Psychological Analysis and Re-education.
The methods of treatment which have been described in the foregoing
pages: sympathy, firmness, isolation, suggestion in its various forms,
and hypnosis; while all useful in their proper place, often prove to be
of no avail in cases of psychoneurosis. Where the distressing symptoms
lie on the surface so that both they and their causes are easily
discoverable by the physician—if, indeed, they have not been known
from the beginning, to the patient himself—it is sometimes possible
to bring about a complete cure without any very penetrating analysis
by the doctor of the mental antecedents of the patient’s present
condition. Thus, for example, a courageous and keen soldier who,
suffering from loss of sleep and from the harassing experiences of the
battlefield, eventually breaks down, the precipitating cause perhaps
being shell-shock, may need little more to set him on his legs than the
comfort, assiduous attention, and pleasant distractions of a Red Cross
hospital. For the civilian whose chief trouble is the irritability
caused by a multiplicity of minor business worries, or family jars, a
few days of isolation, giving perhaps, among the other benefits which
we have mentioned, the opportunity to think things out, may have
excellent results. The beneficent action of hypnosis in removing the
acute disturbances caused by shell-shock has already been illustrated.
But a large number of cases fall into none of these categories.
Sympathy merely annoys them, isolation tortures them, for besides
letting them think—usually in a very unwise way—it helps to confirm
their impression that they are seriously ill, just because it involves
the treatment of them as special cases. Suggestive measures may be to
them like water on a duck’s back, and hypnosis may prove of no avail.
Firmness may have merely the effect of proving to the doctor that
there exist patients firmer than himself. But, fortunately, psychical
methods are not exhausted. There still remains at least one—that of
psychological analysis and re-education.
The employment of psychological analysis in medicine means the
resolution of the patient’s mental condition into its essential
elements, just as by chemical analysis it is possible to determine
that water, for example, is composed of certain definite proportions
of oxygen and hydrogen combined in a particular way. Re-education is
the helping of the patient, by means of the new knowledge gained by
analysis, to face life’s difficulties anew.
It is sometimes urged that if this be all that is meant by
psychological analysis, alienists have been doing this ever since
insanity was first treated, nay, further, doctors have been practising
it since the time of Hippocrates. It is pointed out that when a patient
is first interviewed by the physician, an inquiry is always made into
his mental state and behaviour, and into the presence of delusions and
hallucinations or other unusual mental phenomena. His relatives are
questioned concerning the relation of his recent behaviour to that
at the time when he was considered normal. Now the answer to this
assertion is that such an investigation is useful, indispensable in
fact, but it cannot be called psychological analysis.
The point may become clearer to the untechnical reader if he will
imagine for a moment that a carver, skilled in separating the legs and
wings from the body of a bird, should claim to be practising anatomy.
The anatomist would at once object that while such separation of
limbs from trunk is a small detail which sometimes forms part of the
anatomist’s task, it can scarcely be called more than a preliminary to
his study. For first of all, while to a carver a leg is an ultimate
unit, to the anatomist it is, for the naked eye, a collection of
bones, muscles, tendons, skin, nerves, veins, arteries, nails and the
rest, and, seen through the microscope, a tremendous organisation of
infinitely more complex structures. Furthermore, it might be pointed
out that merely to separate these more minute structures into their
constituent parts and to name them, by no means constitutes the whole
of the work of the intelligent anatomist. He wishes to study the
inter-relations of these parts, the way in which they work together for
the common good of the leg. And lastly, the leg must not be studied
only in separation from the trunk, for its functions are subordinate to
the requirements of the body as a whole.
So, in the same way, to record that a man is suffering from a delusion
of persecution or an unreasonable fear of open spaces is merely
to “carve up” the condition of his mind. First of all it must be
ascertained how far that delusion has interpenetrated with the rest of
his mental life; whether, for example, his false belief is restricted
to a specific kind of persecution from a particular person, or is a
general delusion that everybody and everything in the world is against
him. And again, if the delusion is strictly specific, it is important
to know whether it has been the cause of secondary false beliefs,
produced by rationalisation, to buttress the primary delusion against
the inevitable contradiction from facts which it would otherwise
suffer.
