Chapter IV: Part I: The Psychological Basis of Psychotherapy (2)

We started, for instance, from the old observation that two impressions which come to our mind at the same time have a tendency to reawaken one another; and we saw that psychology was well able to formulate these facts in general statements of the association of ideas. But we realized that that in itself is not really explanation. If the odor which we smell awakes in us the name of a chemical substance, and if we now bring this under the general heading of association of ideas, an explanation is not really given by it. That smell sensation itself is not really understood as a cause of those sound sensations of the word. We have no insight into the connection of those two happenings. But the situation is entirely changed, if we consider the smell effect from the point of view of the parallelistic theory. Now the association of facts would indicate that we got the first two impressions together, because two brain processes were going on at the same time. My nose brought me the smell stimulus, my ear gave me the sound stimulus, each going on in a particular center, or, to express it in a simplified schematic way, each reaching particular brain cells, and the excitement of these brain cells being accompanied by the particular sensations. The physiologist has many possibilities of conceiving the further stages of the process, in order to satisfy the demand of explanation. He may say the excitement of each of these two brain cells, the one in the olfactory center, the other in the auditory center, irradiates in all directions through the fine branches of the brain fibers. Each cell has relations to every other cell in the brain; thus there is also one connecting path between those two cells which were stimulated at once. Now if the two ends of an anatomical path are excited at the same time, the path itself becomes changed. The connecting way becomes a path of least resistance, and that means that if, in future, one of the two brain cells becomes excited again, the overflow of the nervous excitement will not now go on easily in all directions, but only just along that one channel which leads to that other brain cell. A theory like this explains in real explanatory terms, in ways which physics and chemistry can demonstrate as necessary, that any excitement of the odor cell runs over into the sound cell and vice versa. In short, the psychological association of ideas, which we should simply have to accept as inexplainable fact, is thus transformed into a connection which we understand as necessary; and the fact is really explained.

This simple scheme of the physiology of association for a hundred years has given a most decided impulse to the progress of psychology. As the association process can so easily be expressed in physiological terms, the aim was prevalent to understand the interplay of mental life more and more as the result of association. The underlying thought of this whole association psychology was thus a conviction that whenever two mental experiences occur together, either of them keeps the tendency to reawaken the other at a later time. Through the endless combination which life's impressions awaken in the mind from the first hour after birth, the whole stream of memory images and thoughts and aims and imaginations is thus to be explained.

The whole theory of physiological associationism works evidently with two factors. First, there are millions of brain cells of which each one may have its particular quality of sensation, and second, each brain cell may work with any degree of energy, to which the intensity of the sensation would correspond. If I distinguish ten thousand different pitches of tone, they would be located in ten thousand different cell groups, each one connected through a special fiber with a special string in the ear. And each of these tones may be loud or faint, corresponding to the amount of excitement in the particular cell group. Every other variation must then result from the millionfold connections between these brain cells. Indeed, the brain furnishes all possibilities for such a theory. We know how every brain cell resolves itself into tree-like branch systems which can take up excitements from all sides, and how it can carry its own excitement through long connecting fibers to distant places, and how the endings of these fibers clasp into the branches of the next cell, allowing the propagation of excitement from cell to cell. We know further how large spheres of the brain are confined to cells of particular function, that for instance cells which serve visual sensations are in the rear part of the brain hemispheres, and so on. Finally we know how millions of connecting fibers represent paths in all directions, allowing very well a cooeperation by association between the most distant parts of the brain. The theories found their richest development, when it was recognized that large spheres of our brain centers evidently do not serve at all merely sensory states, but that their cells have as their function only the intermediating between different sensory centers. Such so-called association centers are thus like complex switchboards between the various mental centers. Their own activity is not accompanied by any mental content, but has only the function of regulating transmission of the excitement from the one to the other. Above all their operation would make it possible that through associative processes, the wonderful complexity of our trains of thought may be reached.

Yet even the highest development of the association theories did not seem to do justice to the whole richness of the inner life. We may well understand through those association processes that a rich supply of memory pictures is at our disposal, that ideas stream plentifully to our minds and enter into new and ever new combinations. But that alone is not an account of our inner experience. If there is anything essential for inner life, it is the attention which gives emphasis to certain states and neglects others. And that means that certain mental contents are growing not only in strength but in vividness and clearness, and that others are losing their vividness, are inhibited and suppressed. Here were always the real difficulties of the association theories; they seemed so entirely unable to explain from their own means why certain states become foremost in our minds and others fade away, why some have the power to grow and others are neglected. These facts of attention and vividness, inhibition and fading, worked almost as a temptation to give up the physiological explanation altogether and to rely on some mystical power, some mental influence which could pull and push the ideas without any interference and help from the side of the brain. Yet since we have seen that the truth of psychophysical parallelism has the meaning of a postulate which we cannot escape unless we want to give up explanation altogether, it is evident that such falling back into un-physiological agencies would be just as inconsistent as if the naturalist should posit miracles in the midst of chemistry or astronomy. If the facts which cluster about attention cannot be understood by the simple scheme of associationism, the demand must be for a better physiological theory.

