Psychotherapy

Natural Relief.—The fourth step in the application of psychotherapeutics is that all the natural modes for the relief of symptoms, the making of patients comfortable in body as well as in mind, must be employed. In acute rheumatism, for instance, a number of small pillows must be at the disposition of the patient so that his limbs can be fixed in those positions in which there is the least discomfort. Every physician should frequently read Hilton's classical volume on "Rest and Pain" because of its unpretentious significance for psychotherapy, as well as its enduring value in the treatment of painful conditions. Just as soon as a patient finds that simple procedures relieve his pain and add to his comfort, his fear of the seriousness of his ailment is lessened, and he begins to get bettor. Cold water in fevers, cold fresh air in pneumonia, all the natural modes of treating disease, thus become active factors in the application of psychotherapy. When fevers were treated by the administration of hot drinks the effect upon the patient's mind must have been quite serious. Freedom to use cold water, just as one wants it and whenever it is craved for, is of itself an excellent suggestion.

Neuroses in Organic Disease.—Fifth, psychotherapy, by suggestion, may alleviate or even completely eradicate neurotic symptoms that develop in connection with organic diseases. Such neurotic symptoms may prove even more bothersome to the patient than the symptoms due to his underlying affection, and may, by interfering with nutrition, hamper recovery. The appetite of a patient who is worrying about a chronic disease will be disturbed, and, as a consequence of insufficient food, constipation and a whole train of attendant evils may ensue. Headache, sleeplessness, worry at slight irritation and exaggerated complaints from slight pain may all be due to this worry and not to the underlying disease. All these, the result of over-solicitude, are attributed by the patient to his chronic ailment. They can be relieved by simple measures after he is saved from his own worry. Until the patient is made to rouse himself and look hopefully at the situation, eating more, getting out more, and relaxing his mind from its constant attention to himself, he cannot get better.

Application of Principles.—It should be pointed out to the patient that there is a constant tendency to exaggerate the significance of disease. This is true in acute as well as in chronic disease, but in acute diseases the necessity for removing unfavorable influences directly is not so urgent, since usually the presence of the physician, with his simple declaration of the meaning of symptoms, is sufficient to neutralize the effect of previous exaggerations.

Secondly, the action of unfavorable suggestions due to imperfect knowledge (everything unknown is magnified, as Cicero said), or to previous medical opinions which the case does not justify, must be stopped. The natural dread which comes to all men in the presence of symptoms of disease must be as far as possible removed.

Thirdly, the favorable elements in the case should be emphasized. This needs to be thoroughly done in order to secure the patient's co-operation, even though the serious possibilities of his ailment may be pointed out to his friends. These friends, however, must be persons who can be absolutely depended on not to reveal by word, or, what is much more important, by their looks or actions, the possible worse prognosis of the case.

Unfortunately, people expect a doctor to tell them the worst, rather than the best. Many physicians seem to have formed the habit of representing the condition of patients as grave as possible, in order, apparently, that they may have more credit when the patient recovers. Not a little of the tendency of ills to hang on in neurotic persons is due to this habit. Over-cautiousness leads some physicians to reveal a case in its worst aspect, lest, by any chance, something unexpected should happen, and the friends of the patient might think that the physician was incompetent because he had not anticipated it. Some of the serious accidents of disease are quite beyond anticipation; but they occur only rarely. For the sake of safeguarding the possible reflection on the physician because of them, it is quite unjustifiable to make bad prognosis habitually, for this acts deterrently on the vital resistance and delays recovery.

Symptoms of Organic Disease .—It is usually considered that psychotherapy is beneficial only in nervous cases; yet we know that all sorts of affections with tissue changes in the skin, in the circulation, and very probably also in the internal organs, may be produced in hysterical affections—ailments dependent on loss of control over the vaso-motor nervous system. Just as ills can be produced, so they may also be cured. As a matter of fact, analysis of the statistics of disease cured by mental influence, shows that it has been more strikingly manifest in organic than in so-called nervous or functional diseases. Neurotic patients often make extremely unsuitable subjects for the exercise of mental influence, because their very nervousness is a manifestation of lack of power properly to control the mind. Cures by mental influence have oftenest been reported in non-neurotic patients. As Dr. Hack Tuke pointed out in "The Influence of the Mind on the Body" as long ago as 1884, it is in such cases as rheumatism, gout and dropsy that benefit was most frequently reported by mental means.

Tuberculosis, certain digestive and intestinal ailments that evidently are associated with tissue changes, have in recent years come particularly into this category of ailments affected by psychotherapy. Dr. Hack Tuke's declaration, made nearly thirty years ago, seems conservative even at the present day: "The only inference which we are justified in drawing from the statistics of the affections cured by mental means is that the beneficial influence of psychotherapeutics is by no means confined to nervous disorders." Many physicians are likely to hold that when cures take place the so-called organic diseases were not actual, but were only supposed to exist because of certain obscure symptoms that apparently could not otherwise be explained. But many of the cases have had external symptoms, striking and unmistakable. To assume that physicians of experience and authority were in error in diagnosing them is simply to beg the question. It is more probable that mental influence acted curatively even over tissue changes as it so often does, directly under our observation, in the production of such changes in the skin.

