Chapter IX: Part II: The Practical Work of Psychotherapy (2)

As to the conditions of life itself, there are certainly many factors at work which secure favorable influences for our cerebral activity. The progress of scientific hygiene has brought everyone much nearer to a harmonious functioning of the organism, and the progress of technique has removed innumerable difficulties from the play of life. Of course, we stand today before a much more complex surrounding than our ancestors but still more quickly than the complexity have grown the means to master it. We have to know more: yet the effort has not become greater since it has become easier to acquire knowledge. We have to endure much disturbing noise, and yet we forget how the sense organs of our forefathers must have been maltreated, for instance, by flickering light. We are in a rush of work and stand in thousandfold connections; and yet the neural energy which is demanded is not large because a thousand devices of our technical life have become our obedient servants. There is no nation on earth which is more proud of its rush and its hurry than the American people; and yet what an abundance of time is leisurely wasted that would have to be used for work if the country could not live from its richness. Moreover our life has probably become cooler, there is less emotionalism, less sentimentality, more business-like attitude, and that all means less inner friction and excitement; in public life too, less fear of war and less religious struggle. All has become a question of administration and efficiency. Our time is certainly not worse off on the score of neurasthenia than its predecessors.

Above all the intensity of mental stimuli is always relative. The psychologist knows the experiments which determine that we perceive the difference of impressions as alike when the stimuli are proportional. If I have a ten-pound weight in one hand, I may find that I must have one pound more in the other hand to discriminate the difference. Now if I take twenty pounds in the one hand, then it is not sufficient to have one pound more in the other, but I must have twenty-two pounds in the other to feel a difference, and if I take thirty pounds, the other weight must be thirty-three. We feel equal differences when the weights stand in the same relation. The man who owns a hundred dollars will enjoy the gain of five and regret the loss of five just as much as the owner of a hundred thousand dollars would feel the gain or loss of five thousand. This fundamental law of the relativity of psychical impressions controls our whole life. The rush of stimuli which might mean a source of nervous disturbance for the villager whose quiet country life has brought about an adjustment to faint impressions may cause very slight stimulation for the metropolitan accustomed for a lifetime to the rhythm of the surroundings. Yet that quiet countryman may react in his narrow system not less when the modest changes in his surroundings provoke him. The gossip of his neighbor may undermine his nervous system just as much as a political fight or the struggles of the exchange that of the city man.

The same holds true for the purely intellectual engagements. The work which the scholar undertakes should not be measured by the effect which the same appeal to concentrated attention would make on the average man of practical life. There, too, an adjustment to the demand has resulted during the whole period of training and professional work. Every effort should be estimated with reference to the standard of the particular case. This relativity of the mental reaction on the demands of life must always be in the foreground of the psychotherapeutic regime. Even the best physicians too often sin against this principle and accuse the life which a man or woman leads as too exhausting and overstraining simply because it would be overstraining and exhausting to others who are not adjusted to that special standard. Simply to withdraw a patient from the one kind of life and to force on him a new kind with new standards may not be a gain at all. A new adjustment begins and smaller differences from the standard may bring about the same strong intensities of reaction as the large differences brought before. Complete rest, for instance, for a hard brain-worker hardly ought to be recommended unless a high degree of exhaustion has come on. If routine prescriptions are to be admitted at all, they should not be complete rest or complete change of life for any length of time but a continuation of the life for which adjustment has been learned with a reasonable reduction of the demands and stimulations. The intellectual worker ought to decrease his work, the overbusy society woman ought to stay in bed one day in the week, the man in the midst of the rush of life ought to cut down his obligations, but probably each of them does better to go on than simply to swear off altogether.

Their rest ought to have the character of vacation; that means interruptions without the usual activity ought to be short periods spent with the distinct feeling that they are interruptions of that which must last and that they are not themselves to become lasting states. Thus the inner adjustment to the work ought to be kept up and ought not to be substituted by a new adjustment to a less exacting life. In this way the episode of the vacation rest ought to be in a way included in the strenuous life almost as a part of its programme. Strenuosity must not mean an external rush with the gestures of overbusy excitement, but certainly the doctrine of the lazy life is wretched psychotherapy, as long as no serious illness is in question. By far the best alteration is, therefore, even in the periods of interruption, not simply rest but new engagements which awaken new interests and stimulate neglected mental factors, disburdening the over-strained elements of mental life. The most effective agency for this task is contact with beauty, beauty in nature and life, beauty in art and literature and music. To enjoy a landscape ought to be not merely a negative rest for the man of the office building, and good literature or music absorbs the mental energies and harmonizes them. In the second place come games and sport, which may enter into their right if fatigue can be avoided. Harmonious joyful company, as different as possible from the depressing company of the sanitariums, will add its pleasantness.