The development of physiological psychology in recent years has indeed shown the way to such a wider theory, which furnishes the physiological accompaniment also for those experiences of attention and vividness which form the weakness of associationism. This new development has come up with the growing insight that the brain's mental functions are related not only to the sensory impressions, but at the same time to the motor expressions. The older view, still prevalent to-day in popular writings, made the brain the reservoir of physical stimuli, which come from the sense organs to the cortex of the brain hemispheres. There the perceptions arose and through associative interplay the memory pictures and the ideas of action and the feelings arose, and the whole inner life was thus bound up with the processes in these sensorial spheres. When the mind had done its work, finally an impulse was sent to some motor apparatus in the brain which then sent off the impulse to some acting muscles. That whole motor part was thus a kind of appendix to the brain process. The psychical life had nothing to do with it but to give the command for its action. The process in the motor part thus began when the mental proceeding was completed. But it became clear that this view was only the outgrowth of the strong interest which physiology took in the sense processes. If a neutral fair account of the brain actions is attempted, there can hardly be doubt that this whole sensorial view of the brain is only half of the story and that the motor half has exactly the same right to consideration. The cortex of the brain, the functions of which are accompanied by mental processes, is always and everywhere not only the recipient of sensory stimuli but at the same time the starting point of motor impulses. That which is centripetal, leading to the cortex, is therefore not more important for the central process than that which is centrifugal, leading from the cortex. The cortex is the apparatus of transmission between the incoming and the outgoing currents, between the excitements which run to the brain and the discharges which go from the brain, and the mental accompaniments are thus accompaniments of these transmission processes. If the channels of discharge are closed and the transmission is thus impossible, a blockade must result at the central station and the accompanying mental processes must be entirely different from those which happen there when the channels of discharge are wide open. Here too all the special theories are still in the midst of tumultuous discord. Yet this new emphasis on the motor side of the psychical process seems to influence modern psychology more and more.

Nobody can deny that first of all this is the necessary outcome of a biological view of the brain. What else can be the brain's function in the midst of nature than the transforming of impressions into expressions, stimuli into actions? It is the great apparatus by which the organism steadily adjusts itself to the surroundings. There would be no use whatever biologically in a brain which had connections with the sense organs, but which had no connections with the muscular system, and on the other hand, a brain which had motor nerves and muscular adjustment would be entirely useless if it had not sensory nerves and sense organs connected with it. In the one case the world would be experienced, but no response would be possible; in the other case, the means for response would be given, but no adjustment could set in because no experience of the surroundings would be possible. Adjustment every moment demands the relation of the brain in both directions. Through the sensory nerves the brain receives; through the motor nerves the brain directs, and this whole arc from the sense organs through the sensory nerves, through the brain, through the motor nerves and finally to the muscles, is one unified apparatus of which no part can be thought away. The brain in itself would be just as useless for the organism as the heart would be without the arteries and veins.

We must keep this intimate and necessary relation between the sensory and motor parts constantly in view, and must understand that there cannot be any sensory process which does not go over into motor response. Then only the ways are open to develop physiological views which give a physical basis to the processes of attention and vividness and inhibition, just as well as to the processes of memory and association. Such motor theories take many forms. Perhaps we shall most quickly bring the most essential factors together, if we say that full vividness belongs only to those sensations for which the channels of motor discharge are open, while those are inhibited for which the channels of discharge are closed; and any channel of discharge is closed, if action is proceeding in the opposite channel. If I open my hand, the motor paths which lead to closing my fist are blocked; and if I close my fist, the channels which lead to the opening of the hand are closed. Now if only those ideas are vivid which find the channels open, it is clear that all the ideas which would lead to the opposite action have no chance for development; they remain inhibited, and just this relation between the vividness of certain ideas and inhibition for those ideas which lead to the opposite action is the characteristic of the process of attention.

From such a point of view, the total mental life can be brought into the psychophysical scheme. We now have not two variable factors, but three, namely, the qualities of the elements, the intensities of the elements, and, as a third, the vividness of the elements. The quality corresponds, as we saw in the association theory, to the local position and connection of the brain cells; the intensity corresponds to the energy of the excitement; and the vividness, we may add now, corresponds to the relation to motor channels. The whole mental life thus becomes the accompaniment of a steady process of transmitting impressions and memories into reactions. That every experience involves millions of such elements we saw when we spoke of the description of mental life. The effort to explain mental life shows us now that this millionfold manifoldness belongs to a system of reactions of which all parts are in steady correlation: a moving equilibrium of unlimited complexity. Surely no one can reduce this wonderful manifoldness to those clumsy concepts with which popular psychology is reporting the story of the mind and its relations to the brain.

