This element of suggestion is quite obvious when the argument takes the

form of persuasion, a psychotherapeutic method which has found its

independent development. Whoever seeks to persuade relies on the mental

fringe of his propositions. The idea is not to work by its own meaning

but by the manner of its presentation, by its impressiveness, by the

authority, by the warmth of the voice, by the sympathy which stands

behind it, by the attractiveness with which it is offered, by the

advantages which are in sight. Thus persuasion relies on personal powers

to secure conviction where the logic of the argument is insufficient to

overcome contradictions. But just for that reason persuasion is after

all only a special kind of suggestion.

Other methods work on the same basis. Prominent among them is the

psychotherapeutic effect of a formal assurance. The psychotherapist

assures the patient that he will sleep the next night or that the pain

will disappear or that he will be able to walk with such firmness that

the counter-idea is undermined. It depends on the type of patient

whether such suggestions of belief work better when it is assured with

an air of condescension, spoken with an authority which simply ignores

every possible contradiction, or with an air of sympathy and hope.

Experience shows that it is favorable to connect such assurance with the

entrance of a definite signal. "You will sleep to-night when the clock

strikes ten," "The pain will disappear when you enter the door of your

house," or perhaps, "Read this letter three times quietly in a low

voice, and at the end of the third reading your fear will suddenly

stop." Psychological insight will further decide whether it is wiser in

the particular case to assure the patient of the resulting effect or

rather of the power to bring about the effect. With some people, it

works better to insist that the result will happen, with others to

promise that they themselves can secure it; in the one case they feel

themselves as passive instruments, in the other as real actors. To some

hysterics, it is better to say: "You will walk," to others, "You can

walk."

This belief in the future entrance of a change frequently demands an

artificial reenforcement. There belongs first the application of

external factors which awaken in the background of the mind the

supporting idea that something has been changed in the whole situation

or that some helpful influence has made the improvement possible.

Medicines of colored and flavored water, applications of electric

instruments without currents, in extreme cases even the claptrap of a

sham operation with a slight cut in the skin, may touch those brain

cells which words alone cannot reach with sufficient energy and may thus

secure the desired psychophysical effect. The patient who by merely

mental inhibition has lost his voice for weeks may get it back as soon

as the physician has looked into his larynx with a mirror and has held

an electrode without battery connection on the throat. Another way of

helping by make-believe methods is to give the impression that a decided

improvement is noticeable. The uneducated patient believes it easily

when the physician at his very entrance into the office expresses his

surprise about the external symptoms of a change for the better, perhaps

seen in the color of the skin or the shading of the iris in the eye and

reaffirmed by some pseudotests of the muscle reflexes. All that is not

very edifying and the decent physician, who justly feels somewhat

dragged down to the level of the quack in applying such means

frequently, will abstain from them wherever possible. He knows that in

the long run, even the psychasthenics are best treated with frankness

and sincerity and he will therefore only in exceptional cases resort to

such short-cut treatment by making believe. Yet that it is sometimes

almost the only way to help the patient cannot be denied.

A neater way to secure the sufferer's belief in the possibility of a

cure is by securing the desired effect at least once through little

devices. As soon as it is once reached, the patient knows that it can be

reached and this knowledge works as a suggestion. The hysteric who

cannot speak when he thinks of his words, or who cannot walk when he

thinks of his legs, may by the skillful physician be brought to a few

words or steps before he himself is aware of it by completely turning

his attention to something else and producing the stimulus toward the

movement in a reflex-like way. Still more successful is the effort to

resolve the inhibited action into its component parts and to show to the

patient who cannot perform the action as a whole that he can go through

the parts of it after all. As soon as he has passed through a few times,

a new tactual-visual image of the whole complex is secured for his

consciousness and this image works then as a new cue for the entire

voluntary action, overcoming the associated counter-idea.

Another excellent way to overpower a troublesome idea or impulse or

emotion is to reenforce the opposite idea by breaking open the paths for

its motor expression. The effort to hold the counter-idea before

consciousness may be unsuccessful so long as it is only an idea which

tries in vain to produce any motor effect; but if the action itself has

been repeatedly gone through, the idea will find it easier to settle and

it becomes vivid in proportion to the openness of the channels of motor

discharge. This holds true even for emotional states. A certain word

perhaps picked up by the psychasthenic in a particular experience may

produce whenever it is seen a shock and a depressing emotion. If we ask

the patient to go artificially through the movements which express joy

and hilarity, make him intentionally grin and open wide the eyes and

expand the arms and inhale deeply, and after training this movement

complex of joyful expression, speak the dreaded word at the height of

the movement a new feeling combination clusters about the sound and may

overcome the antagonism. Sometimes you will give to the desirable idea

sufficient strength by mere repetition, sometimes you force the

attention better by unusual accentuation, connecting the suggestion with

a kind of shock. From here it is only one step to the suggestion in the

form of a sharp order which breaks down the resistance just by its

suddenness and loudness, supported perhaps by a quick arm movement which

gives a cue for imitative reflexes. In the case of a youngster even a

slap may add to the nervous shock; also a sudden clapping of the hands

may favor effectiveness of the suggestive order.

Often it is wise to give the suggestion, not from without but to

prescribe it in the form of autosuggestions. For instance, advise the

patient not only to have the good will and intention of suppressing a

certain fixed idea or by producing a certain inhibited impulse but to

speak to himself in an audible voice, every morning and every evening,

saying that he will overcome it now. Here, too, the autosuggestion may

become effective by the frequency of the repetition or by the urgency of

the expression or by the accompanying motor reactions. As a matter of

course any associations which reenforce the idea may be used for

assistance. Especially near-lying is the appeal to the man's conscience,

but just such associations which touch the idea of the own personality

and its deepest layers of feelings are always risky. They may touch and

stir up old memories which interfere with success or they may awaken a

feeling of contrast between duty and fulfillment which may disturb the

whole equilibrium. If the physician knows that the good-will of the

patient is insufficient to overcome the pathological disturbance, he

ought not to make him feel ashamed or guilty, and that not only for

moral reasons but also for strictly psychotherapeutic reasons.

In certain easily recognizable cases, it is essential to give the

suggestion with avoidance of any emphasis, only as a hint, passing as if

the suggestion almost slipped from the tongue of the doctor without his

real intention. The hysteric who is resisting the suggestion which is

intentionally given to her is sometimes surprisingly trapped by a

half-hidden suggestion, perhaps not spoken to the patient herself at all

but spoken in a low voice to a colleague in the room. Sometimes we have

to trick those who suffer by "negativism," that is by an obstinacy which

exaggerates that of the ordinary stubborn man. In such cases the

suggestion not to perform an action works best if we want the action

performed. There is hardly an end to the list of such methods for

bringing beliefs and attitudes with suggestive power to the mind of the

sufferer. Definitely to describe the conditions under which the one or

the other form ought to be applied would be no wiser than to tell a

statesman what steps are to be taken in every possible diplomatic

situation. The instinctive selection of the right means among the many

possible ones characterizes both the true statesman and the true doctor.

So far we have spoken only about the character of the suggestion,

presupposing that the receiver remains in his natural state. This

presupposition is certainly often entirely correct, but as far as it is

correct, the results of the suggestion vary greatly with the different

individuals. On the whole, we might say that such suggestions given to

the subject in his normal state are effective only when the subject is

by nature a suggestible being. In considering the psychology of

suggestion, we recognized at once that the degree of natural

suggestibility varies excessively. The non-suggestible mind is only to a

slight degree influenced by any of these proposed forms of suggestion as

long as the suggestibility itself is not heightened. To be sure, the

question whether the person is suggestible by nature or not cannot be

settled simply by his own impression. Many of the most suggestible

persons believe firmly that they are superior to any suggestive

influence.

To bring suggestions to greater effectiveness and to exert their

influence practically upon every possible subject, we have thus not only

to give suggestions or to advise autosuggestion but in both cases we

have to secure, especially for the naturally less suggestible patients,

a somewhat heightened suggestibility. Yet no one can overlook that some

of the methods which we described have in themselves the tendency to

reenforce the mental suggestibility. Those methods of emphasis and

order, of assurance and make-believe, of practical training and of

awakening counter-ideas, of persuasion and even of reasoning, wherever

they are in a high degree successful probably always gain a certain part

of their success by the increased suggestibility which the whole

situation brings with it.

