PART II

THE PRACTICAL WORK OF PSYCHOTHERAPY

VII

THE FIELD OF PSYCHOTHERAPY

We have discussed the psychological tools with which the psychotherapist

has to work but we have not spoken as yet of psychotherapy itself. All

that we have studied has been by way of preparation; and yet the right

preparation is almost the most important factor for the right kind of

work. To rush into psychotherapy with hastily gathered conceptions of

mental life may be sometimes successful for the moment, but must always

be ultimately dangerous. It is often most surprising what a haphazard

kind of psychology is accepted as a basis for psychotherapy even by

scientifically schooled physicians who would never believe that common

sense would be sufficient to settle the problems of anatomy and

physiology; as soon as the mind is in question, no serious study seems

needed. Can we be surprised then that in the amateur medicine of the

country within and without the church any fanciful idea of mental life

may flourish? If we are to recognize the rights and wrongs of

psychotherapy in a scientific spirit, a sober analysis of the mental

facts involved was indeed at the very first most essential. Now we can

easily draw the conclusions from our findings.

We recognized from the start the fundamental difference between two

different attitudes which we can take towards the inner life of any

personality, the purposive view and the causal. We recognized the sphere

to which each belongs and we saw that all medical treatment demands the

causal view, thus dealing with inner life as part of the causal chain of

events. Each inner experience became therefore a series of so-called

contents of consciousness. These contents can be described and must be

analyzed into their elements. The basis of psychotherapy is therefore an

analytic psychology which conceives the inner experience as a

combination of psychical elements.

But the final aim was the causal connection. The appearance and

disappearance of those millions of elements and their connection had to

be explained. We recognized that such an explanation of the contents of

consciousness was possible only through the connections between the

accompanying brain processes. Every psychical change had to be conceived

as parallel to a physiological change. The psychology which is to be the

basis of psychotherapy had to be therefore a physiological psychology.

We recognized that these psychophysiological processes were processes of

transmission between impressions and expressions, that is, between

incoming nervous currents and outgoing nervous currents, between stimuli

and reactions. Thus we have no central process which is not influenced

by the surroundings and which is not at the same time the starting point

of an action. We have normal health of the personality as long as there

is a complete equilibrium in the functions of the organism which adjusts

the activities to the surroundings. Every abnormality is a disturbance

of this equilibrium. A psychology which is the basis of psychotherapy

thus conceives every mental process in relation to both the ideas and

the actions; it avoids all one-sidedness by which the mind is cut off

either from its resources or from its effects. The relations to the

impressions are usually the less neglected: and we must the more

emphasize the fact that the psychology needed for psychotherapy knows no

mental fact which does not start an action and that every change in the

system of actions involves a change in the central experience. Wherever

this equilibrium of adjusted functions is disturbed, some therapy of the

physician has to set in: whether psychotherapy is in order depends upon

the special conditions.

We have recognized that there are no mental facts outside of those which

are in consciousness and that from a psychological point of view

consciousness itself does not have different degrees and different

levels, that all varieties of experience refer thus only to the special

content and its organization. There is thus no subconscious. On the

other hand, we saw that there is no conscious experience which is not

based on a bodily brain process. By these two fundamental facts of

scientific psychology, every possible psychotherapy gets from the start

its clear middle way between two extreme views which are popular today.

The one school nowadays lives from the contrast between consciousness

and subconsciousness and makes all psychotherapy work with and through

and in the subconscious. The other school creates a complete antithesis

between mind and body and makes psychotherapy a kind of triumph of the

mind over the body. Practically every popular treatise on

psychotherapeutic subjects in recent years belongs to the one or the

other group; and yet both are fundamentally wrong. And while, of course,

this mistake is one of theoretical interpretation, it evidently has its

practical consequences. The fantastic position allowed to a subconscious

mind easily gives to the doctrine a religious or even a mystical turn

and the artificial separation between the energies of the mind and those

of the body leads easily to a moral sermon. Whether this amalgamation of

medicine with religion or with morality may not be finally dangerous to

true morality and true religion is a question which will interest us

much later. Here we only have to ask whether it is not harmful to the

interests of the patient and thus to the rights of medicine, and indeed

that must be evident here at the very threshold. Both schools must have

the tendency to extend psychotherapy at the expense of bodily therapy

and to narrow down psychotherapy itself to a therapy by appeals which

in the one case are suggestions to the subconscious and in the other

case persuasions and encouragements to the conscious will. As soon as we

have overcome the prejudices of those two rival schools and have

recognized that both are wrong, that there is no subconscious and that

there is no psychological fact which is not at the same time a

physiological one, we see at once that this common procedure of both

schools is unjustified and dangerous. Mental therapy and physical

therapy ought to be most intimately connected parts of the same

therapeutic effort and mental therapy includes by far more than mere

suggestions and appeals. All that involves of course that its systematic

application belongs in the hands of the well-trained physician and of

nobody else, but on the other hand, it involves that every physician

ought to be well schooled in psychology.

As soon as a disturbance to be cured is considered as a lack of

equilibrium in psychophysical functions, every mental influence, every

suggestion and appeal becomes itself an excitement or an inhibition of

nerve cells. The sharp demarcation line between a psychical agency and a

physical one disappears altogether; the spoken word is then considered

as physical airwaves which stimulate certain brain centers and in the

given paths this stimulation is carried to hundreds of thousands of

neurons. The protracted warm bath or the cold douche influences, too,

large brain parts by changing the blood circulation which controls the

activity of those neurons; or the bromides absorbed in the digestive

apparatus, or the morphine injected, also reach the neurons and again

have a different kind of influence on them, and the electric current may

stimulate the nervous system in still a different way. It may be, and

under many conditions certainly is, essential to influence the brain

cells just in that particular way which results from the spoken word,

but there too the causal influence remains a function of the physical

effect and thus by principle there is no sharp separation from other

physical means. Thus to believe in psychotherapy ought never to mean

that we have a right to make light of the other means which, as

experience shows, may help towards the treatment of disturbances in the

central equilibrium. Suggestions and bromides together may secure an

effect which neither of them alone will bring about. It is most

unfortunate that not without some guilt on the part of the physicians

themselves, the large public has begun to believe that orthodox

psychotherapy has to mean a rejection of drugs and a contempt for the

doctors who prescribe them.

Of course a discussion of psychotherapy cannot enter into the study of

these physical agencies of treatment, but at the threshold, we have to

insist that there exists no opposition between psychophysiological and

physiological means of influencing the brain. It may be true that drugs

and baths and electricity have no influence on the subconscious, but the

trouble is not that the drugs are inefficient but that they cannot

influence what does not exist. In the same way disappears now that new

boundary line for psychotherapy which wants to limit it to mere

suggestion and appeal. If psychotherapy employs all the means by which

we can influence mental states in the interest of the health of the

personality, we have no reason to confine it either to a persuasion of

the subconscious through suggestion and hypnotism or a persuasion of the

conscious, in which it works as a moral appeal. Suggestion and hypnotism

certainly must play a large part in psychotherapy and that part does not

become smaller by the fact that we reject the subconscious

interpretation of them and consider them entirely as psychophysical

processes. And in the same way undoubtedly we have to acknowledge the

psychophysiological effect of persuasion and of the appeals to the

conscious intellect and will. But for us as psychotherapists all those

factors have no moral value but only a therapeutic one, and thus stand

in line with any other influence that may help, even though from a

purposive point of view it stands on a much lower level. A mere mental

distraction by enjoyment and play and sport, an aesthetic influence

through art, a mere stimulus to automatic imitation, an enforced mental

rest, an involuntary discharge of suppressed ideas, and many similar

schemes and even tricks of the mental physician belong with the same

right to psychotherapy.

It is really doubtful whether the moral and religious appeals are always

helpful and not sometimes or often even dangerous for the health of the

individual; and it is not doubtful that morally and religiously

indifferent mental influences are often of the highest curative value.