Tissue Changes From Nerves .—Until one recalls how many physical changes may be brought about by mental influences or emotional disturbances, it is not always clear just how mental influence can affect disease favorably or unfavorably. Prof. Forel, of Zurich, in his "Hygiene der Nerven und des Geistes im Gesunden und Kranken Zusande," Zurich, 1905, English translation 1907, brings together into a single paragraph most of these physical and physiological influences of the mind upon the central nervous system:

Through the brain and spinal cord, thoughts can lead to a paralysing or stimulation of the sympathetic ganglion nodes, and consequently to blushing or blanching of certain peripheral parts. Through disturbance of this mechanism, many nervous disorders arise, such as chilblains, sweats, bleeding of the nose, chills and congestions, various disturbances of the reproductive organs, and, if it lasts long enough, nutritional disturbances in the part of the body supplied by the blood vessels affected. In the same way there are peripheral ganglionic mechanisms which superintend glandular secretion, the action of the intestinal muscles, etc. These likewise can be influenced through the brain by ideas and emotions. Thus we can explain how constipation and a vast number of other disturbances of digestion and of menstruation can be produced through the brain, without having their cause in the place in which they appear. It is for the same reason that such disturbances can be cured by hypnotic suggestion.

Health and the Central Nervous System .—Nature has so constituted and ordered the human economy that its health depends to a great extent on conditions in the central nervous system. We discuss elsewhere the return of vitalism in physiology—that is, the reassertion of a principle of life behind the chemical and physical forces of the human organism regulating it, supplying energy, occasionally enabling it to transcend the ordinary laws of osmosis, or the diffusion of gases. The main seat of this principle of life is in the central nervous system and especially in the cerebral cortex. The importance of this portion of the human anatomy can scarcely be exaggerated. In his inaugural address to the Royal Medical Society,22 delivered at Edinburgh in 1896, Prof. T. S. Clouston, the distinguished English psychiatrist, has a passage on this subject that deserves to be recalled:

[Footnote 23: British Medical Journal, January 18, 1896.]

I would desire this evening to lay down and to enforce a principle that is, I think, not sufficiently, and often not at all, considered in practical medicine and surgery. It is founded on a physiological basis, and it is of the highest practical importance. The principle is that the brain cortex, and especially the mental cortex, has such a position in the economy that it has to be reckoned with more or less as a factor for good or evil in all diseases of every organ, in all operations and in all injuries. Physiologically, the cortex is the great regulator of all functions, the ever active controller of every organ and the ultimate court of appeal in every organic disturbance.

Psychotherapy in Its Relation to Patient and Physician .—In spite of the present-day fad for psychotherapy, I have no illusions with regard to its popularity among patients, unless practiced with due regard to individuals and with proper tact. Psychotherapy has been most effective in the past when it was cloaked beneath the personality of the physician; when it was felt that there was in him a power to do good that must help the patient. This personal influence has to be maintained if the patient's mind is to be influenced favorably. Very few people are willing to think, and still less to welcome the thought, that they themselves are either bringing about a continuance of their symptoms or are hindering their own recovery. They are quick to conclude that this would be a confession that their ills are imaginary. "Imaginary" has no place in medicine. There are physical ills and mental ills. Mental ills are just as real as physical ills. There are no fancied ills. A person may be ailing because he persuades himself that he is ailing, but in that case his mind is so affecting his body that he is actually ailing physically, though the etiology of the trouble is mental.

It is the duty of the physician to get at these mental causes of physical ills and remove them by persuasion, by reassurance, by changing the mental attitude, by making people understand just how mind influences body, but this must be done tactfully. From the beginning of time we have written our prescriptions in such a way that ninety-nine out of one hundred patients have not been able to understand them. It has often been said that we should change this method of prescription writing, and write directions for the compounding of our medicines in plain vernacular. Besides the many scientific reasons against this, it is better for patients not to know exactly the details of their treatment. Physicians, because of their real or supposed knowledge, are usually the worst patients. If, when a physician is ill, a drug is administered in which he has lost confidence, he will really oppose its action by contrary suggestion, and perhaps neutralize it. Confidence added to the action of the drug itself, makes it much more potent and much more direct. Hence the suggestive value of a prescription the ingredients of which are unknown. Every physician knows of patients who have declared that a drug has been tried on them without avail, when it has only been used in such small quantities as to be quite nugatory in its effect. Such use was enough to prejudice them against it so that when given in physiological doses it failed to work properly.