This reenforcement of the psychophysical readiness for suggestions

results indeed quite directly both from expectation of the unknown and

of the half-way mysterious, and from the confidence in the doctor. Of

course it can work very differently. The expectation can upset the

nervous system and produce unrest instead of suggestibility and, instead

of confidence, the patient may feel that discouraging diffidence which

settles easily upon those who have tried one fashionable physician after

another. But where there is real confidence, based perhaps on the fame

of the doctor and on the reports of his powerful achievements, there the

conditions for effective suggestions are greatly strengthened. Still

better is it if this confidence in the man is combined with a sincere

hope for recovery. To lie down on a lounge on which hundreds have been

cured fascinates the imagination sufficiently to give to every

suggestion a much better chance to overcome the counter-idea. The

expectation that something wonderful will happen can even produce an

almost hypnoid state. The effect will be the greater, the less the

barriers of systematic knowledge hinder the entrance of suggested ideas.

The uneducated will on the whole offer less resistance to suggestions,

just as superstitions find the freest play in the minds of the

untrained. It is not by chance that the earlier epidemics of

pathological suggestibility have on the whole disappeared with the

better popular education. In a similar way work fatigue and exhaustion.

The resistance has grown weaker, the suggested idea goes automatically

into activity.

Skillful artificial means can still surpass the effect of these natural

conditions. Here belongs everything which accentuates the authority and

dignity of the originator of the suggestion. The psychologically trained

physician has no difficulty in heightening the effect by simple

surprises, if he cares for such tricks. If the patient for whom a mental

treatment is recognized as necessary shows himself too skeptical to

submit to the powers of the psychotherapist, such captivation of his

belief can easily be secured. Let the man perhaps fixate a penny on the

table with his right eye, while the left is closed and you show him that

you can make another penny suddenly disappear when you move it a certain

distance to the right and appear again when you move it still further.

As the man has never heard of the blind spot in the retina, he accredits

you with a special power. Many similar psychological illusions can well

be used to prepare the mind for unsuspected healing powers.

Still stronger is the effect of personal contact. The psychophysiology

of love indicates the most complex influence which contact sensations

have on the whole nervous system and especially on the vasomotor

apparatus of the body. Probably such vasomotor effect enters in,

changing the blood circulation in the brain, when a personal contact

between the transmitter and receiver of the suggestion is brought about.

If the physician's hand rests quietly on the forehead of the patient who

lies with closed eyes, or if he holds for a long while the hand of the

patient, he may secure a nervous repose and submission which gives to

the suggestions the most fertile soil. Needless to say that here again

everything depends upon the accessories. An unsympathetic doctor may be

entirely powerless where his neighbor has complete success. Neither a

lifeless hand nor an agitating one will bring the desired repose,

neither a cold nor a rough one. There must be strength and energy and

even discipline, and yet sympathy in the pressure of the fingers. Again

a psychologically different effect and yet one often to be preferred

results from mild stroking movements, the stroke always to be repeated

in the same direction, never up and down. The slow change in the

position of the tactual sensations evidently produces a rather strong

influence on the equilibrium of nervous impulses, and here again

vasomotor reflexes seem to arise easily. Another variety of such bodily

influences is given by artificial changes of the positions, for instance

by bending the head of the subject backward while the eyes are closed.

It may be that a certain lack of balance sets in in which the

self-equilibrium is disturbed and an external influence can thus more

easily get control of the psychophysical system. Again a certain

monotony of speaking may easily add to the increase of the

suggestibility.

Everyone knows that another most fruitful cause of this change is any

mystic inspiration, any emotion in which the individual feels himself in

contact with something higher or larger or stronger. Of course, the

church can secure this effect easily, and here again the maximum will be

reached if a bodily contact with the symbol of religious exaltation can

be established. The patient who can touch the relics of the saints or

bathe in the waters of Lourdes or at least feel on his forehead the hand

of the minister, is wrought up to a state of suggestibility which makes

suggestions easily effective. The objective value of religion again has

nothing to do with it, as exactly the same effect can result from the

most barbarous superstition. The amulets of a gypsy might secure the

same resetting of the psychophysical system which the most sacred

symbols awaken, and even many an educated person is unable to cross the

threshold of a palmist or an astrologist, or to attend the performance

of a spiritist, or to sit down with a purchasable trance medium without

feeling an uncanny mental state which is objectively characterized by an

increased suggestibility. But finally, the same effect sets in when the

symbols of other emotional spheres are applied, perhaps for the

patriotic soldier the flag of his country.

All the states of increased suggestibility which we have characterized

so far still remain within the limit of normal wakefulness. We may turn

now to the methods of the psychotherapist which produce in the interest

of the suggestions an artificial state. However we have no right

superficially to claim that the effectiveness of the suggestions is

always greater in such unnatural states. On the contrary, we know that

sometimes well applied suggestions work on wide-awake persons with

increased suggestibility more strongly than on hypnotized subjects. Here

even the instinct of the experienced physician may easily go astray, and

it may need practical tests to find out which way will be the most

accessible to the particular case. Often a certain role belongs even to

natural sleep. It cannot be denied that some people can be influenced to

some degree by words spoken to them during sleep. Most adults either

wake up or show no signs of influence beyond effects on their dreams.

But some absorb especially whispered words in such a way that their

power becomes evident after the waking of the sleeper. Much more is this

true of children. A suggestion to give up vicious habits, perhaps in the

sexual sphere, or to speak fluently and no longer stammer may thus be

beneficial. Yet the danger of this method is not small and extensive use

of it is certainly not advisable. The more easily it can be carried into

every bedchamber and can thus give to every mother and nurse the tools

of a rather powerful therapy, the more a danger signal ought to be

displayed. Interference with the natural sleep by outer influences

creates abnormal conditions which cannot be removed at will. The chances

are great that many unintended bad effects slip in and that not a few

hysterias may be created by a method at the first glance so startling.

Much less objectionable is it to make use of the effect of that period

of half-sleep which precedes the natural sleep, and which is for many a

period of increased suggestibility for autosuggestions. A resolution or

the formulation of a belief which would be ineffective in a wide-awake

state seems to get an accentuated effect on the mind, if it is

repeatedly expressed in this transitional state. The psychasthenic who

in such a half-dozing stage assures himself that he will no longer be

afraid of going over a bridge or hearing a thunderstorm or will feel a

disgust for whiskey or will have the energy for work, has a certain

chance that such autosuggestions become reality the next morning. With

many others there seems no effect to be obtained and not a few seem

unable to catch the right moment. As soon as they begin to speak they

become wide awake or fall asleep before they talk.

Incomparably more value belongs to the artificial sleep, the mesmeric

state of earlier days, the hypnotism of our time. We have discussed its

theory and recognized that an abnormally increased suggestibility is

indeed its chief feature. We know hypnotism in most various degrees; the

lowest can be reached practically by everyone, the highest by rather

few. It is almost arbitrary to decide where those waking states with

high tension of suggestibility end and the hypnotic states begin, and

not less arbitrary to call the higher degrees only hypnotism and to

designate the lower degrees as hypnoid states. If we do it, we certainly

should acknowledge from the start that the hypnoid states are for

therapeutic purposes not a bit less important than the full hypnotic

states. Certainly the hypnoid states do not allow complex hallucinations

and absurd post-hypnotic actions, but they offer excellent starting

points for the removal of light obsessions and phobias and for the

reenforcement of desirable impulses, volitions, and emotions. Many

persons cannot under any circumstances be brought beyond such a hypnoid

degree. The physician who has not theoretical experiments but practical

success in view ought therefore never to trouble himself with the

inquiry exactly which degree has been reached. This advice is given

because nothing interferes with the progress of hypnotic influence so

badly as the constant testing. It must naturally often lead to a point

where the subject finds that he can very well still do what the

hypnotizer told him not to do. If the doctor assures him that he can no

longer move his arm and the patient is yet able to move it, the doctor

secures the very superfluous knowledge that this special degree of

suggestibility has not been reached, but the patient is sliding backward

and the lower degree which actually had been reached will be less

accessible later. The physician might rather resort to the opposite

course and assure the patient, even after the first treatment which

might have been a slight success, that he saw from definite symptoms

that hypnosis had set in. That will greatly smooth the way for real

hypnotic effects the next time.

