Freud's Free Clinics

Psychoanalysis and Social Justice, 1918–1938

Elizabeth Ann Danto

• Publisher: Columbia University Press
• Year: 2005
• eBook ISBN: 9780231506564
• Topic: Psicología
• Subtopic: Historia europea

Today many view Sigmund Freud as an elitist whose psychoanalytic treatment was reserved for the intellectually and financially advantaged. However, in this new work Elizabeth Ann Danto presents a strikingly different picture of Freud and the early psychoanalytic movement. Danto recovers the neglected history of Freud and other analysts' intense social activism and their commitment to treating the poor and working classes.

Danto's narrative begins in the years following the end of World War I and the fall of the Habsburg Empire. Joining with the social democratic and artistic movements that were sweeping across Central and Western Europe, analysts such as Freud, Wilhelm Reich, Erik Erikson, Karen Horney, Erich Fromm, and Helene Deutsch envisioned a new role for psychoanalysis. These psychoanalysts saw themselves as brokers of social change and viewed psychoanalysis as a challenge to conventional political and social traditions. Between 1920 and 1938 and in ten different cities, they created outpatient centers that provided free mental health care. They believed that psychoanalysis would share in the transformation of civil society and that these new outpatient centers would help restore people to their inherently good and productive selves.

Drawing on oral histories and new archival material, Danto offers vivid portraits of the movement's central figures and their beliefs. She explores the successes, failures, and challenges faced by free institutes such as the Berlin Poliklinik, the Vienna Ambulatorium, and Alfred Adler's child-guidance clinics. She also describes the efforts of Wilhelm Reich's Sex-Pol, a fusion of psychoanalysis and left-wing politics, which provided free counseling and sex education and aimed to end public repression of private sexuality.

In addition to situating the efforts of psychoanalysts in the political and cultural contexts of Weimar Germany and Red Vienna, Danto also discusses the important treatments and methods developed during this period, including child analysis, short-term therapy, crisis intervention, task-centered treatment, active therapy, and clinical case presentations. Her work illuminates the importance of the social environment and the idea of community to the theory and practice of psychoanalysis.

1

1918–1922

SOCIETY AWAKES

“Treatment will be free”

1918

THE GERMAN psychoanalyst Max Eitingon wrote in 1925 that his colleagues could no longer honestly argue that “the factor of the patients paying or not paying has any important influence on the course of the analysis.”¹ But Eitingon was merely announcing the fulfillment of Freud’s forecast from the 1918 Budapest speech on the conscience of society. In that speech Sigmund Freud had explicitly disavowed his prewar position, “that the value of the treatment is not enhanced in the patient’s eyes if a very low fee is asked,”² and had repudiated his earlier 1913 image of the psychoanalyst / physician as medical entrepreneur.³ Until the end of his life Freud supported free psychoanalytic clinics, stood up for the flexible fee, and defended the practice of lay analysis, all substantive deviations from a tradition of physicians’ privilege and their patients’ dependence. His consistent loathing of the United States as “the land of the dollar barbarians” echoed his contempt for a medical attitude he believed to be more American than European, more conservative than social democratic.⁴ This broad revision in his view of doctors’ fees from 1913 to 1918 resulted partly from the grievous material and psychological deprivations the Freud family endured during the war and partly from momentous shifts in the larger political landscape of the early twentieth century.

Freud’s sense of civic responsibility was not new. As a child he had witnessed the 1868 installation of the aggressively liberal Bürgerministerium (bourgeois ministry) that promoted religious tolerance and progressive social legislation involving secular education, interdenominational marriages, a ban on discrimination against Jews, and a compassionate penal system.⁵ He admired Hannibal and Masséna, a Jewish general in Napoleon’s army, and was fascinated by the deployment of large-scale military strategies. The idea of becoming a politician seems to have occurred to Freud when, as an adolescent, he “developed a wish … to engage in social activities” and decided to study law.⁶ Law school would train him in the skills of political leadership, and he would grow up to promote the Austrian liberal’s agenda of social reform. But the economic crash of 1873 that shattered Vienna’s private sector banks and industries, and the city’s economic prosperity in general, struck the same year Freud entered the university. The young Freud was deeply affected by “the fate of being in the Opposition and of being put under the ban of the ‘compact majority’” and reacted by developing what he later called, with irony, “a certain degree of independence of judgement.”⁷

