Danto: the Ambulatorium: Freud's Free Clinic in Vienna

The Ambulatorium: Freud's Free Clinic in Vienna Elizabeth Ann Danto At the close of World War I, Freud proposed the creation of clinics providing free treatment, in the first of a series of politically liberal statements promoting the development of a kind of institution that is rarely associated with psychoanalysis today. Using archival and oral history research methods, this study offers a descriptive and statistical history of the Vienna Ambulatorium, the free psychoanalytic clinic and child guidance centre created—we can now surmise—under Freud's direction. Presented within the cultural context of central Europe's inter-war rush of progressivism in 'Red Vienna' and in Germany's Weimar Republic, little-known aspects of the history of psychoanalysis emerge. From 1922 to 1936, the staff of the Ambulatorium treated gratis patients of all ages and social classes, ranging from professional to unemployed. Candidates too were analysed at no cost. Reflecting the urban energy of his era, Freud believed that psychoanalysis could be both productive and free of cost. What emerges is an unexpectedly activist, community-oriented profile of some of the earliest participants in the psychoanalytic movement.

In an extraordinary series of speeches and writings between 1918 and 1935, Freud took the politically liberal step of sanctioning the development of free clinics. In a crucial keynote address to the Fifth Congress of the International Psychoanalytical Association, held in Budapest in September 1918, Freud proposed the formation of: 'institutions or out-patient clinics ... where ... treatment will be free', stating that: it is possible to foresee that the conscience of society will awake 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 ... It may be a long time before the State comes to see these duties as urgent ... Probably these institutions will be started by private charity. Some time or other, however, it must come to this ... (1918 p. 167) It did. By 1922, members of the Vienna Psychoanalytical Society had banded together to establish a free psychoanalytic clinic, the 'Vienna Ambulatorium', to which Freud gave moral and financial support. What follows is a historical and organisational overview of the Vienna Ambulatorium from 1922 to 1936. By 1922, the war-ravaged city of Vienna had embarked on an ambitious project of economic and social regeneration. The municipal authorities introduced fundamental reforms that earned the city the name 'Red Vienna', as Vienna became a laboratory for an experimental blend of culture and politics. Led by the Austrian Socialist leader Otto Bauer and by Victor Adler, a labour leader, the Social Democrat party created an urban environment that responded, perhaps for the first time, to the needs of children and of workers' families. At odds with the rest of Austria, the Viennese thrived on liberalism and social experimentation, fending off the militaristic and religious conservatism (Carsten,

1986) of Central Europe. The development of the Vienna Ambulatorium, which was overseen by Freud's closest associates, including his daughter Anna, indicates the role of psychoanalysis in this process of reform. For many of the analysts who 'understood society as repressive and saw psychoanalysis as a way of relieving repression' (Stewart, 1995, unpublished interview), the Ambulatorium enabled the original social mission of psychoanalysis to be fulfilled. Besides Freud, Helene Deutsch and Wilhelm Reich—along with Siegfried Bernfeld, August Aichorn, Willi Hoffer and Grete Bibring—emerged as major figures with ideological influence. For them, the Vienna Ambulatorium was an instrument of reform; even its administrative aspects (fees, funding strategies, training services) were the focus of activist participation in changing the status quo. It began as an innovative alternative to Vienna's well-established medical and psychiatric services, and its unique though little-known activities have continued to play a part in the history of psychoanalysis, in European intellectual history and in the evolution of free mental health services. Vienna 1922 Austria's First Republic (1918-1938), the country's first constitutional democracy, sought to introduce comprehensive post-war reforms based on the principles of universal protection from poverty and access to public services. The project of economic regeneration incorporated, for example, a vast public re-housing initiative (the Wohnbau houses). Educational programmes were set up in newly built schools and services such as public assistance, rent control and school construction were introduced (Gay, 1988). Public resources were invested in medical and dental clinics, family assistance programmes, aid to children and youth and mothers' consultation centres. Public health and urban sanitation were improved with the introduction of sprinkler trucks and mechanised garbage collection (Gruber, 1991). Schur recalled that by 1932, Vienna had become 'a very progressive city';' health stations were excellent... and the hospitals were really very good. People had insurances when they worked; people who didn't have money were treated for nothing', (1995, unpublished interview). The Viennese sought more fundamental reform, creating what Bauer called 'a revolution of souls' (Gruber, 1991 p . 6), believing that urban culture should encompass the worker's whole life, from the privacy of individual and family life to the political arena and workplace. The relatively new field of psychology flourished; by 1922 various schools of psychology had emerged at Vienna University, ranging from materialism and physiology to psycholinguistics and psychoanalysis. The early leaders of psychology, with differing scientific approaches, shared a politically liberal idealism combined with a new focus on methodology and observation of behaviour, especially of children. Describing the heady atmosphere of 'Red Vienna', Ekstein remembered service programmes that directly addressed children's needs: 'And then of course, there was Sigmund Freud, Anna Freud, [and] August Aichhorn who were concerned not only with theoretical issues, but also with practical issues of education, desiring to have insight into delinquency, learning disturbances' (1991 p. 8). Families and children were the priority of the new welfare system. Julius Tandler, professor of anatomy at Vienna University and architect of Red Vienna's health-care system, believed that healthy children were the foundation of a healthy state (Pappenheim, 1989). A comprehensive system of aid to children reduced the incidence of tuberculosis (the major health threat to working-class children), reduced infant mortality by 50 per cent and the general death rate by 25 per cent. The system included school lunches, school medical and dental examinations, municipal bathing facilities, publicly sponsored vacations and summer camps, and new after- school centres.

