Psychotherapy

In recent years it has been found that most of the good that is accomplished, especially for nervous people, by hypnotic suggestion, can be attained almost, if not quite as well, in this first stage, and without the hypnotic trance. The first stage is much less liable to the dangers of hypnotism in many ways, and it represents one of the most interesting phases of psychotherapy.

The second stage of hypnotism is the hypnotic sleep. The patient loses consciousness of his surroundings, though his senses are still open to suggestion from the operator. Practically all that happens in the room apart from what is brought to the subject through the operator's direction remains unnoticed. If the sleep is very deep, even the suggestions of the operator do not penetrate after a time, so it may be quite difficult to awaken the subject. It may be even some hours before the person hypnotized will come out of the lethargy which has been induced in these cases. Under these circumstances, this second stage partakes somewhat of the nature of the deeper trance condition that characterizes the third stage.

The third stage of hypnotism consists of a profound trance-like condition in which there is catalepsy—that is, firm contracture of muscles all over the body—and as the extensors are stronger than the flexors, this contracture takes place in the extended position. The cataleptic condition is really a nervous spasmodic seizure rather than a true stage of hypnotism. It is probably always harmful for the patient to have it induced. Its occurrence as one manifestation of hysteria, apart from hypnotism, shows its real character. It is with this stage of hypnotism that professional hypnotists, who give exhibitions, make their demonstrations—that is, of course, when their demonstrations are really hypnotic and are not merely, as is often the case, performances by actors trained for the purpose. Catalepsy is entirely pathological; experiment with it then is eminently undesirable, and certainly should not be undertaken except under the most careful precautions and by a physician. One of its dangers was very clearly pointed out by the death of a young man, who in a cataleptic condition was subjected to certain strains upon his thorax which brought about the rupture of an aortic aneurism. Catalepsy never permits of suggestion in such a way as to be helpful to the patient. It always leads to further functional deterioration of the nervous system, and yet it has unfortunately come to mean for many people the most essential characteristic of hypnotism. Its production is supposed to represent the acme of skill in the hypnotist. Nothing could possibly be less true nor be more likely to do harm.

Susceptibility.—As to the number of people who are susceptible to hypnotism, there are great differences of opinion. Liebault declared that practically every one is susceptible in the hands of a patient operator. In a carefully made series of cases his failures were less than three per cent. Van Rentergehem and Van Eeden, in a series of over 1,000 persons, failed only with fifty-eight, or little more than five per cent. Schrenk-Notzing's statistics, collected from many countries, seem to show that only about six per cent. were uninfluenced. Bernheim, at Nancy, was not nearly so successful as Liebault, his master, and his failures amounted to twenty-five per cent. at the beginning and at least twenty per cent. later. I remember that when I was at the Saltpêtrière fifteen years ago, they were inclined to discount the enthusiasm of the Nancy school with regard to the value and significance of hypnotism. They insisted that probably not more than one out of two of the persons presenting themselves at a nervous clinic could be hypnotized to the extent that is ordinarily associated with the word—could be brought beyond the drowsy stage. There are other workers in the subject who have insisted that not more than one out of three ordinary individuals can be so deeply hypnotized as to exhibit the ordinary symptoms. These symptoms consist of complete neglect of surroundings and absolute absorption in the suggestions of the operator.

Some people can be hypnotized to the extent of being thrown into sleep and yet walk and talk under the absolute control of the operator. These are so-called somnambules, the class of persons who are exhibited by professional hypnotizers who want to attract popular attention, and, indeed, the class usually exhibited by physicians before medical societies, and even by professors before their classes. This extreme susceptibility is, however, quite rare. Even the most ardent advocates of hypnotism and of the susceptibility of humanity to it do not claim that more than one in ten of average individuals can be influenced to this degree. There are milder degrees of hypnotism than this, until we reach a state in which all the patients feel is a certain dreamy sense of well-being and a heaviness of the eyes, with a readiness to respond to suggestions. Most people who think of the somnambulistic stage as representing hypnotism would not consider these latter to have been at all subjected to the hypnotic state.

Repeated Efforts .—As to this question of susceptibility, much depends on how often the operator has tried to hypnotize the particular subject, for susceptibility develops with repeated trials, not only where there is a manifest impression at first, but also where there is not. It is not uncommon to find that a patient who cannot be brought at all under the influence of hypnotism in the first or second or third trial, will, at the fifth or sixth trial, yield to the suggestion to go into a hypnotic sleep. A dozen unsuccessful efforts may be followed by the development of a very satisfactory hypnosis. Those who have practiced hypnotism much tell of having tried a score or even two score of times before finally bringing on a hypnotic condition. Dr. J. Milne Bramwell, one of the English authorities on hypnotism, tells the story19 of having tried sixty or more times to hypnotize patients before finally succeeding. It is this persistence that enables successful hypnotic operators to accomplish results where less confident physicians fail. It is also the frequency of trial that makes all the difference in the statistics as to the susceptibility of patients to hypnotism in the hands of different individuals. There must be the confidence of the patient in the physician's power to hypnotize, but, above all, there must be the physician's own confidence in his power to bring on the hypnotic sleep so that he tries and tries again, even to seventy times.