The experience of anti-Semitism first-hand at the university was, in Freud’s life, a powerful motivation to uncover the roots of individual and social aggression. That Freud should focus on the social context of individual behavior was only natural. His model of the civic-minded liberal Jewish family, largely secular, highly accomplished and hard working, was engrained in cosmopolitan Vienna. “Our father was a truly liberal man,” wrote Freud’s sister, Anna Freud Bernays, about their paterfamilias Jacob,

so much so that the democratic ideas absorbed by his children were far removed from the more conventional opinions of our relatives…. About the middle of the last century, the father was all-powerful in a European family and everyone obeyed him unquestioningly. With us, however, a much more modern spirit prevailed. My father, a self-taught scholar, was really brilliant. He would discuss with us children, especially Sigmund, all manner of questions and problems.⁸

Not surprisingly then, Emma Goldman, the early American feminist and anarchist leader, found much in common with the young neurologist and was enormously impressed when she heard Freud’s 1896 lecture in Vienna. “His simplicity and earnestness and the brilliance of his mind combined to give one the feeling of being led out of a dark cellar into broad daylight. For the first time I grasped the full significance of sex repression and its effect on human thought and action. He helped me to understand myself, my own needs; and I also realized that only people of depraved minds could impugn the motives or find impure so great and fine a personality as Sigmund Freud.”⁹

Other liberal activists like Sándor Ferenczi (figure 2), Freud’s great Hungarian psychoanalytic partner, agreed. “In our analyses,” he wrote from Budapest to Freud in 1910, “we investigate the real conditions in the various levels of society, cleansed of all hypocrisy and conventionalism, just as they are mirrored in the individual.”¹⁰ Sándor Ferenczi was an affable, round-faced intellectual and socialist physician who had passionately defended the rights of women and homosexuals as early as 1906. The charming son of a Hungarian Socialist publisher, Ferenczi pushed the limits of psychoanalytic theory further and faster than anyone else. In 1912 he established the Hungarian Psychoanalytic Society, home to major psychoanalysts including Melanie Klein, Sándor Radó, Franz Alexander, Therese Benedek, and Alice and Michael Bálint. In 1929 he revived the free clinic he had planned in Budapest at the university ten years earlier, during a brief professorship in psychoanalysis promoted by the revolutionary regime.¹¹ Freud’s remarkable relationship with Ferenczi is conveyed in the course of over twelve hundred letters exchanged between 1908 and 1933, the year Ferenczi died of pernicious anemia. The epistolary dialogue between the two men is highly charged with personal feeling, records their far-ranging exchanges of psychoanalytic theory, and often alludes, in a sad sarcastic way, to the larger effects of social injustice on their patients. Ferenczi describes how the analyst must listen to the patients because only they truly understand how psychoanalysis fosters social welfare. When women, men, and children lead lives truer to their individual natures, society can loosen its bonds and allow for a less rigid system of social stratification. His analytical work with a typesetter, a print shop owner, and a countess had shown Ferenczi how each individual experienced society’s repressiveness within their respective social strata, none more than the other but each equally deserving of therapeutic benefits. The high-strung typesetter was terrorized by the demands of the newspaper’s foreman; the owner of a print shop felt crushed by guilt over the swindles he perfected to outwit the corrupt rules of the Association of Print Shop Owners; a young countess’s sexual fantasies about her coachman revealed her sense of inner hollowness. And a servant disclosed the masochistic pleasure she obtained by deciding to accept lower wages from aristocrats instead of higher wages from a bourgeois family. “Next to the ‘Iron Law of Wages,’ the psychological determinants,” Ferenczi summarized, “are sadly neglected in today’s sociology.”

