It is really doubtful whether the moral and religious appeals are always helpful and not sometimes or often even dangerous for the health of the individual; and it is not doubtful that morally and religiously indifferent mental influences are often of the highest curative value. The more we abstract from everything which suggests either the mysticism of the subconscious or the moral issues of a mind which is independent of the body, the more we shall be able to answer the question as to the means by which health can be restored. This question is neither a moral nor a philosophical one but strictly one of experience. In this connection, we must remember that we also have had to give up the artificial demarcation line between organic and functional diseases. We recognized that every so-called functional disease has its organic basis too, and that it is entirely secondary whether we are able to find visible traces of the organic disturbance. We had to acknowledge, to be sure, the difference between reparable and irreparable disturbances, but such grouping expresses only in another form the fact that experience alone can show whether the methods of treatment which we know so far will be successful or not. Not a few disturbances of the equilibrium which appeared irreparable to an earlier time yield to the treatment of to-day, and no one can determine whether much which appears irreparable today may not be accessible either to psychotherapeutic or to physical therapeutic means to-morrow. If we were carelessly to identify the reparable troubles with those which we cannot recognize visibly, we should be at a loss to understand why, for instance, many forms of insanity are entirely beyond our psychotherapeutic influences. On the other hand, every physician who uses psychotherapeutic means is surprised to see the effective bodily readjustment where serious disturbances perhaps of the circulatory system or the digestive system existed. What the methods can do and what they cannot do must simply be left to experience, but of course to an experience which is eager to expand itself by ever new experimental curative efforts.

From this point of view we can see clearly the general division of the whole field of possible psychotherapy. Psychotherapy influences psychophysical states in the interest of health. There are only two possibilities open: either the disturbance is in the psychophysical system itself or it is outside of it, that is in the other parts of the body which are somehow under the influence of the mind. In the first case when the disturbance occurs in the mind-brain system itself, we ought to separate two large groups, first those cases in which the system itself is normal and the disturbance comes from without, and second those in which the constitution of the system itself was abnormal and led to disturbances under conditions in which a normal system would not have suffered. We have to consider both groups somewhat more in detail, as each again allows a large variety of cases.

Thus we have before us, first the normal mind-brain system into which a disturbance breaks, injuring more or less severely and for a longer or shorter time the equilibrium of the psychophysical functions. Here belong any bodily processes which produce pain or any bodily defects which produce blanks in the content of consciousness; the pain of sciatica or of rheumatism, or the defect of the blind or of the deaf, certainly interferes in a disturbing way with the perfect harmony of psychophysical activities. But here also belongs the suffering which results from conditions in the surroundings, the loss of a friend, a disappointment in life, any source of worry and grief. Social and bodily conditions alike may thus work to break up the equilibrium. The pain sensation interferes with the normal flow of mental life and the grief may undermine the mental interests. The psychotherapeutic effort may be directed toward removing the source of the disturbance, bringing the patient under other conditions, curing the diseased organ, and where that is not possible, may work directly on the psychophysical state, inhibiting the pain, suppressing the emotion, substituting pleasant ideas, distracting the whole mind, filling it with agreeable feelings, until the normal equilibrium is restored.

The psychophysical system itself was not really harmed by such influences. In the following groups, such is no longer the case. We here think at first of those severe injuries which have their sources in abnormal processes outside of the brain. The anaemia of the patient or the low state of his nutrition or the fever heat of his blood impairs the harmony of the mental functions. Another and for the psychotherapist much more important group is that in which the impairment results from toxic influences. Alcohol, morphine, cocaine, tobacco, and many other drugs may have been misused and may have produced a most marked alteration in the mind-brain system. Desires may have developed which completely destroy the balance of the normal functions and yet the satisfaction of which increases the poisoning effect. But here belongs further the effect of poisons which the body itself produces: the toxic disturbance of uraemia or the coma in diabetes, or especially the grave disturbances resulting from the abnormal action of the thyroid gland, the source of cretinism. Many indications suggest that a near future will consider this group much larger than we are really justified in doing today, probably soon connecting a number of other mental diseases like dementia praecox with toxic effects of bodily origin. Experience shows that in this group not a few chances exist for successful psychotherapeutic influence. Yet the means may be various in character and their effect may be a direct or an indirect one. A psychical shock may remove directly the mental disturbance of the alcoholic state, but it is more important that mental suggestion can remove the alcoholic disturbance indirectly by suppressing the desire for alcoholic excesses. Even where cure by psychotherapeutic means is out of the question, as is the case with feverish delirium or uraemic excitements, no skilled physician ignores the aid which a well-adjusted mental influence can offer to the patient.

We come to a third group. Some outside cause has harmed the central nervous system directly, and has left it in a disabled state after the cause itself has disappeared. Such causes may have been at first purely functional: for instance, a neglect of training, or a wrong training, or an over-activity, but the ill-adjusted function which involved, of course, every time an ill-adjusted organic activity or lack of activity, has led to a lasting or at least relatively lasting disturbance in the system of paths. The neglect of training, for instance, in periods of development may have resulted in the retardation which yields the symptoms of a feeble-minded brain, or the wrong training may have created vicious habits, firmly established in the mind-brain system and gravely disturbing the equilibrium. Above all, the overstrain of function, especially of emotional functions, may lead to that exhaustion which produces the state of neurasthenia. It is true that not a few would doubt whether we have the right to class neurasthenia here where we speak of the harm done to the normal brain. Many neurologists are inclined to hold that neurasthenia demands a special predisposition and is therefore dependent upon a neurotic constitution of the brain itself. But if defenders of such a view, as for instance, Dubois, acknowledge that "we might say that everybody is more or less neurasthenic," we can no longer speak of any special predisposition. Certainly there exists a constitutional neurasthenia sometimes but we have hardly a right to deny that overstrain in the brain activity may produce a series of neurasthenic symptoms in any brain, and the special predisposition is responsible rather for the particular selection among the innumerable symptoms.

Neurasthenia certainly is the classical ground for the psychotherapist. The patient's insomnia and his headache, his feeling of tiredness and his disgust with himself, his capricious manias and his absurd phobias, his obsessions and his fixed ideas all may yield to the "appeal to the subconscious," and as a neurasthenic easily believes in the existence of various organic diseases in his body, Christian Science can perform here even "miracles." In the case of retardation, the psychical influence will have to be in the first place one of training. Yet it would be narrow to overlook that in neurasthenia, too, suggestion has to be only a part of the psychical treatment. Training and rest, distraction and sympathy and many other factors have to enter into the plan. Incomparably small, on the other hand, is the aid which psychotherapy can offer in cases of real destructions in the brain, as in the case of tumors, hemorrhage, paresis or the degeneration by senility. More effective may be its work in concussion of the brain and especially with traumatic neuroses, as in the case when a railroad accident has put the mind-brain system out of gear.

So far we presupposed that the central system itself was normal. No sharp separation line, however, lies between all these disturbances and the equally large group of psychophysical disabilities resulting from a defective constitution of the brain. The normal brain shades over by smallest differences into the abnormal one; yes, even the varieties of temperament and character and intellectual capacity and industry and energy represent, in the midst of our social surroundings, large deviations from the standard. That which might still pass as normal under certain conditions of life would be unadjusted and thus abnormal under other conditions. In the same way, we certainly cannot point out where the natural constitution of a brain ceases to be fit for its organic purposes and where the structural variations are ill-prepared for the struggle for existence. Just as we claimed that an entirely normal brain might be brought by an emotional overstrain to a state of exhaustion and disability, we may claim on the other side that a brain which nature has poorly provided may yet be protected against damage and injury. The inborn factor does not alone decide the fate. Psychophysical prophylaxis may secure steadiness of equilibrium to a system which inherited little resistance. Yet this large borderland region, where an ill-adjusted brain may be saved or lost in accordance with favorable or unfavorable circumstances, shades off again to the darker regions where the inner evolution leads by necessity to disaster even under favorable conditions.