Perhaps most significant for psychoanalysis, the number of kindergartens increased from twenty in 1913 to a hundred and thirteen in 1931, enrolling 10, 000 children (Gruber, 1991). The Widening Scope of Psychoanalysis As the state increased its activities to meet citizens' basic needs, psychoanalysis also broadened its social field. The Ambulatorium and its services developed in parallel with the state's assistance to children and families. In what Anna Freud later called the 'widening scope of psychoanalysis (1966 p. 7). Vienna's focus on children's needs and rights increased in parallel with the emergence of new scientific studies of child development and treatment techniques, and a developing interest in early education. Child analysis itself emerged from the social context of radicalism and service (Stewart, 1995). From 1924, the Montessori method influenced idealistic educators, psychoanalysts (who were providing free consultative services at the Ambulatorium) and other intellectuals dedicated to children's welfare and education (Kramer, 1976). In this milieu, Anna Freud's career as an elementary school-teacher led to a series of public seminars on the theoretical and practical relationship between psychoanalysis and education. A second, more specifically psychoanalytic, kindergarten model emerged when Siegfried Bernfeld founded the Baumgarten Children's Home in 1919. It was started with municipal funding and directed by Willi Hoffer (Young- Bruehl, 1988), whose 1920 psychoanalytically based 'Vienna Course for Educators' reached teachers from the city's nursery, elementary and high schools (A. Freud, 1966). Hoffer's lectures on public education were published later in the Zeitschrift fur Psychoanalytische Padagogik. The nursery, set up by the American paediatrician and child analyst Edith Jackson took in children under 6 whose parents ranged from working mothers to street beggars. As late as 1936, Anna Freud and Dorothy Burlingham founded a nursery for the 'poorest of the poor' (Coles, 1992 p . 16), work they continued later at the Hampstead nurseries in London. Another example is the work of August Aichhorn (1878-1949), a former teacher in the city's public schools and organiser of its municipal child-care institutions, who extended the model of psychoanalytically based social services to disturbed or delinquent teenagers. A powerful player in city politics and in Vienna's school reform movement, Aichhorn came to psychoanalysis in 1922. In 1925 he published Wayward Youth, which explored the successful use of psychoanalytic technique in treating delinquent adolescents in group homes (Ober-Hollabrunn from 1918 to 1920 and St. Andra from 1920 to 1922; Mohr, 1966). Freud expressed his support in an encouraging foreword (1925) that emphasised the 'great social value' of teaching and other work with children, commenting that Aichhorn's 'attitude to his charges had its source in a warm sympathy for the fate of these unfortunates'. This work, said Anna Freud, confirmed that 'all individual development, whether on social or on dissocial lines, was the result of interaction between innate and environmental factors' (1951 p. 52). That psychoanalysis had a political mission was the logical conclusion drawn both by its practitioners and by the state. With Wilhelm Reich and Otto Fenichel, these analysts formed a group of young, politically active clinicians who believed in the role of a social democratic state; 'Unlike Freud and the older analysts, who were liberals, the younger generation of analysts were generally revolutionaries and identified with the Austro-Marxists who controlled the city government from 1919 to 1934' (Gardner & Stevens, 1992 p . 222). The psychoanalysts represented the entirepol itical spe ctrum of the left, from social democrat to communist, while Reich later took aneven more radical left-wing position.