Further, the nature of the delusion must be analysed. Why is it of this
and not of that persecution? Why is this particular person feared or
hated? Is it a constant factor in the patient’s existence, or does it
break out at certain times? If so, the patient’s life at these critical
periods must be carefully examined. The doctor must discover where the
patient was at the time, what he was doing and thinking, who were his
companions, and so on.
Next comes the important inquiry into the history of the delusion. And
here, just as the anatomist is able nowadays to mobilise for service
all his knowledge of comparative anatomy and evolution, so if the
physician has really scientific knowledge, not only of the delusions
in other patients, but also of the development of ordinary beliefs in
sane people,[37] he will be immensely helped in his search, and may be
enabled thereby to make many short cuts to the essential facts. He will
endeavour to date the important stages of development of the delusion;
to find a time when, so far as the patient knows, his mind was free
from it.
Thus we may say that a psychological investigation of a case of mental
disorder dissects its normal as well as its abnormal phenomena into
their functional elements. Compared with the procedure which merely
records such gross units as delusions or hallucinations, it is as
anatomy to mere carving, however skilful the latter may be.
But the psychological investigation is not merely comparable to
anatomical dissection. We have also compared the mind to a chemical
compound, rather than a mechanical mixture. Especially is this true not
only of the normal but also of the abnormal mind, when the latter has
had time to settle down into its new position of relative equilibrium
and integration; when, for example, a delusion has become so fixed
that the patient’s life is entirely ordered in obedience to it, and
he has ceased to have any doubts as to its reality or to struggle
against its domination.[38] It is only when the warring elements in
the mind are relatively independent, and before they have succeeded in
“making terms” with each other, that the mind even remotely resembles a
mechanical mixture. It follows, therefore, that psychological analysis
of a case of mental disorder is usually comparable to _chemical
analysis_ as well as to anatomical dissection.
Now the most striking result of chemical analysis is to show that the
appearance and general properties of the elements composing a compound
are different from the appearance and properties of the compound
itself. This is exactly the case, too, with mental analysis. A mere
dissection of an abnormal condition is sometimes sufficient in the
milder cases to serve as the basis for curative measures,[39] but in
more advanced cases, or those of longer standing, real analysis is
necessary in order to get at the unknown factors.
It is just at this point that a number of investigators of mental
disorder decline to go any farther on the path of research. Up to this
stage, they say, one is relying upon ascertained facts, for one has
the warrant of the patient’s own memory for the data obtained. Further
analysis of a mental phenomenon must inevitably involve appeal to
unconscious factors. And, once one has called in the unconscious as a
means of explanation, psychology becomes a mere “tumbling ground for
whimsies.”
Probably there are few people to whom this statement does not appear
to express the universal verdict of common sense. That is precisely
what it does. But it should be unnecessary to point out that common
sense alone is not always the most reliable guide to the discovery of
fact. Unaided common sense not only informed men for centuries that
the sun moved round the earth, but told them so with such finality and
conviction that extraordinarily unpleasant consequences ensued for
those who did not believe in such an obvious fact. And the old belief,
wholly false as it is, has still to be unlearnt by every child.
In the same way, the ‘common sense’ point of view which we have
described is not flawless. It assumes that a patient is able not only
to surmount the great difficulties of translating his experiences
and beliefs precisely into words—a difficult task even for the
well-educated person—but also to account for and explain them
truthfully.
It may, however, be pointed out that, though this last-mentioned
misleading assumption is widespread, it is by no means so universal
or so tenacious in man as the “belief of his own senses” that the sun
goes round the earth. In fact, quite apart from the teachings of modern
psychology, we frequently find well-founded suspicions in the lay mind
that a man is not always competent to give the basis of and reasons for
his mental condition. This view is summed up in the famous advice to
the future judge, “Give your decision, it will probably be right. But
do not give your reasons, they will almost certainly be wrong.”[40]
What ordinary man, unversed in the subtleties of theology or
comparative religion, could give to an agnostic a satisfactory account
of the reason why—being let us say, a Christian, and a Protestant
Christian—he is a Primitive Methodist or an English Presbyterian? Let
us complicate the matter further by supposing that this sect to which
he now belongs is not that in which he was brought up by his family!
Many of the factors which have contributed to his present religious
beliefs may have been entirely forgotten now, recallable only with the
greatest difficulty[41] and with the help of a second person skilful in
such investigation.