We might begin this large group of the constitutional disturbances with that neurasthenia which develops on the basis of inherited disability. Lack of energy resulting from a feeling of tiredness, a quick exhaustion, a mood of depression, an easy irritation, even despair and self-accusation, sullenness and fits of anger, cranky inclinations and useless brooding over problems, headache and insomnia characterize the picture which everyone finds more or less developed in some of his acquaintances. If we classify symptoms, we may separate from it that which we nowadays are inclined to call psychasthenia. An abnormal suggestibility for autosuggestions stands in the foreground. Fixed ideas and fixed emotions, especially fears, trouble the patient. He may pick up his obsession by any chance experience and no good-will liberates him from the intrusion perhaps for years. The patient is perfectly well aware that his ideas and his emotions are unjustified, he himself does not believe in them, and yet they come with the strength of an outer perception and with the vividness of a real attitude, and his whole mental equilibrium may be upset by the continuous fight against these involuntary interferences. In the light cases, sometimes the one and sometimes the other autosuggestion may hold the stage; in the severe cases, mental life turns more and more around certain definite fears and yet it may all still be in the limits where the daily work can go on and the world may not know of the hidden tortures. Here belongs the fear of open places or the fear of touching certain objects, the fear of doing harm to others or the fear of deciding actions wrongly, the fear of destroying valuable things or the fear of being the center of public attention, the fear of crowds or of closed doors, of altitudes or of bridges. And in all cases emotional reaction may set in with anxieties, and bodily symptoms such as palpitation of the heart may result, whenever an effort is made to disregard the nervous fear. There is perhaps no group of patients which so much deserves the most careful efforts of the psychotherapist. Still more than the hysterics they suffer from the fate of seeing their ills counted as not real. For them everybody has the good advice that they ought to overcome their fancies; and yet they feel their life ruined with their endless fight against the overpowering enemy. And if anywhere, it is here that the psychotherapist is successful. Psychasthenic fear can be removed, while the developed melancholic depression, for instance, is entirely beyond the reach of psychical influence.

We have after all the same psychasthenic state before us when the obsession has impulsive character, from the mere abnormal impulse of lying, or making noise in a quiet place or crying in the dark, or touching certain places, to that of stealing, indecent speech, arson, and perhaps even murder. The symptoms might easily be mistaken for those of graver diseases. Yet the fact that the patient himself really does not will the effect at which he is aiming separates, mostly without difficulty, the diagnosis of psychasthenia from that of insanity. Quite nearly related to it are the manifold variations of abnormal and perverse sexual tendencies. The psychiatrists are perhaps too much inclined to bring all these pathological impulses and desires, fears and anxieties, into the nearest neighborhood to real insanity. The indisputable success of psychotherapy in these spheres ought to add a warning against these expansions of the strictly psychiatric domain. The psychologist will be more inclined to emphasize their relation to simple neurasthenia which itself imperceptibly shades over into our normal life.

All neurasthenic and psychasthenic disabilities show a certain emotional continuity and uniformity. It is the emotional instability and the quick alternation of symptoms which characterize hysteria or rather the hysterias. It seems as if science were near to the point of explaining the hysterical disease by one common principle, but certainly the symptoms are an inexhaustible manifold. The rapid changes of the intense moods of the patient usually stand in the center. Torturing obsessions, abnormal impulses, over-suggestibility, hypochondriac depressions, paralysis of arms or legs, anaesthesia and paraesthesia, a mental stupor and confusion, illusions and perceptions of physiological symptoms may work together in spite of his, or rather her clear intelligence. It is probably on a hysteric basis also that somnambulic states arise during the night, and from them a straight way leads to those mental attacks after which the memory is entirely lost, or for which fundamental associative connections are cut off. And from here we come to the exceptional cases of alternating personality. The more we recognize the myriad symptoms in the hysteric patient as products of the emotional instability, of autosuggestibility and of inhibition, the more we understand the almost miraculous result of psychotherapeutic treatment. Autosuggestions can be fought by countersuggestions, anaesthesia and paraesthesia can be removed often in an instant, dissociated personalities may be built up again through hypnotism, the most severe bodily symptoms may disappear by influences in a waking state. Hysteria alone would justify the demand that every physician in his student days pass with open eyes through the field of psychology. Quite near stand chorea and the epidemic impulses to imitative movements. And we might bring into this neighborhood also the disturbance in the equilibrium of the speech movements through all degrees of stammering and severe impairment. Up to a certain degree, though not often completely, they too yield easily to psychotherapeutic influence.

We enter now that region of constitutional disturbances in which psychotherapy is of small help. It leads from epilepsy to the periodic diseases, especially the maniacal depressive insanity, the paranoia which develops late, and finally to states of idiocy which cover the whole life. We are far from claiming that psychical influences are entirely powerless, the more as we insisted that psychotherapy goes much beyond mere suggestions and appeals. No psychiatrist will work without psychological tools when he deals with the exultations of the maniac and the depressions of the melancholic, with the hallucinations of persecution or the erotic insanities of the paranoiac. Still more the whole register of psychology has to be used, when we are to educate the idiot and the imbecile. But the disappearance of the disease or of the chief symptoms through the mental agencies is in all these cases out of the question. Only in incipient cases, especially of melancholia and mania, the psychotherapeutic work seems not entirely hopeless; and for epilepsy some distinct successes cannot be denied.

We have reviewed the whole field of psychophysical disturbances, those produced through external conditions in the normal brain and those resulting from abnormal brain constitution. We have seen that the work of the psychotherapist is of very unequal value in different parts of the field; in some, as in neurasthenia, in psychasthenia, in hysteria and similar regions most effective, in others like paresis or paranoia reduced to an almost insignificant factor. Where it can help and where not we recognize as a mere question of experience. Certainly the severity of the symptoms alone does not decide it. As the treatment is entirely empirical, no one can foresee whether or not the situation may change to-morrow. We may find psychotherapeutic schemes by which epilepsy or maniacal depressive insanity or traumatic neuroses may become accessible. We simply do not know why we may remove stammering or synthesize a dissociated personality or overcome an inborn sexual perversity, while we are unable to remove the depression of the melancholic. Certainly the symptoms of the circulatory insanity disappear completely in the free intervals; there is no reason to give up hope that psychotherapy might find the way to hasten the appearance of such a normal period.

But we have emphasized from the start that the psychotherapeutic work has not only to set in when the disturbance itself lies in the psychophysical system. We may utilize the influence which the mind-brain system has for the whole body and thus may apply the psychical tool to work on the disturbances in the bodily apparatus. We may discriminate a direct and an indirect influence in the psychical treatment of bodily diseases. Transition from the foregoing group of psychical disturbances offers itself perhaps most easily through the state of insomnia.

The causes of sleeplessness may still lie in the psychophysical sphere; restless thoughts may inhibit the idea of sleep. The effect of sleep is again in the sphere of the mind, the annihilation of conscious contents. But the center which regulates and creates the sleep, probably by contracting the blood-vessels, lies outside of the psychophysical system in the lower centers of the brain. The real disturbance thus lies in the inactivity of this purely bodily apparatus and mental influence which is to create sleep has therefore to work downwards from the mind to a bodily organ. In the same way many other non-psychical centers of the brain may be brought to efficiency through psychophysical regulation.

But the therapeutic effect is certainly not confined to the central nervous system. Whithersoever the centrifugal nerves lead there the mind-brain system may have its curative influence. In the most startling way that is true for the digestive apparatus. The secretions of the stomach, the activity of the intestines can be influenced to a decree which it is difficult to explain. Important also is the relation to the circulatory system, especially the disturbances of the heart: innervation may be corrected, abnormal dilations and contractions of blood-vessels may be regulated. The bladder, uterus, even the pancreas and the liver seem to be influenced by the peripheral effects of the central excitement. And while no warning can be serious enough against the absurd belief that diseases like cancer or tuberculosis can be cured by faith, it must be admitted that psychical influences under special conditions may have a retarding influence on any pathological process in the organism. Much of that certainly is indirect influence but the physician would be reckless if he should ignore the aid which may result from such indirect assistance. Even if psychotherapy could not do more in the treatment of bodily diseases than to secure a joyful obedience to the strict demands of the physician, it would yet have to be accredited with an extremely important service.

In a parallel line comes the effective aid by the stimulation of hope and the suppression of fear, by suggestion of a feeling of encouragement and the inhibition of the emotions of worry. This is a field where even the average physician is most easily inclined to play the amateur psychotherapist. He knows how convalescence is disturbed by psychical depression and how much more quickly health returns, if it is confidently expected; he knows how many dangerous operations are disturbed by despondency and helped by bravery; he knows what a blessed change has come into the treatment of tuberculosis since a psychical factor of social interest has set in; he knows how many ills disappear when regular occupation and interesting work are established or the strain of distasteful work removed. Even the mere suppression of the pain works backwards on the bodily disease which produces it. The pain was a starting point for disturbing reactions; with its disappearance through psychotherapeutic influence, the reactions of the irritated brain come to rest, the diseased body can carry on its struggle without interference and may win the day. Often the psychical influence may not even change the symptoms at all but may remove other troublesome effects. The sufferer from locomotor ataxia may learn to walk again through mental education without any restitution of his spinal cord. In short, there are endless ways in which psychical influence may work towards the general health and towards the victory over bodily disease; and all that may be acknowledged without the slightest concession to the metaphysical creeds of mental healers and Christian Scientists. But to make use of those means and to harness such influences, it cannot be enough to rely on the common-sense of the physician any more than we should trust the common-sense of the surgeon to use his knife without condescending to the study of anatomy. The psychological study of the anatomy of the soul shows a not less complicated system of mental tissues and mental elements.

