Chapter X: Part II: The Practical Work of Psychotherapy (3)

Incomparably more value belongs to the artificial sleep, the mesmeric state of earlier days, the hypnotism of our time. We have discussed its theory and recognized that an abnormally increased suggestibility is indeed its chief feature. We know hypnotism in most various degrees; the lowest can be reached practically by everyone, the highest by rather few. It is almost arbitrary to decide where those waking states with high tension of suggestibility end and the hypnotic states begin, and not less arbitrary to call the higher degrees only hypnotism and to designate the lower degrees as hypnoid states. If we do it, we certainly should acknowledge from the start that the hypnoid states are for therapeutic purposes not a bit less important than the full hypnotic states. Certainly the hypnoid states do not allow complex hallucinations and absurd post-hypnotic actions, but they offer excellent starting points for the removal of light obsessions and phobias and for the reenforcement of desirable impulses, volitions, and emotions. Many persons cannot under any circumstances be brought beyond such a hypnoid degree. The physician who has not theoretical experiments but practical success in view ought therefore never to trouble himself with the inquiry exactly which degree has been reached. This advice is given because nothing interferes with the progress of hypnotic influence so badly as the constant testing. It must naturally often lead to a point where the subject finds that he can very well still do what the hypnotizer told him not to do. If the doctor assures him that he can no longer move his arm and the patient is yet able to move it, the doctor secures the very superfluous knowledge that this special degree of suggestibility has not been reached, but the patient is sliding backward and the lower degree which actually had been reached will be less accessible later. The physician might rather resort to the opposite course and assure the patient, even after the first treatment which might have been a slight success, that he saw from definite symptoms that hypnosis had set in. That will greatly smooth the way for real hypnotic effects the next time.

The best method of hypnotizing is the one which relies essentially on the spoken word, awakening through speech the idea of the approach of sleep. If the hypnotizer assures the subject in monotonous words that a feeling of fatigue is setting in, that he is feeling a tiredness creeping over his shoulders and arms and legs, that his memories are fading away and that he is now hypnotized, for not a few all is done that is needed. The hypnotic state will come and will hold until the verbal suggestion takes it off again. Perhaps the hypnotizer says that he will count three and at three the subject is to open his eyes and feel perfectly comfortable. It is wise to tell the patient beforehand that he will not lose consciousness and that he will remember afterward whatever happens as many people believe that loss of memory belongs to the hypnotic state, and that they were not hypnotized if they can remember what happened. Such a skeptical after-attitude can seriously interfere with the success of the treatment.

Yet in most cases, it will be safer not to rely on words only but to supplement them by manipulations which all converge towards the effect of increasing the suggestibility and thus of overcoming the resistance to the suggestions introduced. It is well known that for this purpose it is advisable to begin the influence with some slight fatiguing stimulations. The effect is most easily reached when the patient fixates perhaps a shining button held over his eyes or listens to monotonous sounds. A particularly strong effect belongs again to very slight touch stimuli. If the subject with his eyes closed is touched perhaps by two pencils at various and unexpected points of the face and hands, a skillful playing on his tactual senses soon produces a half-dozing state of hypnoid character. In the same group belong those so-called passes which evidently have a reflex influence in the blood-vessel system. It is advisable to combine the various elements in such a way that at first physical stimuli upon eye or skin produce an over-suggestible state and that only as soon as this state is reached the verbal suggestion sets in, perhaps with the words, "I shall hypnotize you now." Under such conditions every subject may soon be brought to that degree of hypnotization which is accessible to him. Yet more than one treatment is usually necessary for the higher degrees. Much less importance for therapeutic purposes belongs to that hypnoid state which is reached without the idea of sleep where the subject comes with open eyes into a kind of fascination, produced perhaps by a sudden flash of light or by the firm eye of the hypnotizer. It is a state which can lead to a strong submission of will and which has its legal importance. Therapeutically it can hardly secure an effect which cannot better be secured through the real sleeplike hypnotism. Under certain conditions, chemical substances may well prepare for the hypnotic treatment, for instance bromides or alcohol. Others rely on the suggestive effect of flavored water. But all that is unwise. The confidence of the patient is the best preparation for the securing of the helpful degree of hypnotism.

Of course only a small part of the therapeutic usefulness is secured during the hypnotic state itself. A pain may be removed, sleep be secured, an idea be inhibited, a movement be reenforced in cases where non-hypnotic suggestions would have found insurmountable obstacles. During the hypnosis we may also open the storehouse of memory and bring to light the ideas which disturbed the equilibrium of the suffering mind. Further in those most complex hysteric cases of dissociated personality, new memory connections may be formed during the hypnosis by which a synthesis of the double or triple personalities into the old one may be secured. Yet the general effect which the physician has to hope for from hypnotic treatment is the post-hypnotic one. Not what happens during the hypnosis but what the suggestion will produce after hypnosis is essential to him. The fixed idea is to disappear forever, the paralyzed limb is under control, the desire for morphine and cocaine is gone for all future time, the perverse longing is annihilated, the old energy is to remain again for all time. It is the post-hypnotic after-effectiveness which gives to the hypnoid and to the hypnotic states their importance for the treatment of the most exasperating symptoms. To be sure, the treatment often must be a prolonged one. A man who for years has used thirty grains of morphine a day cannot be rid of the desire after two or three hypnotic sittings. In such a case the treatment may cover three or four months, if it is to be of lasting value and without any damage during the treatment.

