Chapter XI: Part II: The Practical Work of Psychotherapy (4)

I hypnotized the man deeply and suggested that no one can have
power over his actions, that he is the responsible originator of
everything that he does and that no one can influence him and that
from that hour he would feel free from any telepathic intrigue. The
effect of the very insistent and urgently repeated hypnotic
suggestion during the first rather long treatment was such a
surprisingly good one that I decided to continue the
psychotherapeutic cure. I hypnotized him daily for two weeks. The
belief in the real wrong doings of an enemy disappeared entirely
from the first. It was at once apprehended as a mere obsessing idea
in the own mind and this idea itself began to be resolved. It lost
its unity; the absurd impulses were still felt but they became less
and less connected with the idea of another man, and as soon as
they were rightly understood as doings of the own mind, the
opposite motives gained in strength. A stronger and stronger appeal
to his own power made these motives more and more influential.
Slowly the association of the influence of the other man faded away
entirely. I intentionally had not given any attention to the
pseudo-voices, inasmuch as they had not taken any relation to the
ideational delusion. I therefore did not include them in my
suggestions, as I consider it wise to confine hypnotic suggestions
always to as few points as possible. Yet these voices decreased
too. At a certain point in the cure I substituted--to save my own
time--an autosuggestive influence, or rather a mixed one, inasmuch
as I had him read ten times a day a letter of mine which contained
appropriate suggestions. After about six weeks, all the
disturbances for which he had sought my advice had disappeared.

Obsessing ideas of such personal influence involve of course always a certain amount of emotional excitement and they may lead us to the unlimited field of disturbances in which the persecuting idea is surrounded by emotional attitudes. Analysis shows easily that the emotion is an essential factor and that it persists in the disease while the ideas to which it clings may change. Central is the emotion of fear; nearest to it that of worry, but any emotion may give color to the particular case. Again any number of methods may be applied and a few illustrations with quite different ways of treatment may indicate more fully the character of the trouble. There is no doctor in the city and none in the remotest village who may not find such cases in his near neighborhood. Of course slight degrees are easily hidden by the patient's own inhibition of external expression. If such suppression by the own will secures a real overcoming of the unjustified emotion, this is surely better than to begin any medical treatment. But as the suppression usually means simply lack of discharge and thus offers all the conditions for an unhealthy inner growth of the trouble, the neglect of such disturbances is most regrettable, and frankness of the patient must be encouraged. Such situation demands a careful observation of the whole case and a subtle adjustment of the treatment to the individual needs. It may perhaps be helpful at first simply to indicate the varieties of the more frequent disturbances of this kind by quoting from various letters. Each case belongs to a type which can easily be removed by psychotherapeutic influence, generally even by a skillfully directed autosuggestion.

The writer is a young man.

"I have always, as long as I can remember, been very nervous and
sensitive. When about seven years of age, I was attacked by St.
Vitus' Dance. Before that I cannot say whether I was particularly
nervous or not. Afterward it was impressed upon me by the remarks
of relatives that I was nervous, so that I soon took note of this
condition myself. The manner in which this weakness has been
especially troublesome is that it has caused me to be very shy. I
shrank from new acquaintances and disliked being observed. Often in
walking along on the street, I imagined myself closely noticed by
the passerby and I always felt uncomfortable.

"About three years ago I suffered from typhoid fever and after
recovering, a new form of the old trouble showed itself. This time
I imagined that when eating I chewed my food in a manner that was
ridiculous and which made people hardly keep from laughter in
observing me. Often I had to leave the table when half through
because I felt I could not bear having critical eyes upon me any
longer. About three months ago I determined to be troubled no
further by my own foolish fancies and by constantly schooling
myself I have improved very much. Still, however, when I walk alone
along the street, I must fortify myself mentally before passing
each group of people. If once I allow myself to think that they are
looking at me, I feel almost paralyzed, my feet seem too heavy to
lift, my arms do not seem to swing naturally, and in attempting to
look placid and unconcerned, I feel that I am failing utterly. Also
when at table, I must still tell myself before each mouthful that I
have no need for fear, that my manner at table is equal and perhaps
superior to the others beside me. I have gone a certain length in
my self-training, and have relieved myself of a great deal of the
mental distress, but now I believe I can advance no further. What
seems needful now is to do away with the self-consciousness which
brought on my worries, though whether this is possible is hard to
say."

Here the letter of a young woman, the type which fills the army of the mind healers and faith curists.