It may seem that such a psychological view of inner life annihilates that which we feel as the most essential characteristic of our inner experience, its unity and its freedom. In one sense that is certainly true. In the real life which we live and fight through, where our duties and our happiness lie, we know a unity and freedom of our personality which psychology must destroy. Of course that does not mean that psychology denies the truth of that freedom and unity. Moreover it would condemn itself if it were to deny that which gives meaning to the endeavors of our life and thus also to every search for truth. Psychology claims only that we must abstract from it, when we take the psychological standpoint towards life. Freedom of our real life means that we must know ourselves in the midst of our life work as guided by aims and obligations, and that in this purposive existence of ourselves we do not feel ourselves as determined by causes. I will the fulfillment of my ideals only because I will them. That this will itself may be the effect of foregoing causes is an aspect which does not belong to my naive experience. Our freedom means that in our real life our will is not related to causes, that the point of view of causality is thus meaningless for the value of our achievements. And the other man's will too comes in question for us as something to be interpreted and to be appreciated, but not to be explained by connection with causes. As long as we move in this sphere of purposive interest, we are free and deal with free selves; but if in the midst of these free aims, the will arises to consider the actions of others and of ourselves from the standpoint of causality, then we have ourselves decided to enter a new sphere in which it would be meaningless to seek for any will which is not determined by causes. As soon as we have chosen the psychological standpoint and are in the midst of the work of causal reconstruction, any will which is not understood as determined by causes is simply an unsolved problem. In the midst of a causal construction, absence of causes would never mean real freedom.

In that purposive world of immediate life experience, we also are unities inasmuch as we ourselves know us as the same in every new will of ours. We remain identical with ourselves because every purpose is posited in the midst of, and bound up with, the general purpose of ourselves. And in this internal unity of meaning, nothing breaks ourselves into pieces, and the whole manifold of experience is thus expressed by a personality which knows itself in its purposive unity. But this unity again is denied by our own intention as soon as we decide to take the causal view of inner life. The purposive unity must now transform itself into an endless complexity, and our own self becomes a composite of hundreds of thousands of elements.

On the other hand, all this does not mean that psychology cannot have its own consistent conception of the mind's unity and freedom. Our psychological mind is a unity because its manifold is a system in which all parts hang together. A change in any one part involves changes in the whole system. The interrelation, to be sure, is not a strictly psychical one, for we have seen that the causal connection as such appears at the physical side. But, inasmuch as there is no psychical process which does not belong to a physiological one, the interconnection of the mental facts is complete and involves the totality of neural processes of which after all a small part only has its psychological record. We might compare those hundreds of millions of neurons in each brain with the hundreds of millions of individuals who make up the population of the nations, and the psychical accompaniment we might compare with the written historical record of mankind. The written records themselves have no direct interconnection, they are only accompaniments of what happens in these millions of men. And again only the higher layer of the neurons in the population sees its doings recorded in the annals of history; and yet whatever those leaders of action and thought and emotion may achieve is dependent upon and working on the actions of those millions of subcortical population neurons. The historical record has its unity through the interrelation of all parts of historical mankind.

But after all the psychologist has no less a right to speak of freedom. Of course his freedom cannot mean exemption from causality. Whatever happens in the psychological system must be perfectly determined by the foregoing causes. But the psychologist has good reason to discriminate between those actions which result from the normal psychophysical factors and such actions as result from broken machinery. If the brain is poisoned by alcohol or in fever, if an infectious disease has destroyed the brain cells, action is no longer the outcome of the normal cooeperation of the organs, and even those clusters of neural activities which are accompanied by the consciousness of the own personality lose their control of the motor outcome. The man in delirium or paralysis acts without causal connection with his past; the action is, therefore, not the product of his whole personality, and the psychologist is justified in calling the man unfree. But, whenever the motor response results from the undisturbed cooeperation of the normal brain parts, then the inherited equipment and the whole experience and the whole training, the acquired habits and the acquired inhibitions will count in bringing about the reaction. This is the psychological freedom of man. The unity of an interconnected composite and the freedom of causal determination through normal cooeperation of all its parts characterize the only personality which the psychologist has to recognize.

