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object:1.07 - Medicine and Psycho therapy
book class:The Practice of Psycho therapy
author class:Carl Jung
subject class:Psychology
class:chapter


VII
MEDICINE AND PSYCHO THERAPY 1
[192]
Speaking before an audience of doctors, I always experience a certain
difficulty in bridging the differences that exist between medicine on the
one hand and psycho therapy on the other in their conception of pathology.
These differences are the source of numerous misunderstandings, and it is
therefore of the greatest concern to me, in this short talk, to express one or
two thoughts which may serve to clarify the special relationship that
psycho therapy bears to medicine. Where distinctions exist, well-meaning
attempts to stress the common ground are notoriously lacking in point. But
it is extremely important. in his own interests, that the psycho therapist
should not in any circumstances lose the position he originally held in
medicine, and this precisely because the peculiar nature of his experience
forces upon him a certain mode of thought, and certain interests, which no
longer haveor perhaps I should say, do not yet havea rightful domicile
in the medicine of today. Both these factors tend to lead the
psycho therapist into fields of study apparently remote from medicine, and
the practical importance of these fields is generally difficult to explain to
the non-psycho therapist. From accounts of case histories and miraculously
successful cures the non-psycho therapist learns little, and that little is
frequently false. I have yet to come across a respectable specimen of
neurosis of which one could give anything like an adequate description in
a short lecture, to say nothing of all the therapeutic intricacies that are far
from clear even to the shrewdest professional.
[193]
With your permission I will now examine the three stages of medical
procedureanamnesis,
diagnosis,
and
therapyfrom
the
psycho therapeutic point of view. The pathological material I am here
presupposing is pure psychoneurosis.
[194]
We begin with the anamnesis, as is customary in medicine in general and psychiatry in particular that is to say, we try to piece together the
historical facts of the case as flawlessly as possible. The psycho therapist,
however, does not rest content with these facts. He is aware not only of the
unreliability of all evidence, but, over and above that, of the special
sources of error in statements made on ones own behalf the statements
of the patient who, wittingly or unwittingly, gives prominence to facts that
are plausible enough in themselves but may be equally misleading as
regards the pathogenesis. The patients whole environment may be drawn
into this system of explanation in a positive or negative sense, as though it
were in unconscious collusion with him. At all events one must be
prepared not to hear the very things that are most important. The
psycho therapist will therefore take pains to ask questions about matters
that seem to have nothing to do with the actual illness. For this he needs
not only his professional knowledge; he has also to rely on intuitions and
sudden ideas, and the more widely he casts his net of questions the more
likely he is to succeed in catching the complex nature of the case. If ever
there were an illness that cannot be localized, because it springs from the
whole of a man, that illness is a psychoneurosis. The psychiatrist can at
least console himself with diseases of the brain; not so the psycho therapist,
even if he privately believes in such a maxim, for the case before him
demands the thorough psychological treatment of a disturbance that has
nothing to do with cerebral symptoms. On the contrary, the more the
psycho therapist allows himself to be impressed by hereditary factors and
the possibility of psychotic complications, the more crippled he will be in
his therapeutic action. For better or worse he is obliged to overlook such
cogent factors as heredity, the presence of schizophrenic symptoms, and
the like, particularly when these dangerous things are put forward with
special emphasis. His assessment of anainnestic data may therefore turn
out to be very different from a purely medical one.
[195]
It is generally assumed in medical circles that the examination of the
patient should lead to the diagnosis of his illness, so far as this is possible
at all, and that with the establishment of the diagnosis an important
decision has been arrived at as regards prognosis and therapy.
Psycho therapy forms a startling exception to this rule: the diagnosis is a
highly irrelevant affair since, apart from affixing a more or less lucky label
to a neurotic condition, nothing is gained by it, least of all as regards
prognosis and therapy. In flagrant contrast to the rest of medicine, where adefinite diagnosis is often, as it were, logically followed by a specific
therapy and a more or less certain prognosis, the diagnosis of any
particular psychoneurosis means, at most, that some form of
psycho therapy is indicated. As to the prognosis, this is in the highest
degree independent of the diagnosis. Nor should we gloss over the fact that
the classification of the neuroses is very unsatisfactory, and that for this
reason alone a specific diagnosis seldom means anything real. In general, it
is enough to diagnose a psychoneurosis as distinct from some organic
disturbance the word means no more than that. I have in the course of
years accustomed myself wholly to disregard the diagnosing of specific
neuroses, and I have sometimes found myself in a quandary when some
word-addict urged me to hand him a specific diagnosis. The Greco-Latin
compounds needed for this still seem to have a not inconsiderable market
value and are occasionally indispensable for that reason.