We may take as a good example of the historical complexity of
significant attitudes and actions in life, the process of falling in
love—especially if it is not, or at least seems not to be, love at
first sight. It is generally admitted that, in the development of this
psychological phenomenon, onlookers see most of the game. In other
words, the actions of the two persons who are gradually becoming more
and more attracted to each other are partly determined by motives,
which, unknown to them, are patent to their observant relations and
friends.
Further examples may be given to illustrate this important and
oft-disputed point. Let us suppose that a musical critic, after
hearing a new symphony by an unconventional composer, immediately
writes a lengthy appreciation of the performance. It is clear that
nobody would expect him to be able to give, off-hand, an account of
his reasons for every sentence of the criticism. But it is obvious
that a single phrase in this account may be but the apex of a whole
pyramid of memories emanating from the critic’s technical training,
his attitude towards the new departure, experiences highly coloured
with emotion which a few notes of the music may have evoked, and his
mental condition at the time he heard the performance. Nobody denies
that these may have shaped or even determined his criticism. But who
believes either that they were all conscious at the time of writing
the article, or that he could resuscitate them without much time and
trouble and perhaps the help of a cross-examiner?
Again, there are occasions when society expects that a man shall be
unconscious of the reasons for some of his actions. He is expected, for
example, to behave politely, attentively and chivalrously to ladies,
not because at the moment of taking the outside of the pavement he
remembers why he does so, but simply because he has been brought up in
this way. And conversely, too conscious politeness in a man arouses in
others—and often rightly—the suspicion that it is a recent acquisition.
We see then that it is rare for a man to be able to give a true
account, even to himself, of the reasons underlying his important acts
and beliefs, when his mental condition is relatively calm and his
social relationships are normal. But when a case of mental disorder is
in question it becomes quite obvious that the patient is frequently
not in a position to give, either to himself or to another, anything
like a complete or true enumeration and description of the antecedent
experiences which have brought about his present condition.
It therefore becomes necessary to admit that unconscious factors of
great importance may play an influential part in the production of
mental disorder and that, therefore, some way must be found of tapping
these submerged streams.
The most direct way into the complexities of the unconscious mental
processes of a person is afforded by a study of his more “unusual”
actions and thoughts. For few persons are so completely adapted to
their environment or so perfectly balanced that moments never arise in
which their mental behaviour is not surprising, either to themselves
or to others. And even the Admirable Crichtons of our acquaintance are
not entirely immune from errant moments—at least in their sleep. The
dream, then, is the chief gate by which we can enter into the knowledge
of the unconscious. For in sleep, the relatively considerable control
which most of us in waking life possess over the coming and going
of mental events is almost if not entirely abrogated. Thoughts and
desires, which, if they attempted to dominate consciousness in waking
life, would be promptly suppressed, arise, develop and expand to an
astounding extent in the dream.
This statement, of course, is entirely independent of the implications
of any one “theory of dreams.” Its truth is evident to anyone who has
honestly recorded or considered his own dreams for even a short period.
Other unusual mental processes are manifested in such events as “slips
of the tongue,” “slips of the pen,” the mislaying of important objects,
the forgetting of significant facts, or conversely the inability to
get an apparently unimportant memory out of one’s mind. All these
phenomena, common enough in the normal individual, are usually more
frequent in the abnormal mind. Besides the patient’s voluntary account
of, and comments upon, these events,[42] other methods of obtaining
data are possible to the physician. He will note the matters about
which in conversation the patient is apt to become silent, embarrassed
or inexplicably irritated, to hesitate, to say he has forgotten, or
even to lie. All these sidelights upon the mental make-up are carefully
noted by the physician and the deductions from them compared, not only
with the patient’s accounts of himself on different days—narratives
which when put together may show important discrepancies and thin
places—but also with the information obtainable from his family. These
devices serve to bring to light in an extraordinary manner a whole
number of memories, many of them of immense significance for the
comprehension of the patient’s present mental state, which it would
be utterly impossible to discover in mere conversation or even by
cross-questioning.
It is sometimes felt that these methods which savour strongly of
catching the patient tripping, while they may unearth some interesting
details of his past life, do no more than exhibit under a strong
magnifying glass a few minute excrescences upon his otherwise fair
mental countenance. But it should be pointed out that nobody who has
ever honestly collected together and compared the memories which have
coalesced to compose a dozen of his dreams—especially if he has done
so with the help and under the cross-examination of a candid friend
who knows him well—will maintain that the material thus found is
unimportant. As Professor Freud says, “The dream never occupies itself
with trifles.” It is probably just because the thoughts and desires
underlying the dreams have been refused their normal outlet, that they
express themselves in such bizarre forms.