IV

PSYCHOLOGY AND MEDICINE

We are now ready to take the first step towards an examination of the problem of curing suffering mankind. So far we have spoken only of the meaning of psychology, of its principles and of its fundamental theories as to mind and brain. We have moved in an entirely theoretical sphere. Now we approach a field in which everything is controlled by a practical aim, the treatment of the sick. Yet our discussion of psychology should have brought us much nearer to the point where we can enter this realm of medicine. Everything depends on the right point of entrance. That an influence on the inner life of man may be beneficial for his health is a commonplace truth to-day for everybody. Every serious discussion of the question has to consider which influences are appropriate, and in which cases of illness the influence on inner life is advisable. The popular treatises usually start this chapter by speaking of the "mental and moral" factors; and this coupling of mental influences and moral influences characterizes large parts of the discussions of the Christian Scientists and the Christian half-scientists. Yet we must insist that the right entrance to psychotherapy is missed if the difference between morality and mentality is not clearly recognized from the beginning. The confusion of the two harms every statement. To avoid such a fundamental mistake, we had to take the long way around and to examine carefully what psychology really means and what it does not mean.

We know now that inner life can be looked on from two entirely different standpoints: a purposive one and a causal one, and we have seen that these two ways of looking on inner life bring about entirely different aspects of man's inner experience, serve different aims, and stand in different relations to the immediate needs of our real life. We know that the one, the causal aspect, belongs to psychology, while the non-psychological, the purposive aspect, belongs to our immediate mutual understanding in the walks of life. If the physician is to make use of inner experience in the interests of overcoming sickness, he must first decide whether to take the causal or the purposive point of view in dealing with the patient's mind. This problem is too carelessly ignored and through that neglect arises much of the popular confusion. Of course just this carelessness becomes in some ways the ground for apparent strength for many a superstition and prejudice. If the doors of the causal mind and of the purposive mind are both open, and the spectator does not notice that there are two, any trick on thought and reason can easily be played. Whatever cannot pass through the causal door slips in through the other, and whatever does not go in through the door of purpose marches through the entrance of causality. With such methods anything can be proved, and the most unscrupulous doctrines can be nicely demonstrated. If we are to avoid such logical smuggling, we must see clearly which attitude towards mental life belongs properly to the domain of psychotherapy.

But what we have discussed now leaves little doubt as to the necessary decision. The physician is interested in the mental life with the aim of producing a certain effect, namely, that of health. Thus the mental life of the whole personality comes in question for him as belonging to a chain of causes and effects; whichever levers he may move, everything is to be a cause which, in accordance with causal laws, is to produce a certain change. Inner life is thus, in the interests of medical treatment, necessarily a part of a causal system. This means the standpoint of scientific psychology is the only adequate one. The purposive view of inner life ought not to be in question when the patient enters the doctor's office.

To characterize the difference, it may be said at once that it is a purposive view which belongs to the minister. If the minister says to his despairing parishioner, "Be courageous, my friend, and be faithful," nothing but a strictly purposive view gives meaning to the situation. The word friend indicates it, that one subject of will approaches another subject of will, with the intention of sympathy and understanding of the attitude of the other; and the advice to be courageous and faithful means an appeal which has its whole meaning in the relation to aims and ends. The speaker and the hearer are both moving in a sphere of will relations, purposes and ideals, sin and virtue, hope and belief. To take the other extreme: if the neurasthenic in his state of depression and in his feeling of inability seeks relief from the nerve specialist, he too may say: "My friend, be courageous and faithful," yet his words have an entirely different purpose. They are not appeals to a common interest of belief; they are subtle tools with which to touch and to change certain psychophysical processes, certain states in mind and brain; there each word is a sound which awakens certain mental associations, and these associations are expected to be causes of certain effects and these effects are to inhibit those disturbing states of emotional depression. If a few grains of sodium bromide were to produce the same effect, they would be just as welcome. The whole consideration moves in a sphere in which only physiological and psychological processes are happening. Thus the physician may work with the ideas of religious belief, but those ideas are then no longer religious values but natural psychophysical material, which is to be applied whenever it appears as the right means to secure a certain effect.