[196]
The sonorous diagnosis of neuroses secundum ordinem is just a
faade; it is not the psycho therapists real diagnosis. His establishment of
certain facts might conceivably be called diagnosis, though it is
psychological rather than medical in character. Nor is it meant to be
communicated; for reasons of discretion, and also on account of the
subsequent therapy, he usually keeps it to himself. The facts so established
are simply perceptions indicating the direction the therapy is to take. They
can hardly be reproduced in the sort of Latin terminology that sounds
scientific; but there are on the other hand expressions of ordinary speech
which adequately describe the essential psycho therapeutic facts. The point
is, we are not dealing with clinical diseases but with psychological ones.
Whether a person is suffering from hysteria, or an anxiety neurosis, or a
phobia, means little beside the much more important discovery that, shall
we say, he is fils papa. Here something fundamental has been said about
the content of the neurosis and about the difficulties to be expected in the
treatment. So that in psycho therapy the recognition of disease rests much
less on the clinical picture than on the content of complexes. Psychological
diagnosis aims at the diagnosis of complexes and hence at the formulation
of facts which are far more likely to be concealed than revealed by the
clinical picture. The real toxin is to be sought in the complex, and this is a
more or less autonomous psychic quantity. It proves its autonomous nature
by not fitting into the hierarchy of the conscious mind, or by the resistance
it successfully puts up against the will. This fact, which can easily beestablished by experiment, is the reason why psychoneuroses and
psychoses have from time immemorial been regarded as states of
possession, since the impression forces itself upon the nave observer that
the complex forms something like a shadow-government of the ego.
[197]
The content of a neurosis can never be established by a single
examination, or even by several. It manifests itself only in the course of
treatment. Hence the paradox that the true psychological diagnosis
becomes apparent only at the end. Just as a sure diagnosis is desirable and
a thing to be aimed at in medicine, so, conversely, it will profit the
psycho therapist to know as little as possible about specific diagnoses. It is
enough if he is reasonably sure of the differential diagnosis between
organic and psychic, and if he knows what a genuine melancholy is and
what it can mean. Generally speaking, the less the psycho therapist knows
in advance, the better the chances for the treatment. Nothing is more
deleterious than a routine understanding of everything.
[198]
We have now established that the anamnesis appears more than
usually suspect to the psycho therapist, and that clinical diagnosis is, for his
purposes, well-nigh meaningless. Finally, the therapy itself shows the
greatest imaginable departures from the views commonly accepted in
medicine. There are numerous physical diseases where the diagnosis also
lays down the lines for a specific treatment; a given disease cannot be
treated just anyhow. But for the psychoneuroses the only valid principle is
that their treatment must be psychological. In this respect there is any
number of methods, rules, prescriptions, views, and doctrines, and the
remarkable thing is that any given therapeutic procedure in any given
neurosis can have the desired result. The various psycho therapeutic
dogmas about which such a great fuss is made do not, therefore, amount to
very much in the end. Every psycho therapist who knows his job will,
consciously or unconsciously, theory notwithstanding, ring all the changes
that do not figure in his own theory. He will occasionally use suggestion,
to which he is opposed on principle. There is no getting round Freuds or
Adlers or anybody elses point of view. Every psycho therapist not only
has his own methodhe himself is that method. Ars requirit totum
hominem, says an old master. The great healing factor in psycho therapy is
the doctors personality, which is something not given at the start; it
represents his performance at its highest and not a doctrinaire blueprint.Theories are to be avoided, except as mere auxiliaries. As soon as a dogma
is made of them, it is evident that an inner doubt is being stifled. Very
many theories are needed before we can get even a rough picture of the
psyches complexity. It is therefore quite wrong when people accuse
psycho therapists of being unable to reach agreement even on their own
theories. Agreement could only spell one-sidedness and desiccation. One
could as little catch the psyche in a theory as one could catch the world.
Theories are not articles of faith, they are either instruments of knowledge
and of therapy, or they are no good at all.