The more we abstract from everything which suggests either the mysticism

of the subconscious or the moral issues of a mind which is independent

of the body, the more we shall be able to answer the question as to the

means by which health can be restored. This question is neither a moral

nor a philosophical one but strictly one of experience. In this

connection, we must remember that we also have had to give up the

artificial demarcation line between organic and functional diseases. We

recognized that every so-called functional disease has its organic basis

too, and that it is entirely secondary whether we are able to find

visible traces of the organic disturbance. We had to acknowledge, to be

sure, the difference between reparable and irreparable disturbances, but

such grouping expresses only in another form the fact that experience

alone can show whether the methods of treatment which we know so far

will be successful or not. Not a few disturbances of the equilibrium

which appeared irreparable to an earlier time yield to the treatment of

to-day, and no one can determine whether much which appears irreparable

today may not be accessible either to psychotherapeutic or to physical

therapeutic means to-morrow. If we were carelessly to identify the

reparable troubles with those which we cannot recognize visibly, we

should be at a loss to understand why, for instance, many forms of

insanity are entirely beyond our psychotherapeutic influences. On the

other hand, every physician who uses psychotherapeutic means is

surprised to see the effective bodily readjustment where serious

disturbances perhaps of the circulatory system or the digestive system

existed. What the methods can do and what they cannot do must simply be

left to experience, but of course to an experience which is eager to

expand itself by ever new experimental curative efforts.

From this point of view we can see clearly the general division of the

whole field of possible psychotherapy. Psychotherapy influences

psychophysical states in the interest of health. There are only two

possibilities open: either the disturbance is in the psychophysical

system itself or it is outside of it, that is in the other parts of the

body which are somehow under the influence of the mind. In the first

case when the disturbance occurs in the mind-brain system itself, we

ought to separate two large groups, first those cases in which the

system itself is normal and the disturbance comes from without, and

second those in which the constitution of the system itself was abnormal

and led to disturbances under conditions in which a normal system would

not have suffered. We have to consider both groups somewhat more in

detail, as each again allows a large variety of cases.

Thus we have before us, first the normal mind-brain system into which a

disturbance breaks, injuring more or less severely and for a longer or

shorter time the equilibrium of the psychophysical functions. Here

belong any bodily processes which produce pain or any bodily defects

which produce blanks in the content of consciousness; the pain of

sciatica or of rheumatism, or the defect of the blind or of the deaf,

certainly interferes in a disturbing way with the perfect harmony of

psychophysical activities. But here also belongs the suffering which

results from conditions in the surroundings, the loss of a friend, a

disappointment in life, any source of worry and grief. Social and bodily

conditions alike may thus work to break up the equilibrium. The pain

sensation interferes with the normal flow of mental life and the grief

may undermine the mental interests. The psychotherapeutic effort may be

directed toward removing the source of the disturbance, bringing the

patient under other conditions, curing the diseased organ, and where

that is not possible, may work directly on the psychophysical state,

inhibiting the pain, suppressing the emotion, substituting pleasant

ideas, distracting the whole mind, filling it with agreeable feelings,

until the normal equilibrium is restored.

The psychophysical system itself was not really harmed by such

influences. In the following groups, such is no longer the case. We here

think at first of those severe injuries which have their sources in

abnormal processes outside of the brain. The anaemia of the patient or

the low state of his nutrition or the fever heat of his blood impairs

the harmony of the mental functions. Another and for the psychotherapist

much more important group is that in which the impairment results from

toxic influences. Alcohol, morphine, cocaine, tobacco, and many other

drugs may have been misused and may have produced a most marked

alteration in the mind-brain system. Desires may have developed which

completely destroy the balance of the normal functions and yet the

satisfaction of which increases the poisoning effect. But here belongs

further the effect of poisons which the body itself produces: the toxic

disturbance of uraemia or the coma in diabetes, or especially the grave

disturbances resulting from the abnormal action of the thyroid gland,

the source of cretinism. Many indications suggest that a near future

will consider this group much larger than we are really justified in

doing today, probably soon connecting a number of other mental diseases

like dementia praecox with toxic effects of bodily origin. Experience

shows that in this group not a few chances exist for successful

psychotherapeutic influence. Yet the means may be various in character

and their effect may be a direct or an indirect one. A psychical shock

may remove directly the mental disturbance of the alcoholic state, but

it is more important that mental suggestion can remove the alcoholic

disturbance indirectly by suppressing the desire for alcoholic excesses.

Even where cure by psychotherapeutic means is out of the question, as is

the case with feverish delirium or uraemic excitements, no skilled

physician ignores the aid which a well-adjusted mental influence can

offer to the patient.

We come to a third group. Some outside cause has harmed the central

nervous system directly, and has left it in a disabled state after the

cause itself has disappeared. Such causes may have been at first purely

functional: for instance, a neglect of training, or a wrong training, or

an over-activity, but the ill-adjusted function which involved, of

course, every time an ill-adjusted organic activity or lack of activity,

has led to a lasting or at least relatively lasting disturbance in the

system of paths. The neglect of training, for instance, in periods of

development may have resulted in the retardation which yields the

symptoms of a feeble-minded brain, or the wrong training may have

created vicious habits, firmly established in the mind-brain system and

gravely disturbing the equilibrium. Above all, the overstrain of

function, especially of emotional functions, may lead to that exhaustion

which produces the state of neurasthenia. It is true that not a few

would doubt whether we have the right to class neurasthenia here where

we speak of the harm done to the normal brain. Many neurologists are

inclined to hold that neurasthenia demands a special predisposition and

is therefore dependent upon a neurotic constitution of the brain itself.

But if defenders of such a view, as for instance, Dubois, acknowledge

that "we might say that everybody is more or less neurasthenic," we can

no longer speak of any special predisposition. Certainly there exists a

constitutional neurasthenia sometimes but we have hardly a right to deny

that overstrain in the brain activity may produce a series of

neurasthenic symptoms in any brain, and the special predisposition is

responsible rather for the particular selection among the innumerable

symptoms.

Neurasthenia certainly is the classical ground for the psychotherapist.

The patient's insomnia and his headache, his feeling of tiredness and

his disgust with himself, his capricious manias and his absurd phobias,

his obsessions and his fixed ideas all may yield to the "appeal to the

subconscious," and as a neurasthenic easily believes in the existence of

various organic diseases in his body, Christian Science can perform here

even "miracles." In the case of retardation, the psychical influence

will have to be in the first place one of training. Yet it would be

narrow to overlook that in neurasthenia, too, suggestion has to be only

a part of the psychical treatment. Training and rest, distraction and

sympathy and many other factors have to enter into the plan.

Incomparably small, on the other hand, is the aid which psychotherapy

can offer in cases of real destructions in the brain, as in the case of

tumors, hemorrhage, paresis or the degeneration by senility. More

effective may be its work in concussion of the brain and especially with

traumatic neuroses, as in the case when a railroad accident has put the

mind-brain system out of gear.

So far we presupposed that the central system itself was normal. No

sharp separation line, however, lies between all these disturbances and

the equally large group of psychophysical disabilities resulting from a

defective constitution of the brain. The normal brain shades over by

smallest differences into the abnormal one; yes, even the varieties of

temperament and character and intellectual capacity and industry and

energy represent, in the midst of our social surroundings, large

deviations from the standard. That which might still pass as normal

under certain conditions of life would be unadjusted and thus abnormal

under other conditions. In the same way, we certainly cannot point out

where the natural constitution of a brain ceases to be fit for its

organic purposes and where the structural variations are ill-prepared

for the struggle for existence. Just as we claimed that an entirely

normal brain might be brought by an emotional overstrain to a state of

exhaustion and disability, we may claim on the other side that a brain

which nature has poorly provided may yet be protected against damage and

injury. The inborn factor does not alone decide the fate. Psychophysical

prophylaxis may secure steadiness of equilibrium to a system which

inherited little resistance. Yet this large borderland region, where an

ill-adjusted brain may be saved or lost in accordance with favorable or

unfavorable circumstances, shades off again to the darker regions where

the inner evolution leads by necessity to disaster even under favorable

conditions.

We might begin this large group of the constitutional disturbances with

that neurasthenia which develops on the basis of inherited disability.