Still we are not at the end of the psychotherapeutic methods and we may turn to a fascinating group of curative efforts which has especially come to the foreground in recent years. We mentioned before that mischief cannot seldom be traced back to earlier experiences with a strong unpleasurable feeling. In certain cases, the subject remembers such particular experiences as the beginning of his discomfort; in others, especially those of hysteric character, the starting point may have long been forgotten, and yet that early impression evidently left traces in the brain which produce disturbances in conscious life. The psychotherapist nowadays calls these groups of traces "complexes." We recognized clearly that there is no reason to refer such forgotten remainders of the past to any subconscious mind; they are physical after-effects which keep their influence over the equilibrium of the psychophysical system. Now modern psychotherapy finds that the entire disturbances which arise from such emotional disagreeable experiences, forgotten or not forgotten, can often be removed by psychical means. Two ways in particular seem open. As soon as the idea is fully brought back to consciousness again, the patient must be made to express the primary emotion with full intensity. Subtle analysis has repeatedly shown that many of the gravest hysteric symptoms result from such a suppression of emotions at the beginning and disappear as soon as the primary experience comes to its right motor discharge and gains its normal outlet in action. The whole irritation becomes eliminated, the emotion is relieved from suppression and the source of the cortical uproar is removed forever.

Practically still more important seems the other case which refers alike to hysterics and psychasthenics and which is applicable for the forgotten experience not less than for the well-remembered ones. This second way demands that the psychotherapist bring this primary experience strongly to consciousness and then by a new training link it with new and more desirable associations and reactions. The disturbing idea is thus not to be discharged but to be sidetracked so that in future it leads to harmless results. The new setting works towards an entirely new equilibrium. What was a starting point for abnormal fears now becomes an indifferent object of interest and all its evil consequences are cut off. It may be acknowledged that the full elaboration of these methods still belongs to the future. Both methods, the discharging, or the so-called cathartic one, and the side-tracking method evidently demand the discovery of the starting point in the service of the therapy and here again several methods are at the disposal of the psychologist.

A promising way to this end is the inexhaustible association test which we mentioned when we discussed the contributions of the psychological laboratory to the medical diagnosis. A series of short words are spoken to the patient and, as soon as he hears one, he is to pronounce as quickly as possible the first word which comes to his mind. If we use fifty words, we should be able to learn something as to the inner states of the man and as to the working of his mind, if we analyze carefully his particular choices. But two further conditions ought to be fulfilled. The time of the association ought to be measured. Of course there will be wide differences. A word which is often in a certain connection will quickly bring the habitual association. Abstract words will call forth their associations more slowly than concrete words, familiar words more rapidly than unfamiliar words. To measure such association time with fullest accuracy, as it is necessary for the purpose of scientific investigations, delicate electrical instruments are needed that indicate thousandths parts of a second. For the purpose of the practical physician such accuracy would be superfluous. His examination will be perfectly successful if it is carefully done with a stop-watch which shows the fifth part of a second, like those which are used at races. He speaks a word, presses at the same time the button of the watch, and presses the stopper when he sees the lips of the patient moving. He is thus able to examine not only the involuntary choice of association but also the time of every associative process. But a second condition ought also to be fulfilled. After some indifferent words, others ought to be mixed into the series which touch in a tentative way on various spheres corresponding to the possible suspicions. The groups to which the hidden thoughts of psychasthenics, for instance, belong are not many. As soon as our series of words strikes such a group, the reaction of the mind may be discriminated. The effect may be a general perturbation resulting either in an unusual delay of the fitting association or in an effort to cover the sore spot by an unfitting association. Sometimes the dangerous association may rush forward even with unusual rapidity but, as soon as it is uttered, it gives a shock to the mental system, brings the whole associative process into disorder, and the result is that the next following associations are abnormally delayed. The skilled psychologist will quickly take such a change as a cue for the selection of the later words in his series. Of course, he will at first return to neutral words, but as soon as he has found a danger spot, he will approach it from various sides, perhaps in every fourth or fifth word, and may then find out which particular experiences are disquieting the patient. Words like women or money or career or family or disease are often sufficient to get the first inkling of a mental story.