[199]
Psycho therapy can be practised in a great variety of ways, from
psychoanalysis, or something of that kind, to hypnotism, and so on right
down to cataplasms of honey and possets of bats dung. Successes can be
obtained with them all. So at least it appears on a superficial view. On
closer inspection, however, one realizes that the seemingly absurd remedy
was exactly the right thing, not for this particular neurosis, but for this
particular human being, whereas in another case it would have been the
worst thing possible. Medicine too is doubtless aware that sick people exist
as well as sicknesses; but psycho therapy knows first and foremostor
rather should know that its proper concern is not the fiction of a neurosis
but the distorted totality of the human being. True, it too has tried to treat
neurosis like an ulcus cruris, where it matters not a jot for the treatment
whether the patient was the apple of her fathers eye or whether she is a
Catholic, a Baptist, or what not; whether the man she married be old or
young, and all the rest of it. Psycho therapy began by attacking the
symptom, just as medicine did. Despite its undeniable youthfulness as a
scientifically avowable method, it is yet as old as the healing art itself and,
consciously or otherwise, has always remained mistress of at least half the
medical field. Certainly its real advances were made only in the last half
century when, on account of the specialization needed, it withdrew to the
narrower field of the psychoneuroses. But here it recognized relatively
quickly that to attack symptoms or, as it is now called, symptom analysis
was only half the story, and that the real point is the treatment of the whole
psychic human being.
[200]
[201]
What does this mean: the whole psychic human being?
Medicine in general has to deal, in the first place, with man as an
anatomical and physiological phenomenon, and only to a lesser degreewith the human being psychically defined. But this precisely is the subject
of psycho therapy. When we direct our attention to the psyche from the
viewpoint of the natural sciences, it appears as one biological factor among
many others. In man this factor is usually identified with the conscious
mind, as has mostly been done up to now by the so-called humane sciences
as well. I subscribe entirely to the biological view that the psyche is one
such factor, but at the same time I am given to reflect that the psychein
this case, consciousness occupies an exceptional position among all these
biological factors. For without consciousness it would never have become
known that there is such a thing as a world, and without the psyche there
would be absolutely no possibility of knowledge, since the object must go
through a complicated physiological and psychic process of change in
order to become a psychic image. This image alone is the immediate object
of knowledge. The existence of the world has two conditions: it to exist,
and us to know it.
[202]
Now, whether the psyche is understood as an epiphenomenon of the
living body, or as an ens per se, makes little difference to psychology, in
so far as the psyche knows itself to exist and behaves as such an existent,
having its own phenomenology which can be replaced by no other.
Thereby it proves itself to be a biological factor that can be described
phenomenologically like any other object of natural science. The
beginnings of a phenomenology of the psyche lie in psychophysiology and
experimental psychology on the one hand, and, on the other, in
descriptions of diseases and the diagnostic methods of psychopathology
(e.g., association experiments and Rorschachs irrational ink-blots). But
the most convincing evidence is to be found in every manifestation of
psychic life, in the humane sciences, religious and political views and
movements, the arts, and so forth.
[203]
The whole psychic human being we were asking about thus proves
to be nothing less than a world, that is, a microcosm, as the ancients quite
rightly thought, though for the wrong reasons. The psyche reflects, and
knows, the whole of existence, and everything works in and through the
psyche.
[204]
But in order to get a real understanding of this, we must very
considerably broaden our conventional conception of the psyche. Our
original identification of psyche with the conscious mind does not stand the test of empirical criticism. The medical philosopher C. G. Carus had a
clear inkling of this and was the first to set forth an explicit philosophy of
the unconscious. Today he would undoubtedly have been a
psycho therapist. But in those days the psyche was still the anxiously
guarded possession of philosophy and therefore could not be discussed
within the framework of medicine, although the physicians of the
Romantic Age tried all sorts of unorthodox experiments in this respect. I
am thinking chiefly of Justinus Kerner. It was reserved for the recent past
to fill in the gaps in the conscious processes with hypothetical unconscious
ones. The existence of an unconscious psyche is as likely, shall we say, as
the existence of an as yet undiscovered planet, whose presence is inferred
from the deviations of some known planetary orbit. Unfortunately we lack
the aid of the telescope that would make certain of its existence. But once
the idea of the unconscious was introduced, the concept of the psyche
could be expanded to the formula psyche = ego-consciousness +
unconscious.
