysis, as
Freud mentioned doing in a letter to Fliess.(lll) Be that as
it may, as early as 1900, in the Interpretation o f Dreams
Freud warns against the entanglements of treating patients
from o n e s own cercle of acquaintance (112) and he is adamant
on the subject in the Recommendations:(113)
Special difficulties arise when the analyst and his new patient
or their families are on terms of friendship or have social ties
with one another. The psycho-analyst who is asked to undertake the
treatment of the wife or child of a friend must be prepared for it
to cost him that
friendship, no matter what the outcome of the
treatment may he:
nevertheless he must make the sacrificeif he
cannot find a trustworthy substitute."
But not only "previous acquaintance", also "lengthy preliminary
discussions may result in a disadvantageous pre-established
"transference attitude" which must be uncovered before the
actual work can b e g i n . (114)
Freud also advised his patients to tell as few people as posm
sible about it: "That in consequence the world hears nothing
of some of the most successful cures is, of course, a consid
eration that cannot be taken into account."(115)
Knowledge acquired about analysis outside the treatment proper
is considered harmless, not helpful,(l16) and previous reading
useless, (except for
institutionalized patients) . (117)By the
time Freud wrote the
Ratschlage he had come to abandon the ;
habit of giving his patients lengthy expositions of psychoana .

398

lytic t h e o r y , (118) "I require them to learn by personal ex

perience, "{119) within the psychoanalytic setting itself, that
is. .
The adoption of office practice and of a consultation hour in
the course of the nineteenth century is one aspect of the ra
tionalization process that transformed the medical profession,
a rationalization directly bearing upon the nature of the re
lations between doctors and their patients. In many respects,
F r e u d s design of the psychoanalytic setting was a continua
tion arid a consistent elaboration of these rationalized pat
terns of intercourse between an expert therapist and his
clients. The strict regulation of payment and timing, the
isolation of interaction from other contacts through discre
tion, mutual avoidance of acquaintances and relatives and of
alb: contacts outside the setting proper served to further pu
rify a pattern of interaction that had evolved among fin de
siesie physicians.
However, for Freud this rationalization of the setting in
which he practiced did not simply represent his own version
of contemporary professional trends; it was essential to both
his working technique and to his method of theorizing: the
fully rationalized psychoanalytic setting allowed hi m to con
front both the patient and the scientific public - Freud's
twofold audience - with the fact that the patient's produc
tions could not be argued away as artefacts of the particular
situation, nor as having been induced by the therapist, but
that, instead, they had to be explained on the basis of the
patient's own psychic activities. Both the patient, as a matter
of-working technique, and the scientific audience, as a matter
of methodology, had to be convinced that the psychoanalytic
setting was a social null-situation that of itself would not
lead anyone to expect the kind of behavior on the part of the
patients that Freud observed, interpreted and reported in his
writings. Therefore, according to the basic structure of the
argument, it had to be understood from earlier experiences of
the patient himself. In order to carry through his working
technique and to complete the theoretical argument, Freud had
to prescribe two rules for the behavior of the actors in this
setting, the analyst and the analysand. These two complemen
tary rules, the rule of free association and the rule of ab
g-M n<=*rr<-pt represent innovations, if ever there were innova
tions in human interaction; they appear almost entirely with
out; -precedent. The first is known as the "psychoanalytic
groundrule."(120)
"My patients were pledged to communicate to me every idea or
thought that occurred to them in connection with a particular sub
ject -- the success of psydio-analysis depends on his noticing and
reporting what comes into his head and not being misled, for in
stance, into suppressing an idea because it strikes him as unim
portant or because it seems to him meaningless. He must adopt a

399

completely impartial attitude to what occurs to him -- "

To this day the requirement of free association stands as the
sine qua non of psychoanalysis. "Everyone, really reacts to
the statement of the groundrule as if he had already been fa
miliar with it" Michel Fain re m a r k s .(121) Somehow, somewhere
there should be an opportunity to say whatever one pleases
and the groundrule embodies the invitation to precisely that.
Little has changed in the application of this fundamental
rule, though some of Freud's phrasincp might now be replaced
by different words. His primary interest, at first, was in the
repressed content, rather than in the defense mechanisms with
which this repression was carried out and sustained: "whatever
comes into one's head must be reported without criticizing it."
(122) is a formula which might be misunderstood as ruling out
all sorts of hesitations, protestations, apologies which later
on became themselves the focus of interest in psychoanalytic
therapy. Secondly, Freud uses terms such as "pledge" (ver~
pflichtet3 vevspvoehen) that suggest a moral category, where
as what is at stake is a "technical instrumentality".(123) Or,
to repeat from the above quotation, "the success of psycho
analysis depends on" it, quite independently of ethical eval
uations. In the third place, the formula has been criticized
because it might increase a.sense of dissociation between the
speaker and what he speaks about, between "him" and "what
comes
into his head." (124) Whatever may
be of these critical
points against Freud as a theoretician,
they are all of them
outwitted by Freud as a practician: "And now*; Freud began
treatment with Wortis, "you can start and say what you like."
(125)
The second prescription, the rule of abstinence, is more dif
ficult to define and has caused more controversies.
"The treatment must be carried out in abstinence.
I shall state
it as a fundamental principle that the patient's need and longing
should be allowed to persist in her, in order that theymayserve
as forces impelling her to do work and to make changes, and that
we must beware of appeasing those forces by means of surrogates."