To enter into the full richness of this whole, large field of course lies entirely beyond the scope of our short discussion, which seeks as its only aim a clear recognition of the principles. Yet it seems essential to illustrate at least this sketch of the field by a more detailed account of actual developments. Various ways of procedure might appear in order and the most natural one would be, of course, to pass down from disease to disease and sketch special cases from diagnosis to cure. We might go through the various stages of neurasthenia and then through psychasthenia and then through hysteria and so on. And if we had to write a handbook for physicians, it would certainly be the desirable way, in spite of the too frequent repetitions which would become necessary. But as our aim is only a discussion of principles of psychotherapy, we have no right to use this method. Moreover, such a method would suggest the misleading view that the psychotherapist is called and is able to treat diseases. All that he treats are symptoms and he ought not to pretend that he can do more, as long as he abstracts from all other therapeutic agencies. Psychotherapeutic influence may remove the phobia of a psychasthenic or the obsession of a neurasthenic or the emotion of a hysteric, and thus may bring not only momentary relief but a change which may be favorable for general improvement, but certainly the neurasthenia and psychasthenia and hysteria are not really removed by it. Of course, even the treatment of symptoms demands a constant reference to the whole background of the disease. The depression of the neurasthenic must not be treated like the depression of the melancholic, the obsession of the psychasthenic must not be mixed with the fixed ideas of a paranoiac, the hysteric inability to walk must not be confused with an injury of the motor nerves; in short, each symptom has to be treated as part of a complete situation. The efforts of the psychotherapist will move over as large a part of the disease as possible and cover, perhaps, the causes of the disturbance as far as they are of psychical origin. Yet it would remain dilettanteism if we were to accept the popular view that the mere psychotherapeutic aid is a sufficient treatment of the whole disease. The physician has to be much more than a psychotherapist. Our discussion only seeks to point out that whatever else he may be, he must be also a psychotherapist.

The more conservative method which befits us may be, therefore, the method of dealing with symptoms only and abstracting from the more ambitious plan of discussing the diseases entire. We simply separate the mental symptoms and the bodily symptoms which the psychotherapist is to remove. And just in order to classify somehow the manifold mental symptoms, we might separate those in the sphere of ideas, those in the sphere of emotions, and those in the sphere of volitions. Of course, nothing is further from such a plan than the old-fashioned belief that intellect, feeling, and will represent three independent faculties of the soul. Modern psychology has not only substituted the millionfold phenomena for the schematic faculties, but emphasizes above all the interconnectedness of the mental facts. There is no experience into which ideas, and feelings, and impulses do not enter together. And correspondingly we emphasized that on the physiological side too, every sensory excitement is at the same time the middle point of central irradiation and the starting point of motor activity. Thus there can be no disturbance of ideas which does not influence feeling and will, and vice versa. Yet it would be artificial to deny that any one of those various sides of the psychical process may come to prominence, sometimes the impulse, sometimes the emotion, and sometimes the interplay of ideas. The separation means only an abstraction, but it is an abstraction which is justified and suggested by the actual experiences. Thus we shall deal with the psychical treatment of ideational, emotional, volitional, and bodily symptoms.

Common to our discussions will be only the effort to avoid everything which is exceptional and by its unusual complications apparently unexplainable and mysterious. The greater complexity of the case certainly adds much fascination. Yet since we do not want to stimulate mere curiosity but clear understanding of the elements, we avoid every startling record. We confine ourselves carefully to those perhaps trivial experiences which daily enter into the view of those who come in contact with suffering mankind. There will be no startling stories of dissociated personalities, such as appear perhaps every few years on the horizon of the medical world, but we shall speak of those who every day in every town carry their trouble to the waiting room of the doctor and who might return more happily if he had more well-trained interest in the psychotherapeutic factors. Yet before we analyze some typical symptoms, it might be wise to review the whole series of means and tools which the psychotherapist finds at his disposal.



VIII

THE GENERAL METHODS OF PSYCHOTHERAPY

The psychological work of the physician does not begin with his curative efforts. Therapy is always only the last step. Diagnosis and observation have to precede, and an inquiry into the causes of the disease is essential, and in every one of these steps psychology may play its role. The means of psychodiagnostic are not less manifold than those of psychotherapy. Moreover there the technique may be more complex and subtle. The whole equipment of the modern laboratory ought to be put at its disposal. Perceptions and associations, reactions and expressions ought to be examined with the same carefulness with which the conscientious physician examines the blood and the urine.

A particular difficulty of the task more or less foreign to every other medical inquiry is the intentional or unintentional effort of the patient to hide the sources of the trouble and to mislead as to their true character. Too often he is entirely unconscious of the sources of trouble or else he has social reasons to deceive the world and himself, and ultimately the physician. And yet no psychical treatment can start successfully so long as the patient is brooding on secret thoughts at the bottom of his mind. The desire to hide them may often be itself a part of the disease. It is surprising how often unsuspected vistas of thoughts and impulses and emotions are opened by an inquiring analysis where the direct report of the patient does not awaken the least suspicion. In the field of insanity, naturally the physician at once goes to an examination on his own account, but in the borderland regions of the psychasthenics and hysterics and neurasthenics, the intellectual clearness of the patient too easily tempts one into trusting the sincerity of his story; and yet the most important ideas clustering perhaps about love or ambition, about vice or crime, about business failure or family secrets, about inherited or acquired diseases may be cunningly withheld and may frustrate every psychotherapeutic influence. Where suspicion is awake and mere confidential talk and persuasion seem insufficient, the physician may feel justified in the interest of his patient in drawing the thoughts out of their hiding-place by artificial means. Skill, tact, and experience are needed there.

As a matter of course, in the overwhelming mass of cases the frankness and the good will of the patient himself will support the physician and accordingly his examination is not obliged to trap the patient but simply to guide him to important points. But then begins the most essential study of diagnostical differentiation. With all the means not only of psychology but of neurology and internal medicine, he has to separate the particular case from similar ones and to examine whether he deals with, for instance, a hysteric or with a paranoiac, with a neurasthenic or with a case of dementia praecox; and he will not forget that there exist almost no symptoms of serious diseases which the nervous system of the hysteric may not imitate for a time. Not ours is the task of analyzing special methods of neurological and mental differential diagnosis such as are used in the psychiatric clinic and in the office of the nerve specialist. There the family history with reference to nervous and other diseases, the history of the patient himself, the infectious diseases which he has passed through, his habits and anomalies, his use of alcohol and of drugs, his experiences in social life, the demands of his profession, his recent troubles and their first origin are to be recorded carefully. Then begins the physical examination, the study of his sense organs and his nerves, of the motor inabilities, the pains, the local anaesthesias and paraesthesias, the disturbances of the reflexes, of the spasms, tremors, convulsions, and incooerdinations, of the vasomotor and trophic disorders, and so on. In a similar way the psychical examination tests the hallucinations and illusions, the variations and defects of memory and attention, of judgment and reasoning, of orientation and self-consciousness, of emotions and volitions, of intellectual capacities and organized actions. But we do not have to enter here into a discussion of such diagnostic means; our chief interest belongs to the therapy.

The variety of the psychotherapeutic methods is great and only some types are to be characterized here. But one rule is common to all of them: never use psychotherapeutic methods in a schematic way like a rigid pattern. Schematic treatment is a poor treatment in every department of medicine, but in psychotherapeutics it is disastrous. There are no two cases alike and not only the easily recognizable differences of sex and age, and occupation and education, and financial means, and temperament and capacity are decisive, but all the subtle variations of prejudices and beliefs, preferences and dislikes, family life and social surroundings, ambitions and prospects, memories and fancies, diet and habits must carefully be considered. Every element of a man's life history, impressions of early childhood, his love and his successes, his diseases and his distresses, his acquaintances and his reading, his talent, his character, his sincerity, his energy, his intelligence—everything—ought to determine the choice of the psychotherapeutic steps. As it is entirely impossible to determine all those factors by any sufficient inquiry, most of the adjustment of method must be left to the instinct of the physician, in which wide experience, solid knowledge, tact, and sympathy ought to be blended. Even the way in which the patient reacts on the method will often guide the instinct of the well-trained psychotherapist.