The Berlin Model In 1920 Simmel (1882-1947) and Eitingon (1881-1943) opened the first free clinic in

Berlin (Brecht et al., 1990; Jacoby, 1983), acknowledging Freud's 1918 Budapest speech as their source of inspiration (Eitingon, 1923). The Berlin Poliklinik (fur Psychoanalytische Behandlung Nervoser Krankheiten) became the flagship of psychoanalytic progressivism (Jones, 1955). From 1920 to 1933, the Poliklinik's startling clinical innovations included free treatment, length of treatment guidelines and time-limited analysis; Eitingon concluded that analysts 'cannot say that the factor of the patients paying or not paying has any importantinfluence on the course of the analysis ' (1923 p. 264). Berlin was then the centre of the Weimar Republic, and of a thriving new society that aimed to integrate exceptional cultural production with both political and intellectual innovation (Gay, 1968). Berlin produced a vigorous municipal culture akin to 'Red Vienna'. Like its Austrian counterpart, Berlin financed huge public re-housing initiatives plus schools, theatres, sports arenas and a well-documented focus on domestic and cultural technology (Willett, 1996). A sense of social justice prevailed at the Poliklinik; saw the Poliklinik staff as less exploitative than those at more fashionable teaching institutions, at which he thought the 'proletariat' and poorly insured people provided material for medical instruction while private high fee-paying patients were exempted from such use. At the Poliklinik, however, the 'egalitarian character ofpsychoanalysis itself' (Simmel, 1930 pp . 8-9; my italics) dictated that the type of treatment would never be predicated on the ability to pay. Treatment decisions were based only on patient diagnosis and need—not on the candidates' needs for training material. Freud was immensely impressed with the Berlin Poliklinik. His preface to its first annual report expressed the wish: that individuals or societies may be found elsewhere to follow Eitingon's example, and bring similar institutions into existence. If psychoanalysis, alongside its scientific significance, has a value as a therapeutic procedure, if it is capable of giving help to sufferers in their struggle to fulfil the demands of civilization, this help should be available to the great multitude who are too poor themselves to repay an analyst for his laborious work. This seems to be a social necessity particularly in our times, when the intellectual strata of the population, which are especially prone to neurosis, are sinking irresistibly into poverty (1923 p. 285). Seven years later Freud again endorsed the clinic's work, which 'endeavours to make our therapy accessible to the great multitude who suffer under their neuroses no less than the wealthy but who are not in a position to meet the cost of their treatment' (1930 p. 257). The Ambulatorium Opens The Vienna Ambulatorium was inaugurated on 22 May 1922, with congratulations rapidly sent to Freud from colleagues and friends such as Rado and Ferenczi, Secretary and President of the Hungarian Psychoanalytic Society in Budapest. They thanked the Viennese for the inspiration to set up a similar institution in Budapest (Ferenczi & Rado, 1924). Thatmonth, descriptive notices appe ared in the Vienna newspapers, and a substantial appreciative article 'A Psychoanalytic Ambulatorium in Vienna' was published in the Arztliche Reform-Zeitung [Doctors' Reform Newspaper]. On 30 May, Eitingon (1922) also sent collegial congratulations from Berlin. The opening of the Vienna Psychoanalytic Out-Patient Clinic, or 'Ambulatorium', was spearheaded by Eduard Hitschmann (1871-1957). He had been inspired by his colleagues in Berlin and by the atmosphere of liberalism to make Freud's 1918 vision a reality in Vienna. In his 1932 anniversary report Hitschmann recalled the opening of the Berlin Polyclinic in February 1920: It owed its inception to the memorable words of Freud, in which he insisted on the necessity for public centres which would extend the opportunities of psycho-