"For years I have been seeking, or perhaps to be more accurate I
should say waiting, for a mind to drift toward me; a mind that
would understand my particular case of fear brought on by the
constant bullying and nagging from my earliest childhood by those
in my home. This fear of brutality has greatly depleted my nervous
system and has unfitted me for the strong, useful, forceful life I
should have expressed. If I could only rid my mind of the thought
that I am always displeasing, or rather, going to displease people,
for I hardly do displease them; if I could get rid of the fear of
caring what the attitude of other minds toward me is, I feel that I
should then strike out into a strong life of helpfulness to others.
In other words I have always felt behind me a great force pressing
me out into public work. When I was a child, it was so strong that
I was sat down upon brutally, to so great an extent that I feared
to voice my convictions and that fear still clings to me like a
nemesis. It seems that every individual personality in a public or
private audience rises up to overwhelm me, causing my tongue to
grow heavy and my mind to become a blank. This enervating fear
blends into every thought I have, whether sleeping or waking. I
have fought with all my might to rid myself of it but so far in
vain."

Here an expression of a very frequent variety. The writer is a middle-aged man.

"I am possessed of a fear that is constantly with me that something
dreadful is going to happen and I do not seem to be able to
overcome it. I am told by physicians that I am bodily sound,
although very nervous, and that the fear is generated entirely by
autosuggestion. When at its worst, it weakens and terrorizes me and
in my better moments I am tormented with a fear of a recurrence of
a bad spell. It is fear of a fear. A year ago at this time I had a
very bad spell but got along fairly well through the summer, but I
am afraid that I will soon again be in a bad condition and lose all
that I may have gained."

The "fear of a fear" is indeed a symptom which the psychotherapist has to fight extremely often, but as soon as he has really recognized it and analyzed the whole mental condition, he will hardly have any difficulty in uprooting it. I add a letter of a school-teacher in New York. He writes:

"I am teaching in a high school. I am of a nervous temperament and
constitutionally limited in endurance. Often my work is done in a
condition of greater or less exhaustion. I find that I blush very
easily in purely freakish ways, when there is no occasion for it. I
find this blushing connecting itself with certain of the girl
pupils of my classes in a conspicuous way. It occurs hardly ever
except when my class is facing me and I seem to be powerless to
overcome it. I have always tried to live a careful moral life, but
my early life was very much secluded. I lacked entirely the free
intercourse young people usually have together and I felt awkward
with others for a long time. In the matter of the blushing, it
sometimes occurs in the case of girls who are especially pleasing
to me but also not infrequently in the case of some who are not at
all so. The whole thing might be passed over were it not that it
has considerable effect in causing constraint toward my students
and in some cases affecting them very strongly in an emotional way
at the very time of life when such things can do most harm. I
regard the matter as being so serious that it brings directly in
question my right to teach, but I do not feel at all sure I could
find other work that I could do if I give up my present position.
The very thought that on a particular occasion it would be
extremely awkward to blush makes it almost impossible for me to
avoid it."

But we have rather now to consider the therapeutic side, and we may begin again with a routine method of a simple hypnotic treatment.

The patient is a young university professor. His intellectual work
is perfect in all directions. There are no nervous symptoms, though
there are some slight disturbances of digestion. He suffers as soon
as he comes into a crowd of people and as soon as he is on any high
place, where he has to look down; the worst when both conditions
are combined, as for instance, at a concert or a theatre in a
balcony seat. But every meeting of many persons, even at church,
produces all the symptoms of nervous excitement. He was easily
brought into hypnotic state by verbal suggestions. When he was in
hypnosis, I reenforced the conditions for an opposite attitude. I
told him that as soon as he was in a crowd of persons he would feel
especially comfortable, would enjoy himself, would fully enter into
the spirit of the occasion and feel especially secure in their
presence. Whenever he should be on a high place, he would enjoy the
safety of the ground on which he was standing or the seat on which
he was sitting. I assured him that he would neglect entirely
whatever he saw and would rely completely on his safe feeling
resulting from his tactual impressions. After having hypnotized him
three times the disturbance disappeared completely, and even an
evening at the theatre in an exposed box on the balcony was enjoyed
without any discomfort. After about a year, at a period of
fatiguing work, some traces of the anxiety appeared again. This
time two hypnotic sittings were sufficient to remove the
disturbance of the equilibrium, which as far as I know has not come
back. The same hypnotic treatments were used in a secondary way to
remove the digestive trouble.

I again quote the case of a teacher, a profession in which the psychasthenics are unusually frequent. It is a case of a young woman from the Middle West.

The young lady wrote me: "I come of a race of strong women and am
not hysterical or easily frightened by many things that disturb
women. Since my fifteenth year I have been seized by hallucinations
of absurd or serious nature which no reasoning could explain away
and which have gradually undermined my power of resistance to them.
At the age of twenty-two, after a year of unusually hard work, my
nervous endurance gave way, and with this breakdown came a sense of
fear and a horror of crime that I have been unable to overcome. I
have never felt the slightest inclination toward wrongdoing. It is
a feeling rather that my shrinking from any mention of evil makes
it impossible for me to listen or think rationally when such things
are discussed. This feeling has seemed to change my whole attitude
toward life and has left me without power to control my facial
expression or carriage when it takes possession of me. I have been
able to teach more successfully than I could hope, but it is only
by cutting myself off from the friendships and pleasures incident
to my life that I am able to accomplish my work. I have fought this
trouble alone and will still do so if there is no help, but the
thought that it is the source of great distress to those dear to me
makes it very hard."