Moreover, the fact should not be overlooked that in other
sciences—including the most exact, the physical sciences—the most
profoundly important general conclusions are often arrived at by the
examination of unusual phenomena, of nature “caught tripping.” The
study of the thunderstorm was the foundation of our present knowledge
of that great force which is active not only in thunderstorms but
throughout all matter. Observation of the sporadic and relatively
unusual volcanic eruptions of the mind may prove to be an important
foundation of our future knowledge of general psychology. As in the
inorganic, so in the organic world, there is no sharp line dividing
normal from abnormal, and the unusual phenomenon is sometimes simpler
and more easily studied than the usual, as “Sherlock Holmes” was so
fond of demonstrating.[43] From a scientific standpoint, then, we
have every justification for pressing to the utmost our study of the
unusual mental phenomena exhibited by the patient, and for our belief
that their nature is not unimportant, but highly significant for
therapeutical purposes.
Another objection, however, is frequently levelled against such a
procedure, from quite a different direction, or rather from a number
of directions. This objection can be expressed simply in words, such
as “One ought not to probe so deeply into a patient’s innermost mental
life,” and is not to be met by a single argument. The reason is that it
is polyhedral in form, and that each of its faces or aspects must be
considered separately. For it should be obvious to everyone that such
an objection cannot be flippantly waved away.
The aspects of this question which seem to have more particularly
appealed to the critics of the method which we are describing, are at
least four in number, which we may describe as the æsthetic, social,
medical and moral.
The origin of the first, the æsthetic aspect, is easily seen. It is
quite clear that in the investigation of the inmost secrets of a
person’s life (and particularly of a life which has become so entangled
and complicated that the help of another is sought for its restoration
to ‘mental tidiness’) there must emerge frequently much that the
patient finds unpleasant to relate. When we remember that a neurosis
often (perhaps always) occurs as a result of the patient’s inability to
adjust his instinctive demands to the opportunities of his environment,
it becomes clear that in the investigation of his history discussion
is inevitable of mental events in which the fundamental instincts have
played a great part. Now, of those important instinctive impulses, it
is obvious that in a civilised community few are so often thwarted,
deliberately repressed, or otherwise obstructed as the powerful one
of sex. It therefore follows that in a large number of cases the
discussion of sexual matters becomes unavoidable. Some critics have
seized on this point as the weak spot against which to launch their
attacks, descanting upon the unpleasantness, even the nauseousness, of
such discussion. Not all of them, however, make it clear whether in
their opinion it is the patient or the doctor who should be shielded
from such unpleasant experiences. If the latter, the verdict of society
would probably be that the sooner a man requiring such protection was
excused not only from these uncongenial duties, but from all medical
obligations whatever, the better for the community. If the former, it
may be pointed out that every reasonable person will agree that the
man who does not tell the whole truth to his doctor or his lawyer is a
fool. Furthermore, even under present conditions, if it be considered
advisable in the interests of the patient’s bodily health, the doctor
does not hesitate to ask, and the patient to answer, questions about
the most intimate matters, some of them literally and not merely
metaphorically nauseous.
We may therefore dismiss the æsthetic objection as unworthy of the
consideration either of a conscientious doctor, or of a reasonable
patient.
We may turn now to what we have designated the social aspect of the
objection. It should need little explanation. There has arisen a
convention, subscribed to consciously or unconsciously by many, that
the doctor shall ask and the patient answer quite freely questions
relating to the patient’s bodily well-being, but that any unusual
mental occurrences must be considered the patient’s private affair into
which it is not the business of the doctor to pry.
It would be rash to deny that up to a certain point this convention
is susceptible of defence. But, carried too far, it is productive
of disastrous results. Moreover, it is impossible for a doctor to
treat many varieties even of physical disease without becoming to a
great extent the confidant not only of the patient but often of his
family. And there is no doubt that the present unwritten law that the
doctor should confine himself to the patient’s physical ills is often
judiciously disobeyed by very many successful practitioners. Yet it
must be recognised that the convention exists, and like all social
usages is extremely tenacious.