analytic treatment to larger sections of the population. Stimulated by the example of the Berlin Polyclinic, I resolved to establish a similar Institute in Vienna (Hitschmann, 1932 p. 245). The clinic was housed in a medical section of the Vienna University hospital. After inviting Freud to inspect the premises on 22 May 1922 and announcing the clinic's opening, Hitschmann and his colleagues started their work at 18 Pelikangasse. Helene Deutsch (1884-1981) also took part in opening the free clinic. An active member of Freud's inner circle who had spent a year at the Berlin Poliklinik, she described her generation's spirit of 'Revolutionism [which] can never be defined simply through its social application; it is an attribute of individuals who are drawn to everything that is newly formed, newly won, newly achieved' (1973 p. 84) . This spirit of'revolutionism', so threatening to Vienna's entrenched bourgeois values, spurred the development of the Ambulatorium. Whether she was inspired by competitiveness or by her pioneering spirit, the 1920 news of Max Eitingon's Berlin Poliklinik 'awakened [in me] the wish to have a clinic in Vienna. In 1922 this wish was fulfilled' (1973 p. 155) . Hitschmann and Deutsch's wishes resonated with other analysts who, according to Anna Freud's recollections became actively involved with the Ambulatorium where 'they brought ... their energy and their socialist concern for Vienna's lower classes—to whom the Ambulatorium's services were available without charge' (Young-Bruehl, 1988 p . 100). In 1924 Reich (1897-1957) assumed the position of first assistant chief to Hitschmann, then head of the Ambulatorium. They became co-directors over the next eight years. Reich had completed his postgraduate studies in neuropsychiatry at the University Clinic headed by Prof. Wagner von Jauregg in 1922. From then on until the mid-1920s, Reich was regarded as a practitioner who functioned solidly within the psychoanalytic movement and as the imaginative, charismatic leader behind the Institute's technical 'Seminar for psychoanalytic therapy' (Bibring, 1932; Briehl, 1966). Reich's work at the Ambulatorium was rewarding for him as well: it gave him the opportunity to deal with the emotional problems of the poor, furthering his social interests, since it served labourers, farmers students and others with wages too low to afford private treatment, and it brought to the Ambulatorium an analyst well-versed in politics (Sharaf, 1993). Reich saw how 'material poverty and lack of opportunities' (1932 p . 259) exacerbated the emotional suffering and neurotic symptoms of poor people. His experience in handling sexual disturbances, child-rearing and family problems served him well in his own later efforts to develop free sex counselling clinics (Reich, 1937). At the Ambulatorium, he sought to treat allegedly difficult patients who had been diagnosed as 'psychopaths', but were regarded as morally bad rather than 'sick'. Frequently anti-social, they showed destructive tendencies in the form of criminality, addictions, rageful outbursts or suicide attempts. Reich believed that psychoanalysis would free them of rage and allow a more socially productive motivation or energy to emerge (Sharaf, 1993). Richard Sterba (1898-1989), a psychoanalyst who became the first paid staff member of the clinic, remembered the Ambulatorium from his student years. It was located in the same section of city as the University hospitals, on Pelikangasse, a short street leading from the main medical centre, and held office hours two evenings a week. Sterba explained its name: 'In German, the word Klinik signifies a hospital for inpatients. The term is derived from the Greek word klinein, which means "lying down". What in English is called "clinic" is in German designated as Ambulatorium, which is derived from the Latin ambulare, "to walk around"' (1982 p. 25). Felix Deutsch (1884-1964), then director of the clinic for heart diseases at the University hospital, helped to find an appropriate site for the Ambulatorium's out-patient services (Deutsch, 1973). The ambulance section of the cardiology trauma department, or Herzstation

(Felix Deutsch's department within the hospital), already had sound-proof rooms. These arrangements were compatible with the Ambulatorium's needs for patient privacy and confidentiality. The consulting rooms, which could be used only in the afternoon, were rented in 1922. An upper-level hall, or conference room, was also made available and rented for evening meetings of the Ambulatorium staff. Initial Obstacles The Ambulatorium's services were impeded by continual problems with location and licensing that presaged the struggles with the issue of lay analysis and the legitimacy of analytic practice. Despite the analysts' enthusiasm for the project, the fact that 'every other branch of medicine had a free clinic' (Pappenheim, 1995, unpublished interview) and the prevailing atmosphere of Red Vienna, the Austrian government repeatedly hindered the opening of the Ambulatorium (Hitschmann, (1926, 1932). The Local Health Authority repeatedly refused to authorise a licence for the clinic unless it guaranteed that no one other than physicians would practise there. As early as July 1920, when the Berlin Poliklinik opened (without apparent obstacles), Hitschmann petitioned both the State Medical Department and the Council of the Medical Staff of the General Hospital without success (Holzknecht, 1920, 1921). Perhaps because of the ambiguous standing of psychoanalysis in official medicine, the application was finally rejected in July 1921, a year later, following a review from the conservative neurologist, Wagner-Jauregg, director of the Vienna Psychiatric Clinic. Two reasons were given: that a psychoanalytic clinic would be too expensive a state endeavour if sponsored by the Finance Minister, and that it would be too limiting therapeutically if the care excluded non-psychoanalytic forms of psychiatric treatment. The objections showed no sign of abating, even after office space had been secured and co-operation had been enlisted from key members of Vienna's Public Health Department and the Medical Council. In 1921, Hitschmann had received an original and encouraging offer for some vacant rooms in the Garrison Hospital from Tauber, an officer in the Public Health service. He was not able to accept Tauber's proposal, however, because the cost of adapting the rooms to the Ambulatorium's needs proved too high. Felix Deutsch later rescued the project by providing an appropriate suite of rooms in his department (Deutsch, 1973). In February 1922, the Council of the Professional Association of Vienna Physicians barred the Ambulatorium's opening 'on the grounds that it was superfluous and would damage the financial interests of Viennese physicians'. However, after agreeing to strict conditions and a 'medical only' policy, the clinic was allowed to open. Hitschmann (1926, 1932) is unusually pointed here. He states unequivocally that these objections to the Ambulatorium were motivated by the financial interest of establishment physicians. 'This clause', he reports, 'makes it obvious how strong was the fear in Vienna lest the medical profession should suffer damage materially if laymen were permitted to become analysts' (1932 p. 246).

