Psychotherapy

Viewed in this way, grief is an ailment that should properly come to the physician for treatment and with regard to which that important principle is eminently true that the physician cannot always cure, but he can nearly always relieve, and he can always console his patients. On the one hand, an improvement in the general health always make grief easier to bear because it increases the resistive vitality of both mind and body. On the other, any diversion of mind that lifts the burden of grief even to some degree, releases new stimuli and physical powers for the restoration of bodily function to the normal and this brings about an immediate lessening of the depressive condition. In a word, for the vicious circle of unfavorable influences ever pushing the victim farther into depression, a virtuous circle, in the Latin sense of the word virtue, meaning courage, favoring strength, must be formed, that brings about an immediate improvement in the patient's mental and physical well-being. This is not a pretty bit of theory but is the result of the experience of every physician who has ever taken seriously the problems of caring for the grief-stricken.

Natural and Pathological Grief.—It is, of course, not easy to distinguish between grief that may be called morbid in the sense of a melancholy, that is, more than natural—a true mental disease—and that which represents only an affective state accompanied by depression from which there will be complete reaction. A mother loses a favorite, it may be an only son, and is plunged into grief. For days, even weeks, she refuses to take any interest in life, she thinks moodily about the awful affliction that has come to her and how blank the future is, and she cannot be aroused to attend either to her own affairs or to the duties of life around her. Such a grief is, in many cases, not more than the normal depression incident to such a loss. If after months, however, the mother still continues to refuse to take interest in life and the things around her, especially if, besides, she now talks of having been visited with this punishment because of some unpardonable sin in her own life, or because the Deity has been offended beyond all hope of propitiation, then the case verges over into one of true melancholy in which the mental depression is not merely a symptom of a passing condition, but partakes of the nature of a mental disease, or is the consequence of a profound neurotic condition.

It must not be forgotten that there is always the danger that exaggerated grief, as it seems for the moment to be, may be only the first symptom of a true melancholic condition. Only too often friends and physicians have been deceived by this. Some of the sad cases of self-destruction and a few cases of homicide and suicide have followed a condition that seemed to be only abnormal grief for the loss of a relative.

Etiology.—The cause of exaggerated, prolonged grief is, in a considerable proportion of the cases, a melancholic tendency, that is, a failure on the part of the mind to react against depression. The weakness of mind that predisposes to this may be inherent or acquired. Sometimes no special loss is needed to produce melancholia in susceptible individuals, while occasionally it is precipitated by some misfortune, inasmuch as this is a mental disease, very little can be done directly, and yet the patient can be helped and diversion of mind may bring a good measure of relief. More often, however, the reason for persistent grieving is that before the disturbing loss came into the life of the individual there had been a serious deterioration in health. This was due to the conditions preceding the unfortunate event. Wives sometimes have worn themselves out physically and mentally while nursing husbands, or mothers their children, and this has produced a lack of physical force which prevents them from reacting with healthy mentality against the subsequent shock of loss.

Prophylaxis.—For the melancholic tendency prophylaxis cannot be special, but must be general. We cannot prevent people from suffering serious losses, but we can foresee the possibility of a loss proving very depressing, and can, therefore, try to keep the individual in reasonably good physical condition. If this is done the subsequent depression will be much less than it otherwise would be. Very often there is little or no recognition of the fact that there is a definite tendency in some patients to too great an inclination toward melancholic thoughts, and it is not until an exaggerated manifestation of it comes that the danger is realized. It is not easy to make patients realize the dangers, but where the physician talks with assurance and points out definite things to do in order to prevent serious developments, patients, or at least their friends, can be made to appreciate the dangers.

The best demonstration that I know of the value of work as a remedy for grief is my experience with members of religious orders. For them, as a rule, there is no interruption in life no matter what the loss may be. Their work goes on the day after the funeral just as before. This is the most precious possible arrangement, time and occupation of mind are the two factors that will dull the edge of grief and while humanly we may resent the consolation that is thus brought by such conventional things as the passage of time and humdrum occupations, they represent nature's resources. Above all, patients must be given something to do and if that something concerns other suffering human beings, there is every reason to expect relief.

Treatment.—The most important element in the treatment of grief cases is to prevent physical running down as far as possible and to build up the physical condition. Depression that comes to patients who have lost considerable weight, even though it may show some of the signs of melancholia, is always hopeful. Where patients are twenty or thirty pounds under weight the recovery of weight up to the normal condition will often mean the relief of their depressed condition. The one hope lies in this physical improvement. Mental treatment by diversion of mind must, of course, be practiced. This does not mean getting the patients interested once more in trivial things, but to be successful it means arousing the deeper feelings of their nature. Above all, the solace of tears will often save depressed and grieving persons from themselves. An interest in the sufferings of other people that awaken their sympathy will do the most to end exaggerated grieving over their own loss. The self-centeredness of their grief is the principal reason for its exaggeration. It is because of overestimation of their own importance and of the importance of their loss that these people suffer severely.