The chief medical objection, which we shall now consider, is usually
expressed in some such form as the assertion that “it makes the
patient worse to talk about his worries” and that one should rather
“try to make him forget them.” Let us examine these statements, both
of which contain a certain amount of truth, but if applied without
qualification to serious cases of incipient mental disorder can by
their respective negative and positive tendencies do an incalculable
amount of harm. They are often the result of applying experience
acquired by the successful reassuring of a certain type of “malade
imaginaire,” to the consideration of far more complicated cases in
which such easy and straightforward treatment is impossible. A man,
let us say, visits a doctor and confesses to him his fear that he is
suffering from some organic disease. The physician after a careful
examination proves to the patient by objective means that there is
nothing the matter with him; the sufferer is reassured and returns to
his daily business and in due course forgets about this worry or ceases
to be troubled by the memory of it. Here the diagnosis, treatment,
and cure may be uncomplicated and “on the surface.” But even here it
should be emphasised that in one sense, far from “making the patient
worse” to talk about his trouble, the talking about it was the _sine
quâ non_ of cure; otherwise the doctor would never have known of the
fear. In another sense, however, talking about the trouble did make the
sufferer worse—but for a short time only, during a confession of his
apprehensions, or perhaps even for a few days, if more than one visit
to the consulting room were necessary before the doctor’s verdict could
be obtained.
But not all visits to the doctor end so briefly or so easily as this.
The patient’s trouble, on examination, may prove to be organic and
of long standing. Does the doctor consider then that it is his duty
to emulate the Christian Scientist or to “make the patient forget
it?” On the contrary, he does not flinch from the employment of the
most searching methods of investigation, lengthy and often painful
treatment, and, if it seems necessary in the patient’s interest, he
will carry out or arrange for operative interference which may be
difficult, expensive, by no means free from danger, and is quite likely
to “make the patient worse,” perhaps for a considerable time, before
its beneficial results appear.
It is therefore idle to argue that on the one hand psychological
methods of treating mental disorder are unnecessary because some
patients get better without their application; while, on the other,
they are dangerous because they may make a patient worse. The same
remarks could be applied to most of the successful operative methods of
present-day medicine. All of them are fraught with grave potentiality
for harm if applied by unskilled persons.
The degree to which the doctor is medically justified in probing the
patient’s intimacies is obviously dependent upon the individual case.
Not all patients require such drastic incisions; a fact which has been
clearly shown in the special military hospitals. An intelligent man
of strong will, whose social relations have hitherto been normal and
happy, might be temporarily “bowled over” by the emotional stress of
the campaign, but after a few inquiries into the causes of his mental
anguish and a few explanations, he is often set on his feet again.
We must not forget, however, the other side of the picture. There are
many patients, who, far from being made worse by the confidential
recital and discussion of their mental troubles to a suitable person,
experience great relief as a result of this unburdening. Men in the
military hospitals have expressed this over and over again, in such
phrases as, “I have been bursting to tell this to someone who would
understand,” or, “I have seen many doctors since I left the front,
but you are the first who has asked me anything about my mind.”
Frequently the troubles prove to be caused by their ignorance of the
great individual differences in minds, so that the appearance in them
of a new but by no means pathological mental phenomenon frightens them
unduly. We have already referred to cases of this kind in Chapter
I.[44] Another frequent cause of the most intense and continuous mental
anguish is the exaggerated self-reproach which the patients attach to
some real, but in the judgment of others, comparatively trivial defect
or delinquency in themselves. To borrow an expressive phrase, the
neurasthenic has “lost his table of values.” It is in such cases that
a talk with a tactful, sympathetic, broad-minded physician may produce
the happiest results.
To assume that one can make the patient forget such worries as these
without first discovering what they are, is obviously fatuity at its
grossest. Moreover, as we have seen, it is quite insufficient merely
to discover that the patient is “suffering from hallucinations” or
delusions and then to tell him to dismiss them from his mind. To
suppose that, without understanding the nature of and the specific
reasons for the development of a particular hallucination, one can
“make the patient forget” his interpretation of a real experience which
has appealed to him night and day for weeks, or banish a delusion which
is gradually becoming systematised and rationalised—_i.e._, intimately
interwoven into the tissues of the whole of his experience—is an
assumption which has no foundation in fact.