With less diagnostic elegance we sometimes reach the same end by taking careful records of pulse and breathing and involuntary movements during an apparently harmless conversation. The instruments at the disposal of the psychologist are those familiar to every psychological laboratory: the pneumograph, which registers the movements of respiration; the sphygmograph, which writes the pulsation of the artery in the wrist; the automatograph, or other instruments, which register the slight unintentional movements of the arm. If the examiner is skillful, he will not fail to discover the changes in breathing and pulse and reaction as soon as the painful groups of ideas are approached. More of theoretic interest and too cumbersome for practical diagnosis is the unfailing galvanic reaction from the skin in which the glands change their activity and their resistance to the galvanic current under the influence of hidden emotions. Yet all these methods, with exception of the last, are essentially useful only if the starting experience is still accessible to the memory of the patient. He may be unaware that it had anything to do with his nervous symptoms but he recognizes the experience still as soon as his attention is directed towards it. The psychologically more interesting but probably more exceptional situation is the one in which it is not only forgotten but cannot be recognized when it is brought to consciousness. The shortest way to get hold of such past impressions is the hypnotic one. The hypnotic state sharpens the memory and experiences of early childhood or apparently insignificant experiences of later life may be brought back when they would have been inaccessible to any intentional effort of the attention. Even still more surprising is the success if the association is left to a dreamy play of ideas suggested perhaps by gazing into a crystal ball or by a meaningless talking. Perhaps the patient lies with closed eyes on the couch while the physician holds his hand. A few words are given to him as a starting point and then he is thoughtlessly to pronounce whatever comes to his mind, not only unfinished sentences but loose phrases, single words, apparently without meaning and slowly ideas arise which betray the original intrusion. At last memories and lost emotions come again to the surface, and the watchful psychotherapist may discover the complex, which is then to be removed by discharge or by side-tracking. This is the so-called psychoanalytic method.

Finally the psychotherapist may go still one step further. After all it often seems inexplainable that just this or that emotional experience made such a deep and lasting impression while a thousand other experiences passed by without leaving any mischievous after-effect. It seems that indeed the conditions are still more complicated. That emotional disturbance operated dangerously perhaps only because it itself appealed to a suppressed desire and this seems to hold true especially for suppressed emotions of the sexual sphere. The desire for gratification in normal or abnormal channels was perhaps attached by the mind to some group of objects. It was completely suppressed but it left an abnormal tension in the central system. If now a chance experience touches on this group of ideas, there results an explosive reaction; and movements, convulsions, spasms, obsessions, and fears set in which get their particular character not through the secondary intrusion but from the primary desire. To discharge that intrusion leads therefore only to the elimination of those symptoms which resulted from it, but the primary disturbance goes on and any new chance intrusion will produce new explosions. The psychotherapist should therefore go deeper and relieve the mind from those primary desires which may belong to early youth and which are entirely forgotten. Even the method of automatic writing may here sometimes lead to an unveiling of those deepest layers of suppressed desires. In the same way a careful, subtle analysis of dreams may support the search for the hidden source of interference.

We have spoken of the technical methods of the psychotherapist. It would be short-sighted to ignore the great manifoldness of secondary methods which he shares with the ordinary intercourse between man and man, the methods which the teacher uses in the schoolroom, which the parents use in the nursery, which the neighbor uses with his neighbor, methods which build up the mind, methods which train the mind, methods which reenforce good habits and suppress unwholesome ones, methods which stimulate sound emotions and inhibit a quarrelsome temper, methods which indeed are not less important in the psychiatric clinic and in the hospital than in our daily life, and which certainly have central importance in that borderland region which is the particular working field of the psychotherapist.

X

THE MENTAL SYMPTOMS

We have discussed both the psychological theory and the practical work of psychotherapy in a systematic order without any reference to personal chance experience. After studying the fundamental principles, we have sketched the whole field of disturbances in which psychotherapeutic influence might be possible and all the methods available. It seems natural that our next step should be an illustrating of such work by a number of typical cases. Here it seems advisable to leave the track of an objective system and to turn to the record of personal observation. As this is not a handbook for the physician, dealing with the special forms of disease, we emphasized before that we avoid even any attempt in such a direction because it would have to introduce not only the questions of diagnosis, but above all the highly important questions of treatment by physical agencies. We saw that for us nothing else can be desirable, but to show the way in which the various symptoms which suggest mental treatment occur, and how they yield to the psychical methods. We had also agreed beforehand that for a first survey we might separate the mental from the bodily symptoms and group the mental ones with reference to the predominance of ideational, emotional, and volitional factors. And finally it may be said that we abstain from everything which is exceptional or even unusual, and confine ourselves to the routine observations with which the psychotherapist comes in contact every day and the simplest country physician surely every week.