The Ambulatorium's First Ten Years Once sanctioned by the Federal Department of Social Administration in 1922, the Ambulatorium thrived for at least another ten years. Despite periodic orders to close and other threats from municipal authorities cowed by 'official psychiatry'1, the clinic grew to

1 The struggle over the Ambulatorium appears to have reflected the struggle for Freud's position within professional Vienna. Deutsch recalled how this strain developed during her involvement with the inner circle of psychoanalysts. For them, 'Freud was not alone a great teacher; he was a luminous star on the dark road of a new science, a dominating force that brought order into a milieu of struggle. For at that time', she writes, 'the battle was both an

include a training institute directed by Helene Deutsch, a child guidance centre and a special department for the treatment of psychoses. Though the initial clinic plans outlined a separation between the Training Institute and the Ambulatorium, the two organisations became virtually interdependent (Deutsch, 1973). In fact, once the Vienna Training Institute was established three years later, the Ambulatorium became its major source of control cases for candidates. The Child Guidance Centre created a direct link between the Ambulatorium and Red Vienna's social welfare services for children. Recently returned from the Berlin Poliklinik, Hermione Hug-Hellmuth oversaw it from 1922 to 1924 and August Aichhorn took over after retiring from public service in 1932 (Mohr, 1966). Though sometimes accompanied by their parents, 'many young people [came] for advice of their own accord'; the children 'from all strata of the necessitous classes' (Hitschmann, 1932 p. 255) were referred by schools and clubs, teachers, school doctors and personal paediatricians. Menaker, for example, describes how her work in child analysis and play therapy started out in much the same way as Anna Freud's own beginning, with a pathetic little boy of seven who was referred by the Ambulatorium. He was a bed-wetter, and his mother, who was very poor, was desperate about the laundry problems and the added work that his symptoms caused her. He was an only child, and his father was an unskilled worker (1989 p. 98). The Ambulatorium was no more immune to internal politics than external. At the Eighth Congress of the International Psychoanalytical Association held in Salzburg in April 1924, the left-wing psychoanalyst Siegfried Bernfeld asked Ferenczi if he would like to move from Budapest to Vienna and take over the project since 'Hitschmann was very much disliked'. Freud rallied to the idea as well, assuring Ferenczi of his 'complete support' for the invitation. Added incentives included Freud's offer to refer all his foreign patients to Ferenczi and to allow Ferenczi to replace Rank as his successor. Freud apparently thought that 'the only obstacle was that Hitschmann was deeply involved in the establishment of the Poliklinik, so that it might be rather awkward to get rid of him' (Grosskurth, 1991 p. 158). Ferenczi, however, decided to forego the Vienna offer in favour of a professional visit to America. Fees and Funding Freud's direct financial support of the Ambulatorium was dispensed according to a specific formula: for every four patients, one was to be treated for free. Analysts could provide this in three ways: by treating patients in their private offices or at the Ambulatorium, or by contributing the cash equivalent of a session towards the Ambulatorium's upkeep. Freud himself seems to have followed this one-in-five rule. Grete Bibring, who told Robert Stewart (1995) about it, herself owned a bank cheque of Freud's drawn on his account and made out to the Ambulatorium. This appears to confirm that Freud sanctioned, indeed participated in, the one-in-five formula of this funding structure. In 1926, Freud gave the Ambulatorium a large proportion of the funds donated to commemorate his seventieth birthday. Freud's direct participation in the funding structure remains today one of the most interesting aspects of the history of the Ambulatorium.