It is therefore certainly not enough that the knowledge of the physician simply decide beforehand on a definite course of psychical treatment and leave the carrying out to a well-meaning minister or any other medical amateur who schematically follows the indicated path. The finest adjustment has to come in during the treatment itself and the response of the patient often has to suggest entirely new lines of procedure. More than in any other field of medicine, the physician himself has to extend his influence far beyond the office hours and the strictly medical relations. And yet, on the other hand, there is no department of medicine in which the treatment might not profit by the psychotherapeutic influence. With a few vague words of encouragement mechanically uttered, or with a routine of tricks of suggestion by bread pills and colored water and tuning forks, not much will be gained even in the ordinary physician's practice. Subtle adjustment to the personal needs and to the individual conditions is necessary in every case where the psychical factor is to play an important role. It cannot be denied that the one great obstacle in the work of the routine physician is the lack of time and patience which is needed for successful treatment. To prescribe drugs is always quicker than to influence the mind; to cure a morphinist by hyoscine needs less effort than to cure him by suggestion.

The first method to bring back the psychophysical equilibrium is of course the one which is also demanded by common-sense, namely, to remove the external sources of the disturbance. External indicates there not only the outer world but also the own body outside the conscious parts of the brain. If we take it in the widest meaning, this would evidently include every possible medical task from filling a painful tooth to operating on a painful appendix, as in every case where pain results, the mental equilibrium is disturbed by it and the normal mental life of the patient reduced in its efficiency. But in the narrower sense of the word, we shall rather think of those sources of trouble in the organism itself which interfere directly with the mental functions. The examination of any public school quickly leads to the discovery that much which is taken for impaired mental activity, for lack of attention, for stupidity, or laziness may be the result of defective hearing or sight or abnormal growth of the adenoids. Growths in the nose may be operated upon, the astigmatic or the short-sighted eye may be corrected by glasses, the child who is hard of hearing may at least be seated near the teacher; and the backward children quickly reach the average level. No doubt in the life of the adult as well, often almost insignificant and from a strictly physical point of view unimportant abnormities in the bodily system, especially in the digestive and sexual spheres, are sources of irritation which slowly influence the whole personality. To be sure, the brain disturbance may have reached a point where the mere removal of the original affliction is not sufficient to reinstate the normal balance of mental energies, but wherever such a bodily irritation goes on, it is never too late to abolish it in the interests of psychotherapy.

The less evident and yet even more important source of the painful intrusions may lie outside of the organism in the social surroundings and conditions of life. Most of that has to be accepted. The physician cannot bring back the friend who died or the fortune which was lost in speculation or the man who married another girl. He will even avoid suggesting far-reaching social changes in the private life of the patient, changes like divorce in an unhappy marriage or the breaking of the home ties, however often he may get the impression that such a liberation would stop the source of the mental trouble. He will be the more careful not to overstep his medical rights as he seldom has the possibility to judge fairly on the basis of the one-sided complaint, and the probability is great that the character and temperament of the complainant may be a more essential factor of the ailment than the personalities which surround him. Yet even the conservative physician will find abundant opportunities for advice which will remove disturbing energies from the social surroundings of the sufferer. Even a short release from the burdening duties, a short vacation from the incessant needs of the nursery, a break in the monotony of the office, may often do wonders with a neurasthenic. Often within a surprisingly short time the brain gathers the energies to overcome the frictions with unavoidable surroundings.

Yet here the physician has to adjust the prescribed dose of outing very carefully to the special case. We may be guided by the psychological experiments which have been made in the interest of testing the fatigue induced by mental work. If perhaps four hours of concentrated work are done without pauses, experiment shows that the quality of the work deteriorates, measured for instance by the number of mistakes in quick calculation. If certain relatively long pauses are introduced, the standard of work can be kept high all through. But if frequent pauses are made, and each short, the result is with many individuals the opposite. The experiment indicates that these frequent pauses are working as interruptions which hinder the perfect adjustment to the work in hand. That is suggestive. Our neurasthenic may complain about the life which he has to live and yet after all he is frequently so completely adjusted to it that it may not be in his interest to remove him far away from the conditions which cannot ultimately be changed but to which he has to return. The instinct of the physician has to find the middle way between a temporary removal of irritation which really allows a development of new energies and a mere interruption which simply damages the acquired relative adjustment. Every cause of friction which can be permanently annihilated for the patient certainly should be removed.

This negative remedy demands its positive supplement. The patient must be brought under conditions and influences which give fair chances for the recuperation of his energies. Too often from the standpoint of the psychologist, the prescription is simply rest. As far as rest involves sleep, it is certainly the ideal prescription. There is no other influence which builds up the injured central nervous system as safely as sound natural sleep, and loss of sleep is certainly one of the most pernicious conditions for the brain. Again rest is a great factor in those systematic rest cures which for a long while were almost the fashion with the neurologist. Experience has shown that their stereotyped use is often unsuccessful, and moreover that the advantage gained by those months spent in bed completely isolated and overfed is perhaps due to the separation and changed nutrition more than to the overlong absolute rest. Yet used with discrimination, the physiological and the psychical effect of lying in bed for a few weeks has certainly often been a marked improvement, especially with young women. But more often the idea of rest in bed during daytime is not meant at all when the nerve specialist recommends rest to his over-strained patient. It is simply meant that he give up his fatiguing daily work, even if that work is made up of a round of entertainments and calls and social engagements. The neurasthenic and all similar varieties are sent away from the noise of the city, away from the rush of their busy life, away from telephones and street cars, away from the hustling business and politics.

Indeed it is the dogma of most official and unofficial doctors that the restlessness and hurry and noise which all are characteristic of the technical conditions of our time are the chief sources of the prevailing nervousness. There was no time in the history of civilization in which the average man was overwhelmed by so many demands on his nerve energy, no time which asked such an abundance of interests even from the school child. The wild chase for luxury in the higher classes, reenforced by the commercialism of our time, the hard and monotonous labor in our modern mills and mines for the lower classes, the over-excitement brought to everybody by the sensationalism of our newspapers and of our public life all injure the brain cells and damage the equilibrium. That is a story which we hear a thousand times nowadays. Yet it is doubtful whether there is really much truth in such a claim and whether much wise psychotherapy can be deduced from it.

We may begin even with the very justifiable doubt whether nervousness really has increased in our time. Earlier periods had not so many names for those symptoms and were not able to discriminate them with the same clearness. Above all, the milder forms of abnormities were not looked on as pathological disturbances. If a man has a pessimistic temperament, or has fits of temper, or cannot get rid of a sad memory idea, or imagines that he feels an illness which he does not have, or has no energy to work, even today most people are still without suspicion that a neurasthenic or a psychasthenic or a hysteric disturbance of the nervous system may be in its beginning. Earlier times surely may have treated even the stronger varieties of this kind as troublesome variations in the sphere of the normal. On the other hand, there can be no doubt that, for instance, the Middle Ages developed severe diseases of the nervous system in an almost epidemic way which is nearly unknown to our time.

As to the conditions of life itself, there are certainly many factors at work which secure favorable influences for our cerebral activity. The progress of scientific hygiene has brought everyone much nearer to a harmonious functioning of the organism, and the progress of technique has removed innumerable difficulties from the play of life. Of course, we stand today before a much more complex surrounding than our ancestors but still more quickly than the complexity have grown the means to master it. We have to know more: yet the effort has not become greater since it has become easier to acquire knowledge. We have to endure much disturbing noise, and yet we forget how the sense organs of our forefathers must have been maltreated, for instance, by flickering light. We are in a rush of work and stand in thousandfold connections; and yet the neural energy which is demanded is not large because a thousand devices of our technical life have become our obedient servants. There is no nation on earth which is more proud of its rush and its hurry than the American people; and yet what an abundance of time is leisurely wasted that would have to be used for work if the country could not live from its richness. Moreover our life has probably become cooler, there is less emotionalism, less sentimentality, more business-like attitude, and that all means less inner friction and excitement; in public life too, less fear of war and less religious struggle. All has become a question of administration and efficiency. Our time is certainly not worse off on the score of neurasthenia than its predecessors.