Opium given to a trusting patient, in gradually reduced doses until practically there is nothing but the flavor of the drug in the compound that he takes, will continue to have its effect. But to a patient prejudiced against the drug, even large doses of opium will prove unavailing, because the lack of confidence disturbs the mind, directs attention to whatever discomfort may be present, emphasizes the ill and prevents sleep by preoccupying the mind with the thought that neither the drug nor the dose can accomplish its purpose. In a word, medicine plus mental influence is extremely valuable. Medicine minus mental influence is valuable but sometimes ineffective. Medicine, with mental influence opposed to it, is often without effect because of the strong power the mind has over bodily functions.

Most people would rather be cured by some supposedly wonderful discovery, which presumedly made it clear that they had been suffering from a severe and quite unusual ailment, than by ordinary simple methods. The recent growth of interest in psychotherapy and psychology has, however, somewhat prepared people to accept mental influence as an important factor in therapeutics. The direct and frank use of psychotherapy will be of benefit to these people. But in most cases mental influence will have to be exerted in such a way as to conceal from patients that it is their own energy we want to tap to help them cure themselves. This would be for them quite an unsatisfactory method of being cured. In practically all cases such a combination of methods is needed that the place of mental influence is not over-emphasized. As a rule, mental influence must not be used alone. Its place is that of an adjunct, a precious auxiliary, to other methods of treatment.

Psychotherapy represents one of the important elements in therapeutics, and we must learn to use it in a way suitable to our patients. We have to learn to use our drugs in accordance with the nature and physical make-up of the patient. We have to find out by experience just how to use hydrotherapy for each individual. Varying currents of electricity and varying forms of electrical action are needed for different individuals. Just in the same way, our psychotherapy must be dosed out according to the special need of each individual, the form of the affection and the particular kind of mind that is to be dealt with. To learn the place of mental influence in healing, so that we shall not be attributing to other therapeutic factors what is really due to the mind, will be a great advance in therapeutics. This is the mistake that we have been making in the past.

In brief, the applications of the general principles of psychotherapy include all means, apart from the physical, of influencing patients. Drugs will always have a large place in rational therapy. Many physical remedial measures, hydrotherapy, electrotherapy, climatotherapy and others, must be important adjuncts. To these is now added psychotherapy. It has been used before, as have most of the other forms of therapy, but in our day we are trying to systematize therapeutic modes so as to secure the greatest possible information with regard to their exact application. This is what must be done with regard to psychotherapy also. Just now its importance is being exaggerated by ardent advocates. In every department of therapy this has always been done by enthusiasts. The business of the practicing physician must be to select what is best, and above all what is sure and harmless, from the many suggestions offered, so as to build up a practical body of applied truth.

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1

"AEquanimitas and Other Addresses."

2

London, 1901.

3

"Die Psychische Krankenbehandlung im Ihren Wissenschaftlichen Grundlagen." Berlin 1910.

4

Houghton, Mifflin Co., Boston.

5

"See pointed metals, blest with power t' appeaseThe ruthless rage of merciless disease,O'er the frail part a subtle fluid pour,Drenched with the invisible galvanic shower,Till the arthritic staff and crutch foregoAnd leap exulting like the bounding roe!"

6

"Mesmer and Perkins's Tractors,"

International Clinics , Vol. III, Series 19. 1909.

7

Compare the first effects of the Leyden Jar, related in the chapter on Pseudo-Science.

8

Houghton Mifflin Co., Boston.

9

A king of Italy of the later nineteenth century used to send the parings of his toe-nails to friends to be worn in rings for luck and protection against disease.

10

Small, Maynard & Co.. Boston, 1909.

11

Paris, Maloine, 1804.

12

American Magazine , Sept., 1908.

13

McClurg, Chicago, 1903.

14

This article is a translation made by the author shortly after a visit to Ramon y Cajal in Madrid, in 1900. See International Clinics, Phila., Vol. II Series Eleventh.

15

International Clinics , Vol II, Series 11.

16

A number of poetic products of dreams are in our literature, some of them interesting for more than their curious origin. Dr. S. Weir Mitchell, in his latest volume of poems, "The Comfort of the Hills," made an interesting contribution to the psychology of dreams by publishing two poems which were composed by him while asleep. The little poem, "Which?" has all the curious alliterativeness and frequent rhyme that is so likely to be noted in expressions that come during sleep, or just as we awake. The other is more like a somnambulistic effort. What we might suggest here is that the habit of poetizing during sleep would surely be dangerous to any one less eminently sane than their author. We give them as curious examples that will interest patients who complain that their dreams are too vivid.

17

"Louis Agassiz, His Life and Correspondence," edited by Elizabeth Cary Agassiz, Houghton, Mifflin and Co., 1885.

18

The story of Hans, the calculating horse, shows that even animals usually thought rather dull-witted may catch muscle movements so slight as to be scarcely visible to any but one looking particularly for them.

19

"Hypnotism. Its History, Practice and Theory," by J. M. Bramwell, 2nd edn. London, The De la More Press, 1906.

20

Philadelphia, Lippincott, 1909.

21

"Curiosities of Lead Poisoning," International Clinics, Eighth Series, Vol. II.

22

British Medical Journal , January 18, 1896.