The Ambulatorium was maintained by private funds. Like its Berlin counterpart, the

outward and an inner one: externally it was fought with and for Freud against the scientific and professional milieu from which one had sprung; internally it was fought over Freud himself, for his favor and recognition' (1940 p. 171)

members of the local psychoanalytic society united to sustain the clinic with a combination of cash and donations in kind. In his 1923 report, Eitingon had pointed to Freud's 1918 speech to explain that private initiative would precede public financing of a free clinic. Similarly, the Vienna members, all of whom had promised to co-operate in the work of the clinic, supported it from the outset. Each analyst/member carried out an agreement, or initial pledge, to be 'responsible for one or more free treatments' (Hitschmann, 1932 p. 247). Since space at the clinic was limited to three or four treatment rooms, many of the senior analysts saw Ambulatorium patients in their home-based private offices. They did so also because use of the Herzstation was limited to afternoons. As Anna Freud recalled years later, 'Our pioneering analytic institutes of the past were poor, and even to provide cases and treatment rooms for supervised analytic work stretched their resources to the utmost' (1966 p. 80). As the clinic' s administrator, Hitschmann was ambivalent about the stress placed o n the Ambulatorium's internal operations by its relationship with the state. On the one hand, he was pleased that 'our collaboration has always been most harmonious and the spirit of humanity and conscientiousness in dealing with our poor patients has at all times been eminently upheld' (1932 p. 249) . On the other, he disliked the idea that the Ambulatorium was being held to different—and possibly more burdensome—sets of regulatory standards and civic demands than the Berlin Poliklinik. It was different from other municipal clinics in that it accepted only private funds (Pappenheim, 1989). Treatment referrals, however , came from numerous government agencies. The Viennese analysts had to cope with myriad referrals from the municipal welfare authorities, the Courts, (Wagner-Jauregg's) Psychiatric Clinic, Health Insurance Societies and the Matrimonial Advisory Center. 'Here in Vienna', Hitschmann reported, ' we were under the most rigid necessity of accepting only such patients as were demonstrably with out means, so that for many years they contributed nothing whatever financially to our expenses '. Later, as assistant director, Reich solicited small monthly payments from non-indigent patients who could contribute to the clinic's administrative expens es. Yet the 'salaries of the medical staff and fees of part-time physicians made very heavy demands ... over and above the expenses of maintenance' (1932 p. 249). From Free Treatment to Free Training Analysis Clinics in which mental health services were provided free of charge to residents of Berlin and Vienna (Lorand & Console, 1958), as well as to the larger European community, appear to have grown rapidly in central Europe in the 1920s . For children, Viennese psychoanalysts including Alfred Adler2, Siegfried Bernfeld and August Aichhorn developed a range of free services. Adults of all occupations and social strata, from farmers to professionals, students, workers and others who could not afford to pay, were treated by Ambulatorium analysts with the same political commitment as their colleagues in Berlin. At the end o f ten years of operation, Hitschmann was able to report proudly on the Ambulatorium's roster of cases who 'are given the opportunity of undergoing an analysis,free of charge' (1932 p. 255). Clearly, the European analysts were proud of gratifying Freud's

2 Despite their well-known break, Adler and Fieud held many ideas in common. Adler's 1909 presentation 'On the psychology of Marxism' to the Vienna Psychoanalytic Society drew generally favourable response from Freud. In particular, Freud commented that 'the liberating thought that these two processes are the condition for each other: the enlargement of consciousness is what enables mankind to cope with life in the face of the steady progress of repression' (Nunberg, 1962p. 174). Adler later became known for his work in child guidance. His first clinic was so successful that the Viennese authorities asked him to replicate them until 'there were twenty-eight such centres in Vienna ... The psychologists who led these clinics did work without pay. The clinic conducted by Adler personally served, at the same time, to train doctors, teachers, social workers and students' (Orgler, 1963 p. 184)