(126 )
At first sight, the rule seems to impose limitations upon the
patient. Freud makes it very clear that he does not intend the
patient to forego sexual satisfaction in daily l i f e . (127) He
is, however, worried by the prospect that cravings that go
unsatisfied in the treatment may be acted upon outside it with
harmful consequences that can not easily be u n d o n e : (128)
"One best protects the patient from injuries brought about through
carrying out one of his impulses by making him promise not to take
any important decisions affecting his life during the time of his
treatment - for instance, not to choose any profession or defini
tive love-object - but to postpone all such plans until after his
recovery."

400

Promises of this kind are nowadays less often demanded from

patients, maybe because life decisions, such as marriage and
choice of occupation, may not be so definitive anymore, and
certainly because of technical r e asons:(129)
"in fact it might well have quite harmful effects, because it
means the introduction of a certain measure, a prohibition, which
may provoke the patient to act out and which brings with it the
danger of our missing a valuable interpretation."
Van der Sterren's argument, analogous to his discussion of
patients' overly candid communications with a third party,
represents a further purification of the psychoanalytic situ
ation through the elimination of "a certain measure, a pro
hibition," justified with an argument of psychoanalytic tech
nique which favors interpretation over anything else. There
remains the necessity, however, for the patient to verbalize
his fears and longings, rather than act upon them within the
psychoanalytic setting. The physician "is prepared for a
perpetual struggle with his patient to keep in the psychical
sphere all the impulses which the patient would like to direct
into the motor sphere:"{130) This limitation upon the patient,
to feel and express his longings and anxieties intensely,
without doing anything about them with bodily movements, is
the abstinence required from him. And maybe an analysand can
only express these strivings when he has discovered that he
can express them without physically (or magically) realizing
them, and without being acted upon for having expressed them.
This gradual discovery is part of the psychoanalytic process.
Upon further reflection, it appears that the rule of abstinence
imposes restrictions upon the analyst in the first place. The
Recommendations concerned with Observations on Transferrencelove contain a lengthy list of all a therapist should refrain
f r o m : (131) he should not proceed to satisfy a longing through
factual actions, nor should he prohibit or condemn such de
sires in his patients, or justify them, with reference to
some scheme of juridical or ethical arguments, these being
external to the psychoanalytic situation. Nor should he en
courage or discourage such expressions with reference to what
he would like or dislike himself. And, maybe most subtle in
Freud's discussion, the therapist should not do away with these
longings by denying their authenticity or genuineness. The
therapist should limit himself to one activity only, to the
interpretation of these expressions in the context of the
patients's autobiographic material as he has told it so far,
rising- in this interpretation all those rules of transformation
::that .together constitute the body of psychoanalytic technique.
Anri again, these limitations are not imposed upon the therapit? for moral reasons, but because the technique of the treat
me n t requires them: "I am on this occasion in the happy posi,tAih of being able to replace the moral embargo by considera
tions of analytic technique, without any alteration in the
;outcome ."(132)

401

In their entirety these recommendations certainly constituted

a novel manner of people relating to one another, of confront
ing the strivings of one of them: "it is one for which there
is no model in real l i f e . " (133)
In theory, at least, a perfect social null-situation has been
brought about, a completely rationalized relationship that
would lead one to expect only correspondingly business-like,
maybe polite and friendly, behavior on the part of the patient:
(134)
"We believed, to be sure, that we had reckoned with all the motives
concerned in the treatment, that we had completely rationalized the
situation between us and.the patients so that it could be looked
over at a glance like a sum in arithmetic; yet, in spite of all this,
something seems to creep in which has not been taken into account in
our sum."
With this "something" Freud alludes to the transference. These
emotional attachments appear to be so strongly connected to
the person of the analyst and to the specifics of the treat
ment setting that every effort is necessary to convince the
patient and to prove to the scientific audience that they can
not have been induced by either and that, therefore, they must
be a compulsive repetition of earlier, conflictful experiences
on the part of the pa t i e n t :(135)
"This new fact, which we thus recognize so unwillingly, is known by
us as transference. We mean a transference of feelings on to the
person of the doctor, since we do not believe that the situation in
the treatment could justify the development of such feelings. We
suspect, on the contrary, that the whole readiness for these feeling
is derived from elsewhere, that they were already prepared in the
patient, are transferred on to the person of the doctor."

Tfta premeditated and manipulated nature of the

and of the behavior of the therapist within it

V into new fields of human experience and activity, its

S i S n ^ m a y be traced back to developments within the medical
a s J b * # o n Which itself was becoming more >:

^ f ^ a e s

SSt Irerf i n v e n t i o n of the

!j8 l l ! 8 H t a i r?ule of free association and of the abstinence

beyond the developments in the sphere of medicine
part of its social

Dhvsicians found themselves

iU
g S K -M n e S e n ^ ^ r ih e r s a w
J .
f c p i l e d to build a reputation increasingly based on te

through origina!

j^ppJthat

"n^ns o f 'scientific method. He

srasj L?

t b r ndatogether constitute the social null situatio -

Of course, there is an element of suggestion, in so far as

the therapist makes himself available as an object for the
phantasies of his patients, without rightaway correcting or
contradicting them as someone in the outside world might d o . .
(136) But no active intervention is required to achieve this:
(137)
"It remains the first aim of the treatment to attach him /the patiet7
to it and to the person of the doctor. To ensure this, nothing need
be done but to give him time."
Thus, the psychoanalytic situation, fully rationalized, com
parable to an arithmetic sum, or, in the terms of this paper,
the social null-situation, nevertheless produces deviations
from the calculated pattern, and precisely these deviations
are significant expressions of the patient's psychic conflicts.
Habermass catches these ideas very n e a t l y . (138)
"Die gleichsam experimentelle Kontrolle der Wiederholung' unter
.Bedingungen der analytischen Situation bietet dem Arzt gleichermaszen
eine Erkenntnis- wie eine Bebandlungschance."

