Psychotherapy by Hugo Münsterberg (world of reading .TXT) 📕

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 PSYCHOTHERAPYContents

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 rôle. 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 præcox; 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 anæsthesias and paræsthesias, the disturbances of the reflexes, of the spasms, tremors, convulsions, and incoördinations, 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