ANIMAL HYPNOTISM

The hypnotization of animals shows that only a very low grade intelligence is needed for the production of this state. The famous experiment of Father Kircher with the hen, which any one may repeat at any time, is a good illustration. The fascination exerted upon birds by snakes is another familiar example. The bird is paralyzed with terror at the sight of the snake, and so cannot escape from its enemy, fairly glueing its eyes on the terrifying object, and thus loses power to control its wings. Stories of snake fascination are usually told as if the eye of the snake attracted the bird, who thereupon proceeded to approach the snake. These are, however, doubtful stories. The paralysis of motion seems to be the main effect. The rabbit is affected in nearly the same way. There is a tremor of horror in anticipation, and then the animal stands perfectly quiet, though ordinarily he would be quite able to escape, while its enemy approaches. The underlying mechanism is evidently a concentration of attention, which completely precludes the possibility of the exertion of any spontaneous energy except that involved in the one act of watching the awful object.

DANGERS OF HYPNOTISM

There are many and various opinions of the dangers of hypnotism. Some of those who have given it a fair trial have insisted on its dangers. Some of those who have had very large experience have declared emphatically that there is no danger at all. Occasionally it has seemed that such a declaration must be considered as having been dictated by such intensity of interest as sometimes leads men to overlook the darker side of things with which they are much occupied. Certain moral aspects of hypnotism are at least dubious, and, it must be admitted, present opportunities for abuse. There are certain dangers connected with its effect upon nervous patients, and especially with its influence upon character, that have become more and more clear in recent years. Dr. John K. Mitchell, in his "Self Help for Nervous Women," a series of familiar talks on economy in nervous expenditure,20 has dwelt on certain of these dangers of hypnotism for nervous patients in a passage that deserves to be recalled. As a representative of a school of thought that is worthy of special regard from American physicians his expressions must carry weight:

[Footnote 21.]

The greatest danger of all is the use of hypnotism in any form or degree, a two-edged sword, capable indeed of usefulness, but more capable of harm. After years of study, beginning with too easy an approval of it, hypnotism, whether called by that name or by the unsuitable one of suggestion, has been laid aside by the medical profession as a means too dangerous for ordinary use, involving great risk of deterioration of character in the subject if often repeated, and putting a terribly tempting tool in the hands of the user, fascinating in the ease with which it can produce superficial and temporary good results and equally capable of being used for harmful ones.

A susceptible person, once hypnotized, is more and more easily thrown into the hypnotic state until even the slightest hint suffices to bring about the condition. It is not necessary for the hypnotization to go so far as deep sleep; this more advanced stage is indeed seldom required, and to say that persons are not hypnotized because they are not put into a sleep or a trance shows ignorance of the subject.

I am not asserting that very slight degrees of the hypnotic condition are as dangerous as the deeper, but I do say that all degrees of it are dangerous to the integrity and healthy action of the subject's nervous system. The danger of harm increases with every repetition of the hypnotization.

In suggestible, that is, over-susceptible, individuals, who are almost universally neurotic persons, to fix the eyes on a small point, especially a bright one, sometimes even to fix the mind on the one idea of going into the hypnotic state (mild or deep), is enough without further intervention from any one to put them into that state.

In an article on the "Danger and Uses of Hypnotism" Prof. Forel, of Zurich, twenty years ago, while frankly admitting that hypnotism is by no means a panacea for all nervous affections and unfortunate habits, found it to be an extremely valuable help in the treatment of many forms of functional nervous disease. He suggests that some of its many dangers are due to the fact that hypnotism is practiced by men who are too distrustful of it, and this distrust, unconsciously communicated to the patients, produces an unfortunate effect. On the other hand, fear and distrust on the part of the subjects seriously disturbs the process of hypnotization, interferes with its effect and sometimes leads to unfortunate results.

In some cases it seems that the state of dependence on some one else, at least by suggestion, that had been created during the hypnotic experience, resulted in a diminution of will power and caused a less hopeful state on the patient's part than before. I found personally that suggestion in the waking state might in most cases be used quite as efficiently as hypnosis itself, and that when improvement came under these circumstances, the patient always felt more confidence in himself and less in the operator. Anything that restores self-confidence and gives patients the feeling that they can conquer inclinations, tendencies, even habits, if they only will, merely by firmly resolving to do so, is the best possible mental influence for them. The hypnotic relief is always easier, but nothing that is easy is likely to be of lasting value. The enduring effect of gradual cure by suggestion means much more than the hypnotic miracle that these patients are so prone to crave.