402

a S i l l x t n f i o ! ; o f r a tio n a liz a tio n - in t h . ~ c i o l O ~ l

403

NOTES
1. Freud's works will be quoted from The Standard Edition of the Complete
Psychological Works of Sigmund Freud under the general editor-ship of
James Strachey, London: The Hogarth Press, 1 9 6 6
abbreviated as S.E.;
a second reference is matfe to the Sigmund Freud Studienausga.be, edited ny
Alexander Mitscherlich, Angela Richards and James Strachey, Frankfurt a.
M.: Fischer Verlag, 1 9 6 9
abbreviated St.A.
The first of the Recommendations to Physicians Practising Psycho-analysis
(Ratschlage fur den Arzt bei der psychoanalytischen Behandlung) appeared
12 June 1912 in the Zentralblatt fur Psychoanalyse, Vol. 2 (9), p. 1*83.
(An abstract may be found in Ernest Jones, Sigmund Freud, Life and
Work, 3 Vols., London: Hogarth Press (1955), 1958; Vol. II: Years of
Maternity, 1901-1919, pp. 261-266).
2. To the author's knowledge the only available publication except as part
of a complete edition is in Philip Rieff (ed.),Sigmund Freud; Therapy and
Technique, New York: MacMillan/Collier, 1 9 6 3 . The editors of the Studienausgdbe initially intended to omit the Ratschlage, but included them in
the added Erganzungsband (1 9 7 5 ).
3. Recent surveys of this literature in Russell Jacoby, "Negative Psycho
analyse und Marxismus; tlberlegungen zu eaner objektiven Theorie Jler Subjektivitat," Psyche, 29 (1 1 ), Nov. 1 9 7 5 .
Robert A. Jones, "Freud and American Sociology, 1909-191*9," Journal of
the History of the Behavioral Sciences,
10 (l), Jan. 1 9 7 b, pp. 21-39;
Weston La Barre, "Influence of Freud on American Anthropology," American
Imago, 15 (3 ), Fall 1 9 5 8 , pp. 275-328;
Walter Muensterberger and Aaron if. Esman, The Psychoanalytic Study of So
ciety, New York: International Universities Press, 1972.
h. For example T.W. Adorno, et al., The Authoritarian Personality, New
York: Harper and Row, 1950;
Talcott Parsons, various articles;for a bibliography see Robert A. Jones,
1971*;
Fred Weinstein and Gerald Platt, Psychoanalytic Sociology; An essay on
the interpretation of historical data and the phenomena of collective be
havior, Baltimore, 1973.
5- Norbert Elias, Vber den Prozess der Zivilisation; Soziogenetische und
psychogenetische Untersuchmgen, 2 Bnde, Bern und Munchen: Franke Verlag,
(1936), 1969, I. Band, p. 32b, n . 77.
6. See for example Paul Roazen, Freud, Poltical and Social Thought, New
York: Viatage, 1970.
7- Rather than with references the point is better made by listing some
contemporary key-terms: community psychiatry, family therapy, group-psychotherapy, lower-class psychotherapy, network-therapy(?), therapeutic
community.
8. However, G. Devereux, From Anxiety to Method in the Behavioral Scien-"'
ces, The Hague, Paris: Mouton, 1 9 6 7 , represents a first attempt at a
psychoanalytic understanding of social research.