mission of taking psychoanalysis to the poor (Hale, 1978). Perhaps because it was normative to the culture, or because of post-War economic conditions, or because of the free university education, analysts could treat up to one third of their practice for free, as did any other doctor in Vienna (Pappenheim, 1995, unpublished interview). Free services were extended to the analysts as well. That young analysts should be afforded a free training analysis in exchange for service became a sort of unwritten policy, an expression of psychoanalytic social responsibility. Specifically, Pappenheim recalled that 'every training analyst in Vienna was obligated to train two students for free'. Deutsch's memoirs confirm that most analytic candidates received a free training analysis: she quotes from a 1928 letter fro m Freud to Franz Alexander emphasising the importance of a candidate's 'personality' (over formal or official requirements ): 'I am afraid that renouncing any preliminary choice (of candidates) would threaten us with an excess of work ... you could hardly expect that to be agreed on in Vienna, for example, where almost all the training analyses are carried out gratis' (1973 p. 15 9). Bettelheim, himself analysed by Richard Sterba, described the general protocol for a first meeting with one ' s future analyst (1990). In early 1920s Vienna this took place in a social setting in which practical matters such as the daily session's hour and fee were discussed openly. Marianne Kris was analysed by Freud at no cost intermittently from 1 931 to 1938. She recalled the feelings evoked when '[Freud] treated me for free'. Though she barely had the money to pay for her analysis, she questioned whether this gesture was more than professional courtesy. Her father Oscar Rie, the Freud family paediatrician, was not paid for his services. Later, Freud would not let her pay for her analysis. 'It was very generous because it's very different', she explained, 'when a pediatrician pay[s ] a visit, he doesn't lose another vis it he could make; while if one has somebody in analysis for that hour, you can't take anybody else'. Kris's treatment could be interrupted by Freud' s illness or because he decided to use her hour for another patient. At times, she was admittedly 'a little envious ... [though] grateful enough ... That I didn't pay and that I had to interrupt... [did not] hinder the analysis although it might have made it somewhat more difficult—But I could express my feeling[s] ' (Grayson, 1972, unpublished interview). Almost everybody who worked at the Ambulatorium (including Bibring, Hoffer and Reich) was analysed for free ( Ste wart, 1995) . Richard Sterba (1982) describes this process: One evening in December 1923, I went to the ambulatorium to inquire about becoming an analyst. I was seen by an elderly physician whose name was Eduard Hitschmann .I started my analysis in the early Spring of 1924. Since I did not have any money .I was not charged for my analysis . How ever, it was expected that in the future I would conduct the treatment of some patients from the ambulatorium gratuitously or for a minimal contribution to be paid to the ambulatorium (1982 pp . 25- 7).

Service Populations Hitschmann and the staff of the Ambulatorium collected the data on service utilisation at the clinic. Though not nearly as extensive, the Viennese formats probably followed the models developed by Max Eitingon for the Berlin Poliklinik. Sterba developed yearly statistical tables categorising patients by diagnosis, age and sex and occupation or social class. The straightforward numbers were counted by pairs of years (from 1922/23 to 1930/1) and added up into 'grand total' sums. The procedures for consultation/intake and for treatment were not counted separately, and few cross-tabulations were drawn from the data. On average, the Ambulatorium registered between 200 and 250 applicants each year. The years 1923-24 show a surge of 354, which occurred when 'a Viennese newspaper with a

wide circulation published several articles on the Clinic ... quite spontaneously' (Hitschmann, 1932 p. 251) . A second peak (n = 271) occurred in 1926/27. These numbers were categorised by age group and gender. While he refrained from interpretation, Hitschmann did note with interest that 'male applicants for treatment have regularly been more numerous than female' (p. 251). Males were, in fact, seen far more than females (1445:800), especially in the 21- to 30-year-old age group. This peaked in the years 1923/24 with a male-female ratio of 236: 118. In all years under consideration, the 21- to 30-year-old age group (n = 1083) constituted by far the largest group of consumers, followed by the 50 per cent smaller group of 31- to 40-year-olds (n = 537). Though children ages 0 to 10 and elderly people ages 61 to 70 were seen and counted, they represented only a small fraction of the patient population. The highest numbers were seen in 1926/27 with seven male and five female children, and five seniors. The lowest, with no seniors and two children, occurred in 1922/23 and 1928/29. The categorisation of clinic applicants by occupation also subdivides them by gender. These categories, though less precise than those developed by the Berlin Poliklinik, are used to define social class. They include 'salaried employees, working class, professional, domestic service, teaching, without occupation, pensioners, school children and [university] students' (Hitschmann, 1932 p. 253) . Males outnumbered females in almost all categories including schoolchildren and students. The exceptions fell largely to domestic service and the category of 'no occupation'. This category could be interpreted to mean 'unemployment'. Women so outnumber men here (296: 66) that this category probably included female welfare recipients enrolled in Red Vienna's family assistance programmes. In modernist 1920s Vienna, one could no longer simply attribute women's lack of official occupation to their presumed financial dependence on men. Conclusions 'In your private political opinions you might be a Bolshevist', wrote Ernest Jones to Freud, 'but you would not help the spread of y to announce it' (1926 p. 592). As always both deferential and impulsive, Jones tinged their correspondence with a particularly emotional quality. Here, he bursts out with his own discovery of the politi cal nature of Freud's thought, but he does not repudiate it . He understands Freud's fascination with change and is torn between loyalty to the man and loyalty to the 'cause'. Perhaps this struggle has obscured the history of activism in psychoanalysis as well. Freud did share the political mission of the Social Democrats, who implemented their idea of a centrally planned, redistributive state in 1920s Austria. He did not, however, want to be drawn into a specific political movement. Freud's usual cautiousness is indicated in Jones's letter and his well-known objections to communism. In a letter to Arnold Zweig, he showed how his reluctance to support 'the Communist ideal' directly did not preclude him from having a political agenda for he 'remain[ed] a liberal of the old school' (1930 p. 21). In fact, identification with a movement other than psychoanalysis would have blurred the agenda for human liberation. To what extent was Sigmund Freud involved in the development and ongoing support of free clinics? This study of the Vienna Ambulatorium shows that Freud was, in fact, far more involved—both practically and morally—than the literature has shown so far. It also begins to refute the popular myth that psychoanalytic treatment is only as effective as the financial distress incurred by the patient. Freud's commitment to the practice of free treatment has been verified by at least three sources. Did this involvement, however, stem from a personal liberationist mission or from the match between psychoanalysis and the overarching social policies of Vienna's progressive political environment? A bank cheque of Freud's, a congratulatory letter from Ferenczi, Freud's own letter to Alexander and a range of verbal accounts all point to his active participation in free