A few weeks later the lady insisted on coming to Cambridge. I found
that there had never been any hallucinations and that she used the
word in her letter only to indicate some insistent memory images
which had never taken the vividness of real impressions. In the
presence of her friend, I hypnotized her deeply and strengthened
through urgent suggestions her consciousness of her having done the
morally right thing at every situation in her life and her
conviction that she never did and never would commit a crime. Here
as always, if possible, I left alone the emotional idea but
reenforced the opposite. The effect was an immediate one. She felt
freer the next day than she had felt for years. I repeated the
treatment a few times and she assured me that the feeling had
disappeared entirely.

I take the rather severe case of a woman of fifty.

The highly educated and refined lady had lost her husband by an
accident in Switzerland, which had been misrepresented by some of
the newspapers as suicide. Two years later she wrote to me: "I feel
as if I had received indelible photographs on my brain which have
since greatly affected my health and from which I may never
recover. This winter the symptoms I have been able to control
returned and I have been ill. I unfortunately saw the newspaper
headlines with my husband's supposed suicide. Though I exclaimed
then, 'how outrageous,' I felt as if I had been struck and since
then I can seldom read a paper without dread and apprehension, and
the hearing of anyone's suicide fills me with terror. When I
hurried to Europe, on the ocean a week from the day of my husband's
death, I had a curious and overwhelming shock. On opening a drawer
and seeing a pair of scissors, they looked to me like a dagger and
suddenly the whole cabin seemed filled with implements of death.
The doctors said that I would find it hard to get over such
impressions but I told them I would, as I had courage and will. But
I have been realizing in these two years that I may be suffering
from something that may be beyond the control of will. I often
become so nervously sensitive that scissors are unbearable for me
to see, or a steel knife or anything that might express death. Our
family physicians are still against hypnotism, and if I should go
to a neurologist of my own selection, it might be to one who
believed still only in nerve foods, baths, or a sanitarium."

The lady came from the South, with her nurse, to Boston and
insisted on being hypnotized by me. I cannot say whether a really
deep hypnotic state was produced at once as I refrained from
testing it. There was certainly no amnesia. Probably it began only
with a slight drowsiness but at the fifth treatment I found a
relatively deep hypnosis. It was a capricious case in which the
improvement was fluctuating but clearly setting in from the first
day. I trained her in hearing and seeing words like death and
suicide with a reenforced feeling of strength and calmness; I
forced her to see and touch scissors with an artificial attitude of
strength and indifference. At the same time I reenforced her good
mood and her enjoyment in life. When she left for England a few
weeks later, she felt herself mentally cured, and throughout the
summer her letters testified the wonderful change which the
treatment had brought about. Half a year later, as the result of
an exhausting physical local treatment, the psychophysiological
symptoms came back to a certain degree. She requested me by a
letter from England to give her some help by suggestion to suppress
again the recurring intrusions. As I had observed her strong
suggestibility, I sent her over the ocean a little pencil of
mother-of-pearl which she had seen in my hand, and advised her to
look at it until she counted twenty slowly and then to close her
eyes and simply to sleep. The autosuggestive effect was unusually
strong. She writes from London: "When I saw the enclosure of your
letter I felt as if it would burn through my hand and the feeling
became so overpowering that I locked it away with my jewels, but as
the days ran into a week I felt I could not live with it in my
apartment any more, and I felt almost ill, until it occurred to me
I could seal it and take it to my bankers. I felt as dreamy and
absent-minded and paralyzed as if you had just treated me."
Nevertheless the effect was on the whole the desired one and she
returned to America with a wholesome freedom of mind. I hypnotized
her twice again and she writes in her last letter: "I can never
repay you for what you have done for me. You have given me back my
courage and my love of life in its vividness and interest and
color, all that through the last years I had so entirely lost."

Even in cases where the disease itself is inaccessible to psychotherapeutic treatment, the superadded grief and worry brought on by the disease might yield to the mental influence and the whole situation would to a high degree be transformed for the better by it. I have often been asked to hypnotize in such cases, where the depression was wrongly taken as a part of the nervous disease; sometimes I agreed to do it in spite of feeling sure that the disease itself could not be removed. I quote an instance.