At present there is a very general feeling among those who have had considerable experience with hypnotism, that in spite of the claims of certain votaries for it, there is no justification for its frequent or habitual use. It has a definite place in diagnosis, in certain difficult cases, and at the beginning of the treatment of certain forms of the psycho-neuroses. When repeated frequently it is not therapeutic, but is likely to produce serious results in a certain lack of self-control and tendencies to auto-hypnotization with deterioration of character. There is very seldom need of a repetition of deep hypnosis, and, as a rule, all the diagnostic benefit can be secured in one or two seances. Its continued use only illustrates the tendency noted at all times, in the history of medicine, for the unthinking or unprofessional to persist in the application of supposed remedial measures after they have been shown to be useless or even harmful. The subject well deserves further study, but investigations should be carefully made by men who realize the dangers, and who are not likely to be tempted to exploit patients and curious psychological phenomena for the sake of sensational reputation. The use of hypnotism for exhibition purposes, by men who are not physicians, is an unmixed evil, producing entirely wrong impressions on the public, and doing untold evil to the subjects employed.

SECTION III

THE INDIVIDUAL PATIENT

CHAPTER I

PSYCHOTHERAPY AND THE INDIVIDUAL PATIENT

The most important element in Psychotherapy is the individual patient. Old Dr. Parry of Bath said a century ago, "It is much more important to know what sort of a patient has a disease, than what sort of a disease a patient has." Mental influence is not of the slightest avail against pneumonia or typhoid fever, nor constipation nor rheumatism as such; mental influence may be, and often is, of the greatest possible help to the patient suffering from any of these diseases.

We recognize frankly now that for most diseases we can do nothing to counteract the disease directly or to cure it specifically. The idea of specifics in medicine has to a large extent disappeared. Two or three of them possibly we have, but even with regard to these, there are certain doubts as to the essential modes of their activity. We have learned, however, to help the patient to overcome disease. We know how to conserve his forces, to increase his vital reaction, to maintain his nutrition without disturbing his general condition, and to secure elimination in such a way as to prevent nature from being interfered with in her curative purposes. To this, psychotherapy would enable us to add such encouragement of the patient as would tap new sources of energy in him according to the law of reserve energy, and would prevent discouragement and the inhibition of favorable nerve impulses that so often follow. The outcome of any disease depends on two factors. One is the condition of the patient at the time the infection was acquired, the other is the virulence of the infection. We can do nothing to modify this latter element, once the disease manifests itself. We can, however, do much to enable the patient to throw off the disease and, above all, by securing a favorable attitude of mind, we can enable him to use his forces to the best advantage.

Anyone who has noted the difference between the patient's state just before and just after his physician has called, though absolutely no physical remedy has been employed, is able to realize very well how much psychotherapy is able to accomplish. One who did not know, would be sure to assume that some potent remedy had been administered—and there has been. This potent remedy is psychotherapy. Whether the personal magnetism necessary to produce therapeutic effects of this kind can be learned or not depends on the individuality of the physician. Undoubtedly, however, everyone can add to whatever of personal influence he has by definitely recognizing its place, by making every effort to employ it, and then by regular systematic effort in securing as much personal information as possible with regard to the patient. This personal relationship of physician and patient makes instruction easier and suggestion more effective.

The securing of personal information is of the utmost importance in determining the affections that psychotherapy will relieve, because very often details of life and habits are discovered that can be so modified by instruction as to bring about a disappearance of unfavorable physical influences. It is indeed surprising to find how many unreasonable things people do from habit, from unfortunate persuasion, or from lack of knowledge. In many of the minor chronic ailments that are the source of so much mental discomfort to patients, the physician finds that a change in the patients' habits, not necessarily of marked degree, may make all the difference between cheerful health and rather despondent low-spirited feeling. Now that epidemic disease has become rarer, a physician's practice, especially among the better classes, is much more taken up with these minor ailments than with the typical classical diseases.

The ordinary history of their ailments, as patients commonly present them, especially when there are neurotic elements, is likely to be meager in what is objective, but consists mostly of the subjective. Such patients have much to say of their sensations, their feelings, their dreads, their surmises, their conclusions as to their particular condition, and especially the hereditary elements in it, but comparatively little of the objective realities of their ills and of their environment. What the physician needs to know about them is their habits of life, their daily routine of existence, just as minutely as it is possible to obtain the information. There is just one way to get the latter details, and that is to inquire particularly with regard to actual happenings. In chronic conditions of many kinds, it is so helpful that it will always be worth the physician's while to get at these details, especially in supposedly puzzling cases for which various forms of treatment have been already tried.