tic ideas in contemporary (American) culture are Peter L. Berger, "To

wards a Sociological Understanding of Psychoanalysis, Social Research,
32 (1), Spring 1 9 6 5 , pp. 26-1*1; Eric Heller, "Psychoanalysis and Litera
ture," Salmagundi Ik Quarterly of the Humanities and the Social Sciences:
published by Skidmore College; 10th Anniversary Issue7, Fall 1975 - Winter
1976, nos, 31-32, pp. 17-28.
10. An early study, be it somewhat marred by hostility: Kuno Mittenzwey,
"Zur Soziologie der Psychoanalytischen Erkenntnis" in Max Scheler, ed.,
Versucke zu einer Soziologie des Wzssercs,Munchen, 1 9 2 b, pp. 365-375;
N.G. Hale Jr., Freud and the Americans. The beginnings of psychoanalysis
in the United States, 1876-1917, New York: Oxford U.P., 1971;
John C. Burnham, Psychoanalysis and American Medicine: 1894-1918; Medicine,
science and culture /Psychological Issues V (b)_7, New York: International
Universities Press, 1967; Serge Moseovici, La Psychanalyse, Son Image et
Son Public; Etude sur la representation sociale de la psychanalyse, Paris:
Presses Universitaires de France, 1961.
11. The most perceptive study of this kind is Charles Kadushin, Why People
Go To Psychiatrists, New York: Atherton, 1 9 6 9 .
12. No encompassing study of the genesis of the psychoanalytic or psycho
therapeutic profession has yet been made, although there are some socio
logical case studies, such as the chapter on New Haven psychoanalysts in
August B. Hollinghead and Frederick C. Redlich, Social Class and Mental
Illness: A community study, New York: Wiley, 1958; A. Strauss, L. Schatzman, et al., Psychiatric Ideologies and Institutions, New York: Free
Press, Pj6b; A r n o l d A. Rogov, The Psychiatrists, New York: Putnam, 197013. Cf. Vincent Brotne, Freud and his Early Ccrcle, London : llci ncmutin,
1 9 6 7 ; Paid Roazen, Brother Animal;' The story of Freud and Tausk,
Harmondsworth: Penguin, 1973; the literature is enormous, most of it,
however, is concerned with Freuds intellectual biography and with the
history of ideas of the time of the emergence of psychoanalysis. Inter
esting material on Freud's relations with his contemporaries may be found
in a.o. Ola Andersson, Studies in the Prehistory of Psychoanalysis,
Stockholm: Norstedts, 1 9 6 2 , Henry F. Ellenberger, The Discovery of the
Unconscious; The history and evolution of dynamic psychiatry, New York:
Basic Books, 1970. See also E. Jones (1958) and the various collections
of Freud's letters to be quoted below.
lb. Surprisingly little has been written on the history of the psychoana
lytic movement. Cf. S. Freud, On the History of the Psychoanalytic Move
ment, S.E., I1*, p. 1; F. Baumeyer, "Zur Geschichte der Psychoanalyse in
Deutschland," Zeitschzdft fur Psycho-somatische Medizin, 17 (1971),P- 203;
E. Glover, "Psychoanalysis in England," and A.P. Millet, "Psychoanalysis
.in the United States" in (F. Alexander, S. Eisenstein, M. Grotjahn eds.)
Psychoanalytic Pioneers, New York, London: Basic Books, 1 9 6 6 , pp. 519533, 53^-596 respectively.
15. Stlas Weir, Mitchell, an American neurologist, poet, and author,
.1829-1911(, proposed in his Fat and Blood (l8?2), "a form of treatment^
which consists in absolute rest of body and mind, administration of high, ly nutritious and easily digestible food in large quantities, and massage

9. Two very perceptive articles on the pervasive presence of psychoanaly

404

405

to take the place of muscular exercise." (William R.R. Thomson, Black's

Medical Dictionary, 29th ed., London: Black, 1971. Various methods of
electrotherapy were in use; faradization consisted in the application of
alternating electrical currents of low frequency to parts of the "body
affected by hysterical paralysis. Galvanization consisted in a similar
application of direct current. Oosthoeks Encyclcpedie, Utrecht: Oosthoek,
1968-1973.
1 6 . "This treatment by warn baths, massage twice a day and hypnotic sug
gestion was continued for the next few days." /Emmy von M., 1 8 8 8 or 1889(7
Studies on Hysteria, 1893 1895, S.E., 1, p. 52.
"Treatment of the_usual kind was ordered: the electric brush, alkaline
water, purges;" /Frau Cacilie, + 18927, Ibid., S.E., 1, p. 1?6.

1?. Cf. L. Chertok and R. de Saussure, Haissance du Psychoanalyse, de

Mesfiner a. Freud, Paris: Payot, 1973.
18. This was, specifically, a problem with electrization machinery; until
by the middle of this century new, less bulky, more easily transportable,
machines were being designed. Cf. Eerste Nederlandse Systematisch Ingerichte Encyclopedic, Amsterdam: Wetenschappelijke Uitgeverij, 1 9 I16 - 1 9 6 O.
The advent of the transistor solved this problem by the time that the
treatment begun to be abandoned.
-S
19. Ingrid Vieler, Die Deutsche Arztpraxis im 19. Jahrhundert (inaugural
Dissertation Gutenberg U.}, Mainz, T958, p. k .

20. Quoted by Vieler, Ibid.

21. Quoted by Vieler, Op. Cit., p. 1 2 .
22. The word "nicht" must probably be deleted.
23- Edith Heischkel-Artelt "Die Welt des praktischen Arztes im 19* Jahr
hundert" in: W. Artelt und W. Riiegg (hrgs), Der Arzt und der Kranke in
der Gesellschaft des 1$. Jahrhunderts, Frankfurt a. M.: Enke, Stuttgart,
1 9 6 7 , p. 1 0 .
2k. Cf. S. and S.C. Bernfeld, "Freuds First Year in Practice, 1886-1887,"
Bulletin of the Menninger Clinic, 16 (2), March, 1952, p. 3 7 .
E. Jones, Op. cit., I, p. 15725. Erik H. Erikson, "Freud's 'The Origins of Psychoanalysis1," Int.
Journal of Psycho-analysis, 36 (l), 1955, p.
26. The controversy turns about the question whether Freud's opinions
wore received there with as much hostility as he later on reported in his
Autobiography (Selbstdarstellvng); cf. S. & S.C. Bernfeld; Ellenberger,
pp. k37-hk2; Jones (1958), I, pp. 251-255; K. Sablik, "Sigmund Freud und
die Gesellschaft der Arzte in Wien," Wiener Klinische Wochenschrift, 80
(6 ), Februar 1968, pp. 107-110.
27. "in a district near the new university, which since the sixties had
become one of the most fashionable residential areas of the city. The
house was dignified, the rroms large and beautiful." S. & S.C. Bernfeld,
p* 38.
28. Jones (1958), op. cit., I, p. 1 6 7 ; I, p. k2 k.

406

29>/Andre Breton, Les Pas Perdus, ("Interview du Professeur Freud", + 1920?)