Thus I turn from systematic objectivity to my unsystematic reminiscences of many years. Of course, they abound with eccentric abnormities and startling phenomena. As I have devoted myself to psychotherapeutics, always and only from scientific interest, as a part of my laboratory studies and therefore have refused to spend any time on cases which offered no special psychological interest to me, the striking and sensational cases have prevailed in my practice even to an unusual degree. Yet they are unessential for our purposes here, the more as their interest lies mostly in the complex structure of the mental state while the curative features are in the background. Our purpose of demonstrating practical cases as they occur in every village, and as they ought to be understood and treated by every doctor, thus rules out just those experiences which would be prominent in a theoretical study of abnormal psychology. We want to select only simple commonplace cases. Only those who have not learned to see are unaware that such cases are everywhere about them.

As a matter of course, I also leave out everything which refers to insanity, that is, every mental disturbance which lies essentially outside of the domain of psychotherapy. The helpful influence which psychical factors can exert in the asylums for the insane is, as we emphasized, entirely secondary. The psychotherapeutic methods in the narrower sense of the word are in the present state of our knowledge ineffective in the insane asylum. I should also be unable to speak of laboratory experience with insanity, as I insist on sanitarium treatment in every such case. The question of how to differentiate the diagnosis of insanity from that of the other mental abnormities is not our question at this moment. I select the few illustrations which seem to me desirable for the purpose of making more concrete our abstract discussion of methods, essentially from the class of neurasthenics, psychasthenics, hysterics, and so on.

In all these reports, I shall confine the account to the few points which are to illustrate the psychical factors, thus abstaining entirely from the further details which any medical history of the cases would demand and from all results of further examination and other particulars. As a matter of course, I exclude the possibility of identifying the patient. I may start with a typical case of obsessing ideas of simplest character and with simple routine treatment illustrating the emphasis on antagonistic ideas.

A man of mature age, well educated, well built and in every respect
in good health, without nervous history and without other nervous
symptoms, suffered vehemently by the persistent recurrence of a
visual image which entirely absorbed his attention. He knew
exactly the development of his trouble. A woman acquaintance of his
had committed suicide by poisoning herself. He knew her slightly
and the emotion of personal loss played hardly any role in the
case. But he had met her at a gay dinner a short time before her
death. The news of the suicide came to him when he was overtired
from work. The idea of the contrast between seeing his friend
partaking of the dinner and imagining her drinking the poison gave
him a strong shock. There was hardly any grief mixed in. He
remembers that he shivered at the thought of the contrast, and in
that moment the visual image of the woman raising a glass of poison
to her mouth flashed into his mind and thus became almost a part of
the shock. From that time on, the memory image of this scene
returned more and more frequently. At first it associated itself
with any chance mentioning of death or suicide and to a very slight
degree with the idea of a meal. More and more any element of a meal
and of social life, the word soup or meat, the word gown or dance,
brought up at once the picture of the woman, which had in the
meantime lost every element of personal relation. Any sad thought
of her ending had faded away. It remained merely a troublesome
impression. The man fought against it by trying to suppress the
idea but the more he fought against it, the more insistently it
rushed forward through new and ever new association paths. Any
advertisement in the newspaper referring to food, anything in a
shop window referring to ladies' dresses, any household utensils
related to a meal, and especially the meals themselves, forced the
visual image into the centre and captured the attention to such a
degree that a confusing distraction from the real surroundings
resulted. The struggle against the idea became more and more
exasperating, made life a torture, almost suggested despair, even
faint thoughts of suicide, and especially a growing fear that it
was a symptom of the beginning of insanity.

When he came to me, a number of physical cures, especially bromides
and electricity, had been tried in vain by the physician. Some
weeks in the country had not changed the distress. He came to me
with the direct request as a last resort to try hypnotic treatment.
I found in spite of the fact that he and his physician had
constantly spoken of visual hallucinations that the visual image
had no hallucinatory character at all, that is, he never believed
that he saw the image of that woman as if it were actually present,
he never took the product of his imagination for reality, nor had
it the vividness and character of reality. It was hardly more vivid
than any landscape which he tried to remember, only that it
controlled the interplay of ideas in such a persistent way. I found
that he was a strong visualizer and easily suggestible. I told him
beforehand that I should hypnotize him only to a slight degree,
that he would not lose consciousness, that he would remember
everything which I told him. Then I asked him to lie down and had
him gaze on a crystal only for half a minute, then close the eyes.
I asked him to relax and to think of sleep. With the two blunt
points of a compass, I touched his two cheeks at corresponding
places, then his forehead. And now I told him that I would begin
with the hypnotic influence. I put my hand on his forehead and
spoke to him in a monotonous way, saying that he felt a fatigue in
his shoulders, and in his arms, creeping over his whole body and
assured him that he was now fully hypnotized. To what degree he
really was hypnotized cannot be said as no effort was made to test
it by any experiments, thus avoiding any possible reaction against
the feeling of submission. Expression and breathing indicated a
slight hypnoid state. Then I removed my hand and spoke to him in a
warm and assuring way.