A young woman afflicted with epilepsy was brought up in the belief
that she had only from time to time fainting attacks from overwork,
and with them secondarily neurasthenic symptoms, especially spells
of depression colored by a constant fear of the next fainting. She
had heard voices all her life and they frightened her in an
intolerable way. I produced a very slight hypnotic state. I
concentrated my effort entirely on suggestions which were to give
her new interest in life, and diminished the emotional character of
the voices without even trying to make them disappear. I proceeded
for several months. The young woman herself believed that the
fainting attacks came less frequently afterwards; yet I am inclined
to think that that is an illusion. But there was no doubt that her
whole personality became almost a different one with the new share
in the world. The epilepsy remained probably unchanged but all the
superadded emotions were annihilated and she felt an entirely new
courage which allowed her to control herself between her regular
attacks. She had been unable to undertake any regular work before
for a long while, but all that improved. More than a year
afterward, she wrote me: "I have really worked most of the time
this past winter and spring and I think I can see a steady though
slow gain. I am reading quite a little and doing it for the most
part easily. To be sure I have, after I have read, hard times with
the voices but their character is usually less determined and
fearful than formerly. Several times I have thought I must come
again to you but each time I have started again to fight it out for
myself, but now, as I am gaining, I can better estimate the great
help your influence was to me at a juncture when everything seemed
so hopeless and helpless."

Even in slight psychasthenic disturbances, the psychotherapeutic influence is not always successful, especially if there is no time for full treatment. But it is very interesting to see how even in such cases the symptom is somehow changing, almost breaking to pieces. It becomes clear that a protracted effort in the same direction would destroy the trouble completely. Typical is a case like the following.

An elderly woman has been troubled her life long by a
disproportionate fear of thunderstorms with almost hysterical
symptoms. As she had no other complaint, I hardly found it worth
while to enter into a systematic treatment and could not expect
much of a change from a short treatment, considering that her
hysteric response had lasted through half a century. As she begged
for some treatment, I brought her into a drowsy state and told her
that she would in future enjoy the thunderstorms as noble
expressions of nature. The whole procedure took a few minutes. Yet
after some summer months she wrote me a letter which clearly
indicated this characteristic compromise between the habitual dread
and the reenforced counter idea. "I have the same sick dread at the
sight of thunder clouds that I have always had, but I seem to have
gotten somehow a most desperate determination to control my fear. I
have done this to the extent of keeping my eyes open and looking at
the storm. Is that hypnotism or pride?"

Another thunderstorm case may lead us to other methods of treatment. Here again in the field of emotional response, we may consider the methods of going back to primary experience, known or forgotten.

A young married woman of the West had suffered always from
hysterical attacks in response to any sharp sudden impressions,
especially sudden loud noises. The banging of a door, but worst of
all a thunderstorm, could produce hours of weeping and crying and
desperate mental condition with all expressions of excitement. Her
husband wanted me to hypnotize her but I preferred another way. I
tried to get her memory back to the earliest case of which she
could think of this hysterical response. As long as we were in
ordinary conversation, she could not trace it beyond about her
twelfth year. But when I brought her into a drowsy state, her
memory revived older experiences and finally settled at a school
experience in her seventh year of age. She then had an excitable
country school-teacher who relied on whipping the children. Once
her neighbor in the class did something forbidden. Her teacher
mistook her for the culprit and began to whip her most forcibly
before she could explain anything; and while the punishment was
going on and she began to bleed from a wound, she all the time felt
that she wanted to express her innocence and could not speak. After
that, evidently the first attack of hysteric character followed.
From that time on any sudden impression released the same group of
reactions. The suppressed emotion had evidently become a
psychophysical "complex." As soon as I had reached this starting
point of her pathological history, I asked her to bring back to
consciousness as many details as possible of that first incident.
She told me all the names and described the classroom and brought
herself vividly into the whole situation. Then I asked her to tell
me the whole story once more and to express strongly her innocence
and the wrongness of the punishment, and when she had completed her
account, brought out with fullest indignation, I had her tell the
whole thing once more and then a third and a fourth time, until she
was quite tired out from it. That was all I did. Very soon after,
the husband reported that there was a great improvement in every
respect, no hysteric attacks, only slight discomfort. Most of the
stimuli which had previously produced strong reactions now passed
without any disturbance and even thunderstorms were experienced
with relative ease. A year later they came once more to Cambridge,
and she simply passed once more through the same process of
discharge which seems now to have removed the symptoms still
further.

By far more reliable, however, is the method of side-tracking the starting experience into a new associational track.

A gentleman with a decidedly psychasthenic constitution developed a
tendency to hesitate in walking on the street. It was not a
complete stumbling but a disturbing inhibition, which set in when
he was walking alone and his attention was not absorbed by
something on the street. He believed that it came on most strongly
when he looked down at the pavement. He suffered from it vehemently
and avoided going on the street alone. He was unable to connect it
with any starting point. He interpreted it as merely a symptom of
overwork. But going with him through all kinds of experiences which
he had had on the street in previous years, we finally found that
once he was running to catch a street car, when he suddenly saw
almost immediately before him a big hole dug out for laying gas
pipes. He was able to stop himself quickly enough not to fall into
the hole but he got a strong emotional shock from the experience.
He, himself, did not think that his walking troubles set in
immediately after this shock. Yet the hypothesis seemed to me
sufficiently justified that there existed a connection, even though
some weeks lay between that first experience and the first
observation of the abnormal inhibition in walking. On that basis I
tried to train a new associative connection. I made him drowsy and
asked him to think himself once more into the situation of his run
for the car but as soon as he reached the hole to jump over it. He
went through this motor feature on ten successive days with new and
ever new energy and from that time up to the present the trouble on
the street has disappeared entirely.