Paris: Gallim&rd, (nlle ed. rev. corr.), 1 9 6 9 , PP- 99-100.
30. Eller.berger, op. cit., p. k6531. Har.ns Sachs, Freud, Master and Friend, Cambridge, Mass.: Harvard U.P.
1 9 L5 tji-p; 5 1 . Again, this is a matter of controversy. Ellenberger is attenrpting^ to establish a sociological point: "Freud could also be under
stood if*-seer. as a typical representative of the Viennese professional
world;Tof the end of the nineteenth century. It was not unusuaLin Vienna,
an ethnic and social melting pot, that a gifted man from the lower middle
class could climb the social ladder and reach, by middle life, a fairly
high social and financial status, provided that he had gone to secondary
school-and a university." Ellenberger, p. k6 k; "Freud lived, morally, soeially,..and professionally, according to the highest standards of a man
of his .time and status.", ibid., p. k6 3 , Ernst Federn retorts: "Als Bewc-is fur FREUDs Groszburgertum stel It er /Illnberger7 der Berggasse in
Wien als ein elegantes Burgerviertel in der Kahe der kaiserliche Residenz
dariund vergleicht dieses mit dem bescheidenen Wohnsitz ADLERs
. Auf
einem-mit diesen Verbaltnissen nicht vertrauten Leser macht natilrlich
eine so ?genaue Darstellung der sozialen Hiritergrunde einen grosser Eindruck - auf Kosten FREUDs". E. Federn, "Einige Bemerkungen uber die
Schwierigkeiten, eine Geschichte der Psychoanalyse zu schreiben,"
Jahrbuch.der Psychoanalyse (Beitrage zur Theorie und Praxis), 7, Bern
etc., 1971*, p- 1 6 .
The area may well have deteriorated somewhat in later years, which would
explain the divergent testimonies: "a simple Viennese residence on the
first floor of an ordinary house, in an ordinary part of Vienna. There
was. a/butcher-shop downstairs. The entrance was dilapidated, like most
entrances in Vienna during that period." (193k). Joseph Uortis, Fragments
of an Analysis with Freud, New York: Simon and Schuster, 195k, p. 2732. Cf. "The Memoirs of the Wolf-Man" (Serge Pankejeff), in Muriel
Gardiner (ed.), The Wolf-Man and Sigmund Freud, Harmondsworth: Penguin,
1973; Jones, (1958), I, pp. 361, II, pp. k2k-5; Sachs, p. 51;
33- E. Jor.es, op. cit., I, p. 1 5 6 .
3k: Sigmund Freud, Brautbriefe; Briefe an Martha Bemays aus den Jdhren
1882-1$8 0 , Ernst L. Freud, brg.), Frankfurt a.M.: Fischer, 1 9 6 8 ; pp.
1 3 k-135 (letter of May 6 , 1 8 8 6 ).
35. J-M. Charcot, Heue Vorlesungen uber die Krankheiten des Nervensystem
insSesondere uber Hysterie, Leipzig und Vienna: Toeplitz & Deuticke, 1 8 8 6 ;
Freud's Preface: S.E. 1, pp. 21-22.
36.' -H.: Berr.heim, Die Suggestion und ihre Eeilwirkung, Leipzig und Vienna:
Duetirke, 1 8 8 8 ; Freud's Prefaces: S.E. 1, pp. 73-87.
37- Chertok & de Saussure, op. cit., pp. 188-192; E. Jones (1958), op.
'cit., I, p. 2 c 1 . 2 .
38. S.E. 2, p. 3 2 k.

39. "A Case of Successful Treatment by Hypnotism" (1892-3), S.E. 1, p. 119*

407

1(0. S.E. 2, p. 106. And, of course, there is the consultation with Katharina on a mountain top (Studies on Hysteria, S.E. 2, p. 125).
1(1. S.E. 2, p. 1 7 1 .
1(2. Even more than once a day with Frau Cacilie, sessions with whom num
bered "several hundreds," S.E. 2, p. 1 7 8 .
1(3- S.E. 2, p. 155;' Freud apparently would often meet relatives and visi
tors at. the patients homes;(Emmy von N.): "Her dislike,for instance, of
saying anything about herself was so great, that, as I noticed to my as
tonishment in 1 8 9 1 , none of the daily visitors to her house recognized
that she was ill or were aware that I was her doctor." S.E. 2, p. 102.
ltl(.

The Wolf-Man and Sigmund Freud, op. cit., p. 155.

1(5Letter to Fliess, February U, 1 8 8 8 :" Die, wie Sie wissen, nicht sehr
ansehnliche Praxis hat in letzter Zeit durch Charcots Hamen einige Bereicherung erfahren. Der Wagen kostet viel und das Besuchen undHn- und Ausreden, worin raeine Beschaftigung besteht, raubt die schonste Zeit fur die
Arbeit." S. Freud, Aus den Anfangen der Psychoanalyse, Briefe an Wilhelm
Fliess, Abhandlungen und Notizen aus den Jahren 1887-1902, London: Imago,
1950, p* 63. The Vageri was a cab rented for doctors visits.
1(6. A daydream of the surgeon Stromeyer in 1792, quoted by Vieler,,op.
cit., p. 11.
L7 . Moreover, I have adopted the habit of combining cathartic psychothe
rapy with a rest-cure which can, if need be, be extended into a complete
treatment of feeding-up on Weir-Mitchell lines." Studies on Hysteria,
(1895), S.E. 2, p. 26?; St. A., Erganzungsband, p. 6 1 . Simple rest-cures
apparently were prescribed until much later. Cf. The Wolf-Man, op. cit.,
note 32 above.

mingling with the patient'sassociations imperceptibly, to isolate the

transference -- " S.E., 12,p. 13L, St. A., Erg* b., pp. 193-L. Cf. Also,
Jones (1958), op. cit., II, p. 2 6 5 .
55- S.E. 12, p. 131 > St.. A., Erg. b., p. 191.
5 6 . Ibidem.