While the advice of the physician ought thus to emphasize the positive elements which work, not towards rest, but toward a harmonious mental activity, we must not forget some essential negative prescriptions. Everything is to be avoided which interferes with the night's sleep. Furthermore, in the first place, alcohol must be avoided. There cannot be any doubt that alcoholic intemperance is one of the chief sources of brain disturbances and that the fight against intemperance, which in this country is essentially the fight against the disgusting saloon, is a duty of everyone who wants to prevent nervous disaster. There may and must be divergence of opinion as to the safest way to overcome intemperance. The conservative physician will feel grave doubt whether the hasty recommendation of complete prohibition is such a safe way, whether it does not contain many conditions of evil, and whether the fight against the misuse of alcohol will not be more successful if a true education for temperance is accepted as the next goal. But for the man of neurasthenic constitution and for any brain of weak resistance, the limit for permissible alcoholic beverages ought to be drawn very narrow and in such cases temporary abstinence is usually the safest advice. Individual cases must indicate where a glass of light beer with the meal or a glass of a mild wine may be permissible. Strong drinks like cocktails are absolutely to be excluded. In the same way a strong reduction is advisable in tobacco, tea, and especially coffee. A complete withdrawal of all stimulations to which a nervous system has been accustomed for years is not wise, or at least mild substitutes ought to be suggested, but if coffee can be ruled out at once, often much is gained. In the same way all passionate excitements are to be eliminated and sexual life to be wisely regulated. An especial warning signal is to be posted before all strong emotions, and if the patient cannot be asked to leave his worry at home, he can at least be asked to avoid situations which will necessarily lead to excitement and quarrel and possible disappointment.

It is one of the surest tests of psychotherapeutic skill to discriminate wisely whether one or the other of these features of general treatment ought to be emphasized. They usually demand more insight than specific forms of psychotherapy like hypnotic suggestions. These general efforts are also much more directed against the disease itself where the specific methods are merely directed against the symptoms. The separation from disturbing surroundings, the reduction of engagements and work, the complete rest, the suppression of artificial stimulants, the enjoyment of art, of nature, of sport, the distractions of social life, each might be in one case a decisive help and indifferent, perhaps even harmful in another. All is a matter of choice and adjustment to the particular needs in which all the personal factors of inherited constitution, acquired adjustments, social surroundings, temperament, and education, and the probable later development have to be most tactfully weighed. Yet this general treatment may take and very often ought to take the opposite direction, not towards rest but towards work, not towards light distraction but towards serious effort, not towards reduction of engagements but towards energetic regulation. We said that it was an exaggeration to blame the external conditions of our life, the technical manifoldness of our surroundings as the source of the widespread nervousness. The mere complexity of the life, the rapidity of the demands, the amount of intellectual effort is in itself not dangerous and our time is not more pernicious than the past has been; but it is perhaps no exaggeration to say that our time is by many of its features more than the past tending towards an unsound inner attitude of man.

Much of the present civilization leads the average man and woman to a superficiality and inner hastiness which undermines sound mental life much more than the external factors. We look with a condescending smile at the old-fashioned periods in which the demands of authority and discipline controlled the education of the child and after all the education of the adult to his last days. We have substituted for it the demand of freedom with all its blessings, but instead of the blessings we too often get all its vices. A go-as-you-please method characterizes our whole society from the kindergarten to the height of life. We eulogize the principle of following the paths of own true interest and mean by that too often paths of least resistance. Study becomes play, the child learns a hundred things but does not learn the most important one, to do his duty and to do it accurately and with submission to a general purpose. The power of attention thus never becomes trained, the energy to concentrate on that which is not interesting by its own appeal is slowly lost, a flabby superficiality must set in which is moved by nothing but the personal advantage and the zigzag impulses of the chance surroundings. He who has never learned obedience can never become his own master, and whoever is not his own master through all his life lacks the mental soundness and mental balance which a harmonious life demands. Flippancy and carelessness, haphazard interests and recklessness must result, mediocrity wins the day, cheap aims pervade the social life, hasty judgments, superficial emotions, trivial problems, sensational excitements, and vulgar pleasures appeal to the masses. Yellow papers and vaudeville shows--vaudeville shows on the stage, in the courtroom, on the political platform, in the pulpit of the church--are welcome, and of all the results, one is the most immediate, the disorganization of the brain energies.