Lack of energy resulting from a feeling of tiredness, a quick

exhaustion, a mood of depression, an easy irritation, even despair and

self-accusation, sullenness and fits of anger, cranky inclinations and

useless brooding over problems, headache and insomnia characterize the

picture which everyone finds more or less developed in some of his

acquaintances. If we classify symptoms, we may separate from it that

which we nowadays are inclined to call psychasthenia. An abnormal

suggestibility for autosuggestions stands in the foreground. Fixed ideas

and fixed emotions, especially fears, trouble the patient. He may pick

up his obsession by any chance experience and no good-will liberates him

from the intrusion perhaps for years. The patient is perfectly well

aware that his ideas and his emotions are unjustified, he himself does

not believe in them, and yet they come with the strength of an outer

perception and with the vividness of a real attitude, and his whole

mental equilibrium may be upset by the continuous fight against these

involuntary interferences. In the light cases, sometimes the one and

sometimes the other autosuggestion may hold the stage; in the severe

cases, mental life turns more and more around certain definite fears and

yet it may all still be in the limits where the daily work can go on and

the world may not know of the hidden tortures. Here belongs the fear of

open places or the fear of touching certain objects, the fear of doing

harm to others or the fear of deciding actions wrongly, the fear of

destroying valuable things or the fear of being the center of public

attention, the fear of crowds or of closed doors, of altitudes or of

bridges. And in all cases emotional reaction may set in with anxieties,

and bodily symptoms such as palpitation of the heart may result,

whenever an effort is made to disregard the nervous fear. There is

perhaps no group of patients which so much deserves the most careful

efforts of the psychotherapist. Still more than the hysterics they

suffer from the fate of seeing their ills counted as not real. For them

everybody has the good advice that they ought to overcome their fancies;

and yet they feel their life ruined with their endless fight against the

overpowering enemy. And if anywhere, it is here that the psychotherapist

is successful. Psychasthenic fear can be removed, while the developed

melancholic depression, for instance, is entirely beyond the reach of

psychical influence.

We have after all the same psychasthenic state before us when the

obsession has impulsive character, from the mere abnormal impulse of

lying, or making noise in a quiet place or crying in the dark, or

touching certain places, to that of stealing, indecent speech, arson,

and perhaps even murder. The symptoms might easily be mistaken for those

of graver diseases. Yet the fact that the patient himself really does

not will the effect at which he is aiming separates, mostly without

difficulty, the diagnosis of psychasthenia from that of insanity. Quite

nearly related to it are the manifold variations of abnormal and

perverse sexual tendencies. The psychiatrists are perhaps too much

inclined to bring all these pathological impulses and desires, fears and

anxieties, into the nearest neighborhood to real insanity. The

indisputable success of psychotherapy in these spheres ought to add a

warning against these expansions of the strictly psychiatric domain. The

psychologist will be more inclined to emphasize their relation to simple

neurasthenia which itself imperceptibly shades over into our normal

life.

All neurasthenic and psychasthenic disabilities show a certain emotional

continuity and uniformity. It is the emotional instability and the quick

alternation of symptoms which characterize hysteria or rather the

hysterias. It seems as if science were near to the point of explaining

the hysterical disease by one common principle, but certainly the

symptoms are an inexhaustible manifold. The rapid changes of the intense

moods of the patient usually stand in the center. Torturing obsessions,

abnormal impulses, over-suggestibility, hypochondriac depressions,

paralysis of arms or legs, anaesthesia and paraesthesia, a mental stupor

and confusion, illusions and perceptions of physiological symptoms may

work together in spite of his, or rather her clear intelligence. It is

probably on a hysteric basis also that somnambulic states arise during

the night, and from them a straight way leads to those mental attacks

after which the memory is entirely lost, or for which fundamental

associative connections are cut off. And from here we come to the

exceptional cases of alternating personality. The more we recognize the

myriad symptoms in the hysteric patient as products of the emotional

instability, of autosuggestibility and of inhibition, the more we

understand the almost miraculous result of psychotherapeutic treatment.

Autosuggestions can be fought by countersuggestions, anaesthesia and

paraesthesia can be removed often in an instant, dissociated

personalities may be built up again through hypnotism, the most severe

bodily symptoms may disappear by influences in a waking state. Hysteria

alone would justify the demand that every physician in his student days

pass with open eyes through the field of psychology. Quite near stand

chorea and the epidemic impulses to imitative movements. And we might

bring into this neighborhood also the disturbance in the equilibrium of

the speech movements through all degrees of stammering and severe

impairment. Up to a certain degree, though not often completely, they

too yield easily to psychotherapeutic influence.

We enter now that region of constitutional disturbances in which

psychotherapy is of small help. It leads from epilepsy to the periodic

diseases, especially the maniacal depressive insanity, the paranoia

which develops late, and finally to states of idiocy which cover the

whole life. We are far from claiming that psychical influences are

entirely powerless, the more as we insisted that psychotherapy goes much

beyond mere suggestions and appeals. No psychiatrist will work without

psychological tools when he deals with the exultations of the maniac and

the depressions of the melancholic, with the hallucinations of

persecution or the erotic insanities of the paranoiac. Still more the

whole register of psychology has to be used, when we are to educate the

idiot and the imbecile. But the disappearance of the disease or of the

chief symptoms through the mental agencies is in all these cases out of

the question. Only in incipient cases, especially of melancholia and

mania, the psychotherapeutic work seems not entirely hopeless; and for

epilepsy some distinct successes cannot be denied.

We have reviewed the whole field of psychophysical disturbances, those

produced through external conditions in the normal brain and those

resulting from abnormal brain constitution. We have seen that the work

of the psychotherapist is of very unequal value in different parts of

the field; in some, as in neurasthenia, in psychasthenia, in hysteria

and similar regions most effective, in others like paresis or paranoia

reduced to an almost insignificant factor. Where it can help and where

not we recognize as a mere question of experience. Certainly the

severity of the symptoms alone does not decide it. As the treatment is

entirely empirical, no one can foresee whether or not the situation may

change to-morrow. We may find psychotherapeutic schemes by which

epilepsy or maniacal depressive insanity or traumatic neuroses may

become accessible. We simply do not know why we may remove stammering or

synthesize a dissociated personality or overcome an inborn sexual

perversity, while we are unable to remove the depression of the

melancholic. Certainly the symptoms of the circulatory insanity

disappear completely in the free intervals; there is no reason to give

up hope that psychotherapy might find the way to hasten the appearance

of such a normal period.

But we have emphasized from the start that the psychotherapeutic work

has not only to set in when the disturbance itself lies in the

psychophysical system. We may utilize the influence which the

mind-brain system has for the whole body and thus may apply the

psychical tool to work on the disturbances in the bodily apparatus. We

may discriminate a direct and an indirect influence in the psychical

treatment of bodily diseases. Transition from the foregoing group of

psychical disturbances offers itself perhaps most easily through the

state of insomnia.

The causes of sleeplessness may still lie in the psychophysical sphere;

restless thoughts may inhibit the idea of sleep. The effect of sleep is

again in the sphere of the mind, the annihilation of conscious contents.

But the center which regulates and creates the sleep, probably by

contracting the blood-vessels, lies outside of the psychophysical system

in the lower centers of the brain. The real disturbance thus lies in the

inactivity of this purely bodily apparatus and mental influence which is

to create sleep has therefore to work downwards from the mind to a

bodily organ. In the same way many other non-psychical centers of the

brain may be brought to efficiency through psychophysical regulation.

But the therapeutic effect is certainly not confined to the central

nervous system. Whithersoever the centrifugal nerves lead there the

mind-brain system may have its curative influence. In the most startling

way that is true for the digestive apparatus. The secretions of the

stomach, the activity of the intestines can be influenced to a decree

which it is difficult to explain. Important also is the relation to the

circulatory system, especially the disturbances of the heart:

innervation may be corrected, abnormal dilations and contractions of

blood-vessels may be regulated. The bladder, uterus, even the pancreas

and the liver seem to be influenced by the peripheral effects of the

central excitement. And while no warning can be serious enough against

the absurd belief that diseases like cancer or tuberculosis can be cured

by faith, it must be admitted that psychical influences under special

conditions may have a retarding influence on any pathological process in

the organism. Much of that certainly is indirect influence but the

physician would be reckless if he should ignore the aid which may result

from such indirect assistance. Even if psychotherapy could not do more

in the treatment of bodily diseases than to secure a joyful obedience to

the strict demands of the physician, it would yet have to be accredited

with an extremely important service.