2 Portrait of Sándor Ferenczi painted by Olga Székely-Kovács (Judith Dupont)

What might seem to be Freud’s postwar awakening to the harsher realities of life and to social inequality had actually been stirring for years, often in exchanges between the two same friends. “I have found in myself only one quality of the first rank, a kind of courage which is unshaken by convention,” Freud wrote in 1915 to Ferenczi, and he postulated that their psychoanalytic discoveries stemmed from “relentless realistic criticism.”¹² Indeed political reality called for scrutiny on many levels. In 1915 Freud was still loyal to Franz Joseph and to the Vienna where assimilated Jews thrived on high culture, intellectual pursuits, and a politics of social reform. But by then the war had started and the reactionary mayor Karl Lueger, a right-wing populist and anti-Semite, and the Christian Social Party he cofounded in 1885, had superseded the Viennese liberals and dominated municipal politics until World War 1. By 1917 Freud’s family life and professional practice had been thoroughly disrupted. He wrote to Ferenczi of the “bitter cold, worries about provisions, stifled expectations…. Even the tempo in which one lives is hard to bear.”¹³ Sixty-two years old and frankly impatient with battles and the old idea of the absolutist state, Freud remarked that “the stifling tension, with which everyone is awaiting the imminent disintegration of the State of Austria, is perhaps unfavorable.” But, he continued, “I can’t suppress my satisfaction over this outcome.”¹⁴

Even before war’s end Freud’s September 1918 address to the Fifth International Psychoanalytic Congress concentrated specifically on the future, not on the war or individual conflict. The speech appealed for postwar social renewal on a vast scale, a three-way demand for civic society, government responsibility, and social equality. To many of his psychoanalytic colleagues, diplomats and statesmen, friends and family members who listened to Freud read his essay on the future of psychoanalysis, that beautiful autumn day in Budapest augured a bold and new direction in the psychoanalytic movement. Anna Freud and her brother Ernst had accompanied their father to the congress, and the British psychoanalyst Ernest Jones (who could not attend) later claimed that Freud uncharacteristically read his paper¹⁵ instead of producing a speech extemporaneously, and upset his family.¹⁶ But in the cautiously festive atmosphere that predominated on September 28 and 29, Freud’s speech before this sophisticated audience was far more seditious in meaning than in delivery. He would lead them along an unexplored path, he said, “one that will seem fantastic to many of you, but which I think deserves that we should be prepared for it in our minds.”¹⁷ He invoked a series of modernist beliefs in achievable progress, secular society, and the social responsibility of psychoanalysis. And he argued for the central role of government, the need to reduce inequality through universal access to services, the influence of environment on individual behavior, and dissatisfaction with the status quo.

“It is possible to foresee that the conscience of society will awake,” Freud proclaimed,

and remind it that the poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery; and that the neuroses threaten public health no less than tuberculosis, and can be left as little as the latter to the impotent care of individual members of the community. Then institutions and out-patient clinics will be started, to which analytically-trained physicians will be appointed so that men who would otherwise give way to drink, women who have nearly succumbed under the burden of their privations, children for whom there is no choice but running wild or neurosis, may be made capable, by analysis, of resistance and efficient work. Such treatments will be free.” Freud continued. “It may be a long time before the State comes to see these duties as urgent,” he said, “… Probably these institutions will be started by private charity. Some time or other, however, it must come to this.¹⁸

Freud’s argument concerned nothing less than the complex relationship between human beings and the larger governing social and economic forces. Implicitly he was throwing in his lot with the emerging social democratic government.

Even in 1918 psychoanalysis was at imminent risk of premature irrelevance and isolation brought on by elitism. The same fervent independence that had driven the psychoanalytic movement, relatively marginal to Vienna’s medical and academic communities and practiced by an eclectic group of free thinkers, now threatened its durability. Its economic survival depended on a new governmental configuration, one in which the state accepted responsibility for the mental health of its citizens. In a series of ideological positions intended to destigmatize neurosis, Freud was proposing that only the state could place mental health care on a par with physical health care. Individuals inevitably hold a measure of bias toward people with mental illness, and this limits our ability to provide trustworthy care. Redefining neurosis from a personal trouble to a larger social issue places responsibility for the care of mental illness on the entire civic community.¹⁹