Motives of Consolation .—The main resource of the physician who would employ psychotherapy for the treatment of those who are grieving beyond the limit of what is normal, is to supply motives by which they can understand the real significance of their loss. Very often, especially in young folks, there is no proper estimation of values in life and no recognition of the fact that human life was evidently not meant for happiness since that comes to but few, while suffering and partings are inevitable. They come to all, and apparently will always continue to do so. It is the young or, at least, those under middle age, who are most likely to be affected by exaggerated depression over losses and disappointments. Older folks have grown more accustomed to such incidents. These patients must be made to see how many motives there are to take their grief philosophically and while permitting themselves the luxury of sorrow, not to let this interfere either with their physical condition or their mental state to such a degree as to prevent them from taking the proper interest in their duties in life.

The ethical motives that may be urged to keep people from grieving over-much are many, but there is sometimes the feeling in the physician's mind that it is scarcely his business to emphasize them in any way. It is supposed that to the clergyman must be committed the task of consoling people for losses in life. This has always seemed to me a serious mistake. As physicians we know how much the mind influences the body and since it is our duty to care for the body, we must, above all and first of all, care for the mind as far as we can. Mens sana in corpore sano is a very old motto and is usually taken only in the sense that to have a healthy mind one must have a healthy body. In its Latin form, however, it might very well also be taken to mean that to have a healthy body one must have a healthy mind. Since grief has an untoward influence on the body, physicians are bound to learn what to do for it in any and every possible way and to exercise every faculty they have for its relief. This is all the more true because in recent years many persons have no regular religious attendant who would come to offer them consolation or to whom they would go in their trouble. It is not at all with the idea of infringing on the rights of the clergy or invading his territory that I would insist not only on the right of the medical man, but even his duty, to afford consolation to the mind as well as relief for the body.

The Family Physician .—In older times the family physician was a friend of the family to whom people turned in all troubles where he might possibly be of aid, with just as much confidence and as promptly as they did to their religious attendant. Unfortunately, in the progress of medicine, though still more because of the social vicissitudes that have taken place in recent years, this relationship of the family physician has been largely diminished, but that constitutes only one more reason why every physician, to whose attention the grief of a patient for any loss is presented as a cause of ill-health, should know all the means and be ready to employ them for the amelioration of the condition. As a matter of fact, there is often a feeling on the part of patients that it is more or less the business of the clergyman to afford consolation and that the performance of his duty in this matter is somewhat conventional, not as if he performed it less thoroughly because of this, but as if the feeling of the routine practice detracted from its effectiveness. Some of the motives for consolation advanced by the clergyman, then, lose in significance, in some persons' minds at least, because of this feeling, while motives presented by the physician rather gain in weight because of the impression that he is a thoroughly practical man, deeply interested in life's problems from a common-sense standpoint, and who knows the motives for consolation because he has realized that losses are inevitable, suffering unavoidable, and grief sure to come, though somehow we must learn to bear up bravely under life as we find it.

Physicians have always done this in the past, but in more recent years either they have lost the habit, or have considered it unworthy of their profession, or else, perhaps, only too often they themselves have had no motives to offer that might seem sources of consolation for those in suffering and especially those who are grieved for the loss of friends. If life were a mere chance, if there were not an evident purpose in it, if, as Lord Kelvin insisted, science did not demonstrate (not "suggest" but "demonstrate" is the word he used) the existence of a Creator and a Providence, Who, while caring for the huge concerns of the universe, can just as well employ Himself with the little details of human life, then there would be some reason for physicians thinking that their science kept them from seeking consolation from the ordinary motives. Even if they occupy an advanced agnostic position, however, they may still find sources of consolation that, if not so effective as those attached to the old beliefs, at least will provide something for the forlorn to take hold of, that will mitigate their grief and sense of loss and make the present and the future look not all too blank.

Few men have been so thoroughly agnostic as Prof. Huxley, yet on the death of his wife he found that some of the thoughts of the old beliefs might prove a source of consolation. Huxley had loved his wife very dearly and their separation by death meant very much. The epitaph that he wrote for her sums up his doubts yet plucks out of them something to console, expressed in old Scriptural language:

  And if there be no meeting past the grave.  If all is darkness, silence, yet 'tis rest.  Be not afraid, ye waiting hearts that weep.  For God still giveth His beloved sleep;  And if an endless sleep He wills, so best.