Above all the intensity of mental stimuli is always relative. The psychologist knows the experiments which determine that we perceive the difference of impressions as alike when the stimuli are proportional. If I have a ten-pound weight in one hand, I may find that I must have one pound more in the other hand to discriminate the difference. Now if I take twenty pounds in the one hand, then it is not sufficient to have one pound more in the other, but I must have twenty-two pounds in the other to feel a difference, and if I take thirty pounds, the other weight must be thirty-three. We feel equal differences when the weights stand in the same relation. The man who owns a hundred dollars will enjoy the gain of five and regret the loss of five just as much as the owner of a hundred thousand dollars would feel the gain or loss of five thousand. This fundamental law of the relativity of psychical impressions controls our whole life. The rush of stimuli which might mean a source of nervous disturbance for the villager whose quiet country life has brought about an adjustment to faint impressions may cause very slight stimulation for the metropolitan accustomed for a lifetime to the rhythm of the surroundings. Yet that quiet countryman may react in his narrow system not less when the modest changes in his surroundings provoke him. The gossip of his neighbor may undermine his nervous system just as much as a political fight or the struggles of the exchange that of the city man.

The same holds true for the purely intellectual engagements. The work which the scholar undertakes should not be measured by the effect which the same appeal to concentrated attention would make on the average man of practical life. There, too, an adjustment to the demand has resulted during the whole period of training and professional work. Every effort should be estimated with reference to the standard of the particular case. This relativity of the mental reaction on the demands of life must always be in the foreground of the psychotherapeutic regime. Even the best physicians too often sin against this principle and accuse the life which a man or woman leads as too exhausting and overstraining simply because it would be overstraining and exhausting to others who are not adjusted to that special standard. Simply to withdraw a patient from the one kind of life and to force on him a new kind with new standards may not be a gain at all. A new adjustment begins and smaller differences from the standard may bring about the same strong intensities of reaction as the large differences brought before. Complete rest, for instance, for a hard brain-worker hardly ought to be recommended unless a high degree of exhaustion has come on. If routine prescriptions are to be admitted at all, they should not be complete rest or complete change of life for any length of time but a continuation of the life for which adjustment has been learned with a reasonable reduction of the demands and stimulations. The intellectual worker ought to decrease his work, the overbusy society woman ought to stay in bed one day in the week, the man in the midst of the rush of life ought to cut down his obligations, but probably each of them does better to go on than simply to swear off altogether.

Their rest ought to have the character of vacation; that means interruptions without the usual activity ought to be short periods spent with the distinct feeling that they are interruptions of that which must last and that they are not themselves to become lasting states. Thus the inner adjustment to the work ought to be kept up and ought not to be substituted by a new adjustment to a less exacting life. In this way the episode of the vacation rest ought to be in a way included in the strenuous life almost as a part of its programme. Strenuosity must not mean an external rush with the gestures of overbusy excitement, but certainly the doctrine of the lazy life is wretched psychotherapy, as long as no serious illness is in question. By far the best alteration is, therefore, even in the periods of interruption, not simply rest but new engagements which awaken new interests and stimulate neglected mental factors, disburdening the over-strained elements of mental life. The most effective agency for this task is contact with beauty, beauty in nature and life, beauty in art and literature and music. To enjoy a landscape ought to be not merely a negative rest for the man of the office building, and good literature or music absorbs the mental energies and harmonizes them. In the second place come games and sport, which may enter into their right if fatigue can be avoided. Harmonious joyful company, as different as possible from the depressing company of the sanitariums, will add its pleasantness.

While the advice of the physician ought thus to emphasize the positive elements which work, not towards rest, but toward a harmonious mental activity, we must not forget some essential negative prescriptions. Everything is to be avoided which interferes with the night's sleep. Furthermore, in the first place, alcohol must be avoided. There cannot be any doubt that alcoholic intemperance is one of the chief sources of brain disturbances and that the fight against intemperance, which in this country is essentially the fight against the disgusting saloon, is a duty of everyone who wants to prevent nervous disaster. There may and must be divergence of opinion as to the safest way to overcome intemperance. The conservative physician will feel grave doubt whether the hasty recommendation of complete prohibition is such a safe way, whether it does not contain many conditions of evil, and whether the fight against the misuse of alcohol will not be more successful if a true education for temperance is accepted as the next goal. But for the man of neurasthenic constitution and for any brain of weak resistance, the limit for permissible alcoholic beverages ought to be drawn very narrow and in such cases temporary abstinence is usually the safest advice. Individual cases must indicate where a glass of light beer with the meal or a glass of a mild wine may be permissible. Strong drinks like cocktails are absolutely to be excluded. In the same way a strong reduction is advisable in tobacco, tea, and especially coffee. A complete withdrawal of all stimulations to which a nervous system has been accustomed for years is not wise, or at least mild substitutes ought to be suggested, but if coffee can be ruled out at once, often much is gained. In the same way all passionate excitements are to be eliminated and sexual life to be wisely regulated. An especial warning signal is to be posted before all strong emotions, and if the patient cannot be asked to leave his worry at home, he can at least be asked to avoid situations which will necessarily lead to excitement and quarrel and possible disappointment.

It is one of the surest tests of psychotherapeutic skill to discriminate wisely whether one or the other of these features of general treatment ought to be emphasized. They usually demand more insight than specific forms of psychotherapy like hypnotic suggestions. These general efforts are also much more directed against the disease itself where the specific methods are merely directed against the symptoms. The separation from disturbing surroundings, the reduction of engagements and work, the complete rest, the suppression of artificial stimulants, the enjoyment of art, of nature, of sport, the distractions of social life, each might be in one case a decisive help and indifferent, perhaps even harmful in another. All is a matter of choice and adjustment to the particular needs in which all the personal factors of inherited constitution, acquired adjustments, social surroundings, temperament, and education, and the probable later development have to be most tactfully weighed. Yet this general treatment may take and very often ought to take the opposite direction, not towards rest but towards work, not towards light distraction but towards serious effort, not towards reduction of engagements but towards energetic regulation. We said that it was an exaggeration to blame the external conditions of our life, the technical manifoldness of our surroundings as the source of the widespread nervousness. The mere complexity of the life, the rapidity of the demands, the amount of intellectual effort is in itself not dangerous and our time is not more pernicious than the past has been; but it is perhaps no exaggeration to say that our time is by many of its features more than the past tending towards an unsound inner attitude of man.

Much of the present civilization leads the average man and woman to a superficiality and inner hastiness which undermines sound mental life much more than the external factors. We look with a condescending smile at the old-fashioned periods in which the demands of authority and discipline controlled the education of the child and after all the education of the adult to his last days. We have substituted for it the demand of freedom with all its blessings, but instead of the blessings we too often get all its vices. A go-as-you-please method characterizes our whole society from the kindergarten to the height of life. We eulogize the principle of following the paths of own true interest and mean by that too often paths of least resistance. Study becomes play, the child learns a hundred things but does not learn the most important one, to do his duty and to do it accurately and with submission to a general purpose. The power of attention thus never becomes trained, the energy to concentrate on that which is not interesting by its own appeal is slowly lost, a flabby superficiality must set in which is moved by nothing but the personal advantage and the zigzag impulses of the chance surroundings. He who has never learned obedience can never become his own master, and whoever is not his own master through all his life lacks the mental soundness and mental balance which a harmonious life demands. Flippancy and carelessness, haphazard interests and recklessness must result, mediocrity wins the day, cheap aims pervade the social life, hasty judgments, superficial emotions, trivial problems, sensational excitements, and vulgar pleasures appeal to the masses. Yellow papers and vaudeville shows—vaudeville shows on the stage, in the courtroom, on the political platform, in the pulpit of the church—are welcome, and of all the results, one is the most immediate, the disorganization of the brain energies.

A sound mind is a well-organized mind in which a controlling idea is able to inhibit the opposites and is in no danger of being overrun by any chance intrusion into the mind. This power is the act of attention. An attention which is trained and disciplined can hold its ideas against chance impulses. An untrained attention is attracted by everything which is loud and shining, big and amusing. The trouble is not with the rush and hurry of the impressions which demand our attention; the trouble is with our attention which seeks a quick change of new and ever new impressions because it is not disciplined to hold firmly to one important interest. We want the hundred short-cut superficial magazines because we lack the energy to study one large volume; we want the thousand engagements because we are not concentrated enough to devote ourselves fully to one ideal task. The strong mind may find its sound adjustment even without such training for concentrated attention through obedience and discipline but the weak mind has to pay the penalty. For not a few it will mean social disaster. Yet our society is sufficiently adapted to this state so that it gives some good social chances to the superficial too, and this not only to the rich, but to those on every level. Only the nervous system cannot so easily be adjusted to the new regime. The loose interplay of the brain cells without the serious training of discipline must involve disorganization of the mind-brain system which may count often most powerfully in those spheres in which the mere needs of life are felt the least. There is only one great remedy: discipline, training for concentrated attention, for a work in submission of will to a steady purpose. And psychotherapeutic effort will often demand such a training for work rather than a reduction of work and rest.