The best method of hypnotizing is the one which relies essentially on

the spoken word, awakening through speech the idea of the approach of

sleep. If the hypnotizer assures the subject in monotonous words that a

feeling of fatigue is setting in, that he is feeling a tiredness

creeping over his shoulders and arms and legs, that his memories are

fading away and that he is now hypnotized, for not a few all is done

that is needed. The hypnotic state will come and will hold until the

verbal suggestion takes it off again. Perhaps the hypnotizer says that

he will count three and at three the subject is to open his eyes and

feel perfectly comfortable. It is wise to tell the patient beforehand

that he will not lose consciousness and that he will remember afterward

whatever happens as many people believe that loss of memory belongs to

the hypnotic state, and that they were not hypnotized if they can

remember what happened. Such a skeptical after-attitude can seriously

interfere with the success of the treatment.

Yet in most cases, it will be safer not to rely on words only but to

supplement them by manipulations which all converge towards the effect

of increasing the suggestibility and thus of overcoming the resistance

to the suggestions introduced. It is well known that for this purpose it

is advisable to begin the influence with some slight fatiguing

stimulations. The effect is most easily reached when the patient fixates

perhaps a shining button held over his eyes or listens to monotonous

sounds. A particularly strong effect belongs again to very slight touch

stimuli. If the subject with his eyes closed is touched perhaps by two

pencils at various and unexpected points of the face and hands, a

skillful playing on his tactual senses soon produces a half-dozing state

of hypnoid character. In the same group belong those so-called passes

which evidently have a reflex influence in the blood-vessel system. It

is advisable to combine the various elements in such a way that at first

physical stimuli upon eye or skin produce an over-suggestible state and

that only as soon as this state is reached the verbal suggestion sets

in, perhaps with the words, "I shall hypnotize you now." Under such

conditions every subject may soon be brought to that degree of

hypnotization which is accessible to him. Yet more than one treatment is

usually necessary for the higher degrees. Much less importance for

therapeutic purposes belongs to that hypnoid state which is reached

without the idea of sleep where the subject comes with open eyes into a

kind of fascination, produced perhaps by a sudden flash of light or by

the firm eye of the hypnotizer. It is a state which can lead to a strong

submission of will and which has its legal importance. Therapeutically

it can hardly secure an effect which cannot better be secured through

the real sleeplike hypnotism. Under certain conditions, chemical

substances may well prepare for the hypnotic treatment, for instance

bromides or alcohol. Others rely on the suggestive effect of flavored

water. But all that is unwise. The confidence of the patient is the best

preparation for the securing of the helpful degree of hypnotism.

Of course only a small part of the therapeutic usefulness is secured

during the hypnotic state itself. A pain may be removed, sleep be

secured, an idea be inhibited, a movement be reenforced in cases where

non-hypnotic suggestions would have found insurmountable obstacles.

During the hypnosis we may also open the storehouse of memory and bring

to light the ideas which disturbed the equilibrium of the suffering

mind. Further in those most complex hysteric cases of dissociated

personality, new memory connections may be formed during the hypnosis

by which a synthesis of the double or triple personalities into the old

one may be secured. Yet the general effect which the physician has to

hope for from hypnotic treatment is the post-hypnotic one. Not what

happens during the hypnosis but what the suggestion will produce after

hypnosis is essential to him. The fixed idea is to disappear forever,

the paralyzed limb is under control, the desire for morphine and cocaine

is gone for all future time, the perverse longing is annihilated, the

old energy is to remain again for all time. It is the post-hypnotic

after-effectiveness which gives to the hypnoid and to the hypnotic

states their importance for the treatment of the most exasperating

symptoms. To be sure, the treatment often must be a prolonged one. A man

who for years has used thirty grains of morphine a day cannot be rid of

the desire after two or three hypnotic sittings. In such a case the

treatment may cover three or four months, if it is to be of lasting

value and without any damage during the treatment.

Still we are not at the end of the psychotherapeutic methods and we may

turn to a fascinating group of curative efforts which has especially

come to the foreground in recent years. We mentioned before that

mischief cannot seldom be traced back to earlier experiences with a

strong unpleasurable feeling. In certain cases, the subject remembers

such particular experiences as the beginning of his discomfort; in

others, especially those of hysteric character, the starting point may

have long been forgotten, and yet that early impression evidently left

traces in the brain which produce disturbances in conscious life. The

psychotherapist nowadays calls these groups of traces "complexes." We

recognized clearly that there is no reason to refer such forgotten

remainders of the past to any subconscious mind; they are physical

after-effects which keep their influence over the equilibrium of the

psychophysical system. Now modern psychotherapy finds that the entire

disturbances which arise from such emotional disagreeable experiences,

forgotten or not forgotten, can often be removed by psychical means. Two

ways in particular seem open. As soon as the idea is fully brought back

to consciousness again, the patient must be made to express the primary

emotion with full intensity. Subtle analysis has repeatedly shown that

many of the gravest hysteric symptoms result from such a suppression of

emotions at the beginning and disappear as soon as the primary

experience comes to its right motor discharge and gains its normal

outlet in action. The whole irritation becomes eliminated, the emotion

is relieved from suppression and the source of the cortical uproar is

removed forever.

Practically still more important seems the other case which refers alike

to hysterics and psychasthenics and which is applicable for the

forgotten experience not less than for the well-remembered ones. This

second way demands that the psychotherapist bring this primary

experience strongly to consciousness and then by a new training link it

with new and more desirable associations and reactions. The disturbing

idea is thus not to be discharged but to be sidetracked so that in

future it leads to harmless results. The new setting works towards an

entirely new equilibrium. What was a starting point for abnormal fears

now becomes an indifferent object of interest and all its evil

consequences are cut off. It may be acknowledged that the full

elaboration of these methods still belongs to the future. Both methods,

the discharging, or the so-called cathartic one, and the side-tracking

method evidently demand the discovery of the starting point in the

service of the therapy and here again several methods are at the

disposal of the psychologist.

A promising way to this end is the inexhaustible association test which

we mentioned when we discussed the contributions of the psychological

laboratory to the medical diagnosis. A series of short words are spoken

to the patient and, as soon as he hears one, he is to pronounce as

quickly as possible the first word which comes to his mind. If we use

fifty words, we should be able to learn something as to the inner states

of the man and as to the working of his mind, if we analyze carefully

his particular choices. But two further conditions ought to be

fulfilled. The time of the association ought to be measured. Of course

there will be wide differences. A word which is often in a certain

connection will quickly bring the habitual association. Abstract words

will call forth their associations more slowly than concrete words,

familiar words more rapidly than unfamiliar words. To measure such

association time with fullest accuracy, as it is necessary for the

purpose of scientific investigations, delicate electrical instruments

are needed that indicate thousandths parts of a second. For the purpose

of the practical physician such accuracy would be superfluous. His

examination will be perfectly successful if it is carefully done with a

stop-watch which shows the fifth part of a second, like those which are

used at races. He speaks a word, presses at the same time the button of

the watch, and presses the stopper when he sees the lips of the patient

moving. He is thus able to examine not only the involuntary choice of

association but also the time of every associative process. But a second

condition ought also to be fulfilled. After some indifferent words,

others ought to be mixed into the series which touch in a tentative way

on various spheres corresponding to the possible suspicions. The groups

to which the hidden thoughts of psychasthenics, for instance, belong are

not many. As soon as our series of words strikes such a group, the

reaction of the mind may be discriminated. The effect may be a general

perturbation resulting either in an unusual delay of the fitting

association or in an effort to cover the sore spot by an unfitting

association. Sometimes the dangerous association may rush forward even

with unusual rapidity but, as soon as it is uttered, it gives a shock to

the mental system, brings the whole associative process into disorder,

and the result is that the next following associations are abnormally

delayed. The skilled psychologist will quickly take such a change as a

cue for the selection of the later words in his series. Of course, he

will at first return to neutral words, but as soon as he has found a

danger spot, he will approach it from various sides, perhaps in every

fourth or fifth word, and may then find out which particular experiences

are disquieting the patient. Words like women or money or career or

family or disease are often sufficient to get the first inkling of a

mental story.