57. Ibidem.
5 8 . Chertok & de Saussure, op. cit., p. 6 5 , n.

59. D.W.G. Plouquet, Der Arzt; oder uber die Ausbildung, die Studien,
Pflichten und Bitten, und die Klugheit des Arztes, Tubingen, 1797
The medical customs of Freud's and preceding times are reconstructed from
indications found in various guides for the practice of medecine of those
days, following the pioneering example of N. Elias who used manuals of
courtly etiquette in his study of the process of civilization. His argu
ment for their representativeness is, with some modification, also valid
in the present context: "Diese 'Tischzuchten' sind ebensouenig, wie die
nicht-anonymen Manierenschriften des Mittelalters individuelle Produkte
im modernen Sinne des Wortes, Niederschriften personlicher Einfalle von
Einzelnen innerhalb einer reichlich individualisierten Gesellschaft. Was
da schriftlich auf uns gekommen ist, sind Fragmente einer groszen, miindJichen Tradition, Spiegelbildor dessen, was tatsachlich in dieser Gesell
schaft Brauch war, und gerade deswegen bedeutsam, veil es nicht das Grosze,
Auszergewohnliche, sondern das Typische einer Gesellschaft weitertragt.
N. Elias, (1 9 3 6 ), I, P* 77- Although the medical guides quoted in this
study certainly were the personal product of their authors, these doctors
did attempt to convey what was considered in their professional cercles,
'good practice1 or 'proper manners'.
60. Plouquet, op. cit., p.

1(8. Letter to Fliess, December 28, 1 8 8 7 : "Ich selbst habe mich in den
letzten Wochen auf die Hypnose geworfen und allerlei kleine aber merkwurdige Erfolge erzielt." Aus den Anfangen, op. cit., p. 6 1 . Cf. E. Jones
(1998), I, p- 258.
L9 . Most likely for the first time with Emmy von U. in 1889: "this was
the first case in which I employed the cathartic procedure to a large
extent.1 Studies on Hysteria, S.E. 2, p. 105, n.

6 1 . Bernhard Liehrsch, (Bilde des arztlichen Lebens oder) Die wahre Lebenspolitik des Arztes fur alle Verhdltnisse, Berlin, i8L2, p. 1 8 6 .
6 2 . Liehrsch, op. cit., pp. 187-8.
6 3 . Liehrsch, op. cit., p. 189-

6k. Hew Introductory Lectures on Psycho-Analysis, S.E. 21, p

St. A. 1 , p. 531*.

50. S.E. 2, p. 10951. S.E. 2, pp. U0-1.

52. Editor's note, S.E. 2, p. 110.
53. Ibidem; Interpretation of Dreams, (1 9 0 0 ), S.E. li, p. 101; St. A., 2,
p. 121 (see also editor's note).
5l(."Freud's Psychoanalytic Procedure," S.E. 7, p. 2L9; St. A., Erg. 6, p.
102. In "On Beginning the Treatment (Further Recommendations on the
Technique of Psycho-analysis)", (1913), fEatscklageJ, Freud introduces
this lying position as "a certain ceremonial," a "remnant of the hypnotic
period," which is also more convenient for the therapist, since he is not
constantly being stared at. His main reason, however, is most germane to
the argument developed in this article; "to prevent the transference from

408

65. "heuristic" or "search schemes", W.F. van Leeuwen, "Aard en Gebruik

van Psychoanalytische Hypothesen", Inval, 1/2, 1971, pp. 259-276; cf.
also, same author, "Het Psychoanalyt.isch Minimum" in: W.F. van Leeuwen,
"Het. Psychoanalytisch Minimum" in (H.P. Cassee, P.E.Boeke, J.T. Barendregt,
eds)^fCLinische Psychologic in Nederland, dl. I, Van Loghum: Deventer, '73,

EE

&

. Ncrbert Elias, "Sociology and Psychiatry," in (S. Foulkes

G.
Stewart Prince, eds.), Psychiatry in a Changing Society, London,
TayiStock, 196 9 , p. 121.
67. Liehrsch, op* cit., p. 1 8 6 .
W-
;6&.: Liehrsch, op. cit., p. 1 8 8 .
;49v7;WilIiam Hooker, Physician and Patient; or a Practical View of the

409

Mutual Duties, Relations and Interests of the Medical Profession and the
Community, (E. Bentley, ed.), London: 1850, p. 2 8 9 .
70. Thus, the anxieties which someone develops at an early stage concern
ing the integrity of his genitals, he comes to hold at a later age, but
in similar fashion, with respect to his prestige and status in relation
to those around him. While he fears being 'belittled', being made to re
semble those of lower ranks, he refrains from insisting on prompt and
equitable payment, and at the same time harbours fantasies about his
moral greatness. Jeanne Lampl-de Groot has pointed to the significance
of such fantasies in the clinical configuration of masochism: "The patient
feels himself to be a unique, exalted person, an exception, superior to
his fellow wen, a martyr -- his original ideas of being powerful and
grand having been deformed into those of being pitiful and grand - grand
in martyrdomf J . Lampl-de Groot, The Development of the Mind, Psychoana
lytic Papers on Clinical and Theoretical Problems, / Mew fork?: Inter
national Universities Press, 1 9 6 5 , p. 35l.
71. It cannot be emphasized strongly enough that this argument does not
imply that nineteenthcentury doctors were moral masochists in the clini
cal psychological sense of the term. They found themselves to be part of
a social configuration that entailed for them certain contradictions re
garding status, management and payment. Within the profession one .greva
lent manner of solving these contradictions consisted in a moral maso
chistic manoeuvre. How each of these men solved the many other contra
dictions in his life is an entirely different question, and the answer
to that question would allow to establish a clinical psychological char
acterization of each one of them.
72. Quoted by Vieler, op. cit., p. 1 3 .
p. 71 ,