On the other hand the minister also knows, of course, that every word which he speaks has its psychological effect, but he abstracts from that entirely, as his belief should appeal directly to the struggling will of the man. As minister, he is thus not a psychologist. He works with moral means; the physician, with causal means. The view which the doctor has to take of the man before him is therefore thoroughly psychological; whereas that of the religious friend is thoroughly unpsychological, or better, apsychological. Indeed it is misleading, or at least demands a special kind of definition, if people say that the minister has to be a good psychologist. It is just as misleading as the claim, which we hear so often, that for instance Shakespeare was a great psychologist. No, the poet deals with human beings from the purposive standpoint of life and the mere resolving of complex purposes into parts of purposes is not psychology in the technical sense of the term. The poet makes us understand the inner life, but he does not describe or explain it; he makes us feel with other people, but he does not make those feelings causally understood. The realistic novelists sometimes undertake this psychological task, but they are then on the borderland of literature, the analysis of their heroes becomes then a psychological one. Shakespeare understood human beings better than anyone and therefore the men and women whom his imagination created are so fully lifelike that the psychologist may feel justified in using them as material for his psychological analysis, but Shakespeare himself did not enter into that psychological dissection; he kept the purposive point of view. In the same way certainly the minister--the same holds true for the lawyer or the tradesman or anyone who enters into practical dealings with his neighbor--may resolve complex attitudes of will into their components, but each part still remains a will attitude which has to be understood and to be interpreted and to be appreciated, while the psychologist would take every one of those parts as a conscious content to be described and to be explained. But here we abstract from the purposive relations. Our attention belongs now to the doctor's dealing with man; for him cause and effect are the only vehicles of connection. Thus he has to exclude the purposive interpretation of inner life and has to understand every factor involved from a psychological point of view: his psychotherapy must be thoroughly applied psychology.

The day of applied psychology is only dawning. The situation is indeed surprising. The last three or four decades have given to the world at last a really scientific study of psychology, a study not unworthy of being compared with that of physics or chemistry or biology. In the center of the whole movement stood the psychological laboratory with its equipment for the most subtle analysis and explanatory investigation of mental phenomena. The first psychological laboratory was created in Leipzig, Germany, in 1878. It became the parent institution for laboratories in all countries. At present, America alone has more than fifty psychological laboratories, many of them large institutions equipped with precious instruments for the study of ideas and emotions, memories and feelings, sensations and actions. Still more rapid than this external growth of the laboratory psychology was the inner growth of the experimental method. It began with simple experiments on sensations and impulses, and it seemed as if it would remain impossible to attack with the experimental scheme the higher and more complex psychical structures. But just as in physics and chemistry the triumphal march of the experimental method could not be stopped, one part of the psychological field after another was conquered. Attention and memory, association and inhibition, emotion and volition, judgment and feeling all became subjected to the scientific scheme of experiment. And that was all supplemented by the progress of physiological psychology, pathological psychology, child psychology, animal psychology. In this way the last decades created a science which of course was by principle a continuation of the old psychology, but yet which had good reason to designate itself as a "new" psychology.

But in this whole development, until yesterday, the curious fact remained that it was going on without any narrow contact with practical life; it was a science for the scientist and measured by its practical achievements in daily life, it seemed barren and unproductive. Psychology was studied as palaeontology and Sanscrit were studied, without any direct relation to the life which surrounds us. And yet after all it deals with the mental facts which have to enter into every one of our practical deeds, if we are to consider mental life from a psychological point of view. The psychologists were certainly not to be blamed for sticking to their theoretical interests. More than that, they were certainly justified in their reluctance, as everything was in the making, and incomplete theories can easily do more harm than good. But slowly a certain consolidation has set in; large sets of facts have been secured, and psychology seems better prepared to become serviceable to the practical tasks. On the other hand, it has been noticeable for some time that not a few of the psychological results have gone over into unprofessional hands and have been thrown on the market places and have been brought into many a home where no one knew how to deal with them rightly. Thus the need seems urgent that the psychologists give up their over-reserved attitude and recognize it as their duty to serve the needs of the community.

It is not sufficient for that end, simply to take odds and ends of psychology and to hand them over to anyone who can see some use for them. We must have a systematic scientific work done for the special purpose of adjusting psychological knowledge to the definite practical tasks and of examining the psychological facts with that practical end in view. A science must be developed which is related to psychology as engineering is related to physics and chemistry. Just as the technological laboratories of the engineer bring out many new problems which the physicist would never have approached, in the same way we may expect that special institutions for applied psychology will shape the psychological inquiry in a new way.

Such a new science of applied psychology of course has before it a field just as large and manifold as the field of technology, where physical engineering, chemical engineering, mechanical engineering, and electrical engineering and so on are separated. Such a future psychological technology would deal, for instance, with psychopedagogical problems. There belongs everything which refers to the psychology of memory or attention, of discipline, of fatigue, of habit, of imitation or effort; in short, all those mental factors which have to be considered whenever the schoolchild is looked on from a causal point of view. Further there is the psycholegal field where the memory and the perceptions, the suggestibility and the emotions of the witness are to be studied, where the psychological conditions which lead to crime, the means to tap the hidden thoughts of the criminal, the inhibitions for the prevention of crime, the mental effects of punishment and similar causal processes must be determined. There are the psychoscientific problems referring to psychological influences on the observations and judgments and discriminations of the scholar who watches the stars or who translates an inscription. There are the psychoaesthetic problems where the task is to examine causally the factors which lead to the agreeable effects of beautiful surroundings, and from the height of the psychology of aesthetics in painting and sculpture, the inquiry may go to the psychology of the pleasant effects in dress-making or cooking. There are the large groups of psychotechnical problems where the effort refers to the application of psychology in securing the best conditions for labor and industry and commerce. It leads from the mental effects of signals or the mental fatigue in mills to the secrets of advertisements and salesmanship. There are especially important psychodiagnostical studies where the aim is to determine the individual differences of man by experimental methods and to make use of them for the selection of the right man for the right place. There are psychosocial problems where we examine the psychological factors which have to enter into public movements, into social reforms, into legislation and into politics. In this way new and ever new groups may be added; every time the central thought is: how far can causal psychological knowledge help us to reach a certain end? Together with these forms of applied psychology, we find the psychomedical problems; here belongs everything which allows the application of causal psychology in the interests of health.

