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 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 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 rôle. 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, reënforced 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 régime. 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
régime. 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 reënforce 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 reënforced by the attitude of
prayer. Even the physiological conditions of it, the clasping of the
hands, the kneeling, and monotonous sounds reënforce 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
reënforce 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.

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