The most alarming product of the neglect in training is found in many of those retarded children who at fifteen show the intelligence of a boy of eight. They are not imbeciles and do not belong in the psychiatric domain; their development has simply been suspended by a mistaken education. Of course no neglect would have led to it without a constitutional, inherited weakness of the central nervous system, but the weakness would never have led to the retardation if perhaps a mistaken parental indulgence had not allowed a life without forced effort and, therefore, without progress. Even such extreme cases may not show on the surface. The boy may pass as all right if we meet him at a ball; only his tutor knows the whole misery. Still less does the surface view of many a grown-up neurasthenic alarm us who seems to live a well-ordered, perhaps an enviable life, and yet who suffers the penalty of a life without concentrated effort, really without anything to do in spite of a thousand engagements. Moreover this lack of important activity may often be forced on our patients. Married women without children, without household responsibilities, and without interests of their own and without strong nervous constitution will soon lose the power of effort and their brain will succumb. A dreary monotony is dangerous even for the worker; for the non-worker it may be ruinous.

Yet mere flippant excitement and superficial entertainment is nothing but a cheap counterfeit of what is needed. Voluntary effort is needed, and this is the field where the psychotherapist must put in his most intelligent effort. There is no one for whom there is not a chance for work in our social fabric. The prescription of work has not only to be adjusted to the abilities, the knowledge, and social condition, but has to be chosen in such a way that it is full of associations and ultimately of joyful emotions. Useless work can never confer the greatest benefits; mere physical exercises are therefore psychophysically not as valuable as real sport while physically, of course, the regulated exercises may be far superior to the haphazard work in sport. To solve picture puzzles, even if they absorb the attention for a week, can never have the same effect as a real interest in a human puzzle. There is a chance for social work for every woman and every man, work which can well be chosen in full adjustment to the personal preference and likings. Not everybody is fit for charity work, and those who are may be entirely unfitted for work in the interest of the beautification of the town. Only it has to be work; mere automobiling to charity places or talking in meetings on problems which have not been studied will, of course, be merely another form of the disorganizing superficiality. The hysterical lady on Fifth Avenue and the psychasthenic old maid in the New England country town both simply have to learn to do useful work with a concentrated effort and a high purpose. From a long experience I have to confess that I have seen that this unsentimental remedy is the safest and most important prescription in the prescription book of the psychotherapist.

There is one more feature of general treatment which seems almost a matter of course, and yet which is perhaps the most difficult to apply because it cannot simply be prescribed: the sympathy of the psychotherapist. The feelings with which an operation is performed or drugs given do not determine success, but when we build up a mental life, the feelings are a decisive factor. To be sure, we must not forget that we have to deal here with a causal and not with a purposive point of view. Our sympathy is therefore not in question in its moral value but only as a cause of a desired effect. It is therefore not really our sympathy which counts but the appearance of sympathy, the impression which secures the belief of the patient that sympathy for him exists. The physician who, although full of real sympathy, does not understand how to express it and make it felt will thus be less successful than his colleague who may at heart remain entirely indifferent but has a skillful routine of going through the symptoms of sympathy. The sympathetic vibration of the voice and skillful words and suggestive movements may be all that is needed, but without some power of awakening this feeling of personal relation, almost of intimacy, the wisest psychotherapeutic treatment may remain ineffective. That reaches its extreme in those frequent cases in which social conditions have brought about an emotional isolation of the patient and have filled him with an instinctive longing to break his mental loneliness, or in the still more frequent cases where the patient's psychical sufferings are misunderstood or ridiculed as mere fancies or misjudged as merely imaginary evils. Again everything depends upon the experience and tact of the physician. His sympathy may easily overdo the intention and further reenforce the patient's feeling of misery or make him an hypochondriac. It ought to be sympathy with authority and sympathy which always at the same time shows the way to discipline. Under special conditions it is even advisable to group patients with similar diseases together and to give them strength through the natural mutual sympathy; yet this too can be in question only where this community becomes a starting point for common action and common effort, not for mere common depression. In this way a certain psychical value must be acknowledged for the social classes of tuberculosis as they have recently been instituted.

From sympathy it is only one step to encouragement, which indeed is effective only where sympathy or at least belief in sympathy exists. He who builds up a new confidence in a happy future most easily brings to the patient also that self-control and energy which is the greatest of helping agencies. The physical and mental efforts of the physician are alike deprived of their best efficiency if they are checked by worry and fear that the developments of the disease will be disastrous. As soon as new faith in life is given, and given even where a sincere prognosis must be a sad one, a great and not seldom unexpected improvement is secured. There is no doubt that the routine physician is doing by far too little in these respects. His instinctive feeling that disease is a causal process, and that he should therefore keep away from the purposive attitude, leads him too easily to a dangerous narrowness. He treats disease as if it were an isolated process and overlooks the thousandfold connections in which the nervous system stands with the patient's whole life experience in past and future. The physician is thus too easily inclined to underestimate the good which may come in the fight against disease from the ideas and emotions which form the background of the mind of the patient. Even if the disease cannot be vanquished, the mental disturbances which result from it, the pains and discomforts, may be inhibited, as soon as hopes and joyful purposes gain a dominating control of the mind. The nervous patient often needs a larger hold upon life, while the routine prescriptions may too easily reduce that hold by fixing the attention on the symptoms.

Here then is the right place for the moral appeal and the religious stimulation. How psychotherapy is related to the church will interest us later. At this moment morality and religion are for us not inspirations but medicines. But from such a causal point of view, we should not underestimate the manifold good which can come from the causal effect of religious and ethical ideas. Those faith curists who bring mutual help by impressing each other with the beauty and goodness of the world really bring new strength to the wavering mind; and the most natural channel for religious help remains, of course, the word of the minister and the own prayer. Religion may work there causally in a double way. The own personality is submerging into a larger all-embracing hold and thus inhibits the small cares and troubles of merely personal origin. The consciousness sinks into God, a mental process which reaches its maximum in mysticism. The haphazard pains of the personality disappear and are suppressed by the joy and glory of the whole. This submission of will under a higher will and its inhibitory effect for suppression of disturbing symptoms must be wonderfully reenforced by the attitude of prayer. Even the physiological conditions of it, the clasping of the hands, the kneeling, and monotonous sounds reenforce this inhibition of the insignificant dissatisfactions. On the other hand, contact with the greater will must open the whole reservoir of suppressed energies, and this outbreak of hidden forces may work towards the regeneration of the whole psychophysical system. Neglected functions of the brain become released and give to the mind an energy and discipline and self-control and mastery of difficulties which restitutes the whole equilibrium, and with the equilibrium comes a new calmness and serenity which may react almost miraculously on the entire nervous system and through it on the whole organism and its metabolism.

Seen from a causal point of view, however, there is no miracle in it at all. On the contrary, it is a natural psychophysical process which demands careful supervision not to become dangerous. It is not the value of the religion which determines the improvement, and it is not God who makes the cure; or to speak less irreligiously, the physician ought to say that if it is God who cures through the prayer, it is not less God who cures in other cases through bromide and morphine, and on the other side just as God often refuses to cure through the prescribed drugs of the drug store, God not less often refuses to cure through prayer and church influence. But the real standpoint of the physician will be to consider both the drugs and the religious ideas merely as causal agencies and to try to understand the conditions of their efficiency and the limits which are set for them. From such a point of view, he will certainly acknowledge that submission to a greater power is a splendid effect of inhibition and at the same time a powerful effect for the stimulation of unused energies; but he will recognize also that the use of those silent energies is not without dangers.

Certainly nature has supplied us with a reservoir of normally unused psychophysical strength, to which we may resort just as the tissues of our body may nourish us for a few days when we are deprived of food, but such supply, which in exceptional cases may become the last refuge, cannot be used without a serious intrusion and interference with the normal household of mind and body. To extract these lowest layers of energies may mean for the psychophysical system a most exhausting effort which may soon bring a reaction of physical and nervous weakness. The chances are great that such a religious excitement, if it is really to have a deep effect, may go over into a mystic fascination which leads to hysteria or into an exhausting eruption of energies which ends in neurasthenic after-effects. The immediate successes of the strong religious influence on the weakened nervous system, especially on the nervous system of a weak inherited constitution, are too often stage effects which do not last. From a mere purposive point of view, they may be complete successes. They may have turned the immoral man into a moral man, the skeptic into a believer, but the physician cannot overlook that the result may be a moral man with a crippled nervous system, a believer with psychasthenic symptoms. From the point of view of the church, there cannot be too much religion; from a therapeutic point of view, religion works there like any other nervous remedy of which five grains may help and fifty grains may be ruinous.