73. Liehrsch, op. cit., p. 7l-

7b. Sheldon Wolin, Polities and Vision; Continuity and Innovation in

Western Political Thought, Boston etc.: Little, Brown Si Co, i9 6 0 , p. 3 I6 ,
discussing the subject of Utilitarianism, conscience and conformity at
the end of the 1 8 th century.

of his appointment as a professor.

Jose/iind Renee Gicklhorn, Sigmund Freuds akademische Laufbahn im Lichte
deriBpkumente; Wien-Innsbruck: Urban, i9 6 0 . This study has been vehement
ly! a/iackcd by K.R. Eissler, Sigmund Freud und die Wiener Universitat:
ub'ertdie Pseudowissenschaftlichkeii der jiingste FreudBiographik, Bern
kr.dj^iutrtgart: H . Huber,
Jon.es, op. cit., 1, p. 1 5 6 .
"A Case of Successful Treatment by Hypnosis," S.E. 1, p. 118;
$iu^'ed:ycn Hysteria, S.E. 2, pp. 106, 135; Brautbriefe, op. cit., p. 131.
^ ^ ^ f j b h e s , op. cit., 1, p. 157 (Jones quotes no source).
of May 6 , 1886 to Martha Bemays, Brautbriefe, op. cit., p. 13k
p b ^ j : J.discussion of his prospects in a letter to Martha of February
also the gloomy report on the situation in the letter to
August 29, 1 8 8 8 , and on the much improved state of at fairs
hi|^/petter to Fliess of December 8 , 1895, Aus den Anfangen, op. cit.,
/pii^-67 and p. ll7 respectively.
81:/".?.urther Recommendations (I): On Beginning the Treatment," S.E. 12,
:pp//3T-2; St. A., Erg. 6 ., p. 291;B%.::dbidom.

tilCJ^idm; in the Netherlands and in other countries government arrangefor the reimbursement of all or most of the costs of psycho, little is known about the effect of such third-party instii;^ut^a^jipayment on the therapeutic process. Cf. James L. Nash and Jesse
"Free Psychotherapy: An Inquiry into resistance," American
-Psychiatry, 133 (9), Sept. 1976, pp. 1066-1069, and also the
knpnlow & Cohen and by Pasternack & Preiger in that issue.
SZIfTo-idem.
8'9iihie~:
Mdlf-Man and Sigmund Freud, op. cit., p. 1 6 0 , n. 2.

75. Norbert Elias, Die hofische Gesellschaft; Untersuchungen zur Soziolo

gie des Kdnigtums und der h&fischen Aristokratie mit einer Einleitung:
Soziologie und Geschichtswissenschaft, Weuwied und Berlin: Lucbterhand
19o9, p. 1 10.

30/ Sigmund Freud, Briefe 1873-1939, (Ernst & Lucie Freud hrgs), Frankfurt'a/i.;: Fischer (1 9 6 0 ), 2 erw. aufl. 1968, p. 216; letter of January
7, 1 S9 8 -

7o. Idem, p. ill ; italics in original.

92. "Oil Beginning the Treatment," S.E. 12, p. 126; St. A., Erg. 6 ., p.
1 8 6 . // ;

77- See for example, Erich Wulff, "Der Arzt und das Geld; Der Einflusz
von Bezahlungssystemen auf die Arzt-Patient-Beziebung," Das Argument 69,
13. Jrg., Heft 11/1 2, Dez. 1971, p. 953.

9 1 . lifldem, p. 2l7-

93. idem, S.E. 12, p. 127; St. A., Erg. 6 ., p.

9 I. Liehrsch, op. cit., p.

73. E. Jones, op. cit., I, pp. 157-166, describes Freud's financial dif
ficulties at ^the time of his marriage; Freud's letters to Martha Bernays
(cf. Brautbriefe, op. cit.) and to Fliess, (cf. Aus den Anfiingen, op.cit.)
convey a vivid picture of his money worries.
79- In how for antisemitism in Austria hampered Freud's professional op
portunities has become a matter of controversy. Gicklhom and Gicklhorn
have tried to show that Freud was in no way discriminated against in the

410

187.

132.

:9 3 . Idem, S.E. 12, p. 126; St. A., Erg. 6., p.

187- He madeexceptions,
for example with Ferenczi, whoafter three weeks of analysis with Freud
. in October 19ll resumed treatment in June 1 9 1 6 'for three weeks and was
vanalysed for two hours a day'. But, of course, these were times of war.
Jones, ,0958}, II, pp. 195, 213'9.6. Idem, S.E. 12, p. 128; St. A., Erg. 6., p.

411

'38.

97. Item, S.E. 12, pp. 129-30; St. A., Erg. 6 ., p. 1 8 9 .

117. "Recommendations," O.K. 12,p. 120; St. A., Erg. 6., p.

98. Freuds servant girl quoted by Joseph Wortis, Fragments of an Analysis

with Freud, New York: Simon and Schuster, 195**, p. 8 .