In a parallel line comes the effective aid by the stimulation of hope

and the suppression of fear, by suggestion of a feeling of encouragement

and the inhibition of the emotions of worry. This is a field where even

the average physician is most easily inclined to play the amateur

psychotherapist. He knows how convalescence is disturbed by psychical

depression and how much more quickly health returns, if it is

confidently expected; he knows how many dangerous operations are

disturbed by despondency and helped by bravery; he knows what a blessed

change has come into the treatment of tuberculosis since a psychical

factor of social interest has set in; he knows how many ills disappear

when regular occupation and interesting work are established or the

strain of distasteful work removed. Even the mere suppression of the

pain works backwards on the bodily disease which produces it. The pain

was a starting point for disturbing reactions; with its disappearance

through psychotherapeutic influence, the reactions of the irritated

brain come to rest, the diseased body can carry on its struggle without

interference and may win the day. Often the psychical influence may not

even change the symptoms at all but may remove other troublesome

effects. The sufferer from locomotor ataxia may learn to walk again

through mental education without any restitution of his spinal cord. In

short, there are endless ways in which psychical influence may work

towards the general health and towards the victory over bodily disease;

and all that may be acknowledged without the slightest concession to the

metaphysical creeds of mental healers and Christian Scientists. But to

make use of those means and to harness such influences, it cannot be

enough to rely on the common-sense of the physician any more than we

should trust the common-sense of the surgeon to use his knife without

condescending to the study of anatomy. The psychological study of the

anatomy of the soul shows a not less complicated system of mental

tissues and mental elements.

To enter into the full richness of this whole, large field of course

lies entirely beyond the scope of our short discussion, which seeks as

its only aim a clear recognition of the principles. Yet it seems

essential to illustrate at least this sketch of the field by a more

detailed account of actual developments. Various ways of procedure might

appear in order and the most natural one would be, of course, to pass

down from disease to disease and sketch special cases from diagnosis to

cure. We might go through the various stages of neurasthenia and then

through psychasthenia and then through hysteria and so on. And if we had

to write a handbook for physicians, it would certainly be the desirable

way, in spite of the too frequent repetitions which would become

necessary. But as our aim is only a discussion of principles of

psychotherapy, we have no right to use this method. Moreover, such a

method would suggest the misleading view that the psychotherapist is

called and is able to treat diseases. All that he treats are symptoms

and he ought not to pretend that he can do more, as long as he abstracts

from all other therapeutic agencies. Psychotherapeutic influence may

remove the phobia of a psychasthenic or the obsession of a neurasthenic

or the emotion of a hysteric, and thus may bring not only momentary

relief but a change which may be favorable for general improvement, but

certainly the neurasthenia and psychasthenia and hysteria are not really

removed by it. Of course, even the treatment of symptoms demands a

constant reference to the whole background of the disease. The

depression of the neurasthenic must not be treated like the depression

of the melancholic, the obsession of the psychasthenic must not be

mixed with the fixed ideas of a paranoiac, the hysteric inability to

walk must not be confused with an injury of the motor nerves; in short,

each symptom has to be treated as part of a complete situation. The

efforts of the psychotherapist will move over as large a part of the

disease as possible and cover, perhaps, the causes of the disturbance as

far as they are of psychical origin. Yet it would remain dilettanteism

if we were to accept the popular view that the mere psychotherapeutic

aid is a sufficient treatment of the whole disease. The physician has to

be much more than a psychotherapist. Our discussion only seeks to point

out that whatever else he may be, he must be also a psychotherapist.

The more conservative method which befits us may be, therefore, the

method of dealing with symptoms only and abstracting from the more

ambitious plan of discussing the diseases entire. We simply separate the

mental symptoms and the bodily symptoms which the psychotherapist is to

remove. And just in order to classify somehow the manifold mental

symptoms, we might separate those in the sphere of ideas, those in the

sphere of emotions, and those in the sphere of volitions. Of course,

nothing is further from such a plan than the old-fashioned belief that

intellect, feeling, and will represent three independent faculties of

the soul. Modern psychology has not only substituted the millionfold

phenomena for the schematic faculties, but emphasizes above all the

interconnectedness of the mental facts. There is no experience into

which ideas, and feelings, and impulses do not enter together. And

correspondingly we emphasized that on the physiological side too, every

sensory excitement is at the same time the middle point of central

irradiation and the starting point of motor activity. Thus there can be

no disturbance of ideas which does not influence feeling and will, and

vice versa. Yet it would be artificial to deny that any one of those

various sides of the psychical process may come to prominence, sometimes

the impulse, sometimes the emotion, and sometimes the interplay of

ideas. The separation means only an abstraction, but it is an

abstraction which is justified and suggested by the actual experiences.

Thus we shall deal with the psychical treatment of ideational,

emotional, volitional, and bodily symptoms.

Common to our discussions will be only the effort to avoid everything

which is exceptional and by its unusual complications apparently

unexplainable and mysterious. The greater complexity of the case

certainly adds much fascination. Yet since we do not want to stimulate

mere curiosity but clear understanding of the elements, we avoid every

startling record. We confine ourselves carefully to those perhaps

trivial experiences which daily enter into the view of those who come in

contact with suffering mankind. There will be no startling stories of

dissociated personalities, such as appear perhaps every few years on the

horizon of the medical world, but we shall speak of those who every day

in every town carry their trouble to the waiting room of the doctor and

who might return more happily if he had more well-trained interest in

the psychotherapeutic factors. Yet before we analyze some typical

symptoms, it might be wise to review the whole series of means and tools

which the psychotherapist finds at his disposal.

VIII

THE GENERAL METHODS OF PSYCHOTHERAPY

The psychological work of the physician does not begin with his curative

efforts. Therapy is always only the last step. Diagnosis and observation

have to precede, and an inquiry into the causes of the disease is

essential, and in every one of these steps psychology may play its role.

The means of psychodiagnostic are not less manifold than those of

psychotherapy. Moreover there the technique may be more complex and

subtle. The whole equipment of the modern laboratory ought to be put at

its disposal. Perceptions and associations, reactions and expressions

ought to be examined with the same carefulness with which the

conscientious physician examines the blood and the urine.

A particular difficulty of the task more or less foreign to every other

medical inquiry is the intentional or unintentional effort of the

patient to hide the sources of the trouble and to mislead as to their

true character. Too often he is entirely unconscious of the sources of

trouble or else he has social reasons to deceive the world and himself,

and ultimately the physician. And yet no psychical treatment can start

successfully so long as the patient is brooding on secret thoughts at

the bottom of his mind. The desire to hide them may often be itself a

part of the disease. It is surprising how often unsuspected vistas of

thoughts and impulses and emotions are opened by an inquiring analysis

where the direct report of the patient does not awaken the least

suspicion. In the field of insanity, naturally the physician at once

goes to an examination on his own account, but in the borderland regions

of the psychasthenics and hysterics and neurasthenics, the intellectual

clearness of the patient too easily tempts one into trusting the

sincerity of his story; and yet the most important ideas clustering

perhaps about love or ambition, about vice or crime, about business

failure or family secrets, about inherited or acquired diseases may be

cunningly withheld and may frustrate every psychotherapeutic influence.

Where suspicion is awake and mere confidential talk and persuasion seem

insufficient, the physician may feel justified in the interest of his

patient in drawing the thoughts out of their hiding-place by artificial

means. Skill, tact, and experience are needed there.

As a matter of course, in the overwhelming mass of cases the frankness

and the good will of the patient himself will support the physician and

accordingly his examination is not obliged to trap the patient but

simply to guide him to important points. But then begins the most

essential study of diagnostical differentiation. With all the means not

only of psychology but of neurology and internal medicine, he has to

separate the particular case from similar ones and to examine whether

he deals with, for instance, a hysteric or with a paranoiac, with a

neurasthenic or with a case of dementia praecox; and he will not forget

that there exist almost no symptoms of serious diseases which the

nervous system of the hysteric may not imitate for a time. Not ours is

the task of analyzing special methods of neurological and mental

differential diagnosis such as are used in the psychiatric clinic and in

the office of the nerve specialist. There the family history with

reference to nervous and other diseases, the history of the patient

himself, the infectious diseases which he has passed through, his habits

and anomalies, his use of alcohol and of drugs, his experiences in

social life, the demands of his profession, his recent troubles and

their first origin are to be recorded carefully. Then begins the

physical examination, the study of his sense organs and his nerves, of

the motor inabilities, the pains, the local anaesthesias and

paraesthesias, the disturbances of the reflexes, of the spasms, tremors,

convulsions, and incooerdinations, of the vasomotor and trophic

disorders, and so on. In a similar way the psychical examination tests

the hallucinations and illusions, the variations and defects of memory

and attention, of judgment and reasoning, of orientation and

self-consciousness, of emotions and volitions, of intellectual

capacities and organized actions. But we do not have to enter here into

a discussion of such diagnostic means; our chief interest belongs to the

therapy.