The point cannot be too much emphasised that many of these patients are
quite sane, if conduct be regarded as the criterion of sanity; but
they are growing afraid of the appearance of these abnormal phenomena,
and take them for signs of incipient—or, more usually perhaps, of
established—insanity. Hence follows the important corollary that while
treatment by isolation has obvious advantages in certain cases, in the
particular group of patients which we are now discussing it is often
dangerous, for the reasons already emphasised in the last chapter. The
presence of such mental phenomena is usually confided to the physician
only after great hesitation, and such worrying experiences are common
in cases of insomnia and other disorders, which, though troublesome,
do not appear to be grave. It is therefore possible that isolation may
have serious effects in many cases in which its net result seems merely
to be that the patient is no better.
It is granted then that in some instances (by no means all), the
patient may be temporarily pained by the dragging into daylight of the
causes of his worry, but it is usually a case of _reculer pour mieux
sauter_. This procedure is often inevitable in the medical treatment of
many disorders which have become complicated to any considerable extent.
We pass now to a difficult task; the consideration of the moral
objections to the procedure of psychological analysis. The difficulty
obviously lies in the circumstance that, while in the discussion of the
other objections one could continually point to facts upon which at
least, the great majority of civilised people are in cordial agreement,
such unanimity is not so complete upon moral questions. Some of the
varieties of the moral objection, however, are not based on such
disputable grounds. For example, there is the argument that it is bad
for the patient that he should have his inmost mental life dissected
and analysed in the thoroughgoing way which we have described, since
it is important for the preservation of his self-regard that, as far
as possible, he should consider himself “master of his soul.” With the
latter sentiment no reasonable person would quarrel. And where it is
possible (as it often is) for a slight mental tangle to be straightened
out without an extensive and lengthy inquisition, we hold that it is
urgent in the patient’s interest that his privacy shall be respected.
It should be pointed out, however, that since this procedure is equally
in the interests of the honest physician—for it will save him time and
trouble—it is likely to be adopted wherever possible. In the special
military hospitals, for instance, it was often found unnecessary, in
mild cases, to press the inquiry very far; the patient “learning his
lesson” successfully at an early stage of the proceedings.
But it obviously does not follow that the fact of a man having for very
sufficient reasons, admitted the physician into his confidence, must
necessarily bring as a consequence a diminution in his self-respect. On
the contrary, he often emerges from such an examination with increased
confidence and a better opinion of himself, especially if, as so
often happens, his self-reproaches have been unfounded. The civilised
world contains a relatively large proportion of people who habitually
confess their shortcomings to priests. One may recognise that the
confessional has its defects, but the assumption that to have recourse
to it inevitably promotes mental flabbiness is obviously unfounded.
The business man who, when faced with the necessity of successfully
meeting an entirely new situation, consults his legal adviser, is not
usually blamed for his lack of self-reliance. Conducting one’s own
legal transactions, like doctoring oneself, may appear (to the vulgar)
to show independence, but its results are not always happy.
It is therefore perfectly fair to claim that none of the arguments
against the use of psychological analysis have any very great
significance. In some cases, however, they express valuable reminders
that this delicate and powerful instrument, like all others with these
attributes, must be used with care and discretion.
We may now proceed to take stock of our present position and briefly
to summarise the contents of the foregoing remarks. Many cases of
“functional nervous disorder” or “neurosis” exhibit as their most
important characteristics symptoms, the underlying factors of which
are demonstrably _mental_. A neurosis may be regarded as the failure
of an act of adaptation.[45] The resultant mental disturbances do
not seriously affect the “reason” or the “intellect” as was formerly
supposed, but are in character predominantly instinctive and emotional.
The neurotic’s behaviour in the face of an insurmountable difficulty
presents a considerable resemblance to that of a child. The reasons why
this analogy is not always obvious (though often it is quite plain) is
that while in the child one can usually appreciate the cause of the
emotional disturbance and watch its progress, these possibilities are
often excluded in the case of the civilised neurotic adult. Both his
insurmountable difficulty and the historical circumstances which have
made it unconquerable may (they do not always) lie within his inmost
mental life. Further, the child’s difficulty usually is caused simply
by his inability to adjust himself to his environment; or perhaps more
often to adjust his environment to himself. The adult neurotic, on the
other hand, adds to these difficulties the further significant one of
a lack of inner harmony. There are warring elements inside as well as
outside him: he is trying to fight the enemy with an army which has
mutinied.