Moreover this power of inhibiting the little troubles of the body and of bringing to work and effectiveness the deepest powers of the mind belongs not less to any other important idea and overpowering purpose. The soldier in battle does not feel the pain of his wound, and in an emergency everybody develops powers of which he was not aware. The same effect which religion produces may thus be secured by any other deep interest: service for a great human cause, enthusiasm for a gigantic plan, even the prospect of a great personal success. Thus in a psychotherapeutic system, religion has only to take its place in line with many other efforts to inhibit the feeling of misery and to reenforce will and self-control by submission under a greater will. That in the case of religion this submission, from an entirely different purposive point of view, also has a moral and religious value, has in itself no relation to the question of its therapeutic character. It ought not to lead to any one-sided preference, inasmuch as religiously indifferent agencies may be in the particular case a more reliable means of improvement. Moreover the psychological symptoms are, after all, only a fraction of the disease and very different bodily factors, digestion and nutrition, heart and lungs and sexual organs may be most intimately connected with the disturbance of the equilibrium. Medicine today no longer believes that hysteria originates in the diseases of the uterus or that neurasthenia necessarily results from insufficiencies of the stomach, but it would be a graver mistake to believe that mental factors alone decide the progress of the disease, however prominent the mental symptoms may be in it.

From the physician's encouragement and the minister's influence towards new faith in life, a short way leads to the influence of suggestion. It is on the whole the way which leads from the general psychotherapeutic treatment to the specific one directed against particular symptoms.



IX

THE SPECIAL METHODS OF PSYCHOTHERAPY

Of course there is no abrupt division between special and general methods. Yet the different tendency is easily recognized, if we turn only, for instance, from the mere sympathy and encouragement to the method of reasoning with the patient about the origin of his special complaint. Just now the medical profession moves along this line a great deal. Of course no well-trained psychotherapist will make the blunder of arguing with the insane. To dispute by argument with the paranoiac and to try to convince him would not be only without success, but easily irritating. This does not mean that the not less amateurish way ought to be taken of accepting his delusions and appearing to be in full agreement with him. A tactful middle way, preferably a disciplinary ignoring attitude, ought to be taken. But it is entirely different with the mental states of the psychasthenic. The mere statement and objective proof that his obsession is based on an illusion would be ineffective. He knows that himself, but he may take the disturbance as the beginning of a brain disease, as a form of insanity, as a lasting damage which lies entirely beyond his control. Now the physician explains to him how it all came about. He shows to him that the symptoms resulted merely from autosuggestion or are the after-effects of a suggestion from without or of a forgotten emotional experience of the past. That is a new idea to the patient and one which changes the aspect and may have an inhibitory influence.

Of course, the patient does not accept the explanation at once. He feels sure that he is not accessible to suggestion and that he has least of all a tendency to autosuggestions, but the skillful psychotherapist will find somewhere an opening for the entering wedge. He may develop to the patient the modern theories of the origin of neurotic disturbances, all with entire sincerity and yet all shaped in a way which gives to the special case an especially harmless appearance. He may even enter into experimental proof that the patient is really accessible to autosuggestions. A very simple scheme for instance is to put some interesting looking apparatus with a few metal rings on the fingers of the subject and connect it with a battery and electric keys. The key is then pushed down in view of the patient and he is to indicate the time when and the place where he begins to feel the galvanic current. The feeling will come up probably very soon in the one or the other finger, and as soon as he feels sure that the sensation is present, the physician can show him that there was no connection in the wires, that the whole galvanic sensation was the result of suggestion.

Such a method demands patience and good will. The prejudices and deeply-rooted hypochondriac ideas, foolish theories of the patient and pessimistic emotions which have become habitual, must be removed piece by piece until the central symptoms themselves can be undermined and explored. It often takes hours of careful and fatiguing reasoning, in which at any time the patient may suddenly slip back to his old ideas. Yet if the explanatory arguments have once succeeded in making the patient himself believe firmly that his whole trouble resulted from suggestion only, the inhibitory effect of this idea may be an excellent one. The only serious defect of the method is that it often does not work. The credit which neurologists of today give to its effectiveness seems to me much too high. Even slight neurasthenic and psychasthenic disturbances remain too often in complete power when the patient is fully convinced that they originated with an emotional excitement which has long since lost its feeling value or that it resulted from a chance suggestion picked out from indifferent surroundings. The patient knows it and yet goes on suffering from the fruitless fight of his will against the intruder. Where mere reasoning is entirely successful, I am inclined to suspect that an element of suggestion has always been superadded. The authority of the physician has created a state of reenforced suggestibility in which the argument convinces, not by its logic but by its impressiveness.

This element of suggestion is quite obvious when the argument takes the form of persuasion, a psychotherapeutic method which has found its independent development. Whoever seeks to persuade relies on the mental fringe of his propositions. The idea is not to work by its own meaning but by the manner of its presentation, by its impressiveness, by the authority, by the warmth of the voice, by the sympathy which stands behind it, by the attractiveness with which it is offered, by the advantages which are in sight. Thus persuasion relies on personal powers to secure conviction where the logic of the argument is insufficient to overcome contradictions. But just for that reason persuasion is after all only a special kind of suggestion.

Other methods work on the same basis. Prominent among them is the psychotherapeutic effect of a formal assurance. The psychotherapist assures the patient that he will sleep the next night or that the pain will disappear or that he will be able to walk with such firmness that the counter-idea is undermined. It depends on the type of patient whether such suggestions of belief work better when it is assured with an air of condescension, spoken with an authority which simply ignores every possible contradiction, or with an air of sympathy and hope. Experience shows that it is favorable to connect such assurance with the entrance of a definite signal. "You will sleep to-night when the clock strikes ten," "The pain will disappear when you enter the door of your house," or perhaps, "Read this letter three times quietly in a low voice, and at the end of the third reading your fear will suddenly stop." Psychological insight will further decide whether it is wiser in the particular case to assure the patient of the resulting effect or rather of the power to bring about the effect. With some people, it works better to insist that the result will happen, with others to promise that they themselves can secure it; in the one case they feel themselves as passive instruments, in the other as real actors. To some hysterics, it is better to say: "You will walk," to others, "You can walk."

This belief in the future entrance of a change frequently demands an artificial reenforcement. There belongs first the application of external factors which awaken in the background of the mind the supporting idea that something has been changed in the whole situation or that some helpful influence has made the improvement possible. Medicines of colored and flavored water, applications of electric instruments without currents, in extreme cases even the claptrap of a sham operation with a slight cut in the skin, may touch those brain cells which words alone cannot reach with sufficient energy and may thus secure the desired psychophysical effect. The patient who by merely mental inhibition has lost his voice for weeks may get it back as soon as the physician has looked into his larynx with a mirror and has held an electrode without battery connection on the throat. Another way of helping by make-believe methods is to give the impression that a decided improvement is noticeable. The uneducated patient believes it easily when the physician at his very entrance into the office expresses his surprise about the external symptoms of a change for the better, perhaps seen in the color of the skin or the shading of the iris in the eye and reaffirmed by some pseudotests of the muscle reflexes. All that is not very edifying and the decent physician, who justly feels somewhat dragged down to the level of the quack in applying such means frequently, will abstain from them wherever possible. He knows that in the long run, even the psychasthenics are best treated with frankness and sincerity and he will therefore only in exceptional cases resort to such short-cut treatment by making believe. Yet that it is sometimes almost the only way to help the patient cannot be denied.

A neater way to secure the sufferer's belief in the possibility of a cure is by securing the desired effect at least once through little devices. As soon as it is once reached, the patient knows that it can be reached and this knowledge works as a suggestion. The hysteric who cannot speak when he thinks of his words, or who cannot walk when he thinks of his legs, may by the skillful physician be brought to a few words or steps before he himself is aware of it by completely turning his attention to something else and producing the stimulus toward the movement in a reflex-like way. Still more successful is the effort to resolve the inhibited action into its component parts and to show to the patient who cannot perform the action as a whole that he can go through the parts of it after all. As soon as he has passed through a few times, a new tactual-visual image of the whole complex is secured for his consciousness and this image works then as a new cue for the entire voluntary action, overcoming the associated counter-idea.