A sound mind is a well-organized mind in which a controlling idea is able to inhibit the opposites and is in no danger of being overrun by any chance intrusion into the mind. This power is the act of attention. An attention which is trained and disciplined can hold its ideas against chance impulses. An untrained attention is attracted by everything which is loud and shining, big and amusing. The trouble is not with the rush and hurry of the impressions which demand our attention; the trouble is with our attention which seeks a quick change of new and ever new impressions because it is not disciplined to hold firmly to one important interest. We want the hundred short-cut superficial magazines because we lack the energy to study one large volume; we want the thousand engagements because we are not concentrated enough to devote ourselves fully to one ideal task. The strong mind may find its sound adjustment even without such training for concentrated attention through obedience and discipline but the weak mind has to pay the penalty. For not a few it will mean social disaster. Yet our society is sufficiently adapted to this state so that it gives some good social chances to the superficial too, and this not only to the rich, but to those on every level. Only the nervous system cannot so easily be adjusted to the new regime. The loose interplay of the brain cells without the serious training of discipline must involve disorganization of the mind-brain system which may count often most powerfully in those spheres in which the mere needs of life are felt the least. There is only one great remedy: discipline, training for concentrated attention, for a work in submission of will to a steady purpose. And psychotherapeutic effort will often demand such a training for work rather than a reduction of work and rest.

The most alarming product of the neglect in training is found in many of those retarded children who at fifteen show the intelligence of a boy of eight. They are not imbeciles and do not belong in the psychiatric domain; their development has simply been suspended by a mistaken education. Of course no neglect would have led to it without a constitutional, inherited weakness of the central nervous system, but the weakness would never have led to the retardation if perhaps a mistaken parental indulgence had not allowed a life without forced effort and, therefore, without progress. Even such extreme cases may not show on the surface. The boy may pass as all right if we meet him at a ball; only his tutor knows the whole misery. Still less does the surface view of many a grown-up neurasthenic alarm us who seems to live a well-ordered, perhaps an enviable life, and yet who suffers the penalty of a life without concentrated effort, really without anything to do in spite of a thousand engagements. Moreover this lack of important activity may often be forced on our patients. Married women without children, without household responsibilities, and without interests of their own and without strong nervous constitution will soon lose the power of effort and their brain will succumb. A dreary monotony is dangerous even for the worker; for the non-worker it may be ruinous.

Yet mere flippant excitement and superficial entertainment is nothing but a cheap counterfeit of what is needed. Voluntary effort is needed, and this is the field where the psychotherapist must put in his most intelligent effort. There is no one for whom there is not a chance for work in our social fabric. The prescription of work has not only to be adjusted to the abilities, the knowledge, and social condition, but has to be chosen in such a way that it is full of associations and ultimately of joyful emotions. Useless work can never confer the greatest benefits; mere physical exercises are therefore psychophysically not as valuable as real sport while physically, of course, the regulated exercises may be far superior to the haphazard work in sport. To solve picture puzzles, even if they absorb the attention for a week, can never have the same effect as a real interest in a human puzzle. There is a chance for social work for every woman and every man, work which can well be chosen in full adjustment to the personal preference and likings. Not everybody is fit for charity work, and those who are may be entirely unfitted for work in the interest of the beautification of the town. Only it has to be work; mere automobiling to charity places or talking in meetings on problems which have not been studied will, of course, be merely another form of the disorganizing superficiality. The hysterical lady on Fifth Avenue and the psychasthenic old maid in the New England country town both simply have to learn to do useful work with a concentrated effort and a high purpose. From a long experience I have to confess that I have seen that this unsentimental remedy is the safest and most important prescription in the prescription book of the psychotherapist.

