Psychotherapy - Hugo Münsterberg (top 5 books to read txt) 📗

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, anæsthesia and paræsthesia, 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, anæsthesia and paræsthesia 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