Psychotherapy

When my blue devils are cast out, and I recover sanity of spirits, then I say to myself just what you say to me in your letter—that the main thing is not to do but to be; that the work of a man is rather in what he is than in what he does; that one may be a very fine poet yet a very poor creature; that my life has at least been a very full one, rich in varied experiences, touching the world at many points; that had I devoted it exclusively to the cultivation of one gift, though that the best, I might have become a poet as great at least as any of my contemporaries, but that this is by no means certain to me for my natural inclination to, and unfitness for, all the practical side of life are so great that I might just as likely have lapsed into a mere dreamer; that the discipline of active life and forced contact with the world has been specially good for me, perhaps providential, and that what I have gained from it as a man may be more than compensation for whatever I may have lost by it as an artist.

It is surprising to think of a man of this kind becoming so depressed by the death of a son that all the world and the meaning of life took on a somber hue for him. In 1871 Lord Lytton lost a young boy by a very painful illness which had probably been more painful for sympathetic onlookers than for the patient himself. The incident proved sufficient, however, to make the father think that there could not be a beneficent Providence ruling over the world. He felt sure that somehow God's power must be shortened, if such suffering, for which he could see no reason, had to be permitted. He was much depressed after this and never was quite the same in his outlook upon the world and the significance of life. It was easy to understand that this was due rather to his character than his intellect, but it illustrates forcibly how much a deeply intelligent man may be affected by something that seems after all, only the course of nature.

It is sometimes surprising to find from the life stories of men how often those who would be thought least likely to suffer from periodical depression were victims of it. Few Americans in our time have apparently had a more satisfying career than that of James Russell Lowell, a successful author as a young man, then a successful editor, a teacher whom his students appreciated very much, and in later life the subject of many honors and such honors as provided him with splendid opportunities for the exhibition of his special genius. He would seem to be the last who should suffer from depression. His post as Minister to Spain gave him an opportunity which he took magnificently to study the great Spanish authors and to store up material for writing about them. As Minister to England few men were so popular. He was constantly in demand for occasional addresses and his special style enabled him to respond to these demands with brilliant success. Here in America no great occasion was complete without Lowell. In spite of all this that would surely seem ample to satisfy the aspirations of any man, Lowell was often depressed and sometimes even talked about the possibility of suicide. Life seemed at times very empty to him. The story of the lives of such men, if made familiar to patients, proves a source of consolation, for it makes them realize that they are not alone in their experiences, that depression at some times is the lot of man, and that very few people are without the sphere of its influence.

Depression an Incident, not a State.—This suggestion may, in the case of some of those inclined to longer periods of depression, lead to indulgence in the luxury of being depressed and so putting off the doing of things. It must be pointed out, however, that just inasmuch as depression has this effect it is pathological. It seems to be natural to man to suffer from periods of discouragement and depression which keep him from devoting himself too persistently to lines of work that may be insignificant and make him take cognizance of the real values of what he is doing. Depression, however, that continues after the recognition of this takes place is morbid and must be actively resisted. Just inasmuch as depression precedes and prepares patients for a reaction, it is an incident in practically all lives. Indulged in as a luxury, it is abnormal.

Suggestive Treatment.—The most important thing for patients who suffer from periodic depression is to make them understand that this state of mind, far from being personal to them or very rare, or even uncommon, is an extremely frequent experience of men and women. There are certain men and a few women eminently occupied with the external life, busy with many things, though often they are trivial enough, and even when they are important, significant only in a financial or a social way, but meaning nothing for the great realities of life, who seem during their younger active years to escape the periodical attacks of depression that come to most people and come almost without exception to people who think seriously. Some of the best thoughts and inspirations of men come to them as the result of the serious mood that follows an attack of depression. A butterfly existence lacks these sources of inspiration. Far from being objectionable then, attacks of depression, if not allowed to proceed too far, and if kept from paralyzing activity, prove to be intervals when life values are seriously weighed and when a proper estimation of such values is come to. Men are prone without such interruptions to get too interested in trivial concerns that seem to them important because they are occupied with them to the exclusion of other ideas, but that prove to be of no real import when seen on the background of a certain hollowness that there is in human life, if lived merely for its own sake.

The occurrence of periodical depression is a part of the mystery of life and it affords us a better opportunity to get a little closer to the heart of the mystery than almost anything else. It is out of such periods that men have risen "on stepping-stones of their dead selves to higher things" and have even risen to the highest that there is in life. Geniuses have nearly always had deep periods of depression, but in the midst of them have read new meanings into life and have read the lessons of humanity in their own souls better than at any other time. Depression throws a man back on himself and makes him think deeper than in his mind—in what has been called his heart. "The fascination of trifles obscures the good things in life" are words of old-time wisdom and men are weaned from this by fits of depression that are really moods of precious dissatisfaction with their work inasmuch as it falls short of the best accomplishment. Without periodic depression, apparently, a man never gets as close to the heart of life as he otherwise would. Far from being an unwelcome visitant, it should be rather welcome as a stimulus to the possibility of further study of self and the realities of life.