To mention at least one case of the large group in which suppressed sexual emotion was the evident source of an anxiety-neurosis, I mention the case of a woman who showed very strong symptoms of anxiety and oppression and who was cured by a simple advice.

The woman, aged thirty-two, was a saleswoman in a large store
selling gentlemen's gloves and ties. She suffered from time to time
by attacks of vague anxiety in which her heart showed vehement
palpitation. There were paleness and perspiration and at the height
a nervous trembling together with a feeling of despair. These
attacks were not frequent, separated sometimes by weeks, sometimes
by months, but troubling her exceedingly. She had been assured by a
physician that her heart was normal and that she was probably
overworked. She could find absolutely no source of the disturbance.
After a long conversation, I was also unable to discover any direct
or indirect causes until I worked on the basis of those theories
which we have discussed, the theories which connect hysteric
symptoms with chance intrusions which stand in relations to past
suppressed emotions of sexual character. The patient absolutely
denied any present sexual emotions. She had been engaged about
eight years before and acknowledged that at that time there were
strong sexual feelings connected with her fiance, who broke the
engagement. Psychoanalytic methods now brought it to full clearness
that she had her first attack after selling a pair of gloves and
fitting them to the hand of a male customer who had a certain
similarity to her fiance. It was not possible to trace this in the
same way for later cases too, but it seems that bodily contact with
a man by fitting gloves preceded every attack. All this was brought
out partly by questions, partly by free ascending associations
while she, herself, believed that she simply pronounced nonsense
words as they came to her mind, and partly it was secured in a
half-hypnotic state. I came to the conclusion that the suppressed
sexual emotions at the breaking of the engagement were the primary
cause of the disease. The similarity of the first customer together
with the tactual sensations had evidently touched that complex and
brought the suppressed emotion to an explosion which frequently
takes the form of palpitation and similar symptoms. Later the mere
tactual sensation alone produced by the contact with the hand of a
man, possibly with a similar optical impression, perhaps also with
the sound of the voice, brought back the reaction. Instead of
giving treatment, I insisted that she change stores, and become
saleswoman in a house where she would have to do only with women,
and to sell articles which did not bring her into personal contact
with customers. After more than six months of work in her new
place, she reported that the attacks had not come back again.

Of course it may readily be acknowledged that this method does not allow a sharp demarcation line between its various factors. It cannot be denied that an element of straight suggestion may be included. The man whom I train in the forming of a new antagonistic motor response feels it of course all the time also as a silent suggestion to overcome the old disturbance. It is thus to a certain degree impossible to say where the effect of the discharge ends and where that of the hidden suggestion begins. Yet there certainly cannot be any doubt that this revival of the first experience and its improved discharge works directly towards the removal of the troublesome symptom.

Abnormal fear is also the essential factor in most cases of stammering. The patients usually know it themselves. For instance, a lawyer writes to me:

"I have been a stammerer the greater part of my life and have
visited every stammering school in the country, but the relief
obtained has been temporary and in most cases I was not benefited
at all. I am convinced that stammering is due wholly to an abnormal
mental condition, which consists of an unreasoning fear that takes
possession of the individual when he attempts to utter certain
sounds. It is simply a lack of confidence inspired by numberless
failures to articulate properly and is not caused by any organic
trouble, because, taking my own case for example, I can at times
talk as fluently and easily as anyone. I am firmly convinced that
stammering can be cured by hypnotic suggestion. If you could get me
in the hypnotic state and suggest to me repeatedly that from
thenceforth I would have easy fluent speech, I feel absolutely
certain that such would be the case."

Or an engineer writes to me:

"At times I stammer very badly. In an ordinary conversation it is
scarcely perceptible, but it is almost impossible for me to make an
explanation or relate an incident or tell an anecdote. I began to
stammer when I was about seven years of age--I am twenty-nine
now--and continued until I was seventeen, when I broke myself of it
by reading aloud. It came back on me about a year ago, at which
time I was laboring under a very severe nervous strain on account
of business matters. I have since tried to break myself of it in
the way that I did at first, reading aloud, but have been unable to
do so. Can it be cured by hypnotic treatment or suggestion? Can any
hypnotist of ordinary ability do it?"