With less diagnostic elegance we sometimes reach the same end by taking

careful records of pulse and breathing and involuntary movements during

an apparently harmless conversation. The instruments at the disposal of

the psychologist are those familiar to every psychological laboratory:

the pneumograph, which registers the movements of respiration; the

sphygmograph, which writes the pulsation of the artery in the wrist; the

automatograph, or other instruments, which register the slight

unintentional movements of the arm. If the examiner is skillful, he will

not fail to discover the changes in breathing and pulse and reaction as

soon as the painful groups of ideas are approached. More of theoretic

interest and too cumbersome for practical diagnosis is the unfailing

galvanic reaction from the skin in which the glands change their

activity and their resistance to the galvanic current under the

influence of hidden emotions. Yet all these methods, with exception of

the last, are essentially useful only if the starting experience is

still accessible to the memory of the patient. He may be unaware that it

had anything to do with his nervous symptoms but he recognizes the

experience still as soon as his attention is directed towards it. The

psychologically more interesting but probably more exceptional situation

is the one in which it is not only forgotten but cannot be recognized

when it is brought to consciousness. The shortest way to get hold of

such past impressions is the hypnotic one. The hypnotic state sharpens

the memory and experiences of early childhood or apparently

insignificant experiences of later life may be brought back when they

would have been inaccessible to any intentional effort of the attention.

Even still more surprising is the success if the association is left to

a dreamy play of ideas suggested perhaps by gazing into a crystal ball

or by a meaningless talking. Perhaps the patient lies with closed eyes

on the couch while the physician holds his hand. A few words are given

to him as a starting point and then he is thoughtlessly to pronounce

whatever comes to his mind, not only unfinished sentences but loose

phrases, single words, apparently without meaning and slowly ideas arise

which betray the original intrusion. At last memories and lost emotions

come again to the surface, and the watchful psychotherapist may discover

the complex, which is then to be removed by discharge or by

side-tracking. This is the so-called psychoanalytic method.

Finally the psychotherapist may go still one step further. After all it

often seems inexplainable that just this or that emotional experience

made such a deep and lasting impression while a thousand other

experiences passed by without leaving any mischievous after-effect. It

seems that indeed the conditions are still more complicated. That

emotional disturbance operated dangerously perhaps only because it

itself appealed to a suppressed desire and this seems to hold true

especially for suppressed emotions of the sexual sphere. The desire for

gratification in normal or abnormal channels was perhaps attached by the

mind to some group of objects. It was completely suppressed but it left

an abnormal tension in the central system. If now a chance experience

touches on this group of ideas, there results an explosive reaction; and

movements, convulsions, spasms, obsessions, and fears set in which get

their particular character not through the secondary intrusion but from

the primary desire. To discharge that intrusion leads therefore only to

the elimination of those symptoms which resulted from it, but the

primary disturbance goes on and any new chance intrusion will produce

new explosions. The psychotherapist should therefore go deeper and

relieve the mind from those primary desires which may belong to early

youth and which are entirely forgotten. Even the method of automatic

writing may here sometimes lead to an unveiling of those deepest layers

of suppressed desires. In the same way a careful, subtle analysis of

dreams may support the search for the hidden source of interference.

We have spoken of the technical methods of the psychotherapist. It would

be short-sighted to ignore the great manifoldness of secondary methods

which he shares with the ordinary intercourse between man and man, the

methods which the teacher uses in the schoolroom, which the parents use

in the nursery, which the neighbor uses with his neighbor, methods which

build up the mind, methods which train the mind, methods which reenforce

good habits and suppress unwholesome ones, methods which stimulate sound

emotions and inhibit a quarrelsome temper, methods which indeed are not

less important in the psychiatric clinic and in the hospital than in our

daily life, and which certainly have central importance in that

borderland region which is the particular working field of the

psychotherapist.

X

THE MENTAL SYMPTOMS

We have discussed both the psychological theory and the practical work

of psychotherapy in a systematic order without any reference to personal

chance experience. After studying the fundamental principles, we have

sketched the whole field of disturbances in which psychotherapeutic

influence might be possible and all the methods available. It seems

natural that our next step should be an illustrating of such work by a

number of typical cases. Here it seems advisable to leave the track of

an objective system and to turn to the record of personal observation.

As this is not a handbook for the physician, dealing with the special

forms of disease, we emphasized before that we avoid even any attempt in

such a direction because it would have to introduce not only the

questions of diagnosis, but above all the highly important questions of

treatment by physical agencies. We saw that for us nothing else can be

desirable, but to show the way in which the various symptoms which

suggest mental treatment occur, and how they yield to the psychical

methods. We had also agreed beforehand that for a first survey we might

separate the mental from the bodily symptoms and group the mental ones

with reference to the predominance of ideational, emotional, and

volitional factors. And finally it may be said that we abstain from

everything which is exceptional or even unusual, and confine ourselves

to the routine observations with which the psychotherapist comes in

contact every day and the simplest country physician surely every week.

Thus I turn from systematic objectivity to my unsystematic reminiscences

of many years. Of course, they abound with eccentric abnormities and

startling phenomena. As I have devoted myself to psychotherapeutics,

always and only from scientific interest, as a part of my laboratory

studies and therefore have refused to spend any time on cases which

offered no special psychological interest to me, the striking and

sensational cases have prevailed in my practice even to an unusual

degree. Yet they are unessential for our purposes here, the more as

their interest lies mostly in the complex structure of the mental state

while the curative features are in the background. Our purpose of

demonstrating practical cases as they occur in every village, and as

they ought to be understood and treated by every doctor, thus rules out

just those experiences which would be prominent in a theoretical study

of abnormal psychology. We want to select only simple commonplace cases.

Only those who have not learned to see are unaware that such cases are

everywhere about them.

As a matter of course, I also leave out everything which refers to

insanity, that is, every mental disturbance which lies essentially

outside of the domain of psychotherapy. The helpful influence which

psychical factors can exert in the asylums for the insane is, as we

emphasized, entirely secondary. The psychotherapeutic methods in the

narrower sense of the word are in the present state of our knowledge

ineffective in the insane asylum. I should also be unable to speak of

laboratory experience with insanity, as I insist on sanitarium treatment

in every such case. The question of how to differentiate the diagnosis

of insanity from that of the other mental abnormities is not our

question at this moment. I select the few illustrations which seem to me

desirable for the purpose of making more concrete our abstract

discussion of methods, essentially from the class of neurasthenics,

psychasthenics, hysterics, and so on.

In all these reports, I shall confine the account to the few points

which are to illustrate the psychical factors, thus abstaining entirely

from the further details which any medical history of the cases would

demand and from all results of further examination and other

particulars. As a matter of course, I exclude the possibility of

identifying the patient. I may start with a typical case of obsessing

ideas of simplest character and with simple routine treatment

illustrating the emphasis on antagonistic ideas.