CHAPTER VII

INSOMNIA

To the minds of many people insomnia is one of the most serious ills to which human nature is heir. Most of this quite false impression is due to the sensational cultivation of dreads with regard to insomnia by newspapers and in general conversation. If we were to credit such impressions, there is a certain number of unfortunates who, for some unknown reason, find it impossible to sleep and who, night after night, drag out the weary hours wooing sleep that does not come, until when daylight dawns they are in despair, distracted by lack of rest. This is presumed to occur night after night, until finally the worn-out mind succumbs to the intolerable anguish of being kept constantly on the rack of wakefulness and the patient becomes insane or saves himself from that by suicide. No wonder, then, that many a one of these patients takes to the use of habit-forming drugs to produce sleep. These, though effective only to a small degree, soothe him for the time, but finally render him such a wreck that there is not even will power enough for him to take his own life and end his intolerable suffering.

Such gruesome pictures of the awful effects of insomnia run rife and produce dreads in the community until just as soon as the ordinary nervous supersensitive person loses an hour or two of sleep two or three nights in a month, he begins to conjure up the specter of insomnia with its awful terrors and still more awful possibilities, and begins to bewail the fate that has chosen him as an unfortunate victim. This exaggerated dread that slight losses of sleep, for which there are often excellent reasons, will develop into an incurable condition of persistent wakefulness has more to do than any other single factor with the production of the state called insomnia which is, however, never half as bad as it is pictured.

Absolute Sleeplessness.—A certain number of patients insist that they sleep very little at night and some tell their friends and even their physicians quite ingenuously that they sleep none at all, and that this has been the case with them for a prolonged period. Practically every physician has heard such stories, and at the beginning of his professional career has usually wondered how the patients continued to live and enjoy reasonably good health in spite of the lack of absolutely necessary brain cell rest. After the physician has the opportunity to investigate some of these stories he understands them better. Patients in hospital, who insist that they are wakeful all the night, prove usually when faithfully watched by a nurse to be wakeful for an hour or two at the beginning of the night and then to sleep for hours at a time, and all of them sleep for intervals more or less prolonged, though they may wake a number of times during the night and may think that they have not been asleep because they hear the clock regularly or some other recurring noise. It is improbable that patients ever spend several nights in succession without sleep and their story is only an index of the persuasion that they are under that they do not sleep, though they are having so many thoroughly restful intervals that their brain cells suffer but little from the need of sleep. Indeed, the principle source of nervous wear and tear for them consists in their persuasion that they do not sleep and the resultant impelling suggestion that a breakdown must before long be inevitable.

Individual Differences.—There are too many safeguards in nature's ordinary dealings with human beings for us to think that people can pass many nights absolutely without rest. Brain cells may apparently be very wakeful, they may be quite ready to take up at once and seemingly without a break trains of thought interrupted sometime before, yet somehow they succeed in obtaining their needed rest. In this matter, as is well known, though it needs to be emphasized again for the benefit of nervous individuals, different people have very different needs. Some require many continuous hours of sleep or they soon begin to have symptoms of nervous exhaustion. Others live on only with snatches of sleep at intervals, or with interrupted sleep during a limited portion of the twenty-four hours, yet enjoy good health for many years. A few seem to be able to live in health and strength with but a few hours of sleep. It may possibly be thought that those who are living their lives with a small amount of sleep are drawing drafts on their future vital powers, and that what they make up in intensity of activity now by shortening sleep, they will discount by shortness of life. How utterly untrue this impression is, however, will be best understood from the fact that many of the men who have worked hardest and slept the least number of hours in the day, have lived to be eighty or even ninety years of age and some of them have even been centenarians.

Cell Rest.—The great differences in the brain cells of different individuals in what concerns sleep becomes more readily intelligible when we recall the extreme differences as regards the need of rest of the various cells in the same individual. While the brain cells seem to require for healthy life, as a rule, nearly one-third of the time, and a man who is constantly taking much less than eight hours of sleep is probably hindering rather than helping his productiveness, especially if his work is intellectual, there are cells in the body that need no such amount of rest as this. Peristaltic movements occur in the digestive tract almost constantly, with only short intervals, and these cells get their rest between their movements. Pulmonary cells and tissues must do the same thing, and are able to do it without any special strain being put on them. The extreme example of the lack of need for prolonged rest is found in the heart. Two-fifths of every second the cells of this organ have a rest during the diastole, but during the remaining three-fifths of every second for all of life they must not only be ready to work but actually engaged in it or serious symptoms ensue. The cells in the brain that subtend cardiac and respiratory activity must be even more able to do without rest, since their action is ceaseless during life. By analogy with these it is not difficult to understand that the brain cells which are involved in consciousness should on occasion be able to stand prolonged periods of activity, or at least of wakefulness. Persistent wakefulness does not appeal to us as so surely destructive after this consideration.