I told him that in future he would give his full attention to his
meal, and not give the slightest attention to any image of his
friend. If he should think of the friend the memory would appear
indifferent, he would not even notice the image and would give his
whole mind to the objects with which he was engaged. In the same
way, when he should be reading newspapers or looking in
shopwindows, his whole attention would belong to that which he
really perceived. Any passing inner image would be ignored. Then I
awoke him from his sleep. He was unwilling to believe that he had
been in hypnosis at all. I told him that the effect would prove it
and in his fully wakeful state I explained to him why there was not
the slightest fear of insanity justified, that it was a
psychasthenic state resulting from fatigue and shock and from a
wrong attitude of his attention during the past months, and then I
asked him to return the next day. Intentionally I had not given the
suggestion that the image would disappear. I could not expect it
would disappear entirely after a first treatment and even a faint
appearance of it would have at once fascinated the attention and
brought about the whole disturbance of the equilibrium which might
become habitual. Instead of it I gave the impulse to the
counter-idea, that is, I reenforced the attention towards that
which he really saw around him and thus withdrew the attention from
the rival image in the mind. The success was complete. He came the
next day in a much happier frame of mind, reporting that he still
had seen the image of the woman every few minutes, especially
strongly at the breakfast table, but it had no longer troubled him.
It was more in the background of consciousness, sometimes it
appeared transparent, it no longer held his attention, and he felt
free to give his full attention to the actual surroundings.

On that basis I hypnotized him the second day and he had hardly
heard me saying that he ought to try to sleep when he was evidently
in a much deeper hypnotic state than the first time. Again I
suggested only the opposite attitude, the positive turning to the
surroundings and the complete neglect and indifference for the
possible memory image. This time the effect was still stronger. On
the third day he reported that he still saw the image but he no
longer minded it, as it was like a veil through which he looked at
real objects and that left him entirely indifferent. His mind was
hardly engaged with it any more. The real spell of the attention
was broken. On the basis of this situation, I took the last step
and suggested that the image of the woman would disappear
altogether and would not trouble him any more. In the next
twenty-four hours, it still returned two or three times, but
colorless and faint. The following day I was able to eliminate it
altogether. Even when the last trace of the inner struggle between
the memory and the perceived surroundings had disappeared, I went
on with two hypnotic sittings to give stability to the new
equilibrium, to insist that the image would not come back and to
settle completely that inner repose with which every fear of
possible disease evaporated. I feel sure that the cure would not
have been reached so quickly, possibly not at all, if the second
suggestion, the disappearance of the image, had been given at the
first step. The improvement was secured because the antagonistic
process itself was used for the suggestion. On the other hand,
there was no doubt that in this case the strong will of the patient
or suggestion in a normal state would not alone have been
sufficient. The hypnotic treatment was indicated by the symptoms
and justified by the results.

I may take another typical case in which also the obsession was brought about by an idea without emotional value or at least by an idea which had lost its emotional character; the idea came somewhat nearer to hallucination, but had its chief elements on tactual ground where the transition from image to hallucinatory perception is easier. I add this case to demonstrate that hypnosis is not the only open way of treatment in such cases and that the variations must always be adjusted to the special conditions. The case gains importance by the fact that the patient was himself a physician well trained in mental observation.

The patient is a highly educated physician of middle age. He
reports that he had been neurasthenic all his life with slight
ever-changing symptoms. He has always been troubled by the
"perseveration" of tactual images which had a strong feeling tone
and which were associated with seen or heard reports of the
experiences of others. For instance, when he read in a newspaper
that someone had hurt his hand with a pin, or that someone had cut
his foot on a nail, he immediately felt a not directly painful but
uncomfortable sensation at the particular place in the hand or in
the foot, together with a shrinking of the whole body and such
tactual sensation usually returned during the following days in
fainter and fainter form until it faded away. Most troublesome had
always been the reading of any torture processes in historical
books or in fiction. Yet there had never been a case in which the
sensations really had the vividness of hallucinations and never a
case in which the after effects had not disappeared at least in a
few weeks.

This time the effect had already lasted four months and it became
more and more troublesome. The patient had not the slightest fear
of mental disease and no anxiety, but he felt a very serious
disturbance by the instinctive effort to get rid of the intrusion.
The place of the disturbance was the wrists. The starting point was
a definite experience. On an unusually hot summer day the physician
had listened for a long time to the complaints of a female patient
who suffered vehemently from a nervous fear of scissors and knives
and who was afraid that she would cut her artery at the wrist. He
believes that it was the exhausting heat of the day which weakened
him to a point where the story of his patient affected him very
strongly and made him think of it all the time. Yet there was no
sensation element involved. A few hours later, he sat in a hotel at
his dinner. Just in front of him a butler started to carve a duck
with a long, sharp knife. In that moment he felt as if the knife
passed through the wrists of both arms. He felt for a moment almost
faint; arms and legs were contracted and an almost painful
sensation lingered in the skin, and did not disappear for hours.