Attitude Toward Death .—The ordinary attitude of people toward death is a very curious one. Death is the one absolutely certain thing in life after birth, yet most of us live our lives without much regard to it, and whenever it comes and under whatever circumstances, at whatever age, it is always a shock to us. No matter how old people are it always comes a little before it is expected. When death comes it is always a shock and all that can be said of it is what Hamlet resents when the commonplace consolations for the loss of his father, who also lost a father and so on all down the course of history, are offered to him. Perhaps, however, as much the reason for his resentment was the person who offered the consolation as the form of the consolation itself, which, after all, exhausts nearly all that we can say in this matter for grief for near and dear ones:

  King.    'Tis sweet and commendable in your nature, Hamlet,    To give these mourning duties to your father:    But, you must know, your father lost a father;    That father lost, lost his; and the survivor bound    In filial obligation, for some term    To do obsequious sorrow: but to persevere    In obstinate condolement, is a course    Of impious stubbornness: 'tis unmanly grief:        . . . Fie! 'tis a fault to heaven,    A fault against the dead, a fault to nature.    To reason most absurd, whose common theme    Is death of fathers, and who still hath cried,    From the first corse, till he that died to-day,    "This must be so."

Death and Pain .—One of the most effective consolations in our day for all classes of people, quite apart from religious affiliations or beliefs, is the sociological import of death and suffering in the world. Life, without suffering and death in it, would be a riot of selfishness. Men, as a rule, would not care for others at all, the weak would go to the wall, the individuals who possess less efficiency than others would simply have to make out as best they could, and bad as social conditions are now, they would be intolerably worse. As it is the young and strong and vigorous have very little of true sympathy. Nothing makes a man feel for others like having gone through some suffering himself. On the other hand, nothing makes him feel the impotence of struggling ceaselessly for vain success and the futile rewards of life than to lose near and dear friends whose share in that success and joy over the rewards would constitute their only real value and justification. As a man grows older and has gone through some of the sufferings and has had to bear the losses of life, he learns more and more to feel for others, he is ready even to make sacrifices that others may not have to suffer as he has suffered, he has charity for them for the sake of his own suffering and that of near and dear ones, and things are much better than they could possibly be without suffering and death.

Therapy by Example .—Many men have taken losses so seriously as to think that life held no more for them, and have foolishly given up their occupations, yet have found that Time, the great healer, could work his marvels in their case as well as in most others and that new interests and, above all, their life work, could arouse them to a sense of duty and bring them back to the old routine of life. Dr. Mumford, in his "Sketch of Sir Astley Cooper," tells the story of how even that veteran surgeon gave up everything at the death of his wife and yet found, after a year of idleness, that he had to come back to the old life again. Dr. Mumford says: "Sir Astley Cooper was an emotional man. In 1827 his wife died, and the event prostrated him with grief. He felt that all the interests of life were over for him. He fell into an acute physical decline, sold his town house, threw up his practice and other professional employments, and retired to his country place to pass his last days. Within a year of the sad event he had returned to town, taken another house, resumed practice with increased vigor, and married again. He was then sixty years old, he lived on until 1841, and died in his seventy-fourth year."

A typical example of how much a strong man whose diplomatic ability had stamped him as one of the large men of his generation may yet be afflicted beyond measure by a loss of this kind is to be found in the life of the second Lord Lytton. I have told it somewhat in detail in the chapter on Periodic Depression. After the death of his boy Lord Lytton, who for more than a week of anguish had watched unceasingly at the death-bed of his dying son, came to the conclusion that God was not in His world or, at least, that the arm of Providence was shortened if such (as it seemed to him) needless suffering was permitted. The boy had probably suffered much less than the bystanders thought and much less than he seemed to, for in these cases nearly always there is a merciful deadening of the senses that to a great extent eliminates suffering, but Lord Lytton could not understand and refused ever to look at life from the same standpoint afterwards. This is, of course, only what happens in many cases, but it represents an exaggeration of grief since death and suffering have always been in the world and sometimes they will come to those near and dear to us, much as we may resent it.

Neither profound intelligence nor the sympathetic genius of the poet or artist is sufficient to safeguard men against the severer forms of griefs for loss. Louis, the distinguished French physician (to whom we in America are indebted so much as the Master of the Boston and Philadelphia schools of diagnosis, and, above all, for his teaching of the differentiation between typhoid and typhus fever), suffered so much from the loss of his son that he could scarcely be consoled. Dante Gabriel Rossetti was so much affected by the death of his wife that he put into her coffin the only manuscript copy of his poems that he possessed. It is interesting to learn that some years later he had the coffin exhumed and took out his manuscript at the urging of friends, and published the poems. Many other examples of this kind might be given, for exaggeration of grief affects all classes and conditions in life. They are practically always pathological, usually on a basis of somewhat disturbed mentality, though often the real underlying and predisposing condition is the physical exhaustion that has preceded the loss and which makes patients unable to bear the strain of it after weeks of care, solicitude, anxiety and neglect of eating and sleep.

