CONTROL OF THE NEUROTIC[17]
The first thing in the examination and treatment of neurosis is
the elimination of any physical trouble. It is only after such an
elimination that one should resort to psychotherapeutic treatment.
In psychopathic or neurotic diseases one should take into
consideration the fact that the patients are characterized by
the tendency of formation of habits which are hard to break. The
patients are apt to ask that the same thing be done again and
again for the simple reason that it has been done several times
before. In other words, _psychopathic neurosis is characterized
by automatism and routine_. This tendency to _recurrence_ is
characteristic of all forms of primitive life as well as of mental
activities which are on the decline,--it is the easiest way to get
along.
Effort is abhorrent to the patient. He is afraid of change in the
same way as the savage is afraid of any novelty or of any change
in custom. Tradition is holy, and in a double sense, because it
has been handed down by former generations, regarded as divine and
superior, and because the new is strange and, therefore, may prove
dangerous and of evil consequence. What has not been tried may
prove harmful, pernicious, and even deadly. The old has been tried
and approved by generations and the consequences are known, while
the new may be in alliance with evil powers. This holds true in all
cases obsessed by the impulse of self-preservation and the fear
instinct. What the patients have tried several times and what has
proved good and pleasant is demanded by the patient to be repeated;
the new is not known and may be risky, dangerous. I have great
difficulty in making changes in the life of advanced psychopathic
cases, because of the fear of the new, _neophobia_. Once the change
is made, and the patient becomes adapted to the new way, then the
old way is shunned. In short, _neophobia is an essential trait of
psychopathic patients_.
The physician must take this trait of neophobia into account, and
as the patient begins to improve, he must gradually and slowly wean
the patient of this phobia, inherent in the very nature of the
malady. The patient must learn to do _new_ things, and not simply
follow mechanically a régime, laid out by the physician.
_The patient’s life must become personal._ The patient should be
made to change many of his ways, and above all he should learn to
follow reason, rather than habit and routine. Everything, as much
as possible, should be reasoned out,--he should be able to give a
rational account of his habits and actions. Whatever appears to be
a matter of routine, irrational and unaccountable habit, simply a
matter of recurrence, of repetition of action, should be discarded,
should be changed to actions and adaptations for which the patient
could give a rational account.
We must remember that the patient lives in the condition of
recurrent mental states, that his mental activity, as I have
pointed out, follows the laws of recurrence, characteristic of
the type of recurrent moment consciousness.[18] It is, therefore,
the physician’s object to lift the patient out of this low form
of mental activity to the higher types of rational, personal life
in which the patient can rise above the perturbations of life,
above the pettiness of existence with its worries and fears. This
procedure is essential.
We can realize how pernicious are those schemes which physicians
and many people in sanitariums lay out for the patients just to
keep them busy for the time of their stay under special care. As
soon as the patients leave, they are in the same predicament as
before. The patients wish to have their lives conducted in the same
mechanical, automatic routine. In this way they are really on the
same low plane of mental life, on the plane of recurrent moment
consciousness, a type which forms the pathological web and woof of
the patient’s life.
Unless the patient is lifted out of this low, mean, and animal form
of conscious activity, he cannot be regarded as cured. Instead of
having the patient’s life saturated and controlled by the recurrent
automatisms of the fear instinct, he should learn to be controlled
by the light of reason. “A free man is he,” says Spinoza, “who
lives under the guidance of reason, who is not led by fear.”
Epicurus and the ancient Epicureans laid special stress on the
necessity of getting rid of fear through reason, enlightenment, and
education. Thus the great poet Lucretius:
“The whole of life is a struggle in the dark. For even as children
are flurried and dread all things in the thick darkness, thus we in
the daylight fear things not a whit more to be dreaded than those
which the children shudder at in the dark and fancy future evils.
This terror, therefore, and darkness of mind must be dispelled
not by the rays of the sun and glittering shafts of day, but by
knowledge of the aspect and law of nature.”
As Carlyle tersely puts it: “The first duty of a man is still that
of _subduing Fear_. We must get rid of Fear; we cannot act at all
till then. A man’s acts are slavish, not true but specious (we may
add psychopathic); his very thoughts are false, he thinks too as
a slave and coward, till he has got Fear under feet.... Now and
always, the completeness of his victory over Fear will determine
how much of a man he is.”
The patient complains of lack of confidence. This is a
pathognomonic symptom of psychopathic states. At the same time
there is confidence in the symptom complex which is often described
by him with microscopic minuteness. The patient has no doubt about
that. He is in search of some one who can overcome this symptom
complex in a way which he specially approves. The patient matches
his morbid self-will against the physician’s control. The physician
is not to be subdued by the authority of the diseased personality,
he should not let himself be controlled by the ruling symptoms of
the patient’s life. Either the physician meets with _opposition_,
and after some time, must give up the treatment of the case, or
he is victimized by the patient’s demands, and must comply with
them. In the latter case the patient may stick to the physician
for some time. In both cases the patient is not really cured. It
is only when the _diseased self_ becomes subdued and falls under
the physician’s control, it is only then that a cure is really
possible, it is only then that the normal healthy self may come to
the foreground.
The first and foremost characteristic of psychopathic states is the
narrowing down of the patient’s life interests. He begins to lose
interest in abstract problems, then in that of his own profession
or occupation, then he loses interest in the welfare of his party
or his country, and finally, in his family, wife, and children.
Even in the case of love, the psychopathic patient seeks to utilize
the person he loves for his own, neurotic benefit, namely, his
neurotic comfort and health. He loves the person as a glutton
likes his meal, or as a drunkard his liquor. The self becomes
narrowed down to health, the key to his supposed spiritual life.
