SECTION IV
GENERAL PSYCHOTHERAPEUTICS

CHAPTER I
GENERAL PRINCIPLES OF PSYCHOTHERAPY

In formal, deliberate psychotherapeutics the first and most important principle is the treatment of the individual patient, and not of his disease. It is much more important to know the kind of an individual who has pneumonia, as a rule, than to be able to tell the amount of pulmonary involvement. If heart, kidneys or lungs are affected when the disease declares itself, the outlook is extremely unfavorable. Similar conditions are true of the patient's mind. If he is of the worrying kind, the outlook is serious. If, on the contrary, he faces it bravely, and without after-thought except that of responding to medical treatment, he will probably get well.

Pneumonia is only one example of the part the individual plays in therapeutics. In the popular mind it is supposed that for each disease there is a definite remedy, and that when the physician gives that remedy the patient gets well. This idea of specific remedies has come to the people from the physician, but only the quack now pretends to cure disease, the physician helps the patient to overcome the affection from which he is suffering.

No Incurable Patients.—There are many incurable diseases, but there are no patients to whom a doctor should say with truth, "I can do nothing for you." We may be unable to do anything for the underlying disease. That may be absolutely incurable. In spite of this, there are practically always symptoms for which the patient can be afforded so much relief that he feels better than before. This is the most important attitude of mind for the physician who would use psychotherapy. He can always do something. Prof. Richet said not long since, "Physicians can seldom cure, but they can nearly always relieve and they can always console," and it is the physician's duty to lift up and console the mind as well as to heal the body.

Unfavorable Suggestions.—Patients often have many opinions and conclusions with regard to their ailments which are not confided to their medical attendants, and which constitute the basis of many annoying symptoms. They have mental convictions with regard to the incurableness of their ailments, the supposed progressive character of the disease, and the development of symptoms which will still further annoy them, that are often more serious and harder to bear than the symptoms from which they are actually suffering. Unless the physician has their complete confidence, these patients may suffer much in silence, though the revelation of their state of mind would often be sufficient to afford a good measure of relief, and the correction of false notions would do nearly all the rest. Psychotherapy confers its benefits mainly by securing the most complete rapport between the mind of patient and physician. Good advice is often more important than any medicine. The correction of wrong notions will do more to relieve the patient, and make whatever symptoms he has bearable, than most of the anodyne drugs. The stimulation of hope means more than almost anything else in arousing the latent forces of nature and predisposing to recovery. The removal of unfavorable suggestions is but little less efficient.

Study of the Individual .—The great differences in the relations between physicians and their patients is well recognized. To some physicians a patient will present only conventional symptoms, while a follow practitioner will discover the elements of an interesting case. Above all, the painstaking physician, interested in psychology, will find mental and other personal manifestations in his patient that distinctly modify the course of the disease. We must know all that is possible about the patient's attitude of mind toward his malady, and all the ideas that he has acquired with regard to it, either from previous relations with physicians or from what he may have read or heard from others. The removal of many false notions that are thus working harm will reward the medical practitioner who gets at his patient's ideas. The old rule in therapeutics is non nocere—to be sure to do no harm. The special rule in psychotherapy is to be sure to remove all the ideas that are doing harm to the patient and making his symptoms mean more to him than they really signify.

Neutralizing Contrary Suggestion .—In the application of psychotherapy, then, the first principle is the neutralization of unfavorable mental influence. In our day men have such a smattering of knowledge about disease, especially about the worst forms of it, that they are likely to be in a frame of mind with regard to many affections that is quite unfavorable. Many patients think disease and not health. Disease means discomfort, and consequent loss of vital energy and disturbance of the resistive vitality that would enable the patient to throw off the affection. Sometimes the physician does not realize what a large part unfavorable suggestions are playing in the affection. Sometimes patients conceal their state of mind lest the doctor should confirm their worst fears. The preliminary to all successful treatment is to remove unfavorable suggestion.

Favorable Suggestion.—The next thing is to set certain favorable suggestions at work. It is possible always to do this. Even in certain of the acute diseases favorable suggestion has its place, and for all chronic cases this form of therapeutics is extremely important. The very presence of the physician, especially if he is thoroughly in control of himself, placid, imperturbed, evidently ready to use all his powers without any excitement, is of itself the strongest kind of favorable suggestion. From the very beginning of medical history the presence of the physician has in most cases meant even more than his medicines.

Münsterberg, in his recent book on Psychotherapy, has emphasized this in a way that deserves to be recalled:

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 reinforce 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 may be acknowledged for the social classes of tuberculosis as they have recently been instituted.

Favorable Environment.—After the removal of unfavorable suggestion and the implanting of favorable suggestion, the next point must be the persistent occupation of the patient's mind with thoughts favorable to his condition. A nurse who is inclined to be pessimistic must be taken out of the sick room, and there must be only cheerful faces and cheery people around him. Hence the modern trained nurse, and especially the picked nurse, who does not allow herself to be disturbed, who is not fussy, who is not forcibly cheerful but quietly placid and confident and cheery, means much for the patient's recovery. Relatives are almost sure to exert strong unfavorable suggestions, though time was when the devoted wife or mother might be depended upon to cover up all her personal feelings and give the best possible service for the mental uplift of the patient. When she can thus conceal her own solicitude, a near relative may be the best possible auxiliary in psychotherapeutics.

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

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

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

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