From that day at the sight of knives or razors, not only in his
hands or his direct neighborhood, but also in a store and finally
in a picture, stirred up at once the optical image of that carving
knife cutting into the skin of the wrist, only with the difference
that it seldom was found in both arms, usually in the one or the
other. The sensation became a strictly tactual one with optical
overtone, but there was no emotion in it. The pain element had
disappeared. Also the shock, which still recurred in the first days
slowly disappeared. The longer the symptom lasted, the more the
optical factor faded away, and the tactual factor came into the
foreground after three or four weeks. Perhaps seeing a razor in a
store window or a pocket knife open no longer stirred up the image
of cutting the wrist, but simply a strong tactual sensation, as if
the skin of the wrist was scratched and pinched. Finally, after
about two months, the association character disappeared to a high
degree and the scratching and cutting sensation in the skin became
independent and automatic. The patient awoke in the morning with a
vivid tactual hallucination of being cut without associating with
it any picture of a knife. Throughout the day, in the midst of work
and in the midst of conversation, sometimes one and sometimes the
other wrist became the center of the exasperating sensation, easily
bringing with it involuntary reactions as if to withdraw the arm.
This became more and more frequent and more and more vivid.

The doctor, fully aware of the borderland character of this
experience, felt sure that his inner fight against the disturbance
would get control of it. The usual tonics did not show any
influence. On the other hand, there were no other nervous symptoms
and, with his most acute analysis, he did not find the slightest
trace of emotion any longer. When the symptoms reached a point at
which they seriously interfered with his comfort, he asked me for
psychotherapeutic treatment, under the condition that I was not to
apply hypnotism. He was absolutely averse to the use of hypnotism
in his own case because he was afraid that to be hypnotized would
mean for him a certain disposition to fall into hypnotic sleep by
auto-suggestion, as he knew the vividness of his imaginative
sensations. He wanted to avoid that the more as his own
professional work might sometimes demand hypnotizing in his own
practice. In any case he had an aversion to it and asked for other
means.

Under these circumstances, it seemed to me the most logical
conclusion that the counter idea with its antagonistic reactions
might be reenforced by direct perception. The abnormal tactual
sensation forced on consciousness the idea of the cutting of the
wrist. The necessary counter action would be to force to
consciousness the idea of the uninjured wrist and the corresponding
reactions. As the wrist can be easily made accessible to sight and
as I anticipated that the visual sensations would be more forceful
than the tactual ones, I told him to look straight at his own
wrists for ten minutes three times a day after waking, after
luncheon, and before going to bed. He had to hold his two forearms
close in front of his eyes and stare at them, giving his full
attention to the visual impression of the smooth, uninjured skin of
the wrist. If during this process, the tactual counter-sensations
were vivid, he had to go on with the staring at both arms, both
held near together until the perception had crowded out the rival
touch sensation. When this performance had been carried out six
times, he did not notice the coming up of the tactual sensation
with vividness any longer. From the third day it had disappeared
entirely. I told him to go on with the process still every morning
for some weeks. The physician himself considered the cure as
complete.

Our first case dealt with hypnosis, our second case removed the intruding idea by a perception in a waking state. To point at once to the variety of methods which we sketched, we may turn again to a case of emotionless idea removed by the method of switching off and side-tracking the originating and physiological "complex."

The patient is a school-teacher in the Middle West, a nervous,
thin-looking woman of about twenty-five. Her only complaint is a
persistent idea that she may at any time get a child. She has had
this idea "as long as she can remember," according to her first
expression. She never had any intimate acquaintance with any man,
she was never engaged, she hated bitterly every thought of
immorality, she knows and has assured herself by much reading that
it is entirely impossible that she might get a child without sexual
contact. Yet this thought recurs to her all the time, even when she
is talking with other people. It embarrasses her in school, in
spite of her teaching only girls in a private institution. This
thought keeps her away from company and the effect of its
embarrassing occurrence depresses her, but she is sure that the
thought itself does not include any emotion. It is a mere thinking
of it with a full consciousness that it is absurd, and yet she
cannot suppress it.

I began at once to try to find the origin of her queer obsession.
After some efforts to pierce into her memories, we came to an
experience of her youth. When she was about thirteen years of age,
a young girl whom she had admired much for her beauty, living in
the neighborhood of her parents, suddenly got a child which died
after a few days. At that time no thought of immorality seems to
have entered into that news. It was evidently mere sadness about
the quick death of the child which gave to the experience its
emotional tone. She was at that time completely naive. She received
an intense shock in the thought that an unmarried girl may suddenly
get a child which would then quickly die. She cannot tell whether
the thought that she herself would get a child had ever entered her
mind before this occurrence in her neighborhood, nor can she say
that it occurred immediately or very soon after it. She now knows
only that she has always had that thought, but whether that means
more than ten years, she does not know.