There is one more feature of general treatment which seems almost a matter of course, and yet which is perhaps the most difficult to apply because it cannot simply be prescribed: the sympathy of the psychotherapist. The feelings with which an operation is performed or drugs given do not determine success, but when we build up a mental life, the feelings are a decisive factor. To be sure, we must not forget that we have to deal here with a causal and not with a purposive point of view. Our sympathy is therefore not in question in its moral value but only as a cause of a desired effect. It is therefore not really our sympathy which counts but the appearance of sympathy, the impression which secures the belief of the patient that sympathy for him exists. The physician who, although full of real sympathy, does not understand how to express it and make it felt will thus be less successful than his colleague who may at heart remain entirely indifferent but has a skillful routine of going through the symptoms of sympathy. The sympathetic vibration of the voice and skillful words and suggestive movements may be all that is needed, but without some power of awakening this feeling of personal relation, almost of intimacy, the wisest psychotherapeutic treatment may remain ineffective. That reaches its extreme in those frequent cases in which social conditions have brought about an emotional isolation of the patient and have filled him with an instinctive longing to break his mental loneliness, or in the still more frequent cases where the patient's psychical sufferings are misunderstood or ridiculed as mere fancies or misjudged as merely imaginary evils. Again everything depends upon the experience and tact of the physician. His sympathy may easily overdo the intention and further reenforce the patient's feeling of misery or make him an hypochondriac. It ought to be sympathy with authority and sympathy which always at the same time shows the way to discipline. Under special conditions it is even advisable to group patients with similar diseases together and to give them strength through the natural mutual sympathy; yet this too can be in question only where this community becomes a starting point for common action and common effort, not for mere common depression. In this way a certain psychical value must be acknowledged for the social classes of tuberculosis as they have recently been instituted.

From sympathy it is only one step to encouragement, which indeed is effective only where sympathy or at least belief in sympathy exists. He who builds up a new confidence in a happy future most easily brings to the patient also that self-control and energy which is the greatest of helping agencies. The physical and mental efforts of the physician are alike deprived of their best efficiency if they are checked by worry and fear that the developments of the disease will be disastrous. As soon as new faith in life is given, and given even where a sincere prognosis must be a sad one, a great and not seldom unexpected improvement is secured. There is no doubt that the routine physician is doing by far too little in these respects. His instinctive feeling that disease is a causal process, and that he should therefore keep away from the purposive attitude, leads him too easily to a dangerous narrowness. He treats disease as if it were an isolated process and overlooks the thousandfold connections in which the nervous system stands with the patient's whole life experience in past and future. The physician is thus too easily inclined to underestimate the good which may come in the fight against disease from the ideas and emotions which form the background of the mind of the patient. Even if the disease cannot be vanquished, the mental disturbances which result from it, the pains and discomforts, may be inhibited, as soon as hopes and joyful purposes gain a dominating control of the mind. The nervous patient often needs a larger hold upon life, while the routine prescriptions may too easily reduce that hold by fixing the attention on the symptoms.

Here then is the right place for the moral appeal and the religious stimulation. How psychotherapy is related to the church will interest us later. At this moment morality and religion are for us not inspirations but medicines. But from such a causal point of view, we should not underestimate the manifold good which can come from the causal effect of religious and ethical ideas. Those faith curists who bring mutual help by impressing each other with the beauty and goodness of the world really bring new strength to the wavering mind; and the most natural channel for religious help remains, of course, the word of the minister and the own prayer. Religion may work there causally in a double way. The own personality is submerging into a larger all-embracing hold and thus inhibits the small cares and troubles of merely personal origin. The consciousness sinks into God, a mental process which reaches its maximum in mysticism. The haphazard pains of the personality disappear and are suppressed by the joy and glory of the whole. This submission of will under a higher will and its inhibitory effect for suppression of disturbing symptoms must be wonderfully reenforced by the attitude of prayer. Even the physiological conditions of it, the clasping of the hands, the kneeling, and monotonous sounds reenforce this inhibition of the insignificant dissatisfactions. On the other hand, contact with the greater will must open the whole reservoir of suppressed energies, and this outbreak of hidden forces may work towards the regeneration of the whole psychophysical system. Neglected functions of the brain become released and give to the mind an energy and discipline and self-control and mastery of difficulties which restitutes the whole equilibrium, and with the equilibrium comes a new calmness and serenity which may react almost miraculously on the entire nervous system and through it on the whole organism and its metabolism.

Seen from a causal point of view, however, there is no miracle in it at all. On the contrary, it is a natural psychophysical process which demands careful supervision not to become dangerous. It is not the value of the religion which determines the improvement, and it is not God who makes the cure; or to speak less irreligiously, the physician ought to say that if it is God who cures through the prayer, it is not less God who cures in other cases through bromide and morphine, and on the other side just as God often refuses to cure through the prescribed drugs of the drug store, God not less often refuses to cure through prayer and church influence. But the real standpoint of the physician will be to consider both the drugs and the religious ideas merely as causal agencies and to try to understand the conditions of their efficiency and the limits which are set for them. From such a point of view, he will certainly acknowledge that submission to a greater power is a splendid effect of inhibition and at the same time a powerful effect for the stimulation of unused energies; but he will recognize also that the use of those silent energies is not without dangers.