It follows then that any attempt to restore equilibrium between
himself and his social environment must be accompanied by a similar
endeavour to bring about his inner harmony. Therefore, in such cases,
a certain amount of psychological analysis is indispensable. Without
such investigation the application of physical or psychical methods of
treatment must inevitably be a shot in the dark.
The task of psychological analysis is rendered difficult by the fact
that not all the motives of the patient’s present beliefs, attitudes
and actions are conscious; the entry into consciousness of some of
the unacceptable motives and memories is obstructed by various mental
processes. When the action of these shielding mechanisms has been
subverted by various means the real significance and history of the
patient’s present mental condition becomes clear to him. In the light
of this new self-knowledge he begins to cure himself. In a few cases he
may require little or no subsequent assistance, but usually a process
of re-education[46] is necessary. He may still require to be helped
over some of the obstacles which he meets, and he may need more or
less frequent encouragement and advice to an extent determined by his
disposition, temperament, and character. By these means he is “freed
from himself,” liberated from the exaggerated emotional tone which has
become attached to so many of his memories, and so enabled to face life
anew with a harmonious and integrated mind.
The procedure which we have discussed is precisely that which the
sensible mother adopts towards a child who exhibits sudden and
unreasonable fear, anger, or any socially undesirable emotion. The same
method is adopted towards the man who, having muddled his financial
affairs, appeals for advice to an experienced and judicious business
friend. “Firmness”—of the unsympathetic and unintelligent order—may
occasionally produce good results in both these instances, but usually
it only makes matters worse. Paying for the commercial muddler a few
of his chief debts may remove his embarrassment for the time, but if
unaccompanied by an attempt to reform his business methods, the result
will usually be merely that such a treatment will enable him to incur
fresh liabilities. So it is when a symptom or set of symptoms in a
neurosis is unintelligently removed: new troubles frequently break out
in fresh places.
We believe that there exist and can exist no serious arguments against
the procedure of psychological analysis and re-education which we have
just described. But now we come to speak of a procedure introduced
during the last few years which has certainly not escaped criticism
both of the most flattering and the most hostile kind. This is the
method of “psychoanalysis” which we owe to Professor Sigmund Freud, of
Vienna, who developed it as an extension and elaboration of the pioneer
work of his former master, Professor Pierre Janet[47], of Paris.
Perhaps few terms in medicine have aroused so much misunderstanding,
so much criticism, well-informed and ill-informed—and so much enmity
as this word “psychoanalysis.” This latter fact alone, however, should
not prejudice the reader for or against it. He will probably remember
that it is the exception, rather than the rule, for an innovation to be
received without hostility, not only from the general public, but also
from experts who work in provinces bordering upon the field in which
the new method is introduced.
It should be pointed out that much of the heated discussion which has
raged around this word psychoanalysis is due to the fact that the
term has different meanings, as used, not only by its enemies, but by
its friends. Psychoanalysis, according to Dr. Jung, is a _method_;
“a method which makes possible the analytic reduction of the psychic
content to its simplest expression, and the discovery of the line of
least resistance in the development of a harmonious personality.”[48]
Psychoanalysis is therefore a method of psychological analysis. Why,
then, have we not used the term psychoanalysis in the earlier part of
the book? It was purely to avoid unnecessary and acrimonious discussion
on any particular doctrinal aspect of the question which this term may
be taken to imply.
It is clear to every thinking person that, in analysing a mental state
the physician should use every legitimate means at his disposal. If
these means include, as they do, the valuable assistance derived
from the study of the patient’s dreams, his “associations” whether
free or constrained,[49] and other mental phenomena, the doctor may
use them freely without thereby subscribing to any one “doctrine of
psychoanalysis.”
The term psychoanalysis has been widely applied, not only to the
diagnostic method, but also to the theories which underlie and
determine the subsequent process of re-education. This seems to be a
misuse of the useful word “analysis.” It may be objected that in all
scientific analysis there is some directive hypothesis to be confirmed
or disproved, and that in this sense all analysis is based on theory.
This is true, but it seems inadvisable to confuse the analytic process
with the theory which directs one form of it.