Solicitude Over Sleep.—For those who are much disturbed by the loss of even slight amounts of sleep and who are prone to complain rather bitterly if they are not able to get more than five or six hours a night, I find it a useful preliminary to any more formal treatment of their so-called insomnia to recall the examples of some of the great workers who succeeded in accomplishing marvelously good work though they took much less sleep than the amount the patient secures, yet seems to think inadequate. In spite of such lack of sleep, these workers lived to advanced old age. There are many well-authenticated illustrations of this in recent times. Perhaps the most striking testimony to the power of the human mind to continue work without requiring the refreshment of sleep, except for very short periods, is that of Humboldt, the great traveller, scientist writer and diplomat. Max Müller, in his autobiography tells the story. It was when he himself was about forty. Humboldt said to him: "Ah! Max, when I was your age I had time to accomplish something, now I find that I must take at least five hours of sleep every night." At the moment Humboldt was over eighty. Müller said to him: "But, Your Excellency, how much sleep, then, did you take when you were my age?" "Oh!" he said, "I used to turn the light down, throw myself on the lounge for a couple of hours, and then get up and go on with my work again." Humboldt, after a life full of the hardest kind of work of many kinds, lived well past ninety in the full vigor of his intellectual powers.

There are many other examples that might readily be quoted. The traditions of the University of Berlin contain many illustrations of men who did very little sleeping, yet succeeded in accomplishing an immense amount of work and lived far beyond the Psalmist's limit. Virchow, whom I knew very well, did not take more than four or five hours of sleep on most nights in the year. He would be in the Lower House of the Prussian Legislature, which, like the House of Commons, holds its meetings late at night, until one A. M. or later and would be at his laboratory shortly after seven. There was a tradition at the University of Berlin in my time there of one of the older professors in the theological department who went to bed only every alternate night. He had a forty-eight-hour day for work with a seven-hour break. He lived to the age of eighty-five. I know one of our most distinguished workers in medicine here in America who was so busy and so tired at the end of his day that he could not write his book. He would fall asleep on his chair at his desk to wake up only when the milkman came in the morning. He had constructed for himself a special stool without back or sides, shaped like a bench, so that whenever he fell asleep on it he fell off. The fall would wake him up and he would then go on with his work for some hours. He did this sort of thing for many years, and yet he is alive and in the full possession of intellectual health at the age of eighty-three. He learned this expedient from a German professor of medicine who told him of it and at the same time told him that it was no uncommon practice among German professors. Indeed, most of the famous long-livers of the nineteenth century were also well known for the small amount of sleep they required, and apparently there is no need of being anxious lest loss of sleep should prove serious, unless one is adding to whatever detriment to health it may be by worrying about it find so setting two damaging factors at work.

TREATMENT

Probably the most important immediate assurance that can be given to those who come complaining of insomnia is that practically no one has ever been seriously hurt by the wakefulness called insomnia. Patients suffering from brain tumors, from serious disturbance's of cerebral circulation that give objective signs, from various organic diseases, as of the heart or liver, or certain constitutional diseases, have been made worse by the wakefulness induced by their affections. In the cases where there were no definite objective signs and wakefulness was the only symptom we have no cases on record of serious injury resulting. Men have come complaining of wakefulness for days or weeks and sometimes, though it is strange to understand it, for months or even years, and yet have lived their lives without serious developments and have neither gone into insanity nor into any premature loss of vitality, much less a fatal termination. It is not subjective symptoms but objective signs that are of value for the diagnosis of the serious organic conditions. This reassurance lifts a load from patients' minds at once and does more than anything else to relieve them of the burden of solicitude which is the main factor in the continuance of their insomnia.

Suggestive Treatment.—The psychotherapy of sleep consists in changing the patient's attitude of mind toward his sleep. It is quite impossible for him to sleep normally and regularly if he worries much about it and if the afternoon and evening hours are mainly spent in wondering whether he will sleep, anxious as to when he is going to sleep like other people, marvelling how long he will last in health and sanity if his tendency to wakefulness continues. There is no factor so strong in insomnia as getting one's self on one's mind. It weighs as an intolerable burden, an incubus that is sure to keep its subject awake. Insomnia is a mental and not a physical ailment in much more than nine out of every ten cases. It is not the brain but the mind that is at fault. Patients must be made to realize that if they go quietly to bed, confident that if they do not sleep the early part of the night they will sleep later, and that in case they should lose considerable sleep, so long as they lie quietly for eight hours in bed, their physical organism is not likely to come to any serious trouble. They must be quiet, peaceful and unworried. They must not begin to toss at the first sign of not going promptly to sleep for by so doing they may put off completely the possibility of falling to sleep. Finally they must prepare for sleep by passing a quiet evening, as a rule, occupied with diversions of various kinds.