1 1 8 . Jones, op. cit., II, p. 258.

1 19 .

9 9 . lianris Sachs, Freud, Master and Friend, Cambridge: Harvard U.P., 19**5,
p. 8 9 . Cf. Ellenberger, op. cit., p. **63; F- Wittels, Sigrmmd Freud, Der
Mann, die Lehre, die-Sakule, Leipzig etc.: Tal, 192**, p. 3 5 .

100. Liersch, op. cit., pp. 97, 96.

101. An Outline of Psychoanalysis (19**0), S.E. 32, p. 17**; St. A., Erg. 6 .
p. **1 2 .
102. Studies

on Hysteria (l895), S.E. 2, p.127-

103. Idem, S.E. 2, p. 1 6 0 .This incident and others, similar to it, may
have gravely hampered the advent of family therapy. "As regards the
treatment of their the patientsJV? relatives I must confess nyself utter
ly at a loss, and I have in general little faith in any individual treat
ment of them." "Recommendations" (1912), S.E. 12, p. 120; St. A., Erg. 6 .
p. 1 8 0 .
10*i. Ploucquet, (1797), op. cit., p. 80.
105. Liersch, (l8**2), op. cit., p. 99.
106. And even more clearly with the clients of hypnotizers, cf. Chertok
and de Saussure, op. cit.
107. Jones, op. cit., II, op. cit., p. 255108. S.E. 2,

p. 105, n. 1.

109- S.E. 2 ,

p. 1 6 0 .

"Recommendations," S.E.

1 2, p.

120;

St.

A.,

Erg. 6 ., p.

180.

l80.

120. The Interpretation of Dreams, S.E. **, pp. 100-101; St. A., 2, p. 1(.1.
121. Michel Fain, "De Crondregel", Inval, I (1), Autumn 1968, p. 2**; cf.
"the groundrule does not need to be discussed. It works much bet.ter if
one sticks to it oneself, and the patient will discover that this rule
applies." (transl.),C.Th. van Schaik, "Over het Initiele Interview,"
Inval, I (l), Autumn 1 9 6 8 , p. 15122. "The Dynamics of Transference" (1912), S.E. 12, p. 107; St. A., Erg.
6 ., p. 167
123. Stone, op. cit., p. 3312*t. Roy Schafer, A Dew Languagefor Psychoanalysis,
London: Yale University Press, 1976, p. 1**9.

Hew Haven and

125- Reported by Joseph Wortis, Fragments of an Analysis wuth Freud,

Hew York: Simon and Schuster, 195**. p*
126. "Recommendations (On Transference Love)", S.E. 12, p. 165; St. A.,
Erg. 6 ., p. 2 2 *4 . In this chapter on transference love the patient is
taken as feminine.
127- "Lines of Advance in Psycho-Analytic Therapy," S.E. 17, p- 162; St.
A., Erg. 6 ., p. ?*+**.
128. "Recommendations (Remembering and Repeating)," S.E. 12, p. 153; St.
A., Erg. 6 ., p. 213.

110. Jones mentions many of these unavoidable exceptions to the rule, and
Roazen adds a few, among them Anna Freud's analysis with her father, op.
cit., p. 1 9 b, n. 8 .

129. H.A. van der Sterren, "Life Decisions During Analysis," International
Journal of Psycho-Analysis, **7 (2-3), 1966, p. 297.
130. S.E.

12,

p.153; St. A.,Erg-, 6 ., p. 213-

111. Stone, op. cit., p. 122.

131. S.E.

12,

pp. 160-168; St. A.,Erg. 6 ., pp. 220-228.

112. S.E. **, p. 106; St. A., 3, p. 126.

132. S.E.

12,

p.16*j;St. A., Erg. 6 ., p. 223-

113- "On Beginning the Treatment," S.E. 12, p. 125; St. A,, Erg. 6 . p.
185.

133. S.E.

12,

p.166;St. A., Erg. 6 ., p. 225.

13**. Introductory Lectures, (1916-17), S.E. 1 6 , p. **38; St. A.

il*t. Ibidem.
115.'Idem, S.E. 12, p. 137; St. A., Erg. 6 ., p. 1 9 6 .
H.H. Van der Sterren, "Zur Psychoanalytischen Technik," Jahrbuch der
Psychoanalyse (3), Koln und Opladen, 196**, p. 1 6 6 , comments that conver
sations with others about the analysis should not be prohibited, but
after analysis of the countertransference (e.g. envy toward the third
party), such activities on the part of the patient are to be interpreted
in the context of the transference (e.g. as attempts to arouse envy in
the analyst).
Ho. "On Beginning the Treatment," S.E. 12, p. 126; St. A., Erg. 6 .,
p. 1 8 6 .

412

135- S.E. 1 6 , p. 1*1*2; St. A.

1, p. **22.

1 , p. **25.

136. S.E. 16, p. **53; St. A. 1, p. 1*35137. "Recommendations ( Beginning the Treatment)," S.E. 12, p. 139; St. A.
Erg. 6 -, p. 199.1 3 8 . Jurgen Habermass, Erkenntnis und Interesse, Frankfurt a.M.: Suhr.kamp (1968), 1973, p. 2 8 *t.
1 3 9 *, Rorbert Elias, "Problems of Detachment and Involvement,"
Journal of Sociology, 7, ( 1 9 5 6 ) , p. 2 3 1 .

: 1**0. Idem, p. 23**, n. 1.

413

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