The variety of the psychotherapeutic methods is great and only some

types are to be characterized here. But one rule is common to all of

them: never use psychotherapeutic methods in a schematic way like a

rigid pattern. Schematic treatment is a poor treatment in every

department of medicine, but in psychotherapeutics it is disastrous.

There are no two cases alike and not only the easily recognizable

differences of sex and age, and occupation and education, and financial

means, and temperament and capacity are decisive, but all the subtle

variations of prejudices and beliefs, preferences and dislikes, family

life and social surroundings, ambitions and prospects, memories and

fancies, diet and habits must carefully be considered. Every element of

a man's life history, impressions of early childhood, his love and his

successes, his diseases and his distresses, his acquaintances and his

reading, his talent, his character, his sincerity, his energy, his

intelligence--everything--ought to determine the choice of the

psychotherapeutic steps. As it is entirely impossible to determine all

those factors by any sufficient inquiry, most of the adjustment of

method must be left to the instinct of the physician, in which wide

experience, solid knowledge, tact, and sympathy ought to be blended.

Even the way in which the patient reacts on the method will often guide

the instinct of the well-trained psychotherapist.

It is therefore certainly not enough that the knowledge of the physician

simply decide beforehand on a definite course of psychical treatment and

leave the carrying out to a well-meaning minister or any other medical

amateur who schematically follows the indicated path. The finest

adjustment has to come in during the treatment itself and the response

of the patient often has to suggest entirely new lines of procedure.

More than in any other field of medicine, the physician himself has to

extend his influence far beyond the office hours and the strictly

medical relations. And yet, on the other hand, there is no department of

medicine in which the treatment might not profit by the

psychotherapeutic influence. With a few vague words of encouragement

mechanically uttered, or with a routine of tricks of suggestion by bread

pills and colored water and tuning forks, not much will be gained even

in the ordinary physician's practice. Subtle adjustment to the personal

needs and to the individual conditions is necessary in every case where

the psychical factor is to play an important role. It cannot be denied

that the one great obstacle in the work of the routine physician is the

lack of time and patience which is needed for successful treatment. To

prescribe drugs is always quicker than to influence the mind; to cure a

morphinist by hyoscine needs less effort than to cure him by suggestion.

The first method to bring back the psychophysical equilibrium is of

course the one which is also demanded by common-sense, namely, to remove

the external sources of the disturbance. External indicates there not

only the outer world but also the own body outside the conscious parts

of the brain. If we take it in the widest meaning, this would evidently

include every possible medical task from filling a painful tooth to

operating on a painful appendix, as in every case where pain results,

the mental equilibrium is disturbed by it and the normal mental life of

the patient reduced in its efficiency. But in the narrower sense of the

word, we shall rather think of those sources of trouble in the organism

itself which interfere directly with the mental functions. The

examination of any public school quickly leads to the discovery that

much which is taken for impaired mental activity, for lack of attention,

for stupidity, or laziness may be the result of defective hearing or

sight or abnormal growth of the adenoids. Growths in the nose may be

operated upon, the astigmatic or the short-sighted eye may be corrected

by glasses, the child who is hard of hearing may at least be seated near

the teacher; and the backward children quickly reach the average level.

No doubt in the life of the adult as well, often almost insignificant

and from a strictly physical point of view unimportant abnormities in

the bodily system, especially in the digestive and sexual spheres, are

sources of irritation which slowly influence the whole personality. To

be sure, the brain disturbance may have reached a point where the mere

removal of the original affliction is not sufficient to reinstate the

normal balance of mental energies, but wherever such a bodily irritation

goes on, it is never too late to abolish it in the interests of

psychotherapy.

The less evident and yet even more important source of the painful

intrusions may lie outside of the organism in the social surroundings

and conditions of life. Most of that has to be accepted. The physician

cannot bring back the friend who died or the fortune which was lost in

speculation or the man who married another girl. He will even avoid

suggesting far-reaching social changes in the private life of the

patient, changes like divorce in an unhappy marriage or the breaking of

the home ties, however often he may get the impression that such a

liberation would stop the source of the mental trouble. He will be the

more careful not to overstep his medical rights as he seldom has the

possibility to judge fairly on the basis of the one-sided complaint, and

the probability is great that the character and temperament of the

complainant may be a more essential factor of the ailment than the

personalities which surround him. Yet even the conservative physician

will find abundant opportunities for advice which will remove disturbing

energies from the social surroundings of the sufferer. Even a short

release from the burdening duties, a short vacation from the incessant

needs of the nursery, a break in the monotony of the office, may often

do wonders with a neurasthenic. Often within a surprisingly short time

the brain gathers the energies to overcome the frictions with

unavoidable surroundings.

Yet here the physician has to adjust the prescribed dose of outing very

carefully to the special case. We may be guided by the psychological

experiments which have been made in the interest of testing the fatigue

induced by mental work. If perhaps four hours of concentrated work are

done without pauses, experiment shows that the quality of the work

deteriorates, measured for instance by the number of mistakes in quick

calculation. If certain relatively long pauses are introduced, the

standard of work can be kept high all through. But if frequent pauses

are made, and each short, the result is with many individuals the

opposite. The experiment indicates that these frequent pauses are

working as interruptions which hinder the perfect adjustment to the work

in hand. That is suggestive. Our neurasthenic may complain about the

life which he has to live and yet after all he is frequently so

completely adjusted to it that it may not be in his interest to remove

him far away from the conditions which cannot ultimately be changed but

to which he has to return. The instinct of the physician has to find the

middle way between a temporary removal of irritation which really allows

a development of new energies and a mere interruption which simply

damages the acquired relative adjustment. Every cause of friction which

can be permanently annihilated for the patient certainly should be

removed.

This negative remedy demands its positive supplement. The patient must

be brought under conditions and influences which give fair chances for

the recuperation of his energies. Too often from the standpoint of the

psychologist, the prescription is simply rest. As far as rest involves

sleep, it is certainly the ideal prescription. There is no other

influence which builds up the injured central nervous system as safely

as sound natural sleep, and loss of sleep is certainly one of the most

pernicious conditions for the brain. Again rest is a great factor in

those systematic rest cures which for a long while were almost the

fashion with the neurologist. Experience has shown that their

stereotyped use is often unsuccessful, and moreover that the advantage

gained by those months spent in bed completely isolated and overfed is

perhaps due to the separation and changed nutrition more than to the

overlong absolute rest. Yet used with discrimination, the physiological

and the psychical effect of lying in bed for a few weeks has certainly

often been a marked improvement, especially with young women. But more

often the idea of rest in bed during daytime is not meant at all when

the nerve specialist recommends rest to his over-strained patient. It is

simply meant that he give up his fatiguing daily work, even if that work

is made up of a round of entertainments and calls and social

engagements. The neurasthenic and all similar varieties are sent away

from the noise of the city, away from the rush of their busy life, away

from telephones and street cars, away from the hustling business and

politics.

Indeed it is the dogma of most official and unofficial doctors that the

restlessness and hurry and noise which all are characteristic of the

technical conditions of our time are the chief sources of the prevailing

nervousness. There was no time in the history of civilization in which

the average man was overwhelmed by so many demands on his nerve energy,

no time which asked such an abundance of interests even from the school

child. The wild chase for luxury in the higher classes, reenforced by

the commercialism of our time, the hard and monotonous labor in our

modern mills and mines for the lower classes, the over-excitement

brought to everybody by the sensationalism of our newspapers and of our

public life all injure the brain cells and damage the equilibrium. That

is a story which we hear a thousand times nowadays. Yet it is doubtful

whether there is really much truth in such a claim and whether much wise

psychotherapy can be deduced from it.