There are many factors which inhibit sleep that must be removed or at least obviated. These are very different in different individuals and the suggestion of getting them out of the way helps a great deal in making people realize that they are better prepared for sleep than before. They have been keeping themselves awake by contrary unfavorable suggestions. They must be taught to aid themselves in going to sleep by a series of favorable suggestions attached to the doing of certain things that are helpful and, above all, avoiding acts of various kinds that have an unfavorable suggestive influence. In this way an accumulation of suggestions can be secured that will prove helpful.

Drugs.—Of course, patients must be warned with regard to the taking of drugs. Certain drugs may be taken for an occasional loss of a night's sleep, where the loss of sleep is regular and frequent, however, drugs are sure to do more harm than good. Opium leads to a serious habit, chloral is dangerous because it must be increased, most of the coal-tar somnifacients produce serious after results and their physical effect is in the end probably more deleterious than would be the loss of the sleep which they are supposed to counteract. This is true for even the vauntedly least harmful of them, and it is important to make patients understand it.

External Conditions to be Inhibited.—In the treatment of insomnia two sets of inhibitory conditions are particularly to be looked to, those external to the patient, and those internal. Unless every possible obstacle is removed there can be no assurance of the relief of sleeplessness, while very often the careful regulation of a few conditions that are disturbing the patient will bring sleep fully and promptly. It is curious what small annoyances will sometimes prove disturbing.

No Pillow .—I have found patients who had heard somewhere the idea that it was natural for man to sleep without a pillow. The pillow in this theory was supposed to be an added refinement of men in a state of luxury, but a real degeneration opposed to nature, and the many presumed benefits of sleeping on a perfectly level mattress with the head no higher than the rest of the body was emphasized. While in ordinary health these patients had found that after the preliminary discomfort of getting used to sleeping without a pillow, they were apparently the better for it. People will feel better for almost anything if they are only persuaded that they ought to. After a certain length of time, however, worry or work had a tendency to keep them more or less wakeful and then insomnia came on, that is, for several hours at the beginning of the night they did not go to sleep and became very much worried about it.

In several of these cases I have found one of the most helpful adjuncts to more direct treatment of their wakefulness was the restoration of the pillow. Just how the hygienic theory of pillowless sleep originated, or on what it is supposed to be founded, I do not know. The only theory of sleep that seems to have many adherents at present is that it is due to brain anemia. With the head a little higher than the rest of the body the force of gravity tends to help in the production of this brain anemia. The experience of mankind seems to confirm this. Certainly, from the earliest records of history men have slept with something under their head, even though they could find nothing better than a log or a stone. To sleep without a pillow is, owing to the conformation of the head and neck and shoulders, almost inevitably to sleep mainly on the back. From the anatomical relations of the internal organs it is easy to understand that sleeping on the side is more comfortable and healthy than sleeping on the back and hence most people naturally take this position. Relaxation is much more complete and comfort is greater. What the majority of men do is almost surely dictated by instinct, and instinct is the most precious guide we have in the natural functions of life. We are not so differently formed from the animals that the analogy from their habits should not have some weight for us. Patients should then be advised always to sleep with a reasonably firm pillow, not too low, so that the head is a little higher than the body and the lateral position perfectly comfortable.

Too high Pillow .—There is an abuse in the other direction of too high a pillow that deserves to be noted. Occasionally the physician hears complaints of waking up with tired feelings in the large muscles of the back of the neck near their insertion into the occiput. This is sometimes complained of as an occipital headache. Not infrequently it will be found that these people are sleeping on pillows that are too large, or that they pile up several of them. Most physicians have found in their experience that having the head quite a little higher than the rest of the body materially aided sleep, especially in elderly people. This is true even when there is no distinct heart lesion, but this favorable position is best secured not by means of one or more high pillows, but by raising the head of the bed, or by the insertion of bolsters beneath the mattress, so that there is a gentle slope upward from the hips to the head. High pillows should, as a rule, be discouraged, especially in young folks where the assumption of the strained positions which they cause, may encourage various deformities in the anatomy of the head and shoulders so that stoop shoulders or a craned neck result. On the other hand, before attempting to give drugs to elderly people, the arrangement of the mattress so as to put the head a foot, or even more, higher than the body should be tried and will often be found to give relief where other things fail.