Self-preservation and fear permeate the patient’s life.
We notice that the patient’s life activity, especially his
mental functions, becomes narrowed down. His attention becomes
circumscribed to a few subjects and objects. This is the limitation
of the _extent_ of attention. There is afterward a limitation
of the _temporal span_ of attention. The patient cannot keep
his attention on any subject for any length of time. This span
of attention becomes more and more limited with the growth and
severity of the psychopathic malady. If the patient is educated and
has had an interest in various subjects, the latter become more and
more limited in scope. Finally the patient becomes reduced to the
least amount of effort of the attention, and that only for a brief
period of time. When the trouble reaches its climax, the patient
loses all interest and capacity of reading and of studying. He
cannot think, he becomes less and less original in his thoughts,
he becomes even incapable of thinking. The patient’s whole mind
becomes limited to himself and to the symptoms of his disease.
Along with it the fear instinct grows in power, inhibiting all
other activities. There is a limitation of the patient’s personal
self. The personality becomes reduced to the lowest levels of
existence, caring for his own selfish pains and small pleasures,
which are exaggerated and magnified to an extraordinary degree. In
other words, the _personal_ life of the patient becomes more and
more limited as the pathological process goes on. It becomes harder
and harder for the patient to take an active interest in life.
It is clear that under such conditions the tendency of the patient
is to rest and brood about himself, and keep indulging his limited
interests, which get still more narrowed as the pathological
process becomes more extensive and intensive. Under such conditions
it is suicidal to indulge the patient and suggest to him a _rest
cure_, a cure which lies along the line of the disease process,
thus tending to intensify the disease. What the patient needs is
to change his environment, and be put under conditions in which
his interests of life can be aroused. His life activities should
be stimulated to functioning on the right lines, laid out by
physicians who understand the patient’s condition. _Rest is harmful
to the neurotic. What the patient needs is work, work, and work._
What we must remember in the treatment of psychopathic patients is
the fact that we deal here with the aberrations of the impulse of
self-preservation, the most powerful, the most fundamental, and
the least controllable of animal impulses, accompanied with the
fear instinct, which is the most primitive of all animal instincts.
This morbid state of the impulse of self-preservation must be fully
realized before any treatment is begun. The physician must also see
and study closely the line on which the self-preservation impulse
is tending, and comprehend the associations along which the impulse
takes its course in the history of the patient and in the symptom
complex.
What one must especially look after is the elusive feeling of
self-pity which manifests itself under various garbs, and hides
itself under all kinds of forms. As long as the patient is
introspective and has the emotional side of self-pity present, so
long is his condition psychopathic.
The extreme selfishness and the uniqueness with which psychopathic
patients regard their own condition should be eradicated from
their mind. It must be impressed on them that their case is quite
common, and that there is nothing exceptional about them. It
must be made clear to them that the whole trouble is a matter of
mal-adjustment, that they have developed inordinately the impulse
of self-preservation and the fear instinct until their mental life
has become morbid and twisted. The whole personality has to be
readjusted. It is the special tendency of psychopathic patients to
regard themselves as unique, privileged above all other patients,
they are a kind of geniuses among the afflicted, possibly on
account of the special endowments possessed by them, gifts of quite
exceptional and mysterious a character. “Have you ever met with a
case like mine?” is the stereotyped phrase of the psychopathic,
neurotic patient. As long as the patient entertains that conception
of _nobility_, the impulse of self must still be regarded as morbid.
The neurotic must be made to understand clearly that there is
no aristocracy in disease, and that there is no nobility of the
specially elect in the world of morbid affections, any more than
there is in the domain of physical maladies.
The egocentric character of the psychopathic patient puts him in
the position of the savage who takes an animistic, a personal view
of the world and of the objects that surround him. Natural forces
are regarded as dealing with man and his fate, often conspiring
against man. Magic is the remedy by which the savage tries to
defend himself, and even to control the inimical or friendly
natural forces or objects, animate and inanimate, with which he
comes in contact. This same attitude, animistic and personal, of
the primitive man is present in the psychopathic patient. The
patient is afraid that something fearful may happen to him. Against
such accidents he takes measures often of a defensive character
which differ but little from the magic of the savage and the
barbarian. That is why these patients are the victims of all kinds
of fakes, schemes, panaceas of the wildest type, unscrupulous
patent medicines, absurd régimes, mental and religious, whose
silliness and absurdity are patent to the unprejudiced observer.
The mental state of the psychopathic or neurotic patient is that
of the savage with his anthropomorphic view of nature, with his
fears based on the impulse of self-preservation. _The psychopathic
patient is in a state of primitive fear and of savage credulity
with its faith in magic._
The emotional side of the impulse of self-preservation and of the
fear instinct should always be kept in mind by the physician who
undertakes the treatment of psychopathic cases. The physician must
remember that the emotions in such cases are essentially of the
instinctive type, that they therefore lie beyond the ken of the
patient’s immediate control and action of the personal will. The
physician should not, therefore, be impatient, but while protecting
the invalid against the fears that assail the latter, he should
gradually and slowly undermine the violence of the impulse of
self-preservation and the anxiety of the fear instinct. For in
all psychopathic maladies the main factors are the impulse of
self-preservation and the fear instinct.
FOOTNOTES:
[17] The discussion here is necessarily brief. The reader is
referred for details to my work “The Causation and Treatment of
Psychopathic Diseases,” Ch. XVII, General Psychotherapeutic Methods.
[18] See Sidis, “The Foundations,” Part II, Moment-Consciousness.