When we come to consider the theoretical presuppositions which underlie
the different methods of re-education adopted by various physicians,
it is not surprising, at this early stage of our knowledge, to discover
differences of opinion. The physician will find at every step that in
“tidying up” the disentangled functions of the patient’s mentality he
will need not one theory but many, for his problem is life itself.
All his own human sympathy, with its indispensable basis, a knowledge
of his own strength and weaknesses, all his learning in physical
science and psychology, all his knowledge of morality and religion
must be available for immediate and efficient use. In one interview
he may have to lay down the law for the benefit of some ignorant and
distressed patient who is desperately anxious to follow his advice
unquestioningly; in the next he may be at close grips with a mind more
flexible and independent than his own, knowing well that his every
little victory must be consolidated, and that every position won may
be subsequently counter-attacked by his patient. He must be ready to
suggest, discuss, persuade as the time and the conditions indicate.
While, therefore, the ultimate lines on which an ideal diagnostic
analysis and curative re-education will be possible are as yet
undefined, it would serve no good purpose in a book of this length to
raise discussion on the question of psychoanalysis. Its future will
be settled, not in the heated atmosphere of the debate, not in the
acrid polemics of the correspondence columns, but in the calm, careful
examination by the individual worker of his own actual findings and the
honest comparison of them with those of others.
FOOTNOTES:
[37] Such development involves a complicated set of processes the
nature of which is by no means obvious to unaided common sense.
[38] “... for example, a patient may maintain that he is the king, but
that an organised conspiracy exists to deprive him of his birthright.
In this way delusions are sometimes elaborated into an extraordinarily
complicated system and every fact of the patient’s experience is
distorted until it is capable of taking its place in the delusional
scheme.” Bernard Hart, _The Psychology of Insanity_, Cambridge, 1914,
p. 32.
[39] _Cf._ p. 15_f._
[40] _Cf._ Hart, _op. cit._, p. 66_f._
[41] The reader may pass an interesting time in trying to give himself
or others an historical account of the events in his life which
caused him to choose his present profession. He will probably find
that memories emerge of incidents and conversations which have been
forgotten for years. Yet he may find that they have influenced his
present life and his action at any moment of the present, to a very
great extent. Their present action clearly has been unconscious.
[42] It should not be forgotten that when a patient in an early
stage of mental disorder voluntarily seeks the doctor, his _active
co-operation_ in the task of tracing the causal factors of his trouble
is of the greatest value. This assistance cannot be relied upon after
the patient has been certified as insane and removed to an asylum, or
even after he has been taken to the doctor at the instance of others.
For obvious reasons he is then more likely to hide than to reveal his
eccentricities. The simulation of insanity is comparatively rare: it
is difficult and usually easily detected. It is dissimulation—the
concealment of symptoms of disease—which is the doctor’s greatest
enemy. The deluded man may hide his delusions because “everyone knows
that these beliefs are mad:” the melancholic may pretend for the time
to be cheerful in order that his liberty may not be interfered with.
(_Cf._ K. Jasper’s _Allgemeine Psychopathologie_, Berlin, 1913, p.
317.) Such attitudes of the patient are obviously strengthened by our
present custom of delaying the treatment of mental disorder.
[43] In his account of the wonderful exploits of “Sherlock Holmes,”
Sir Arthur Conan Doyle was merely applying, with inimitable skill and
literary resourcefulness, the methods of clinical diagnosis in medicine
to the detection of imaginary crimes. The unusual phenomenon in
medicine or in crime often affords the most obvious clue to the expert
who can appreciate its significance, whereas a simple dyspepsia or a
commonplace murder may present insoluble problems, because they reveal
no distinctive signs to guide the investigator.
[44] p. 17_f._
[45] Dr. C. G. Jung’s view, _Analytic Psychology_, p. 234.
[46] It is of importance to remember that successful re-education
utilises the emotional factors in the patient’s mental make-up, by
helping him to realise the value of the things which will make life
once more attractive and worth living. In this process the more the
physician knows of the patient’s social, moral or religious relations,
the earlier and more satisfactory will be his success.
[47] CORRECTION.
An unfortunate error in the second paragraph on page 73 escaped our
notice during the correction of proofs. Professor Pierre Janet was not
formerly the teacher of Professor Freud, but his fellow pupil when they
were studying under Charcot in Paris.
[48] _Op. cit._, p. 256_f._
[49] _Cf._ Hart, _op. cit._, p. 69_f._, Jung, _op. cit._