I should affirm this question, which is one of the most frequent put to the psychotherapist. And yet, if I myself have entirely given up the cure of stammerers in recent years, it was not only because there was little chance to learn anything new scientifically from it but also because it was ultimately disappointing, as the severe cases cannot be cured entirely. Every hypnotist can quickly secure a strong improvement. In even new cases I found an almost surprising improvement in the first two weeks, an improvement which stirs up the most vivid hopes of the sufferers. Then the improvement becomes slower and finally it stops before a complete cure is reached. The patient notices it and it easily works back on his emotion and thus begins again to disturb the speech, unless a very careful continuous counter-suggestion is given. Slight disturbances, to be sure, can be removed entirely. The essential point will always be to suggest to the stammerer the full belief that he is able to speak every word and that he is able to speak it in every situation. But where there is a limit for improvement, we must take for granted that the disturbing fear is only superadded to an organic trouble. In such cases, probably the inability of certain nervous paths was primarily irreparable. These inabilities then became the source of discomfort and of fear and this fear added greatly to the disturbance. Hypnotism then quickly removes that part of the disturbance which had been superadded by the mental emotion but it cannot remove that primary factor, the objective inability, and every cure thus finds its limit there.

Near the field of emotions stand also the many varieties of sexual abnormities and perversities. I abstain from discussing any special cases but it may be said that suggestive treatment is in this region powerful to an almost surprising degree. Even homosexual tendencies which go back to the beginnings of the memory of the individual yield, as my experience shows, in a few weeks, if again the suggestion is not so much directed towards the suppression as to the creation of the antagonistic reaction, that means in this case, of the normal sexual desire.

Both ideas and emotions, of course, lead to actions. Moreover we always insisted that the resulting action is an essential part of the psychophysical situation and that every mental experience has to be characterized as a starting point for action. Yet this factor of activity and of attitude sometimes stands in the foreground. The controlling idea is then the idea of an end of action, the predominant emotion, the emotion anticipated from a certain activity. Typical for that are those disturbances in which an abnormal impulse or an abnormal desire awakes perhaps a desire for ruinous drugs like morphine or cocaine or an impulse to criminal deeds, like stealing. But the disturbances of the psychomotor factor are not less present when the central complaint is a lack of energy, the most frequent symptom of the neurasthenic; and our whole discussion has made it clear that a mere lack of attention belongs to the same category.

Of course, the abnormal impulse is psychophysically not different, whether it leads to a legally important result like the impulse to kill or leads to an indifferent result. The subjective suffering may be the same in both cases. The starting point of the impulse may be any chance experience. The psychasthenic may pick up such impulses from any model for imitation or from any haphazard report. It may be entirely freakish and yet beyond conscious control.

A physician had read in a well-known book on hysteria about a case
in which a girl was troubled by a constant effort to move the big
toe in her shoes. This idea worked on him as a suggestion for
several months. At my advice he fought it by auto-suggestion. He
brought himself into a slightly drowsy state by staring into a
crystal ball and assuring himself by spoken sentences with
monotonous repetition for a long while that he has perfectly the
power to hold the toe at rest. From the second day only a slight
kinaesthetic sensation remained; the movement itself disappeared.

Or a more unusual case.

A young lady once noticed in a man a different color in the two
eyes. It gave her an uncanny feeling, together with the natural
impulse to compare the two eyes. Accordingly she shifted her own
eyes from one eyeball to the other in the man's face. The accent
which this shifting impulse had received by the disagreeable
feeling evidently forced her to repeat this movement with everyone.
At first it became half a play, but soon a disturbing habit and
finally an intolerable impulse. Whenever she talked with anyone,
she lost control of her eyes and was obliged to enter into a kind
of pendulum movement from eye to eye. The situation became so
unendurable that the thought of suicide began to occur to her. I
hypnotized her four times, suggesting to her complete indifference
as to the face of those with whom she spoke and at the same time
certain new habits of fixation. The impulse lost its hold and when
I saw her last, it had completely disappeared.

By far more frequent than such neutral impulses are the desires, for instance, of the alcoholist. On the whole it may be said that psychotherapy can gain its easiest triumphs in the field of alcoholism and a wide propagation of psychotherapeutic methods and of a thorough understanding of psychotherapy would be fully justified, even if no other field were accessible but that of the desire for alcoholic intemperance. The moral disaster and economic ruin resulting from alcoholic intemperance, the physical harm to the drinker and to his offspring is so enormous, and the temporary cure of the victim is so probable that the movement certainly deserves most serious interest. Yet I speak of temporary cure and I refer here especially to the restriction with which I introduced the psychotherapeutic methods in general. They do not deal with diseases but with symptoms; and they certainly do not deal with constitutions, but with results of the cooeperation of constitution and circumstances. That the given constitution may be brought anew under conditions which again stir up similar symptoms is always possible, and just with alcoholism the danger lies near unless beneficial influences remain in power. Certainly no one has a right to neglect such psychotherapeutic aid simply because relapses are possible. Even a temporary relief can be a great blessing. Moreover, the temporary relief is the safest basis to work towards the prevention of a recurrence of the evil. Only in two directions is further restriction needed. Psychotherapeutic methods are in my opinion of very small avail in cases of periodic drinkers. Such periodic attacks of patients who have not even a desire for alcohol in intervals between the attacks, intervals which may last a quarter of a year, are related to epilepsy. It seems that constant hypnotic influence during the interval has a certain power to reduce the periodic impulse. I personally have not seen any special improvement from it. The second restriction would be that the drinker has to be under constant supervision during the first days of hypnotic treatment. No patient, not even the morphinist, is so skillful in deceiving his friends and even the physician. Even the most emphatic gestures of sincerity ought to be distrusted.