Another excellent way to overpower a troublesome idea or impulse or emotion is to reenforce the opposite idea by breaking open the paths for its motor expression. The effort to hold the counter-idea before consciousness may be unsuccessful so long as it is only an idea which tries in vain to produce any motor effect; but if the action itself has been repeatedly gone through, the idea will find it easier to settle and it becomes vivid in proportion to the openness of the channels of motor discharge. This holds true even for emotional states. A certain word perhaps picked up by the psychasthenic in a particular experience may produce whenever it is seen a shock and a depressing emotion. If we ask the patient to go artificially through the movements which express joy and hilarity, make him intentionally grin and open wide the eyes and expand the arms and inhale deeply, and after training this movement complex of joyful expression, speak the dreaded word at the height of the movement a new feeling combination clusters about the sound and may overcome the antagonism. Sometimes you will give to the desirable idea sufficient strength by mere repetition, sometimes you force the attention better by unusual accentuation, connecting the suggestion with a kind of shock. From here it is only one step to the suggestion in the form of a sharp order which breaks down the resistance just by its suddenness and loudness, supported perhaps by a quick arm movement which gives a cue for imitative reflexes. In the case of a youngster even a slap may add to the nervous shock; also a sudden clapping of the hands may favor effectiveness of the suggestive order.

Often it is wise to give the suggestion, not from without but to prescribe it in the form of autosuggestions. For instance, advise the patient not only to have the good will and intention of suppressing a certain fixed idea or by producing a certain inhibited impulse but to speak to himself in an audible voice, every morning and every evening, saying that he will overcome it now. Here, too, the autosuggestion may become effective by the frequency of the repetition or by the urgency of the expression or by the accompanying motor reactions. As a matter of course any associations which reenforce the idea may be used for assistance. Especially near-lying is the appeal to the man's conscience, but just such associations which touch the idea of the own personality and its deepest layers of feelings are always risky. They may touch and stir up old memories which interfere with success or they may awaken a feeling of contrast between duty and fulfillment which may disturb the whole equilibrium. If the physician knows that the good-will of the patient is insufficient to overcome the pathological disturbance, he ought not to make him feel ashamed or guilty, and that not only for moral reasons but also for strictly psychotherapeutic reasons.

In certain easily recognizable cases, it is essential to give the suggestion with avoidance of any emphasis, only as a hint, passing as if the suggestion almost slipped from the tongue of the doctor without his real intention. The hysteric who is resisting the suggestion which is intentionally given to her is sometimes surprisingly trapped by a half-hidden suggestion, perhaps not spoken to the patient herself at all but spoken in a low voice to a colleague in the room. Sometimes we have to trick those who suffer by "negativism," that is by an obstinacy which exaggerates that of the ordinary stubborn man. In such cases the suggestion not to perform an action works best if we want the action performed. There is hardly an end to the list of such methods for bringing beliefs and attitudes with suggestive power to the mind of the sufferer. Definitely to describe the conditions under which the one or the other form ought to be applied would be no wiser than to tell a statesman what steps are to be taken in every possible diplomatic situation. The instinctive selection of the right means among the many possible ones characterizes both the true statesman and the true doctor.

So far we have spoken only about the character of the suggestion, presupposing that the receiver remains in his natural state. This presupposition is certainly often entirely correct, but as far as it is correct, the results of the suggestion vary greatly with the different individuals. On the whole, we might say that such suggestions given to the subject in his normal state are effective only when the subject is by nature a suggestible being. In considering the psychology of suggestion, we recognized at once that the degree of natural suggestibility varies excessively. The non-suggestible mind is only to a slight degree influenced by any of these proposed forms of suggestion as long as the suggestibility itself is not heightened. To be sure, the question whether the person is suggestible by nature or not cannot be settled simply by his own impression. Many of the most suggestible persons believe firmly that they are superior to any suggestive influence.

To bring suggestions to greater effectiveness and to exert their influence practically upon every possible subject, we have thus not only to give suggestions or to advise autosuggestion but in both cases we have to secure, especially for the naturally less suggestible patients, a somewhat heightened suggestibility. Yet no one can overlook that some of the methods which we described have in themselves the tendency to reenforce the mental suggestibility. Those methods of emphasis and order, of assurance and make-believe, of practical training and of awakening counter-ideas, of persuasion and even of reasoning, wherever they are in a high degree successful probably always gain a certain part of their success by the increased suggestibility which the whole situation brings with it.

This reenforcement of the psychophysical readiness for suggestions results indeed quite directly both from expectation of the unknown and of the half-way mysterious, and from the confidence in the doctor. Of course it can work very differently. The expectation can upset the nervous system and produce unrest instead of suggestibility and, instead of confidence, the patient may feel that discouraging diffidence which settles easily upon those who have tried one fashionable physician after another. But where there is real confidence, based perhaps on the fame of the doctor and on the reports of his powerful achievements, there the conditions for effective suggestions are greatly strengthened. Still better is it if this confidence in the man is combined with a sincere hope for recovery. To lie down on a lounge on which hundreds have been cured fascinates the imagination sufficiently to give to every suggestion a much better chance to overcome the counter-idea. The expectation that something wonderful will happen can even produce an almost hypnoid state. The effect will be the greater, the less the barriers of systematic knowledge hinder the entrance of suggested ideas. The uneducated will on the whole offer less resistance to suggestions, just as superstitions find the freest play in the minds of the untrained. It is not by chance that the earlier epidemics of pathological suggestibility have on the whole disappeared with the better popular education. In a similar way work fatigue and exhaustion. The resistance has grown weaker, the suggested idea goes automatically into activity.

Skillful artificial means can still surpass the effect of these natural conditions. Here belongs everything which accentuates the authority and dignity of the originator of the suggestion. The psychologically trained physician has no difficulty in heightening the effect by simple surprises, if he cares for such tricks. If the patient for whom a mental treatment is recognized as necessary shows himself too skeptical to submit to the powers of the psychotherapist, such captivation of his belief can easily be secured. Let the man perhaps fixate a penny on the table with his right eye, while the left is closed and you show him that you can make another penny suddenly disappear when you move it a certain distance to the right and appear again when you move it still further. As the man has never heard of the blind spot in the retina, he accredits you with a special power. Many similar psychological illusions can well be used to prepare the mind for unsuspected healing powers.

Still stronger is the effect of personal contact. The psychophysiology of love indicates the most complex influence which contact sensations have on the whole nervous system and especially on the vasomotor apparatus of the body. Probably such vasomotor effect enters in, changing the blood circulation in the brain, when a personal contact between the transmitter and receiver of the suggestion is brought about. If the physician's hand rests quietly on the forehead of the patient who lies with closed eyes, or if he holds for a long while the hand of the patient, he may secure a nervous repose and submission which gives to the suggestions the most fertile soil. Needless to say that here again everything depends upon the accessories. An unsympathetic doctor may be entirely powerless where his neighbor has complete success. Neither a lifeless hand nor an agitating one will bring the desired repose, neither a cold nor a rough one. There must be strength and energy and even discipline, and yet sympathy in the pressure of the fingers. Again a psychologically different effect and yet one often to be preferred results from mild stroking movements, the stroke always to be repeated in the same direction, never up and down. The slow change in the position of the tactual sensations evidently produces a rather strong influence on the equilibrium of nervous impulses, and here again vasomotor reflexes seem to arise easily. Another variety of such bodily influences is given by artificial changes of the positions, for instance by bending the head of the subject backward while the eyes are closed. It may be that a certain lack of balance sets in in which the self-equilibrium is disturbed and an external influence can thus more easily get control of the psychophysical system. Again a certain monotony of speaking may easily add to the increase of the suggestibility.

Everyone knows that another most fruitful cause of this change is any mystic inspiration, any emotion in which the individual feels himself in contact with something higher or larger or stronger. Of course, the church can secure this effect easily, and here again the maximum will be reached if a bodily contact with the symbol of religious exaltation can be established. The patient who can touch the relics of the saints or bathe in the waters of Lourdes or at least feel on his forehead the hand of the minister, is wrought up to a state of suggestibility which makes suggestions easily effective. The objective value of religion again has nothing to do with it, as exactly the same effect can result from the most barbarous superstition. The amulets of a gypsy might secure the same resetting of the psychophysical system which the most sacred symbols awaken, and even many an educated person is unable to cross the threshold of a palmist or an astrologist, or to attend the performance of a spiritist, or to sit down with a purchasable trance medium without feeling an uncanny mental state which is objectively characterized by an increased suggestibility. But finally, the same effect sets in when the symbols of other emotional spheres are applied, perhaps for the patriotic soldier the flag of his country.