It might be answered that this demand for a strictly causal point of view can hardly be fulfilled, because, if I am acting,--it may be in the interest of education or law or technique or medicine,--I must always have an end in view and to select such an end belongs after all to my system of purposes. If I am a teacher and have to deal with children, then it may be said that after all, my knowledge of causal psychology cannot help me if I am uncertain for which ideals I want to educate these children. Psychology can tell me that I need these means, if I want to reach certain effects, but I cannot find out by psychology which effects are desirable. Psychology may tell me how to make a good business man or a good scholar or a good soldier out of my boy, but whether I want him to become a soldier or a merchant I must decide for myself with reference to general aims, and that leads me back to the purposive view of life. Such argument is entirely correct. Yes, it is evident that it is in full harmony with our whole understanding of the purpose of psychology. We saw that psychology with its causal treatment of man's mind does not express the immediate reality, but is a certain reconstruction which allows a calculation of certain effects. Thus it is itself a system existing for a subject who has certain ends in view. The whole causal view of man is thus a tool in the service of the purposive man. This is the reason why it is indeed utterly absurd to think that psychology can ever help us to determine which end we ought to reach.

In education, for instance, very many different ends might be reached; psychology cannot decide anything. The decision as to the aims of education must be made by ethics, which indeed takes not a causal but a purposive attitude. Only after ethics has selected the aim, psychology can teach us how to reach it. Of course this principle must hold for the physician too. All his causal dealing with the mind presupposes that he has selected a certain end in harmony with his purpose. The only difference is that, in the case of the physician, there can be no possible doubt as to the desirable end; what he aims at is a matter of course, namely, the health of the patient. To desire the health of the sufferer is thus itself a function which belongs entirely to the purposive view of the world, and only in the interest of this purpose does the physician apply his knowledge of psychology or of the causal sciences of physics, physiology, and chemistry. Indeed only with this limitation have we the right to say that the psychotherapist takes the causal,--and that means the psychological,--view of his patient. As far as he decides to take care of the health of his patient, this decision itself belongs to the purposive world and to his moral system. The physician is thus ultimately just like the minister and just like anyone who deals with his neighbor, a purposive worker; but while the minister, for instance, remains on this purposive track, the physician puts a causal system into the service of his purpose. He knows the end, and his whole aim is to apply his causal knowledge of the physical and psychical world to the one accepted end of restoring the health of the patient. He has to ask thus in general: what has psychology to-day to offer which can be applied in the interests of medicine?

It would be an inexcusable narrowness to confine that chapter of applied psychology which is to deal with the psychomedical problems to the work of psychotherapy. Medicine involves diagnosis of illness as well as therapeutics. Between the recognition and the treatment of the illness lies the observation of its development and all this is preceded by steps towards the prevention of illness. In every one of these regions, psychology may be serviceable. Psychotherapy is thus only one special part of psychomedicine. But the situation becomes still more complex by the fact that the illness to be treated or the disturbance to be removed may stand in different relations to the psychophysical processes. The illness may be a disturbance in the psychophysical brain parts, or it may belong to other brain parts which are only in an indirect way under the influence of mental states or which are themselves indirectly producing changes in the mental life. And finally the disturbance may exist outside of the brain in any part of the body, and yet again through the medium of brain and nervous system it may produce effects in the mind or be open to the influence of the mind. Thus we have entirely different groups of medical interests and it would be superficial to ignore the differences.

Both psychodiagnostic and psychotherapeutic studies must be devoted to cases in which the mind itself is abnormal, further to cases in which the normal minds registers the abnormalities in other parts of the body, and finally to cases in which the normal mind influences abnormal processes in the body. These latter two cases have to be subdivided into those where the bodily disturbance still lies in the brain parts and those where it lies outside of the brain. But the situation becomes still more complex by the mutual relations of those various processes. The impulse to take morphine injections may have reached the character of a mental obsession and thus represent an abnormality of the mind, but yielding to it produces at the same time disturbances in the whole body which thus become again external sources for abnormal experiences in otherwise normal layers of the mind.