In spite of every precaution in this matter, the physician sometimes finds, after a series of consultations, that some point which when brought to light he considers to be of great importance, has been thought so trivial by the patient that it was never mentioned, in spite of the most careful questioning. In all medical practice the rule is that mistakes of diagnosis are much more due to neglect in eliciting necessary information than either to lack of expertness in diagnosis, or lack of knowledge of the significance of symptoms.

In the affections that can be relieved by psychotherapeutics, the most important element for diagnosis, besides a minute knowledge of the patient's habits, is just as detailed information as possible with regard to his ways and modes of thought as to his ills. Practically every motive, as well as every action of the day, must be scrutinized, and often it will be found that little things mean much for the individual. "Trifles make perfection, but perfection is no trifle," as said by Michelangelo, might well be changed for the physician to, "Trifles make all the difference between health and discomfort, though health is no trifle."

CHAPTER II

THE MORNING HOURS

In getting the history of patients for diagnostic purposes the safest way is to begin with the getting up in the morning and then to follow out the various actions of the day. The hour and mode of rising should be inquired into. Practically all nervous people, and nearly all those beyond middle life, feel less fit in the morning hours than at any other time in the day. Apparently as a consequence of their will having been allowed to lose its hold during sleep, it does not secure thorough command over the organism for some time. Nervous people, as a rule, wake up with a tired feeling, a dread of the day, wondering whether life is worth living. They dread—for it is a real dread—to get up and tackle the daily round of life once more.

If they have nothing very definite to do, then slight tired feelings or discomfort, even of very minor degree, may lead them to think that they cannot get up. Any yielding in this matter is almost sure to do harm. When there are no objective signs, that is, when there is no fever recognizable by the thermometer and there has been no diarrhea or any physical weakness, nervous patients should get up promptly at a particular hour every morning, because, as a rule, within a half hour after getting up they feel better, and by the time they are washed and have had their breakfast, life has grown not only quite possible but even plausible, and the day's work does not seem such a nightmare as it was at first. It is not advisable to tell people all this as soon as they confess their habit of dawdling in the morning, for they must be gradually brought to discipline themselves. The detail emphasizes the necessity of knowing how they get up as well as when.

Mode of Awaking.—It is often valuable to know how patients awake. Sometimes it will be found that they are anxious and solicitous to be at work at a particular hour, or to catch a train at a particular time, and that as a consequence their sleep is disturbed in the early morning hours. At best it may be fitful and when they awake they fear to go to sleep again lest they oversleep. An alarm clock will sometimes remedy this state of affairs. Better still is an arrangement by which someone, who can be depended on, will wake them at a particular time. Occasionally patients cannot content themselves in spite of the assurance that they will be waked. They dread that the alarm clock may not go off, or that the awakener may make a mistake, and so they go to bed with a dominant idea, which is more or less constantly present in their mind during all their sleeping hours, disturbing sleep and preventing complete rest. It may be necessary to insist on a change of occupation for such persons, or a change of residence that will do away with the necessity for early rising. When this is done, many a neurotic condition that has before proved intractable will disappear.

Amount of Sleep.—It is of cardinal importance to know how long patients sleep. In our large cities most people have too little sleep. A comparison of the hours when they get to bed with those when they get up will often show that at least three or four nights in the week some patients who are complaining of nervous symptoms, especially nervous indigestion, are sleeping less than seven hours. There are but few men, and still fewer women, who will retain their health under such conditions. Some men have been able to do it, but they are comparatively rare. King Alfred's rule of dividing the day into three eight-hour periods—one for sleep, one for work, and the third for bodily necessities and recreation, still remains the best for human nature. Whenever people try to live the strenuous life and get along on less than eight hours of sleep, they are almost sure, sooner or later, to render themselves uncomfortable, to make themselves liable to all sorts of neurotic symptoms and, above all, to detract from their efficiency for whatever work they are engaged in. Whether they sleep or not, they should be in bed for nearly eight hours.

Bathing.—Morning Bath.—In our larger cities at least, many of the inhabitants begin the day with a bath. In this matter one finds all sorts of harmful fads that need to be corrected. Many men take a cold bath, and unless they are particularly strong and vigorous, this is rather an exhausting experience for the beginning of the day, when the last nutrition the body absorbed is twelve hours before. On the other hand, large, athletic men who manufacture a great deal of heat, their muscles—the heat-making organs—being well developed, will be benefited by having a cold bath because of the abstraction of heat that it involves. It is not, however, infrequent to find that the man for whom it will be good is not taking it, while the thin, neurotic individual, already exhausting more of his vitality by worry and dieting and in various fads with regard to his health than is good for him, is regularly taking his cold plunge or douche. Unless especially asked about it, few men give particulars in this matter, yet they are extremely important.