We may begin even with the very justifiable doubt whether nervousness

really has increased in our time. Earlier periods had not so many names

for those symptoms and were not able to discriminate them with the same

clearness. Above all, the milder forms of abnormities were not looked on

as pathological disturbances. If a man has a pessimistic temperament, or

has fits of temper, or cannot get rid of a sad memory idea, or imagines

that he feels an illness which he does not have, or has no energy to

work, even today most people are still without suspicion that a

neurasthenic or a psychasthenic or a hysteric disturbance of the nervous

system may be in its beginning. Earlier times surely may have treated

even the stronger varieties of this kind as troublesome variations in

the sphere of the normal. On the other hand, there can be no doubt that,

for instance, the Middle Ages developed severe diseases of the nervous

system in an almost epidemic way which is nearly unknown to our time.

As to the conditions of life itself, there are certainly many factors at

work which secure favorable influences for our cerebral activity. The

progress of scientific hygiene has brought everyone much nearer to a

harmonious functioning of the organism, and the progress of technique

has removed innumerable difficulties from the play of life. Of course,

we stand today before a much more complex surrounding than our ancestors

but still more quickly than the complexity have grown the means to

master it. We have to know more: yet the effort has not become greater

since it has become easier to acquire knowledge. We have to endure much

disturbing noise, and yet we forget how the sense organs of our

forefathers must have been maltreated, for instance, by flickering

light. We are in a rush of work and stand in thousandfold connections;

and yet the neural energy which is demanded is not large because a

thousand devices of our technical life have become our obedient

servants. There is no nation on earth which is more proud of its rush

and its hurry than the American people; and yet what an abundance of

time is leisurely wasted that would have to be used for work if the

country could not live from its richness. Moreover our life has probably

become cooler, there is less emotionalism, less sentimentality, more

business-like attitude, and that all means less inner friction and

excitement; in public life too, less fear of war and less religious

struggle. All has become a question of administration and efficiency.

Our time is certainly not worse off on the score of neurasthenia than

its predecessors.

Above all the intensity of mental stimuli is always relative. The

psychologist knows the experiments which determine that we perceive the

difference of impressions as alike when the stimuli are proportional.

If I have a ten-pound weight in one hand, I may find that I must have

one pound more in the other hand to discriminate the difference. Now if

I take twenty pounds in the one hand, then it is not sufficient to have

one pound more in the other, but I must have twenty-two pounds in the

other to feel a difference, and if I take thirty pounds, the other

weight must be thirty-three. We feel equal differences when the weights

stand in the same relation. The man who owns a hundred dollars will

enjoy the gain of five and regret the loss of five just as much as the

owner of a hundred thousand dollars would feel the gain or loss of five

thousand. This fundamental law of the relativity of psychical

impressions controls our whole life. The rush of stimuli which might

mean a source of nervous disturbance for the villager whose quiet

country life has brought about an adjustment to faint impressions may

cause very slight stimulation for the metropolitan accustomed for a

lifetime to the rhythm of the surroundings. Yet that quiet countryman

may react in his narrow system not less when the modest changes in his

surroundings provoke him. The gossip of his neighbor may undermine his

nervous system just as much as a political fight or the struggles of the

exchange that of the city man.

The same holds true for the purely intellectual engagements. The work

which the scholar undertakes should not be measured by the effect which

the same appeal to concentrated attention would make on the average man

of practical life. There, too, an adjustment to the demand has resulted

during the whole period of training and professional work. Every effort

should be estimated with reference to the standard of the particular

case. This relativity of the mental reaction on the demands of life must

always be in the foreground of the psychotherapeutic regime. Even the

best physicians too often sin against this principle and accuse the life

which a man or woman leads as too exhausting and overstraining simply

because it would be overstraining and exhausting to others who are not

adjusted to that special standard. Simply to withdraw a patient from the

one kind of life and to force on him a new kind with new standards may

not be a gain at all. A new adjustment begins and smaller differences

from the standard may bring about the same strong intensities of

reaction as the large differences brought before. Complete rest, for

instance, for a hard brain-worker hardly ought to be recommended unless

a high degree of exhaustion has come on. If routine prescriptions are to

be admitted at all, they should not be complete rest or complete change

of life for any length of time but a continuation of the life for which

adjustment has been learned with a reasonable reduction of the demands

and stimulations. The intellectual worker ought to decrease his work,

the overbusy society woman ought to stay in bed one day in the week, the

man in the midst of the rush of life ought to cut down his obligations,

but probably each of them does better to go on than simply to swear off

altogether.

Their rest ought to have the character of vacation; that means

interruptions without the usual activity ought to be short periods spent

with the distinct feeling that they are interruptions of that which must

last and that they are not themselves to become lasting states. Thus the

inner adjustment to the work ought to be kept up and ought not to be

substituted by a new adjustment to a less exacting life. In this way the

episode of the vacation rest ought to be in a way included in the

strenuous life almost as a part of its programme. Strenuosity must not

mean an external rush with the gestures of overbusy excitement, but

certainly the doctrine of the lazy life is wretched psychotherapy, as

long as no serious illness is in question. By far the best alteration

is, therefore, even in the periods of interruption, not simply rest but

new engagements which awaken new interests and stimulate neglected

mental factors, disburdening the over-strained elements of mental life.

The most effective agency for this task is contact with beauty, beauty

in nature and life, beauty in art and literature and music. To enjoy a

landscape ought to be not merely a negative rest for the man of the

office building, and good literature or music absorbs the mental

energies and harmonizes them. In the second place come games and sport,

which may enter into their right if fatigue can be avoided. Harmonious

joyful company, as different as possible from the depressing company of

the sanitariums, will add its pleasantness.

While the advice of the physician ought thus to emphasize the positive

elements which work, not towards rest, but toward a harmonious mental

activity, we must not forget some essential negative prescriptions.

Everything is to be avoided which interferes with the night's sleep.

Furthermore, in the first place, alcohol must be avoided. There cannot

be any doubt that alcoholic intemperance is one of the chief sources of

brain disturbances and that the fight against intemperance, which in

this country is essentially the fight against the disgusting saloon, is

a duty of everyone who wants to prevent nervous disaster. There may and

must be divergence of opinion as to the safest way to overcome

intemperance. The conservative physician will feel grave doubt whether

the hasty recommendation of complete prohibition is such a safe way,

whether it does not contain many conditions of evil, and whether the

fight against the misuse of alcohol will not be more successful if a

true education for temperance is accepted as the next goal. But for the

man of neurasthenic constitution and for any brain of weak resistance,

the limit for permissible alcoholic beverages ought to be drawn very

narrow and in such cases temporary abstinence is usually the safest

advice. Individual cases must indicate where a glass of light beer with

the meal or a glass of a mild wine may be permissible. Strong drinks

like cocktails are absolutely to be excluded. In the same way a strong

reduction is advisable in tobacco, tea, and especially coffee. A

complete withdrawal of all stimulations to which a nervous system has

been accustomed for years is not wise, or at least mild substitutes

ought to be suggested, but if coffee can be ruled out at once, often

much is gained. In the same way all passionate excitements are to be

eliminated and sexual life to be wisely regulated. An especial warning

signal is to be posted before all strong emotions, and if the patient

cannot be asked to leave his worry at home, he can at least be asked to

avoid situations which will necessarily lead to excitement and quarrel

and possible disappointment.

It is one of the surest tests of psychotherapeutic skill to discriminate

wisely whether one or the other of these features of general treatment

ought to be emphasized. They usually demand more insight than specific

forms of psychotherapy like hypnotic suggestions. These general efforts

are also much more directed against the disease itself where the

specific methods are merely directed against the symptoms. The

separation from disturbing surroundings, the reduction of engagements

and work, the complete rest, the suppression of artificial stimulants,

the enjoyment of art, of nature, of sport, the distractions of social

life, each might be in one case a decisive help and indifferent, perhaps

even harmful in another. All is a matter of choice and adjustment to the

particular needs in which all the personal factors of inherited

constitution, acquired adjustments, social surroundings, temperament,

and education, and the probable later development have to be most

tactfully weighed. Yet this general treatment may take and very often

ought to take the opposite direction, not towards rest but towards work,

not towards light distraction but towards serious effort, not towards

reduction of engagements but towards energetic regulation. We said that

it was an exaggeration to blame the external conditions of our life, the

technical manifoldness of our surroundings as the source of the

widespread nervousness. The mere complexity of the life, the rapidity of

the demands, the amount of intellectual effort is in itself not

dangerous and our time is not more pernicious than the past has been;

but it is perhaps no exaggeration to say that our time is by many of its

features more than the past tending towards an unsound inner attitude of

man.