Freud endorsed the idea that a traditional monarchy’s power to set a country’s laws should now be redistributed democratically to its citizenry. Like his friends and contemporaries the Austrian Socialist politician Otto Bauer and the Social Democrat Victor Adler, Freud believed that social progress could be achieved through a planned partnership of the state and its citizens. Citizens had the right to health and welfare and society should be committed to assist people in need within an urban environment deliberately responsive to the developmental needs of children and worker’s families. In practical terms, he now demanded an interventionist government whose activist influence in the life of the citizens would forestall the increasingly obvious despair of overworked women, unemployed men, and parentless children. The political and social gains derived from the psychoanalysts’ new alliances would, at the very least, confer legitimacy on a form of mental health treatment often practiced by nonphysicians or by physicians reluctant to join the establishment.

Freud concluded his Budapest speech with a demand for free mental health treatment for all. He developed the argument for founding free outpatient clinics in the smoothly systematic manner of a born statesman. The possibility of shifting psychoanalysis from a solely individualizing therapy to a larger, more environmental, approach to social problems hinged on four critical points: access, outreach, privilege, and social inequality. First, the psychoanalyst’s “therapeutic activities are not far-reaching.”²⁰ As if anticipating his critics, Freud noted how this scarcity of resources conferred on treatment the characteristic of a privilege, and this privilege limited the benefits psychoanalysis might achieve if its scope were broadened. Second, “there are only a handful” of clinicians who are qualified to practice analysis. The shortage of both providers and patients suggested that psychoanalysis might fall into the clutch of a dangerous elitism. This predicament must be overcome if analysts were to alert significantly more people to its curative potential. Third, “even by working very hard, each [analyst] can devote himself in a year to only a small number of patients.”²¹ This quandary is intrinsic to the intensive and time-consuming format of analytic work, but to Freud it also meant that analysts could not assume a position of social responsibility commensurate with their obligation. Individual analytic patients (called analysands in English, then as now) held to the same appointment at a daily hour five days each week until the treatment was completed. Their treatment usually lasted about six months to a year, perhaps less than we imagine today but, as Freud had commented wryly even in 1913, “a longer time than the patient expects.”²²

Freud’s fourth point, that the actual “vast amount of neurotic misery” the analyst can eliminate is “almost negligible” at best compared to its reality in the world, reads like a simple disclaimer. But it is in this passage that the social consciousness of Freud’s adolescence and university days reemerges. Human suffering need not be so widespread in society nor so deeply painful individually. Moreover, suffering does not stem from human nature alone, because it is, at least in part, imposed unfairly and largely according to economic status and position in society, a social inequality vividly depicted in Ferenczi’s 1910 letter. Inequality, Freud summarized, is the fundamental problem, and he lamented how explicit socioeconomic factors confine psychoanalytic treatment to the “well-to-do-classes.” Affluent people “who are accustomed to choos[ing] their own physicians” are already able to influence their treatment. But poor people, who have less choice in their medical care, are precisely those who have less access to psychoanalytic treatment and its benefits.²³ Psychoanalysis had become socially and economically stratified early in its development. At this crucial juncture in its short history, its lack of social awareness has rendered it virtually powerless. “At present we can do nothing for the wider social strata, those who suffer extremely from neuroses.”²⁴

Who could better reverse this course than this very audience? Freud’s September 28 speech, born more of political anger than wartime dejection, had an astonishing effect on its listeners. The concept of the free mental health clinic may have predated the Budapest congress, but the number of organizational projects launched there by the assembled participants, especially Anton von Freund, Max Eitingon, Ernst Simmel, Eduard Hitschmann, and Sándor ...

Table of contents

• Cover 
• Half title
• Title
• Copyright
• Dedication
• Contents 
• Acknowledgments
• “The Conscience of Society”—Introduction
• 1. 1918–1922: Society Awakes
• 2. 1923–1932: The Most Gratifying Years
• 3. 1933–1938: Termination
• Notes
• Bibliography
• Index