Of course the interest of the psychologist as such remains always related to the psychological factor, but the relation of the psychological factor itself to the total disturbance may be of most different character. If I diagnose or treat the fixed idea of a psychasthenic, the psychological factor itself represents the disturbance. On the other hand, if I study the pain sensations of a patient who suffers from a disease of the spinal cord, then the sensations themselves, the only psychological factor in the case, are only indications of a disease which belongs to an entirely different physical region; the mind itself is normal. Or, on the other hand, if I try to educate a sufferer from locomotor ataxia to develop his walking by building up in his mind new motor ideas to regulate his cooerdinated movements, the mind again is entirely normal but the physician needs his psychology on account of the influence which the mind has on the bodily system. Again, we must insist that psychomedicine covers this whole ground. Wherever a psychical factor enters into the calculations of the physician either by reason of its own abnormality or by its relation as effect or as cause to a diseased part of the body in the brain or without, there we have a psychomedical task, and as far as it is therapeutic, we have psychotherapy.

The psychodiagnostic research lies outside of the compass of our book, but we cannot emphasize sufficiently the great importance which belongs to that work. Moreover, just in the field of psychodiagnostics, the methods of the modern experimental psychological laboratory are most promising and successful. Let us not forget that we deal with such psychological factors even when we test the functions of eye and ear and skin and nose by examining the sensations and perceptions. The oculist who analyzes the color sensations of a patient and the aurist who finds defects in the hearing of the musical scale and discovers that certain pitches cannot be discriminated, is certainly dealing, for diagnostic purposes, with the material that the psychological laboratory has sifted and studied. Even that sensation symptom which enters into so many diseases, the sensation of pain, belongs certainly within the compass of the psychologist and it is only to be regretted that the systematic study of the pain sensations, mostly for evident practical reasons, has been much neglected in the psychological laboratory.

The psychologists have been at work all the more eagerly in the fields of association and memory, attention and emotion, habit and volition, distraction and fatigue. Here subtle methods have been elaborated, methods which surely common sense cannot supply, and which showed differences of mental behavior with the exactitude with which the microscope reveals the hidden differences of form. If physicians are slow in accepting the help which the psychological laboratory can furnish, it may be in good harmony with the desirable conservative policy in medicine, but finally the time must come when this instinctive resistance against new methods will be overcome. The recent attachment of psychological laboratories to certain leading psychiatric clinics is a most promising symptom. Yet the diagnostic studies with the means of the psychological laboratory cannot be confined to the cases of mental disease. The mild abnormalities of the mind, and especially the nervous disturbances which exist outside the field of insanity, demand this support of psychology much more. And even the normal personality will be more safely protected from disease and from social dangers for its mental constitution if the resources of experimental psychology are employed. The more we know of the psychological constitution of the individual, the more we can foresee the development which is to be hoped for or feared and which may be encouraged or retarded.

The psychologist may determine, for instance, the degree of attention with its resistance against distracting stimuli, the power of memory under various conditions and on various material, the mental excitability and power of discrimination, the quickness and correctness of perception, the chains of associations, the rapidity of the associative process for various groups, the types of reaction, the forming of habits and their persistence, the conditions of fatigue and of exhaustion, the emotional expressions and the emotional stability, the time needed for recreation and the resistance against drugs, the degree of suggestibility and the power of inhibition: and every result in any of these lines may contribute to the diagnosis and prognosis of cases. The chronoscope here measures the reaction times and association times in thousandths of a second; the kymograph, by the help of the sphygmograph, writes the record of the pulse and its changes in emotional states, while the pneumograph records the variations of breathing, and the plethysmograph shows the changes in the filling of blood vessels in the limbs which is immediately related to the blood supply of the brain. Here belongs also the ergograph, which gives the exact record of muscular work with all the influences of will and attention and fatigue, the automatograph which writes the involuntary movements, especially also the galvanoscope which may register the influence of ideas and emotions on the glands of the skin, and thus lead to an analysis of repressed mental states, and hundreds of other instruments which are used in the psychological laboratory.