A man of mature age, well educated, well built and in every respect

in good health, without nervous history and without other nervous

symptoms, suffered vehemently by the persistent recurrence of a

visual image which entirely absorbed his attention. He knew

exactly the development of his trouble. A woman acquaintance of his

had committed suicide by poisoning herself. He knew her slightly

and the emotion of personal loss played hardly any role in the

case. But he had met her at a gay dinner a short time before her

death. The news of the suicide came to him when he was overtired

from work. The idea of the contrast between seeing his friend

partaking of the dinner and imagining her drinking the poison gave

him a strong shock. There was hardly any grief mixed in. He

remembers that he shivered at the thought of the contrast, and in

that moment the visual image of the woman raising a glass of poison

to her mouth flashed into his mind and thus became almost a part of

the shock. From that time on, the memory image of this scene

returned more and more frequently. At first it associated itself

with any chance mentioning of death or suicide and to a very slight

degree with the idea of a meal. More and more any element of a meal

and of social life, the word soup or meat, the word gown or dance,

brought up at once the picture of the woman, which had in the

meantime lost every element of personal relation. Any sad thought

of her ending had faded away. It remained merely a troublesome

impression. The man fought against it by trying to suppress the

idea but the more he fought against it, the more insistently it

rushed forward through new and ever new association paths. Any

advertisement in the newspaper referring to food, anything in a

shop window referring to ladies' dresses, any household utensils

related to a meal, and especially the meals themselves, forced the

visual image into the centre and captured the attention to such a

degree that a confusing distraction from the real surroundings

resulted. The struggle against the idea became more and more

exasperating, made life a torture, almost suggested despair, even

faint thoughts of suicide, and especially a growing fear that it

was a symptom of the beginning of insanity.

When he came to me, a number of physical cures, especially bromides

and electricity, had been tried in vain by the physician. Some

weeks in the country had not changed the distress. He came to me

with the direct request as a last resort to try hypnotic treatment.

I found in spite of the fact that he and his physician had

constantly spoken of visual hallucinations that the visual image

had no hallucinatory character at all, that is, he never believed

that he saw the image of that woman as if it were actually present,

he never took the product of his imagination for reality, nor had

it the vividness and character of reality. It was hardly more vivid

than any landscape which he tried to remember, only that it

controlled the interplay of ideas in such a persistent way. I found

that he was a strong visualizer and easily suggestible. I told him

beforehand that I should hypnotize him only to a slight degree,

that he would not lose consciousness, that he would remember

everything which I told him. Then I asked him to lie down and had

him gaze on a crystal only for half a minute, then close the eyes.

I asked him to relax and to think of sleep. With the two blunt

points of a compass, I touched his two cheeks at corresponding

places, then his forehead. And now I told him that I would begin

with the hypnotic influence. I put my hand on his forehead and

spoke to him in a monotonous way, saying that he felt a fatigue in

his shoulders, and in his arms, creeping over his whole body and

assured him that he was now fully hypnotized. To what degree he

really was hypnotized cannot be said as no effort was made to test

it by any experiments, thus avoiding any possible reaction against

the feeling of submission. Expression and breathing indicated a

slight hypnoid state. Then I removed my hand and spoke to him in a

warm and assuring way.

I told him that in future he would give his full attention to his

meal, and not give the slightest attention to any image of his

friend. If he should think of the friend the memory would appear

indifferent, he would not even notice the image and would give his

whole mind to the objects with which he was engaged. In the same

way, when he should be reading newspapers or looking in

shopwindows, his whole attention would belong to that which he

really perceived. Any passing inner image would be ignored. Then I

awoke him from his sleep. He was unwilling to believe that he had

been in hypnosis at all. I told him that the effect would prove it

and in his fully wakeful state I explained to him why there was not

the slightest fear of insanity justified, that it was a

psychasthenic state resulting from fatigue and shock and from a

wrong attitude of his attention during the past months, and then I

asked him to return the next day. Intentionally I had not given the

suggestion that the image would disappear. I could not expect it

would disappear entirely after a first treatment and even a faint

appearance of it would have at once fascinated the attention and

brought about the whole disturbance of the equilibrium which might

become habitual. Instead of it I gave the impulse to the

counter-idea, that is, I reenforced the attention towards that

which he really saw around him and thus withdrew the attention from

the rival image in the mind. The success was complete. He came the

next day in a much happier frame of mind, reporting that he still

had seen the image of the woman every few minutes, especially

strongly at the breakfast table, but it had no longer troubled him.

It was more in the background of consciousness, sometimes it

appeared transparent, it no longer held his attention, and he felt

free to give his full attention to the actual surroundings.

On that basis I hypnotized him the second day and he had hardly

heard me saying that he ought to try to sleep when he was evidently

in a much deeper hypnotic state than the first time. Again I

suggested only the opposite attitude, the positive turning to the

surroundings and the complete neglect and indifference for the

possible memory image. This time the effect was still stronger. On

the third day he reported that he still saw the image but he no

longer minded it, as it was like a veil through which he looked at

real objects and that left him entirely indifferent. His mind was

hardly engaged with it any more. The real spell of the attention

was broken. On the basis of this situation, I took the last step

and suggested that the image of the woman would disappear

altogether and would not trouble him any more. In the next

twenty-four hours, it still returned two or three times, but

colorless and faint. The following day I was able to eliminate it

altogether. Even when the last trace of the inner struggle between

the memory and the perceived surroundings had disappeared, I went

on with two hypnotic sittings to give stability to the new

equilibrium, to insist that the image would not come back and to

settle completely that inner repose with which every fear of

possible disease evaporated. I feel sure that the cure would not

have been reached so quickly, possibly not at all, if the second

suggestion, the disappearance of the image, had been given at the

first step. The improvement was secured because the antagonistic

process itself was used for the suggestion. On the other hand,

there was no doubt that in this case the strong will of the patient

or suggestion in a normal state would not alone have been

sufficient. The hypnotic treatment was indicated by the symptoms

and justified by the results.

I may take another typical case in which also the obsession was brought

about by an idea without emotional value or at least by an idea which

had lost its emotional character; the idea came somewhat nearer to

hallucination, but had its chief elements on tactual ground where the

transition from image to hallucinatory perception is easier. I add this

case to demonstrate that hypnosis is not the only open way of treatment

in such cases and that the variations must always be adjusted to the

special conditions. The case gains importance by the fact that the

patient was himself a physician well trained in mental observation.

The patient is a highly educated physician of middle age. He

reports that he had been neurasthenic all his life with slight

ever-changing symptoms. He has always been troubled by the

"perseveration" of tactual images which had a strong feeling tone

and which were associated with seen or heard reports of the

experiences of others. For instance, when he read in a newspaper

that someone had hurt his hand with a pin, or that someone had cut

his foot on a nail, he immediately felt a not directly painful but

uncomfortable sensation at the particular place in the hand or in

the foot, together with a shrinking of the whole body and such

tactual sensation usually returned during the following days in

fainter and fainter form until it faded away. Most troublesome had

always been the reading of any torture processes in historical

books or in fiction. Yet there had never been a case in which the

sensations really had the vividness of hallucinations and never a

case in which the after effects had not disappeared at least in a

few weeks.

This time the effect had already lasted four months and it became

more and more troublesome. The patient had not the slightest fear

of mental disease and no anxiety, but he felt a very serious

disturbance by the instinctive effort to get rid of the intrusion.

The place of the disturbance was the wrists. The starting point was

a definite experience. On an unusually hot summer day the physician

had listened for a long time to the complaints of a female patient

who suffered vehemently from a nervous fear of scissors and knives

and who was afraid that she would cut her artery at the wrist. He

believes that it was the exhausting heat of the day which weakened

him to a point where the story of his patient affected him very

strongly and made him think of it all the time. Yet there was no

sensation element involved. A few hours later, he sat in a hotel at

his dinner. Just in front of him a butler started to carve a duck

with a long, sharp knife. In that moment he felt as if the knife

passed through the wrists of both arms. He felt for a moment almost

faint; arms and legs were contracted and an almost painful

sensation lingered in the skin, and did not disappear for hours.

From that day at the sight of knives or razors, not only in his

hands or his direct neighborhood, but also in a store and finally

in a picture, stirred up at once the optical image of that carving

knife cutting into the skin of the wrist, only with the difference

that it seldom was found in both arms, usually in the one or the

other. The sensation became a strictly tactual one with optical

overtone, but there was no emotion in it. The pain element had

disappeared. Also the shock, which still recurred in the first days

slowly disappeared. The longer the symptom lasted, the more the

optical factor faded away, and the tactual factor came into the

foreground after three or four weeks. Perhaps seeing a razor in a

store window or a pocket knife open no longer stirred up the image

of cutting the wrist, but simply a strong tactual sensation, as if

the skin of the wrist was scratched and pinched. Finally, after

about two months, the association character disappeared to a high

degree and the scratching and cutting sensation in the skin became

independent and automatic. The patient awoke in the morning with a

vivid tactual hallucination of being cut without associating with

it any picture of a knife. Throughout the day, in the midst of work

and in the midst of conversation, sometimes one and sometimes the

other wrist became the center of the exasperating sensation, easily

bringing with it involuntary reactions as if to withdraw the arm.