CHAPTER V

DOUBTING

In recent years the attention of physicians has been called to the fact that many people are made profoundly miserable by an unconquerable tendency to doubt about nearly everything that has happened to them, or is happening, or is about to happen. This is not a new phenomenon, but introspection has emphasized it, leisure gives more opportunity for it, and so physicians hear more of it now than they did in the past. This doubting tendency sometimes makes serious inroads on the peace of mind of sufferers from it because they cannot make up their minds to do things, even to take exercise, to eat as they should in quantity or quality, and to share the ordinary life around them sufficiently to get such diversion of mind as will keep their physical functions normal. The state used to be described as a neurasthenia (nervous weakness), but in recent years has come better to be designated as in the class of psychasthenias (lack of mental energy). It is always a mental trouble in the sense that it is difficult for these patients to make up their minds about things, yet it is not a mental disease in the ordinary sense of the term, and these people are often eminently sane and thoroughly intellectual when their attention has been once profoundly attracted. They may even, under favorable circumstances, be active and useful helpers in great causes, yet there is always to be observed in them a certain noteworthy difference in mentality from the normal. The physician can do more for an affection of this kind than is usually thought, and he is probably the only one who can thoroughly appreciate and sympathize and, therefore, be helpful in the condition.

Sufferers are often laughed at by their friends and relatives and are likely to be the subjects of at least a little ridicule if they take their troubles to their physician. As a matter of fact, however, doubting is a typical case for psychotherapeutics and not only can much be done for its relief, but it can be kept from disturbing the general health, which it is prone to do if neglected, and by mental discipline and acquired habits of self-control, the doubting habit may be almost completely eradicated.

Exaggeration of Ordinary State of Mind.—The first thing absolutely necessary to impress upon the minds of these victims of their own doubts is that their condition is by no means unique, it is not even very singular, but is only an exaggeration of that hesitancy and tendency to put off making decisions that practically every person finds in a lifelong experience. This frame of mind is rather cultivated by education and by a large accumulation of knowledge. The less one knows the easier it is to come to decisions about difficult problems and to form conclusions without hesitancy. The young man will decide anything under the sun, and a few other things besides, almost without a moment's hesitation, and after but slight consideration. Twenty years later he looks back and wonders how he did it, and having done it, how he succeeded in turning the practical conclusions to which he came to advantage. The scholar is eminently a doubter and a hesitater, and we recognize that he loses certain of the qualities that would make him a practical man of affairs, though he gains so much more that broadens and deepens life's significance that there can be no doubt about the value of his liberal education.

"Hamlet" is just the story of one of these doubters and hesitaters. He saw his duty clearly and that duty was imperative. In spite of cumulative evidence, however, he refused to go on to the performance of that duty, urging to himself now one and now another reason of delay, until finally he wonders whether it would not be worth the while to take his own life, rather than try any longer to solve the problems that lie around him demanding solution. When he finally does something, his hand is forced and circumstances have so arranged themselves that instead of one clean-cut punishment for a great crime, there is the tragedy that involves six lives, including his own. The play seems to involve such exceptional characters and to be written around such an unusual set of circumstances that it might be thought that it would prove uninteresting for men and women generally. As a matter of fact, however, "Hamlet" is the most popular of Shakespeare's plays and probably the most popular play, both for readers and auditors, that was ever written. There are commentaries by the hundred on it in nearly every modern language. Men have been more interested in this figment of Shakespeare's imagination than in any man that ever lived. Caesar and Napoleon have not attracted so much attention. Only Homer and Dante have been perhaps more written about than Hamlet.

Shakespeare has emphasized the condition of Hamlet by showing us an eminently well educated man. His deep interest in literature, and especially in dramatic literature and all that relates to the stage, can be appreciated very readily from his speech to the players. No one but a man of profound critical ability and deep intellectual interests could have so summed up the actors' relation to the drama. Of course, this is Shakespeare himself talking and unthinking people have said that this was a purple patch fastened on the play because it gave the author an opportunity to express his views with regard to actors and their ways. Instead of that, it is of the very essence of the development of Hamlet's character and shows us the scholarly amateur who knows so much about many things that he has become quite unable to make up his mind about the practical problems that lie before him. James Russell Lowell says that Shakespeare sent Hamlet to Wittenberg, though Wittenberg was not founded until centuries after Hamlet existed—and Shakespeare probably knew that very well—because Wittenberg in Shakespeare's time, on account of its connection with Luther and the religious revolt in Germany, had the widespread repute of occupying men's minds with doubts about many of the things that had been deemed perfectly settled before, and its popular reputation serves to give an added hint as to the character of Hamlet as the dramatist saw it.