Yet it would be misleading to think only of complex apparatus when experimental psychology is in question. An experiment is given whenever the observation is made under conditions which are artificially introduced for the purpose of the observation. Thus there is no need of the physical instrument. If I bring a spoonful of soup to my mouth at dinner and I become interested in the combination of warmth sensation and touch sensation and taste sensation and smell sensation, then I have performed an experiment if I take one more spoonful of soup just for the purpose of the observation. The physician too may carry out important psychological experiments, without needing the outfit of a real laboratory. Association experiments, for instance, promise to become of steadily growing importance. To make them serviceable to the problems of his office, nothing but a subtle psychological understanding is needed, inasmuch as any routine work schematically applied to every case alike would be utterly useless. Give your man perhaps a hundred words and let him speak the very first word which comes to his mind when he hears the given ones. You call rose, and he may say red or flower or lily or thorn; you call frog and he may answer pond or turtle or green or jump, and if you choose your hundred words with psychological insight, his hundred answers will allow a full view of his mental make-up. This is an experiment which does not require any instruments at all but a man's subtle analysis of the replies. That is not seldom sufficient to secure the diagnosis of complex mental variations. The method yields still more if the time for such a reply is measured, but there again not the costly chronoscope of the laboratory is indispensable; a simple stop watch which gives the fifths of a second would be fully sufficient for all practical purposes. From such simple facts of the mental inventory the association experiments may lead to complex questions which slowly may disentangle the confused ideas, for instance, of a dementia praecox, and thus lead to subtle differential diagnosis.

The psychological laboratory alone can also elaborate the methods of studying, for instance, the feeble-minded with all the individual variations. New and ever new methods have been tried; the memory was tested by reading and repeating figures or letters, or colored papers were shown or cardboards of different forms or nonsense syllables, and the powers of remembering were studied. Or the accuracy of arm movements was examined, or the quickness of understanding associated words, or the success in planning a complex movement like throwing a ball at a target, or the tapping of a key in the rhythm of a metronome, or the discrimination and recognition of the pieces in the game of dominoes and many another scheme. The laboratory has to analyze the conditions for such methods and the psychologist has to prepare the means for the use of the physician, just as the chemist has to prepare the sleeping powders. In a similar way the laboratory may furnish means to analyze the mental disturbances by a comparison with the experimental results of artificial influences, for instance, of over-fatigue or half-sleep, of drugs or alcohol, of poisons and emotional excitements. The psychological resolving of the mental symptoms may of course, in the same way, furnish the diagnosis where the mental variation is only a distant effect of a bodily ailment. The changes in the emotions, for instance, may lead to the recognition of a heart disease; lack of attention may be a hint of the overgrowth of the adenoids; irritability or apathy or delirious character of the mental behavior may indicate whether uraemic acid is in the system or an infectious disease: anaemia and undernutrition may be diagnosed and the psychology of fever demands too a much closer analysis with the means of the psychological laboratory than it has received so far.

We have not spoken as yet about those psychological methods which themselves introduce abnormal mental states like hypnotism, and which also not seldom are only means for diagnostic purposes. The hypnotic state may bring to memory forgotten experiences of which the physiological effects may have lasted in the brain and which may have brought injury to the psychophysical system. Hypnotic inquiry can thus lead to the recognition of the first causes in many hysterical states and where hypnotism is not the best adjusted tool, a certain dreamlike staring may be more effective. We have to return to much of that later in full detail because just for instance in hysteria, the clear recognition of the sources and of the character of the disease may at the same time prove to be in itself the right starting point for curative treatment.

We have spoken so far only about the relations of psychology and medicine from the point of view of diagnosis; the relations from the point of view of therapy will make up the second part of this book. We shall describe the methods and the results, the possibilities and the limitations with manifold detail. That is the chief topic of this volume. All that is needed to prepare for this principal problem is on the one side a preparatory clearing up of some fundamental conceptions, especially of those two which have played the chief role in the whole discussion, namely the subconscious and suggestion. And on the other side, we may consider at first some fundamental discriminations which steadily influence the inquiries and controversies in the field. I think of the difference between normal and abnormal mental states, between psychical and physical facts in psychotherapy, between functional and organic diseases, and to return to our starting point, between mental and moral influences.

Every curative effort presupposes that the normal state of health has been lost and that a diseased state has set in. Yet the mental analysis suggests still less than the bodily inquiry, just where the normal functioning is really lost. It would be easy to draw a demarcation line if the pathology of the mind introduced any mental features which are unknown in our normal existence, but the opposite is true. No mental disease introduces elements which do not occur in the sphere of health. A degenerated brain cell looks differently under the microscope from a normal one, but the ideas of a paranoiac, the emotion of a maniac, the volition of a hysteric, the memory idea of a paralytic is each in its own structure not different from such elements in any one of us. The total change lies thus only in the proportion; there is too much or too little of it. The pathological mental life is like a caricature of a face--each feature is contained, as in the ordinary portrait, but the proportion is distorted, there is too much or too little of chin or of nose. But who can indicate exactly the point where the distortion of the features constitutes a caricature? Every grotesque change in the relations ruins the healthy state: what makes us sure that the harmony of health is spoiled?