This became more and more frequent and more and more vivid.

The doctor, fully aware of the borderland character of this

experience, felt sure that his inner fight against the disturbance

would get control of it. The usual tonics did not show any

influence. On the other hand, there were no other nervous symptoms

and, with his most acute analysis, he did not find the slightest

trace of emotion any longer. When the symptoms reached a point at

which they seriously interfered with his comfort, he asked me for

psychotherapeutic treatment, under the condition that I was not to

apply hypnotism. He was absolutely averse to the use of hypnotism

in his own case because he was afraid that to be hypnotized would

mean for him a certain disposition to fall into hypnotic sleep by

auto-suggestion, as he knew the vividness of his imaginative

sensations. He wanted to avoid that the more as his own

professional work might sometimes demand hypnotizing in his own

practice. In any case he had an aversion to it and asked for other

means.

Under these circumstances, it seemed to me the most logical

conclusion that the counter idea with its antagonistic reactions

might be reenforced by direct perception. The abnormal tactual

sensation forced on consciousness the idea of the cutting of the

wrist. The necessary counter action would be to force to

consciousness the idea of the uninjured wrist and the corresponding

reactions. As the wrist can be easily made accessible to sight and

as I anticipated that the visual sensations would be more forceful

than the tactual ones, I told him to look straight at his own

wrists for ten minutes three times a day after waking, after

luncheon, and before going to bed. He had to hold his two forearms

close in front of his eyes and stare at them, giving his full

attention to the visual impression of the smooth, uninjured skin of

the wrist. If during this process, the tactual counter-sensations

were vivid, he had to go on with the staring at both arms, both

held near together until the perception had crowded out the rival

touch sensation. When this performance had been carried out six

times, he did not notice the coming up of the tactual sensation

with vividness any longer. From the third day it had disappeared

entirely. I told him to go on with the process still every morning

for some weeks. The physician himself considered the cure as

complete.

Our first case dealt with hypnosis, our second case removed the

intruding idea by a perception in a waking state. To point at once to

the variety of methods which we sketched, we may turn again to a case of

emotionless idea removed by the method of switching off and

side-tracking the originating and physiological "complex."

The patient is a school-teacher in the Middle West, a nervous,

thin-looking woman of about twenty-five. Her only complaint is a

persistent idea that she may at any time get a child. She has had

this idea "as long as she can remember," according to her first

expression. She never had any intimate acquaintance with any man,

she was never engaged, she hated bitterly every thought of

immorality, she knows and has assured herself by much reading that

it is entirely impossible that she might get a child without sexual

contact. Yet this thought recurs to her all the time, even when she

is talking with other people. It embarrasses her in school, in

spite of her teaching only girls in a private institution. This

thought keeps her away from company and the effect of its

embarrassing occurrence depresses her, but she is sure that the

thought itself does not include any emotion. It is a mere thinking

of it with a full consciousness that it is absurd, and yet she

cannot suppress it.

I began at once to try to find the origin of her queer obsession.

After some efforts to pierce into her memories, we came to an

experience of her youth. When she was about thirteen years of age,

a young girl whom she had admired much for her beauty, living in

the neighborhood of her parents, suddenly got a child which died

after a few days. At that time no thought of immorality seems to

have entered into that news. It was evidently mere sadness about

the quick death of the child which gave to the experience its

emotional tone. She was at that time completely naive. She received

an intense shock in the thought that an unmarried girl may suddenly

get a child which would then quickly die. She cannot tell whether

the thought that she herself would get a child had ever entered her

mind before this occurrence in her neighborhood, nor can she say

that it occurred immediately or very soon after it. She now knows

only that she has always had that thought, but whether that means

more than ten years, she does not know.

I considered it a justifiable hypothesis that this strong emotional

experience early in life had become the starting point for that

secondary absurd thought. I considered that primary experience as

cause for a deep physiological brain excitement which had

irradiated towards the ideas of her personality. It had stirred up

there associations which kept their psychological character while

the primary disturbance had long lost its psychical accompaniment.

It worked its mischief in a physiological sphere but was probably

still the starting point for the persistent obsession. My aim was

to remove this cause. It would have brought little improvement

simply to suppress the freak idea as long as that physiological

source was active. On the other hand I should not have the means to

stop the physiological after-effects of that real experience: I had

to sidetrack it and to secure thus a reduction. I decided therefore

to work on the basis of that hypothesis, to accept that

physiological complex as existing, but to switch it off by linking

it with appropriate associations, thus setting it right in the

whole system of her thoughts.

For that purpose I brought her into a hypnoid state, bending her

head backwards and speaking to her with slow voice until I saw that

a slight drowsy state was reached. In this state I asked her to

think back as vividly as she could of that experience of her youth,

to fancy herself meeting that pretty girl, her neighbor, once more.

She is to imagine that she speaks with her. Now I make her talk

with me and she assures me that she sees the scene distinctly. She

believes she sees the girl on the street. I ask her to tell the

girl how indignant she feels over her behavior; she is to tell her

that she understands now all which she did not understand in her

childhood, that she knows now that she must have lived an immoral

life; that she must have had a friend and that a pure girl like

herself could never under any circumstances come into such a

situation, that no pure girl could suddenly have a child. She is to

express to the other girl her deepest disapproval of such conduct

and her own feeling of happiness that anything like that could

never happen to her. In accordance with my demands, she worked

herself entirely into the scene: without using audible voice, she

internally spoke with great vividness to her neighbor. When I awoke

her from her drowsy state, she was quite exhausted from the

excitement. I repeated that scene with her four times. She assured

me that she felt it every time more dramatically. The power of the

obsession weakened from the first day. After the fourth time, it

had disappeared. The subcortical complex had evidently found its

normal channels of discharge.

In discussing this method of side-tracking the complex, we mentioned

that in other cases the result is reached by bringing the memory of that

first experience to a vivid motor discharge, without substituting any

other ideas. For that purpose no direct personal influence is necessary.

Treatment might just as well be performed "by correspondence," provided

that the right starting point is discovered and that right suggestions

are given. As an illustration, I may choose a case which shows at least

the maximum distance treatment by mail, from Boston to Seattle. This

particular case presented no difficulty in getting hold of the starting

point as my correspondent, whom I have never seen, himself at once

pointed to the original source of his obsessing idea.

The patient who lived with his family in Seattle wrote to me the

following: "----I shall undertake to describe in a few words a

condition which the writer has fought against for about eight years

and which has subjected him to untold mental anguish.----I was

backward in a social way but altogether happy. After working in a

bank about a year, was discovered one evening by the cashier

smoking a cigar in the basement, was unable to look him in the face

at the time. Went home that night and thought very little about it,

but on the following morning during the regular course of business,

I stepped up to him to ask some question, and as usual,

unconsciously looked him in the face. His glance was questioning

and suspicious, and that was the beginning of a life of anguish for

me. At first I could not look him in the eyes, then when looking at

some other person, I happened to think of it and so on, until in

two or three days it was impossible to look at anyone who came to

my window. The cashier did everything he could for me. No use: I

quit my position, lost most of my friends, had to leave a happy

home and came to Seattle to work for an old school friend. In the

first year, owing to new environments, I managed to conceal my

mental condition to a certain degree. All of a sudden, I was again

plunged into the depths of black despair. It took me about two

years to (partially) forget it, when the same thing occurred again,

and I lost my grip. The last time about eighteen months ago was

almost more than I could stand. These three or four instances I

speak of were cases of extreme despondency, but my usual mental

condition is extremely unhappy. If occasions arise where I have to

sit and talk to anyone for ten minutes, controlling myself is such

an effort that it leaves me with a case of the blues.... I shall

come and see you as the relief would give me a new lease on life."