[205]
The unconscious was understood personalistically at first that is to
say, its contents were thought to come exclusively from the sphere of ego-
consciousness and to have become unconscious only secondarily, through
repression. Freud later admitted the existence of archaic vestiges in the
unconscious, but thought they had more or less the significance of
anatomical atavisms. Consequently we were still far from an adequate
conception of the unconscious. Certain things had yet to be discovered,
although actually they lay ready to hand: above all the fact that in every
child consciousness grows out of the unconscious in the course of a few
years, also that consciousness is always only a temporary state based on an
optimum physiological performance and therefore regularly interrupted by
phases of unconsciousness (sleep), and finally that the unconscious psyche
not only possesses the longer lease of life but is continuously present.
From this arises the important conclusion that the real and au thentic
psyche is the unconscious, whereas the ego-consciousness can be regarded
only as a temporary epiphenomenon.
[206]
In ancient times the psyche was conceived as a microcosm, and this
was one of the characteristics attri buted to the psychophysical man. To
attri bute such a characteristic to the ego-consciousness would be
boundlessly to overestimate the latter. But with the unconscious it is quitedifferent. This, by definition and in fact, cannot be circumscribed. It must
therefore be counted as something boundless: infinite or infinitesimal.
Whether it may legitimately be called a microcosm depends simply and
solely on whether certain portions of the world beyond individual
experience can be shown to exist in the unconsciouscertain constants
which are not individually acquired but are a priori presences. The theory
of instinct and the findings of biology in connection with the symbiotic
relationship between plant and insect have long made us familiar with
these things. But when it comes to the psyche one is immediately seized
with the fear of having to do with inherited ideas. We are not dealing
with anything of the sort; it is more a question of a priori or prenatally
determined modes of behaviour and function. It is to be conjectured that
just as the chicken comes out of the egg in the same way all the world
over, so there are psychic modes of functioning, certain ways of thinking,
feeling, and imagining, which can be found everywhere and at all times,
quite independent of tradition. A general proof of the rightness of this
expectation lies in the ubiquitous occurrence of parallel mythologems,
Bastians folk-thoughts or primordial ideas; and a special proof is the
autochthonous reproduction of such ideas in the psyche of individuals
where direct transmission is out of the question. The empirical material
found in such cases consists of dreams, fantasies, delusions, etc.
[207]
Mythologems are the aforementioned portions of the world which
belong to the structural elements of the psyche. They are constants whose
expression is everywhere and at all times the same.
[208]
You may ask in some consternation: What has all this to do with
psycho therapy? That neuroses are somehow connected with instinctual
disturbances is not surprising. But, as biology shows, instincts are by no
means blind, spontaneous, isolated impulses; they are on the contrary
associated with typical situational patterns and cannot be released unless
existing conditions correspond to the a priori pattern. The collective
contents expressed in mythologems represent such situational patterns.
which are so intimately connected with the release of instinct. For this
reason knowledge of them is of the highest practical importance to the
psycho therapist.
[209]
Clearly, the investigation of these patterns and their properties must
lead us into fields that seem to lie infinitely far from medicine. That is thefate of empirical psychology, and its misfortune: to tall between all the
academic stools. And this comes precisely from the fact that the human
psyche has a share in all the sciences, because it forms at least half the
ground necessary for the existence of them all.
[210]
It should be clear from the foregoing discussion that everything
psycho therapy has in common with symptomatology clinically understood
i.e., with the medical pictureis, I will not say irrelevant, but of
secondary importance in so far as the medical picture of disease is a
provisional one. The real and important thing is the psychological picture,
which can only be discovered in the course of treatment behind the veil of
pathological symptoms. In order to get closer to the sphere of the psyche,
the ideas derived from the sphere of medicine are not enough. But, to the
extent that psycho therapy, considered as part of the healing art, should
never, for many cogent reasons, slip out of the doctors control and should
therefore be taught in medical faculties, it is forced to borrow from the
other scienceswhich is what other medical disciplines have been doing
for a long time. Yet whereas medicine in general can limit its borrowings
to the natural sciences, psycho therapy needs the help of the humane
sciences as well.
[211]
In order to complete my account of the differences between medicine
and psycho therapy, I ought really to describe the phenomenology of those
psychic processes which manifest themselves in the course of treatment
and do not have their counterpart in medicine. But such an undertaking
would exceed the compass of my lecture, and I must therefore refrain. I
trust, however, that the little I have been privileged to say has thrown some
light on the relations between psycho therapy and the medical art.



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