treatment. His participation in the Ambulatorium's system of voluntary self-funding was perhaps a simple compliance with the Viennese professional norm, in which most doctors treated up to one third of their practice for free (Pappenheim, 1995). Yet, as we know, Freud conformed to very little. Rado and Ferenczi's congratulatory letter of 24 May 1924, just after the 22 May opening of the Ambulatorium, was addressed solely to Freud. This pointed salutation is evidence that Freud's contemporaries must have been aware of his involvement in the opening of the Ambulatorium. Indeed, Rado and Ferenczi represented the sentiments of the entire Hungarian Psychoanalytic Society's membership. Interestingly, it was in Budapest that Freud had first articulated his mission to society (1918). Freud endorsed the free training of analytic candidates (Deutsch, 1973; Grayson, 1972; Sterba, 1982) as well as free treatment. According to Pappenheim (1995), a climate that sanctions free education promotes an environment in which people will, in turn, then donate time and skills—and vice versa. Psychoanalysis was no exception. The Ambulatorium's mission to treat people regardless of their ability to pay in fact corresponded to the ideological norms of Red Vienna. Within the city's politically charged environment, the Ambulatorium broadened the scope of psychoanalysis by affording Vienna's indigent families the quality of mental health services that was traditionally reserved for private patients. 'Every branch of medicine had a free clinic. So it wasn't so unusual for some of the socially minded psychoanalysts to decide that we should have one too' recalled Pappenheim (1995). Perhaps Freud's controversial, even hostile, relationship with the university and medical establishment, had impeded its initial success. But by the mid- twenties, the Ambulatorium had created links between Viennese social services and the psychoanalytic community. The psychoanalysts were fundamentally social democrats furthering the aims of a social democratic government. The Ambulatorium thrived, however, on the momentum of Freud's liberalism and the pioneering activism of his followers. The Vienna Psychoanalytic Society, members of Freud's Wednesday circle since 1902, are well known as the first generation of psychoanalysts and routinely called 'pioneers'. As much as pioneering a science, however, they advocated social change, holding to a modern idea of change as positive, conveying the possibility of a mirroring harmony between the state and its citizens. They were social democrats whose professional activity signified participation in everyday politics. They supported the progressive ideals of their government colleagues and expected that psychoanalysis would transform ideals into reality. The Ambulatorium was a testament to their efforts. Helen Schur remembers Red Vienna as a time when 'you did something for people who didn't have money. Money didn't play such a great role. Nobody was really rich, but they cared more about others'. When asked for recollections about the issue of free treatment and the social obligations of psychoanalysis, Schur responded: 'I think they saw that this would be the liberation of people. To really make them free of neuroses, to be much more able to work, you know, like Freud said, to love properly and to work'. 'And that people were entitled to this liberation?' I asked. 'As much as people are entitled to something', she responded (1995, unpublished interview).

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