This letter was written on the twenty-third of January, 1908. I

replied to him at once that he certainly ought not to come from the

Pacific to the Atlantic, but that I wanted him to write to me much

more about that first occurrence. As he was evidently right in

considering that episode as the starting point of his troublesome

associations, I supposed that these associated ideas had not yet

become independent but were still the effect of that first

"complex." Therefore I wanted to bring that to complete discharge.

Accordingly I wrote him to think himself once more into that

happening of years ago, to pass through it with all the power of

his imagination, to describe it to me then in as full a statement

as possible and to express in the letter also his conviction that

there was no reason to avoid the eyes of his superior, that he

might have looked straight into his face. As soon as he got my

reply, he wrote to me on the sixth of February a description of

that first episode, filling nineteen pages, telling me all about

his relations to those various men and every minute detail was

brought clearly to consciousness again. I did not add anything

further, but the expected occurred. On the eighteenth of February,

he writes to me: "In the last week or ten days, the writer has

noted a decided improvement regarding mental condition. The result

is a new interest in life. If you can spare the time, would like to

have you write me a few lines. Gratefully yours." At the end of the

month he writes: "Received your letter about half an hour ago.

Hasten to assure you with a great deal of pleasure that I am

feeling much better. Since sending you the letter regarding the

first case, I have noticed day by day an improvement." On the

eighth of March: "Since writing you last I have noticed a gradual

improvement. It has given me wonderful encouragement." On the tenth

of March: "Just a line to say that I am still improving." On the

twelfth of April: "I desire to say that since the taking up of

treatment with you, life has had a far different appearance to me

than it has had for the last ten years." On the twenty-first of

April: "Since my first letter to you, there has been such an

improvement that I have accepted a position which carries with it

much responsibility."

This case leads over to the large group in which the obsessing idea

involves the relation to a particular person. I find in such cases

autosuggestion more liberating than heterosuggestion if the development

has not gone too far. Of course autosuggestion can never take hypnotic

character, but makes use with profit of the transition state before

normal sleep. The type of these cases which are everywhere about us may

be indicated by the following letter.

The writer is a young woman of twenty-four, whom I did not know

personally. She wrote to me as follows: "I am a writer by

profession and during the last year and a half have been connected

with a leading magazine. In my work, I was constantly associated

with one man, the managing editor. This man exerted a very peculiar

influence over me. With everyone else connected with the magazine,

I was my natural self and at ease, but the minute this man came

into the room, I became an entirely different person, timid,

nervous, and awkward, always placing myself and my work in a bad

light. But under this man's influence, I did a great deal of

literary work, my own and his too. I felt that he willed me to do

it. The effect of this influence was that I suffered constantly

from deep fits of depression almost amounting to melancholia. This

lasted until last fall, when I felt that I should lose my mind if I

stayed under his influence any longer. So I resigned my position

and broke away. Then I felt like a person who, having a drug to

stimulate him to do a certain amount of work, has that drug

suddenly taken away, and without it I am unable to write at

all...." I wrote to the young lady that she could cure herself

without hypnotism and without my personal participation. I urged

her simply to speak to herself early in the morning and especially

in the evening before going to sleep, and to say to herself that

the man had never helped her at her work, but that she did it

entirely of her own power, and that he had never had any influence

on it, and that she can write splendidly since she has left the

place, and much better than before. A few months later, she came to

Cambridge and thanked me for the complete success which the

auto-suggestive treatment had secured. She was completely herself

again and was fully successful in filling a literary position in

which she had to write the editorials, the book reviews, the

dramatic criticisms, and the social news. As a matter of course,

such treatment had removed only the symptom. The over-suggestible

constitution had not been and could not be changed. Thus it was not

surprising that in the meantime, while her full literary strength

had come back, she had developed some entirely different symptoms

of bodily character which I had to remove by hypnotism.

As soon as the obsessing idea of the influence of another person takes

still a stronger hold and develops systems, the suspicion of insanity

always lies near; especially when hallucinations are superadded, the

probability is great that we then have to do with the delusions of a

paranoiac, and thus no case for psychotherapeutic treatment. Yet it is

always wise to keep a psychasthenic interpretation in view as long as

the insanity is not evident. I may mention such an extreme case.

The patient, a man of middle age, highly educated, for years had

heard voices calling his name. A man with whom he had some personal

quarrel, had, as he believed, hypnotized him from a distance and

made him act queerly or do things which he really did not want to

do, by telepathic influence. It is a development which is found

quite frequently. Abnormal organic sensations or abnormal impulses

and inhibitions which the patient cannot account for by his own

motives become connected with some vague ideas which are in the

air, like wireless telegraphy or telepathy or hypnotism from a

distance or electrical influence, or magnetism or telephoning,

these then attached to an acquaintance who stands in a certain

emotional relation. Here, too, some organic sensations evidently

had been the starting point and the idea of the man with whom he

quarreled had been secondarily attached. From this starting point

more and more detail was reached. Every action was brought into

connection with the powerful enemy who controlled more and more

even the normal and reasonable doings of the patient. My first

impression was decidedly that of a paranoiac. Yet in some ways the

case suggested another view. There had remained an insight into the

unreality of the obsession. The patient did not really believe the

theory of the telepathic hypnotic influence. He felt it more as an

idea which he could not get rid of and he did not know clearly

himself whether he requested hypnotic treatment on my part for the

purpose of counteracting the hypnotic power of his enemy or for the

purpose of liberating him from his exasperating fixed idea.

Moreover, I found that his voices had no hallucinatory character,

but were merely sound images. I decided to make the experiment

without great hope of success.

I hypnotized the man deeply and suggested that no one can have

power over his actions, that he is the responsible originator of

everything that he does and that no one can influence him and that

from that hour he would feel free from any telepathic intrigue. The

effect of the very insistent and urgently repeated hypnotic

suggestion during the first rather long treatment was such a

surprisingly good one that I decided to continue the

psychotherapeutic cure. I hypnotized him daily for two weeks. The

belief in the real wrong doings of an enemy disappeared entirely

from the first. It was at once apprehended as a mere obsessing idea

in the own mind and this idea itself began to be resolved. It lost

its unity; the absurd impulses were still felt but they became less

and less connected with the idea of another man, and as soon as

they were rightly understood as doings of the own mind, the

opposite motives gained in strength. A stronger and stronger appeal

to his own power made these motives more and more influential.

Slowly the association of the influence of the other man faded away

entirely. I intentionally had not given any attention to the

pseudo-voices, inasmuch as they had not taken any relation to the

ideational delusion. I therefore did not include them in my

suggestions, as I consider it wise to confine hypnotic suggestions

always to as few points as possible. Yet these voices decreased

too. At a certain point in the cure I substituted--to save my own

time--an autosuggestive influence, or rather a mixed one, inasmuch

as I had him read ten times a day a letter of mine which contained

appropriate suggestions. After about six weeks, all the

disturbances for which he had sought my advice had disappeared.

Obsessing ideas of such personal influence involve of course always a

certain amount of emotional excitement and they may lead us to the

unlimited field of disturbances in which the persecuting idea is

surrounded by emotional attitudes. Analysis shows easily that the

emotion is an essential factor and that it persists in the disease while

the ideas to which it clings may change. Central is the emotion of fear;

nearest to it that of worry, but any emotion may give color to the

particular case. Again any number of methods may be applied and a few

illustrations with quite different ways of treatment may indicate more

fully the character of the trouble. There is no doctor in the city and

none in the remotest village who may not find such cases in his near

neighborhood. Of course slight degrees are easily hidden by the

patient's own inhibition of external expression. If such suppression by

the own will secures a real overcoming of the unjustified emotion, this

is surely better than to begin any medical treatment. But as the

suppression usually means simply lack of discharge and thus offers all

the conditions for an unhealthy inner growth of the trouble, the neglect

of such disturbances is most regrettable, and frankness of the patient

must be encouraged. Such situation demands a careful observation of the

whole case and a subtle adjustment of the treatment to the individual

needs. It may perhaps be helpful at first simply to indicate the

varieties of the more frequent disturbances of this kind by quoting from

various letters. Each case belongs to a type which can easily be removed

by psychotherapeutic influence, generally even by a skillfully directed

autosuggestion.