Much of the present civilization leads the average man and woman to a

superficiality and inner hastiness which undermines sound mental life

much more than the external factors. We look with a condescending smile

at the old-fashioned periods in which the demands of authority and

discipline controlled the education of the child and after all the

education of the adult to his last days. We have substituted for it the

demand of freedom with all its blessings, but instead of the blessings

we too often get all its vices. A go-as-you-please method characterizes

our whole society from the kindergarten to the height of life. We

eulogize the principle of following the paths of own true interest and

mean by that too often paths of least resistance. Study becomes play,

the child learns a hundred things but does not learn the most important

one, to do his duty and to do it accurately and with submission to a

general purpose. The power of attention thus never becomes trained, the

energy to concentrate on that which is not interesting by its own

appeal is slowly lost, a flabby superficiality must set in which is

moved by nothing but the personal advantage and the zigzag impulses of

the chance surroundings. He who has never learned obedience can never

become his own master, and whoever is not his own master through all his

life lacks the mental soundness and mental balance which a harmonious

life demands. Flippancy and carelessness, haphazard interests and

recklessness must result, mediocrity wins the day, cheap aims pervade

the social life, hasty judgments, superficial emotions, trivial

problems, sensational excitements, and vulgar pleasures appeal to the

masses. Yellow papers and vaudeville shows--vaudeville shows on the

stage, in the courtroom, on the political platform, in the pulpit of the

church--are welcome, and of all the results, one is the most immediate,

the disorganization of the brain energies.

A sound mind is a well-organized mind in which a controlling idea is

able to inhibit the opposites and is in no danger of being overrun by

any chance intrusion into the mind. This power is the act of attention.

An attention which is trained and disciplined can hold its ideas against

chance impulses. An untrained attention is attracted by everything which

is loud and shining, big and amusing. The trouble is not with the rush

and hurry of the impressions which demand our attention; the trouble is

with our attention which seeks a quick change of new and ever new

impressions because it is not disciplined to hold firmly to one

important interest. We want the hundred short-cut superficial magazines

because we lack the energy to study one large volume; we want the

thousand engagements because we are not concentrated enough to devote

ourselves fully to one ideal task. The strong mind may find its sound

adjustment even without such training for concentrated attention through

obedience and discipline but the weak mind has to pay the penalty. For

not a few it will mean social disaster. Yet our society is sufficiently

adapted to this state so that it gives some good social chances to the

superficial too, and this not only to the rich, but to those on every

level. Only the nervous system cannot so easily be adjusted to the new

regime. The loose interplay of the brain cells without the serious

training of discipline must involve disorganization of the mind-brain

system which may count often most powerfully in those spheres in which

the mere needs of life are felt the least. There is only one great

remedy: discipline, training for concentrated attention, for a work in

submission of will to a steady purpose. And psychotherapeutic effort

will often demand such a training for work rather than a reduction of

work and rest.

The most alarming product of the neglect in training is found in many of

those retarded children who at fifteen show the intelligence of a boy of

eight. They are not imbeciles and do not belong in the psychiatric

domain; their development has simply been suspended by a mistaken

education. Of course no neglect would have led to it without a

constitutional, inherited weakness of the central nervous system, but

the weakness would never have led to the retardation if perhaps a

mistaken parental indulgence had not allowed a life without forced

effort and, therefore, without progress. Even such extreme cases may not

show on the surface. The boy may pass as all right if we meet him at a

ball; only his tutor knows the whole misery. Still less does the surface

view of many a grown-up neurasthenic alarm us who seems to live a

well-ordered, perhaps an enviable life, and yet who suffers the penalty

of a life without concentrated effort, really without anything to do in

spite of a thousand engagements. Moreover this lack of important

activity may often be forced on our patients. Married women without

children, without household responsibilities, and without interests of

their own and without strong nervous constitution will soon lose the

power of effort and their brain will succumb. A dreary monotony is

dangerous even for the worker; for the non-worker it may be ruinous.

Yet mere flippant excitement and superficial entertainment is nothing

but a cheap counterfeit of what is needed. Voluntary effort is needed,

and this is the field where the psychotherapist must put in his most

intelligent effort. There is no one for whom there is not a chance for

work in our social fabric. The prescription of work has not only to be

adjusted to the abilities, the knowledge, and social condition, but has

to be chosen in such a way that it is full of associations and

ultimately of joyful emotions. Useless work can never confer the

greatest benefits; mere physical exercises are therefore

psychophysically not as valuable as real sport while physically, of

course, the regulated exercises may be far superior to the haphazard

work in sport. To solve picture puzzles, even if they absorb the

attention for a week, can never have the same effect as a real interest

in a human puzzle. There is a chance for social work for every woman and

every man, work which can well be chosen in full adjustment to the

personal preference and likings. Not everybody is fit for charity work,

and those who are may be entirely unfitted for work in the interest of

the beautification of the town. Only it has to be work; mere

automobiling to charity places or talking in meetings on problems which

have not been studied will, of course, be merely another form of the

disorganizing superficiality. The hysterical lady on Fifth Avenue and

the psychasthenic old maid in the New England country town both simply

have to learn to do useful work with a concentrated effort and a high

purpose. From a long experience I have to confess that I have seen that

this unsentimental remedy is the safest and most important prescription

in the prescription book of the psychotherapist.

There is one more feature of general treatment which seems almost a

matter of course, and yet which is perhaps the most difficult to apply

because it cannot simply be prescribed: the sympathy of the

psychotherapist. The feelings with which an operation is performed or

drugs given do not determine success, but when we build up a mental

life, the feelings are a decisive factor. To be sure, we must not forget

that we have to deal here with a causal and not with a purposive point

of view. Our sympathy is therefore not in question in its moral value

but only as a cause of a desired effect. It is therefore not really our

sympathy which counts but the appearance of sympathy, the impression

which secures the belief of the patient that sympathy for him exists.

The physician who, although full of real sympathy, does not understand

how to express it and make it felt will thus be less successful than his

colleague who may at heart remain entirely indifferent but has a

skillful routine of going through the symptoms of sympathy. The

sympathetic vibration of the voice and skillful words and suggestive

movements may be all that is needed, but without some power of awakening

this feeling of personal relation, almost of intimacy, the wisest

psychotherapeutic treatment may remain ineffective. That reaches its

extreme in those frequent cases in which social conditions have brought

about an emotional isolation of the patient and have filled him with an

instinctive longing to break his mental loneliness, or in the still more

frequent cases where the patient's psychical sufferings are

misunderstood or ridiculed as mere fancies or misjudged as merely

imaginary evils. Again everything depends upon the experience and tact

of the physician. His sympathy may easily overdo the intention and

further reenforce the patient's feeling of misery or make him an

hypochondriac. It ought to be sympathy with authority and sympathy which

always at the same time shows the way to discipline. Under special

conditions it is even advisable to group patients with similar diseases

together and to give them strength through the natural mutual sympathy;

yet this too can be in question only where this community becomes a

starting point for common action and common effort, not for mere common

depression. In this way a certain psychical value must be acknowledged

for the social classes of tuberculosis as they have recently been

instituted.

From sympathy it is only one step to encouragement, which indeed is

effective only where sympathy or at least belief in sympathy exists. He

who builds up a new confidence in a happy future most easily brings to

the patient also that self-control and energy which is the greatest of

helping agencies. The physical and mental efforts of the physician are

alike deprived of their best efficiency if they are checked by worry and

fear that the developments of the disease will be disastrous. As soon as

new faith in life is given, and given even where a sincere prognosis

must be a sad one, a great and not seldom unexpected improvement is

secured. There is no doubt that the routine physician is doing by far

too little in these respects. His instinctive feeling that disease is a

causal process, and that he should therefore keep away from the

purposive attitude, leads him too easily to a dangerous narrowness. He

treats disease as if it were an isolated process and overlooks the

thousandfold connections in which the nervous system stands with the

patient's whole life experience in past and future. The physician is

thus too easily inclined to underestimate the good which may come in the

fight against disease from the ideas and emotions which form the

background of the mind of the patient. Even if the disease cannot be

vanquished, the mental disturbances which result from it, the pains and

discomforts, may be inhibited, as soon as hopes and joyful purposes gain

a dominating control of the mind. The nervous patient often needs a

larger hold upon life, while the routine prescriptions may too easily

reduce that hold by fixing the attention on the symptoms.