Only a short time ago I dealt with a young man whom his parents and
a chauffeur had accompanied to Boston, exclusively for the purpose
of watching him constantly while I was to attempt to cure him from
excessive whiskey drinking. The chauffeur accompanied him from his
room in the Boston hotel to the threshold of my laboratory. All
through the day he was with his parents, and at the hotel the
management had given the strictest orders not to sell any drink to
the young spendthrift. He was an earlier student of mine and had
attached himself to me with such an apparent sincerity as removed
every possible doubt of his pledge. Intentionally I had not even
asked him for a pledge not to drink but only for a pledge to
confess to me the next day if he ever should take any alcohol. In a
tentative way I suggested to him in a half hypnotic state on the
first day that he would feel disgust for whiskey. I did not expect
much of an improvement before at least three or four treatments. I
was therefore most surprised when he most solemnly assured me the
next day that he awoke in the morning with an assured feeling that
he should never touch whiskey again and that he had not the
slightest desire for it. Instead of a systematic development of
suggestions, I confined myself therefore to a mere repetition of
the treatment of the first day and as every morning the same
assurance came forth, there seemed to be no need for any
variation. It was not before the fifth day that I discovered that
he had taken from the start a pint of whiskey every day. When he
first arrived he had bribed a laundress of the hotel to bring to
his room every day the whiskey hidden in the laundry and he drank
it during the night. Then I declined any further participation.

The danger of deceit is of course less imminent when not the family but the patient himself takes the initiative. Yet even here distrust is wise. The patient has sometimes the most sincere intention to be cured, but under pressure of his craving he admits compromises which he hides from the physician. Having reduced the large quantity of alcohol to which he was accustomed, he hides the fact that he yet takes a few drinks, which he thinks cannot prevent the cure. Yet inasmuch as a complete cure has to rely on psychical factors, this consciousness of deceiving even with small transgressions interferes badly with progress and, inasmuch as the cunningness of the patient is itself a symptom of the disturbance, the strongest possible precaution is advisable at the beginning. For that reason it is also not best to begin at once with complete prohibition, but to lead to a total abstinence in about one week. But certainly in the case of every drunkard, total abstinence is the only desirable goal. A pronounced drinker ought never to be transformed simply into a moderate one. The return to intemperance would result rapidly. On the other hand it would be unfair to deny that psychotherapy has cured the symptom if the desire really once disappeared completely, even if, after years, new temptations develop a new desire. I myself had diphtheria three times in my life; my constitution is thus probably especially favorable to that disease but I do not estimate less the fact that I was perfectly cured the second time, in spite of the fact that I caught it a few years later a third time. To be sure, such experiences of relapse cannot be spared any psychotherapist. I may give a typical instance.

A well-known professional man of fifty years, through a long
bachelorhood, was accustomed to close his work at four o'clock and
then to sit comfortably in his study with a book and an unlimited
supply of brandy. He took one cognac after another and every
evening he was completely intoxicated. He married a young wife and
felt the need of changing his habits, the more as he himself saw
symptoms of his excess which alarmed him. When he came to me, I saw
that he was seriously wishing to give up, and he understood himself
that there was only the one way, namely, complete abstinence. He
felt that he could not reach it by his own will power alone and
sought my aid. I hypnotized him six times, suggesting at first a
reduction to four drinks, then to two, then to one and then to pure
mineral water. I concentrated my effort on stirring up the
antagonistic attitude, the dislike of the smell of brandy and the
aversion to its taste. The effect was excellent. After the fifth
time the mental torture which he had felt in the first afternoons
had completely disappeared. I considered further hypnotizing
superfluous and felt sure after the sixth time that the man was
cured. For about a year he remained abstinent, but in the meantime
his professional life brought severe disappointments, and with cool
consideration he decided that he might have at least some pleasure
from life and forget its miseries. Accordingly after a year he
determined again to take some brandy in his study, and of course,
that led rapidly to an increase of the dose and today he is
probably at the old point. And yet it may be said with correctness
that psychotherapy had done its duty. If at the right moment before
he took the first step again, even the slightest counter-suggestion
had been applied, the disastrous second development could have been
easily avoided.