I considered it a justifiable hypothesis that this strong emotional
experience early in life had become the starting point for that
secondary absurd thought. I considered that primary experience as
cause for a deep physiological brain excitement which had
irradiated towards the ideas of her personality. It had stirred up
there associations which kept their psychological character while
the primary disturbance had long lost its psychical accompaniment.
It worked its mischief in a physiological sphere but was probably
still the starting point for the persistent obsession. My aim was
to remove this cause. It would have brought little improvement
simply to suppress the freak idea as long as that physiological
source was active. On the other hand I should not have the means to
stop the physiological after-effects of that real experience: I had
to sidetrack it and to secure thus a reduction. I decided therefore
to work on the basis of that hypothesis, to accept that
physiological complex as existing, but to switch it off by linking
it with appropriate associations, thus setting it right in the
whole system of her thoughts.

For that purpose I brought her into a hypnoid state, bending her
head backwards and speaking to her with slow voice until I saw that
a slight drowsy state was reached. In this state I asked her to
think back as vividly as she could of that experience of her youth,
to fancy herself meeting that pretty girl, her neighbor, once more.
She is to imagine that she speaks with her. Now I make her talk
with me and she assures me that she sees the scene distinctly. She
believes she sees the girl on the street. I ask her to tell the
girl how indignant she feels over her behavior; she is to tell her
that she understands now all which she did not understand in her
childhood, that she knows now that she must have lived an immoral
life; that she must have had a friend and that a pure girl like
herself could never under any circumstances come into such a
situation, that no pure girl could suddenly have a child. She is to
express to the other girl her deepest disapproval of such conduct
and her own feeling of happiness that anything like that could
never happen to her. In accordance with my demands, she worked
herself entirely into the scene: without using audible voice, she
internally spoke with great vividness to her neighbor. When I awoke
her from her drowsy state, she was quite exhausted from the
excitement. I repeated that scene with her four times. She assured
me that she felt it every time more dramatically. The power of the
obsession weakened from the first day. After the fourth time, it
had disappeared. The subcortical complex had evidently found its
normal channels of discharge.

In discussing this method of side-tracking the complex, we mentioned that in other cases the result is reached by bringing the memory of that first experience to a vivid motor discharge, without substituting any other ideas. For that purpose no direct personal influence is necessary. Treatment might just as well be performed "by correspondence," provided that the right starting point is discovered and that right suggestions are given. As an illustration, I may choose a case which shows at least the maximum distance treatment by mail, from Boston to Seattle. This particular case presented no difficulty in getting hold of the starting point as my correspondent, whom I have never seen, himself at once pointed to the original source of his obsessing idea.

The patient who lived with his family in Seattle wrote to me the
following: "----I shall undertake to describe in a few words a
condition which the writer has fought against for about eight years
and which has subjected him to untold mental anguish.----I was
backward in a social way but altogether happy. After working in a
bank about a year, was discovered one evening by the cashier
smoking a cigar in the basement, was unable to look him in the face
at the time. Went home that night and thought very little about it,
but on the following morning during the regular course of business,
I stepped up to him to ask some question, and as usual,
unconsciously looked him in the face. His glance was questioning
and suspicious, and that was the beginning of a life of anguish for
me. At first I could not look him in the eyes, then when looking at
some other person, I happened to think of it and so on, until in
two or three days it was impossible to look at anyone who came to
my window. The cashier did everything he could for me. No use: I
quit my position, lost most of my friends, had to leave a happy
home and came to Seattle to work for an old school friend. In the
first year, owing to new environments, I managed to conceal my
mental condition to a certain degree. All of a sudden, I was again
plunged into the depths of black despair. It took me about two
years to (partially) forget it, when the same thing occurred again,
and I lost my grip. The last time about eighteen months ago was
almost more than I could stand. These three or four instances I
speak of were cases of extreme despondency, but my usual mental
condition is extremely unhappy. If occasions arise where I have to
sit and talk to anyone for ten minutes, controlling myself is such
an effort that it leaves me with a case of the blues.... I shall
come and see you as the relief would give me a new lease on life."