The writer is a young man.

"I have always, as long as I can remember, been very nervous and

sensitive. When about seven years of age, I was attacked by St.

Vitus' Dance. Before that I cannot say whether I was particularly

nervous or not. Afterward it was impressed upon me by the remarks

of relatives that I was nervous, so that I soon took note of this

condition myself. The manner in which this weakness has been

especially troublesome is that it has caused me to be very shy. I

shrank from new acquaintances and disliked being observed. Often in

walking along on the street, I imagined myself closely noticed by

the passerby and I always felt uncomfortable.

"About three years ago I suffered from typhoid fever and after

recovering, a new form of the old trouble showed itself. This time

I imagined that when eating I chewed my food in a manner that was

ridiculous and which made people hardly keep from laughter in

observing me. Often I had to leave the table when half through

because I felt I could not bear having critical eyes upon me any

longer. About three months ago I determined to be troubled no

further by my own foolish fancies and by constantly schooling

myself I have improved very much. Still, however, when I walk alone

along the street, I must fortify myself mentally before passing

each group of people. If once I allow myself to think that they are

looking at me, I feel almost paralyzed, my feet seem too heavy to

lift, my arms do not seem to swing naturally, and in attempting to

look placid and unconcerned, I feel that I am failing utterly. Also

when at table, I must still tell myself before each mouthful that I

have no need for fear, that my manner at table is equal and perhaps

superior to the others beside me. I have gone a certain length in

my self-training, and have relieved myself of a great deal of the

mental distress, but now I believe I can advance no further. What

seems needful now is to do away with the self-consciousness which

brought on my worries, though whether this is possible is hard to

say."

Here the letter of a young woman, the type which fills the army of the

mind healers and faith curists.

"For years I have been seeking, or perhaps to be more accurate I

should say waiting, for a mind to drift toward me; a mind that

would understand my particular case of fear brought on by the

constant bullying and nagging from my earliest childhood by those

in my home. This fear of brutality has greatly depleted my nervous

system and has unfitted me for the strong, useful, forceful life I

should have expressed. If I could only rid my mind of the thought

that I am always displeasing, or rather, going to displease people,

for I hardly do displease them; if I could get rid of the fear of

caring what the attitude of other minds toward me is, I feel that I

should then strike out into a strong life of helpfulness to others.

In other words I have always felt behind me a great force pressing

me out into public work. When I was a child, it was so strong that

I was sat down upon brutally, to so great an extent that I feared

to voice my convictions and that fear still clings to me like a

nemesis. It seems that every individual personality in a public or

private audience rises up to overwhelm me, causing my tongue to

grow heavy and my mind to become a blank. This enervating fear

blends into every thought I have, whether sleeping or waking. I

have fought with all my might to rid myself of it but so far in

vain."

Here an expression of a very frequent variety. The writer is a

middle-aged man.

"I am possessed of a fear that is constantly with me that something

dreadful is going to happen and I do not seem to be able to

overcome it. I am told by physicians that I am bodily sound,

although very nervous, and that the fear is generated entirely by

autosuggestion. When at its worst, it weakens and terrorizes me and

in my better moments I am tormented with a fear of a recurrence of

a bad spell. It is fear of a fear. A year ago at this time I had a

very bad spell but got along fairly well through the summer, but I

am afraid that I will soon again be in a bad condition and lose all

that I may have gained."

The "fear of a fear" is indeed a symptom which the psychotherapist has

to fight extremely often, but as soon as he has really recognized it and

analyzed the whole mental condition, he will hardly have any difficulty

in uprooting it. I add a letter of a school-teacher in New York. He

writes:

"I am teaching in a high school. I am of a nervous temperament and

constitutionally limited in endurance. Often my work is done in a

condition of greater or less exhaustion. I find that I blush very

easily in purely freakish ways, when there is no occasion for it. I

find this blushing connecting itself with certain of the girl

pupils of my classes in a conspicuous way. It occurs hardly ever

except when my class is facing me and I seem to be powerless to

overcome it. I have always tried to live a careful moral life, but

my early life was very much secluded. I lacked entirely the free

intercourse young people usually have together and I felt awkward

with others for a long time. In the matter of the blushing, it

sometimes occurs in the case of girls who are especially pleasing

to me but also not infrequently in the case of some who are not at

all so. The whole thing might be passed over were it not that it

has considerable effect in causing constraint toward my students

and in some cases affecting them very strongly in an emotional way

at the very time of life when such things can do most harm. I

regard the matter as being so serious that it brings directly in

question my right to teach, but I do not feel at all sure I could

find other work that I could do if I give up my present position.

The very thought that on a particular occasion it would be

extremely awkward to blush makes it almost impossible for me to

avoid it."

But we have rather now to consider the therapeutic side, and we may

begin again with a routine method of a simple hypnotic treatment.

The patient is a young university professor. His intellectual work

is perfect in all directions. There are no nervous symptoms, though

there are some slight disturbances of digestion. He suffers as soon

as he comes into a crowd of people and as soon as he is on any high

place, where he has to look down; the worst when both conditions

are combined, as for instance, at a concert or a theatre in a

balcony seat. But every meeting of many persons, even at church,

produces all the symptoms of nervous excitement. He was easily

brought into hypnotic state by verbal suggestions. When he was in

hypnosis, I reenforced the conditions for an opposite attitude. I

told him that as soon as he was in a crowd of persons he would feel

especially comfortable, would enjoy himself, would fully enter into

the spirit of the occasion and feel especially secure in their

presence. Whenever he should be on a high place, he would enjoy the

safety of the ground on which he was standing or the seat on which

he was sitting. I assured him that he would neglect entirely

whatever he saw and would rely completely on his safe feeling

resulting from his tactual impressions. After having hypnotized him

three times the disturbance disappeared completely, and even an

evening at the theatre in an exposed box on the balcony was enjoyed

without any discomfort. After about a year, at a period of

fatiguing work, some traces of the anxiety appeared again. This

time two hypnotic sittings were sufficient to remove the

disturbance of the equilibrium, which as far as I know has not come

back. The same hypnotic treatments were used in a secondary way to

remove the digestive trouble.

I again quote the case of a teacher, a profession in which the

psychasthenics are unusually frequent. It is a case of a young woman

from the Middle West.

The young lady wrote me: "I come of a race of strong women and am

not hysterical or easily frightened by many things that disturb

women. Since my fifteenth year I have been seized by hallucinations

of absurd or serious nature which no reasoning could explain away

and which have gradually undermined my power of resistance to them.

At the age of twenty-two, after a year of unusually hard work, my

nervous endurance gave way, and with this breakdown came a sense of

fear and a horror of crime that I have been unable to overcome. I

have never felt the slightest inclination toward wrongdoing. It is

a feeling rather that my shrinking from any mention of evil makes

it impossible for me to listen or think rationally when such things

are discussed. This feeling has seemed to change my whole attitude

toward life and has left me without power to control my facial

expression or carriage when it takes possession of me. I have been

able to teach more successfully than I could hope, but it is only

by cutting myself off from the friendships and pleasures incident

to my life that I am able to accomplish my work. I have fought this

trouble alone and will still do so if there is no help, but the

thought that it is the source of great distress to those dear to me

makes it very hard."

A few weeks later the lady insisted on coming to Cambridge. I found

that there had never been any hallucinations and that she used the

word in her letter only to indicate some insistent memory images

which had never taken the vividness of real impressions. In the

presence of her friend, I hypnotized her deeply and strengthened

through urgent suggestions her consciousness of her having done the

morally right thing at every situation in her life and her

conviction that she never did and never would commit a crime. Here

as always, if possible, I left alone the emotional idea but

reenforced the opposite. The effect was an immediate one. She felt

freer the next day than she had felt for years. I repeated the

treatment a few times and she assured me that the feeling had

disappeared entirely.

I take the rather severe case of a woman of fifty.