Here then is the right place for the moral appeal and the religious

stimulation. How psychotherapy is related to the church will interest us

later. At this moment morality and religion are for us not inspirations

but medicines. But from such a causal point of view, we should not

underestimate the manifold good which can come from the causal effect of

religious and ethical ideas. Those faith curists who bring mutual help

by impressing each other with the beauty and goodness of the world

really bring new strength to the wavering mind; and the most natural

channel for religious help remains, of course, the word of the minister

and the own prayer. Religion may work there causally in a double way.

The own personality is submerging into a larger all-embracing hold and

thus inhibits the small cares and troubles of merely personal origin.

The consciousness sinks into God, a mental process which reaches its

maximum in mysticism. The haphazard pains of the personality disappear

and are suppressed by the joy and glory of the whole. This submission of

will under a higher will and its inhibitory effect for suppression of

disturbing symptoms must be wonderfully reenforced by the attitude of

prayer. Even the physiological conditions of it, the clasping of the

hands, the kneeling, and monotonous sounds reenforce this inhibition of

the insignificant dissatisfactions. On the other hand, contact with the

greater will must open the whole reservoir of suppressed energies, and

this outbreak of hidden forces may work towards the regeneration of the

whole psychophysical system. Neglected functions of the brain become

released and give to the mind an energy and discipline and self-control

and mastery of difficulties which restitutes the whole equilibrium, and

with the equilibrium comes a new calmness and serenity which may react

almost miraculously on the entire nervous system and through it on the

whole organism and its metabolism.

Seen from a causal point of view, however, there is no miracle in it at

all. On the contrary, it is a natural psychophysical process which

demands careful supervision not to become dangerous. It is not the value

of the religion which determines the improvement, and it is not God who

makes the cure; or to speak less irreligiously, the physician ought to

say that if it is God who cures through the prayer, it is not less God

who cures in other cases through bromide and morphine, and on the other

side just as God often refuses to cure through the prescribed drugs of

the drug store, God not less often refuses to cure through prayer and

church influence. But the real standpoint of the physician will be to

consider both the drugs and the religious ideas merely as causal

agencies and to try to understand the conditions of their efficiency

and the limits which are set for them. From such a point of view, he

will certainly acknowledge that submission to a greater power is a

splendid effect of inhibition and at the same time a powerful effect for

the stimulation of unused energies; but he will recognize also that the

use of those silent energies is not without dangers.

Certainly nature has supplied us with a reservoir of normally unused

psychophysical strength, to which we may resort just as the tissues of

our body may nourish us for a few days when we are deprived of food, but

such supply, which in exceptional cases may become the last refuge,

cannot be used without a serious intrusion and interference with the

normal household of mind and body. To extract these lowest layers of

energies may mean for the psychophysical system a most exhausting effort

which may soon bring a reaction of physical and nervous weakness. The

chances are great that such a religious excitement, if it is really to

have a deep effect, may go over into a mystic fascination which leads to

hysteria or into an exhausting eruption of energies which ends in

neurasthenic after-effects. The immediate successes of the strong

religious influence on the weakened nervous system, especially on the

nervous system of a weak inherited constitution, are too often stage

effects which do not last. From a mere purposive point of view, they may

be complete successes. They may have turned the immoral man into a moral

man, the skeptic into a believer, but the physician cannot overlook

that the result may be a moral man with a crippled nervous system, a

believer with psychasthenic symptoms. From the point of view of the

church, there cannot be too much religion; from a therapeutic point of

view, religion works there like any other nervous remedy of which five

grains may help and fifty grains may be ruinous.

Moreover this power of inhibiting the little troubles of the body and of

bringing to work and effectiveness the deepest powers of the mind

belongs not less to any other important idea and overpowering purpose.

The soldier in battle does not feel the pain of his wound, and in an

emergency everybody develops powers of which he was not aware. The same

effect which religion produces may thus be secured by any other deep

interest: service for a great human cause, enthusiasm for a gigantic

plan, even the prospect of a great personal success. Thus in a

psychotherapeutic system, religion has only to take its place in line

with many other efforts to inhibit the feeling of misery and to

reenforce will and self-control by submission under a greater will. That

in the case of religion this submission, from an entirely different

purposive point of view, also has a moral and religious value, has in

itself no relation to the question of its therapeutic character. It

ought not to lead to any one-sided preference, inasmuch as religiously

indifferent agencies may be in the particular case a more reliable means

of improvement. Moreover the psychological symptoms are, after all, only

a fraction of the disease and very different bodily factors, digestion

and nutrition, heart and lungs and sexual organs may be most intimately

connected with the disturbance of the equilibrium. Medicine today no

longer believes that hysteria originates in the diseases of the uterus

or that neurasthenia necessarily results from insufficiencies of the

stomach, but it would be a graver mistake to believe that mental factors

alone decide the progress of the disease, however prominent the mental

symptoms may be in it.

From the physician's encouragement and the minister's influence towards

new faith in life, a short way leads to the influence of suggestion. It

is on the whole the way which leads from the general psychotherapeutic

treatment to the specific one directed against particular symptoms.

IX

THE SPECIAL METHODS OF PSYCHOTHERAPY

Of course there is no abrupt division between special and general

methods. Yet the different tendency is easily recognized, if we turn

only, for instance, from the mere sympathy and encouragement to the

method of reasoning with the patient about the origin of his special

complaint. Just now the medical profession moves along this line a great

deal. Of course no well-trained psychotherapist will make the blunder of

arguing with the insane. To dispute by argument with the paranoiac and

to try to convince him would not be only without success, but easily

irritating. This does not mean that the not less amateurish way ought to

be taken of accepting his delusions and appearing to be in full

agreement with him. A tactful middle way, preferably a disciplinary

ignoring attitude, ought to be taken. But it is entirely different with

the mental states of the psychasthenic. The mere statement and objective

proof that his obsession is based on an illusion would be ineffective.

He knows that himself, but he may take the disturbance as the beginning

of a brain disease, as a form of insanity, as a lasting damage which

lies entirely beyond his control. Now the physician explains to him how

it all came about. He shows to him that the symptoms resulted merely

from autosuggestion or are the after-effects of a suggestion from

without or of a forgotten emotional experience of the past. That is a

new idea to the patient and one which changes the aspect and may have an

inhibitory influence.

Of course, the patient does not accept the explanation at once. He feels

sure that he is not accessible to suggestion and that he has least of

all a tendency to autosuggestions, but the skillful psychotherapist will

find somewhere an opening for the entering wedge. He may develop to the

patient the modern theories of the origin of neurotic disturbances, all

with entire sincerity and yet all shaped in a way which gives to the

special case an especially harmless appearance. He may even enter into

experimental proof that the patient is really accessible to

autosuggestions. A very simple scheme for instance is to put some

interesting looking apparatus with a few metal rings on the fingers of

the subject and connect it with a battery and electric keys. The key is

then pushed down in view of the patient and he is to indicate the time

when and the place where he begins to feel the galvanic current. The

feeling will come up probably very soon in the one or the other finger,

and as soon as he feels sure that the sensation is present, the

physician can show him that there was no connection in the wires, that

the whole galvanic sensation was the result of suggestion.

Such a method demands patience and good will. The prejudices and

deeply-rooted hypochondriac ideas, foolish theories of the patient and

pessimistic emotions which have become habitual, must be removed piece

by piece until the central symptoms themselves can be undermined and

explored. It often takes hours of careful and fatiguing reasoning, in

which at any time the patient may suddenly slip back to his old ideas.

Yet if the explanatory arguments have once succeeded in making the

patient himself believe firmly that his whole trouble resulted from

suggestion only, the inhibitory effect of this idea may be an excellent

one. The only serious defect of the method is that it often does not

work. The credit which neurologists of today give to its effectiveness

seems to me much too high. Even slight neurasthenic and psychasthenic

disturbances remain too often in complete power when the patient is

fully convinced that they originated with an emotional excitement which

has long since lost its feeling value or that it resulted from a chance

suggestion picked out from indifferent surroundings. The patient knows

it and yet goes on suffering from the fruitless fight of his will

against the intruder. Where mere reasoning is entirely successful, I am

inclined to suspect that an element of suggestion has always been

superadded. The authority of the physician has created a state of

reenforced suggestibility in which the argument convinces, not by its

logic but by its impressiveness.