This letter was written on the twenty-third of January, 1908. I
replied to him at once that he certainly ought not to come from the
Pacific to the Atlantic, but that I wanted him to write to me much
more about that first occurrence. As he was evidently right in
considering that episode as the starting point of his troublesome
associations, I supposed that these associated ideas had not yet
become independent but were still the effect of that first
"complex." Therefore I wanted to bring that to complete discharge.
Accordingly I wrote him to think himself once more into that
happening of years ago, to pass through it with all the power of
his imagination, to describe it to me then in as full a statement
as possible and to express in the letter also his conviction that
there was no reason to avoid the eyes of his superior, that he
might have looked straight into his face. As soon as he got my
reply, he wrote to me on the sixth of February a description of
that first episode, filling nineteen pages, telling me all about
his relations to those various men and every minute detail was
brought clearly to consciousness again. I did not add anything
further, but the expected occurred. On the eighteenth of February,
he writes to me: "In the last week or ten days, the writer has
noted a decided improvement regarding mental condition. The result
is a new interest in life. If you can spare the time, would like to
have you write me a few lines. Gratefully yours." At the end of the
month he writes: "Received your letter about half an hour ago.
Hasten to assure you with a great deal of pleasure that I am
feeling much better. Since sending you the letter regarding the
first case, I have noticed day by day an improvement." On the
eighth of March: "Since writing you last I have noticed a gradual
improvement. It has given me wonderful encouragement." On the tenth
of March: "Just a line to say that I am still improving." On the
twelfth of April: "I desire to say that since the taking up of
treatment with you, life has had a far different appearance to me
than it has had for the last ten years." On the twenty-first of
April: "Since my first letter to you, there has been such an
improvement that I have accepted a position which carries with it
much responsibility."

This case leads over to the large group in which the obsessing idea involves the relation to a particular person. I find in such cases autosuggestion more liberating than heterosuggestion if the development has not gone too far. Of course autosuggestion can never take hypnotic character, but makes use with profit of the transition state before normal sleep. The type of these cases which are everywhere about us may be indicated by the following letter.

The writer is a young woman of twenty-four, whom I did not know
personally. She wrote to me as follows: "I am a writer by
profession and during the last year and a half have been connected
with a leading magazine. In my work, I was constantly associated
with one man, the managing editor. This man exerted a very peculiar
influence over me. With everyone else connected with the magazine,
I was my natural self and at ease, but the minute this man came
into the room, I became an entirely different person, timid,
nervous, and awkward, always placing myself and my work in a bad
light. But under this man's influence, I did a great deal of
literary work, my own and his too. I felt that he willed me to do
it. The effect of this influence was that I suffered constantly
from deep fits of depression almost amounting to melancholia. This
lasted until last fall, when I felt that I should lose my mind if I
stayed under his influence any longer. So I resigned my position
and broke away. Then I felt like a person who, having a drug to
stimulate him to do a certain amount of work, has that drug
suddenly taken away, and without it I am unable to write at
all...." I wrote to the young lady that she could cure herself
without hypnotism and without my personal participation. I urged
her simply to speak to herself early in the morning and especially
in the evening before going to sleep, and to say to herself that
the man had never helped her at her work, but that she did it
entirely of her own power, and that he had never had any influence
on it, and that she can write splendidly since she has left the
place, and much better than before. A few months later, she came to
Cambridge and thanked me for the complete success which the
auto-suggestive treatment had secured. She was completely herself
again and was fully successful in filling a literary position in
which she had to write the editorials, the book reviews, the
dramatic criticisms, and the social news. As a matter of course,
such treatment had removed only the symptom. The over-suggestible
constitution had not been and could not be changed. Thus it was not
surprising that in the meantime, while her full literary strength
had come back, she had developed some entirely different symptoms
of bodily character which I had to remove by hypnotism.

As soon as the obsessing idea of the influence of another person takes still a stronger hold and develops systems, the suspicion of insanity always lies near; especially when hallucinations are superadded, the probability is great that we then have to do with the delusions of a paranoiac, and thus no case for psychotherapeutic treatment. Yet it is always wise to keep a psychasthenic interpretation in view as long as the insanity is not evident. I may mention such an extreme case.

The patient, a man of middle age, highly educated, for years had
heard voices calling his name. A man with whom he had some personal
quarrel, had, as he believed, hypnotized him from a distance and
made him act queerly or do things which he really did not want to
do, by telepathic influence. It is a development which is found
quite frequently. Abnormal organic sensations or abnormal impulses
and inhibitions which the patient cannot account for by his own
motives become connected with some vague ideas which are in the
air, like wireless telegraphy or telepathy or hypnotism from a
distance or electrical influence, or magnetism or telephoning,
these then attached to an acquaintance who stands in a certain
emotional relation. Here, too, some organic sensations evidently
had been the starting point and the idea of the man with whom he
quarreled had been secondarily attached. From this starting point
more and more detail was reached. Every action was brought into
connection with the powerful enemy who controlled more and more
even the normal and reasonable doings of the patient. My first
impression was decidedly that of a paranoiac. Yet in some ways the
case suggested another view. There had remained an insight into the
unreality of the obsession. The patient did not really believe the
theory of the telepathic hypnotic influence. He felt it more as an
idea which he could not get rid of and he did not know clearly
himself whether he requested hypnotic treatment on my part for the
purpose of counteracting the hypnotic power of his enemy or for the
purpose of liberating him from his exasperating fixed idea.
Moreover, I found that his voices had no hallucinatory character,
but were merely sound images. I decided to make the experiment
without great hope of success.