My experience indicates the best results where the suggestions are from the start directed as much against the unfavorable social conditions, with their temptations and impulses to imitation, as against the alcoholic beverages themselves. On the whole it is easier to break the vicious drinking habits of the social drinker than those of the lonely drinker, a point which ought to be well considered in settling the complex problem of prohibition versus the temperance movement.

The situation of alcoholism repeats itself in still more ruinous forms with morphinism and cocainism, vices which grow in this country to an alarming degree. The psychotherapeutic treatment of such drug habits demands much patience and much skillful adjustment to the psychological conditions. Its general difference from the treatment of alcoholism is given by the circumstance that any too rapid withdrawing of the drug is certainly dangerous, if the organism is adjusted to a relatively strong dose. On the other hand, I may say that I have not seen a single case in which a really patient and insistent treatment of morphinism has not been successful, even if the destructive dose of forty grains a day had become habitual. The condition is only that the patient himself have the best will, a will which yet is not strong enough to win the fight without psychotherapeutic help. But no one ought to expect that the psychotherapist can secure miracles like some of the pill cures which treat the drug fiend in three days. Moreover neither physician nor patient ought to believe that the worst is to come at the beginning. On the contrary, it is the end which is hardest, the reduction of the small dose to nothing. As illustration, I give an extreme case.

A man who was formerly station master on a railroad had been
operated on in a hospital after an accident, and as some pain in
the hip remained which disturbed his sleep, the physician of the
hospital gave him some morphine and provided him with the material
for morphine injection after leaving the hospital. Then began the
usual story. He became more and more dependent upon his injection,
the dose was steadily increased, he found unscrupulous physicians
who yielded to his demand for morphine prescriptions; he lost his
position with the railway by the growing effects of the morphine
poisoning, he became divorced, sank lower and lower, his daily dose
fluctuating between thirty-five and forty grains a day, and when he
came to me, he presented a picture of the lowest type of hopeless
manhood. He spent practically the whole day in bed and was only
able to totter slowly along with a cane. He assured me that life
was hell for him. He could not sleep, he could not eat, he could
not think, he had made up his mind to commit suicide if I could not
help him. I foresaw that it would in the best case demand months of
insistent energy to make a man out of that unfortunate wreck. He
had gone through three different morphine cures in three
sanitariums and none had helped him, and every physician whom he
had consulted had declared his case as beyond any physical cure. I
decided to make the somewhat disproportionate sacrifice of time in
order to study whether even such an extreme case of morphinism is
accessible to psychotherapeutic treatment. Four months later, he
left my laboratory looking like an athlete, strong and vigorous,
joyful and energetic. For three weeks he had not received any
morphine, had good appetite, slept well, and had happily married.
As his wife was a trained nurse, she will take good care that no
new slip shall ever occur.

There was nothing remarkable in those four months of treatment. He
was easily hypnotized, and I hypnotized him at first every day,
then every second day, then every week. It was without difficulty
that I reduced the forty grains to about six grains a day. Then the
struggle began. To test the case as a strictly psychological
problem I left the effort entirely to his own will, that is, I did
not deprive him of the morphine supply but left the regulation in
his own hands. During that whole winter he had a bottle with a
thousand morphine tablets standing on his desk. Thus he would have
been entirely able to satisfy any craving, but by his own will he
followed my suggestions and never took more than I permitted. It
meant a terrible struggle. The tortures which he had to pass
through were perhaps worse than those which he had experienced at
the time of his lowest downfall. They came to a focus when he tried
to go from five grains to three grains a day and then again when
he approached half a grain. From there he had to move to a fourth
of a grain, then to an eighth, and even that had still to be
divided into four different doses which were then reduced to three,
to two, and finally to one dose and ultimately to injections of
warm water. A rapid increase in general strength and a return of
appetite for food began when he had reached the five grain limit. I
did not allow on any occasion the introduction of a substitute. On
the other hand, I added every day suggestions covering the various
secondary symptoms, especially the pains in the stomach and the
feelings of faintness and the emotional depression.

There, is no doubt that under favorable conditions, especially if the dose of morphine is not too strong, autosuggestion can bring about a similar effect. A reduction of ten per cent every week can be carried through, if a pledge is given to one's self in a drowsy state. The great value of autosuggestion showed itself not seldom in the fact that morphinists who had applied to me by mail for a cure in the mistaken belief that I do work in a professional way for payment and who got from me a written reply that I could not receive them, but that they can help themselves, wrote to me that my letter gave them strength to reduce their dose considerably.

Quite similar is the situation with cocainism or with the combination of morphine and cocaine which is so frequent nowadays with young physicians. I have repeatedly seen cures where the case already gave the impression of insanity. Again I give a rather extreme case.