Certainly nature has supplied us with a reservoir of normally unused psychophysical strength, to which we may resort just as the tissues of our body may nourish us for a few days when we are deprived of food, but such supply, which in exceptional cases may become the last refuge, cannot be used without a serious intrusion and interference with the normal household of mind and body. To extract these lowest layers of energies may mean for the psychophysical system a most exhausting effort which may soon bring a reaction of physical and nervous weakness. The chances are great that such a religious excitement, if it is really to have a deep effect, may go over into a mystic fascination which leads to hysteria or into an exhausting eruption of energies which ends in neurasthenic after-effects. The immediate successes of the strong religious influence on the weakened nervous system, especially on the nervous system of a weak inherited constitution, are too often stage effects which do not last. From a mere purposive point of view, they may be complete successes. They may have turned the immoral man into a moral man, the skeptic into a believer, but the physician cannot overlook that the result may be a moral man with a crippled nervous system, a believer with psychasthenic symptoms. From the point of view of the church, there cannot be too much religion; from a therapeutic point of view, religion works there like any other nervous remedy of which five grains may help and fifty grains may be ruinous.

Moreover this power of inhibiting the little troubles of the body and of bringing to work and effectiveness the deepest powers of the mind belongs not less to any other important idea and overpowering purpose. The soldier in battle does not feel the pain of his wound, and in an emergency everybody develops powers of which he was not aware. The same effect which religion produces may thus be secured by any other deep interest: service for a great human cause, enthusiasm for a gigantic plan, even the prospect of a great personal success. Thus in a psychotherapeutic system, religion has only to take its place in line with many other efforts to inhibit the feeling of misery and to reenforce will and self-control by submission under a greater will. That in the case of religion this submission, from an entirely different purposive point of view, also has a moral and religious value, has in itself no relation to the question of its therapeutic character. It ought not to lead to any one-sided preference, inasmuch as religiously indifferent agencies may be in the particular case a more reliable means of improvement. Moreover the psychological symptoms are, after all, only a fraction of the disease and very different bodily factors, digestion and nutrition, heart and lungs and sexual organs may be most intimately connected with the disturbance of the equilibrium. Medicine today no longer believes that hysteria originates in the diseases of the uterus or that neurasthenia necessarily results from insufficiencies of the stomach, but it would be a graver mistake to believe that mental factors alone decide the progress of the disease, however prominent the mental symptoms may be in it.

From the physician's encouragement and the minister's influence towards new faith in life, a short way leads to the influence of suggestion. It is on the whole the way which leads from the general psychotherapeutic treatment to the specific one directed against particular symptoms.

IX

THE SPECIAL METHODS OF PSYCHOTHERAPY

Of course there is no abrupt division between special and general methods. Yet the different tendency is easily recognized, if we turn only, for instance, from the mere sympathy and encouragement to the method of reasoning with the patient about the origin of his special complaint. Just now the medical profession moves along this line a great deal. Of course no well-trained psychotherapist will make the blunder of arguing with the insane. To dispute by argument with the paranoiac and to try to convince him would not be only without success, but easily irritating. This does not mean that the not less amateurish way ought to be taken of accepting his delusions and appearing to be in full agreement with him. A tactful middle way, preferably a disciplinary ignoring attitude, ought to be taken. But it is entirely different with the mental states of the psychasthenic. The mere statement and objective proof that his obsession is based on an illusion would be ineffective. He knows that himself, but he may take the disturbance as the beginning of a brain disease, as a form of insanity, as a lasting damage which lies entirely beyond his control. Now the physician explains to him how it all came about. He shows to him that the symptoms resulted merely from autosuggestion or are the after-effects of a suggestion from without or of a forgotten emotional experience of the past. That is a new idea to the patient and one which changes the aspect and may have an inhibitory influence.

Of course, the patient does not accept the explanation at once. He feels sure that he is not accessible to suggestion and that he has least of all a tendency to autosuggestions, but the skillful psychotherapist will find somewhere an opening for the entering wedge. He may develop to the patient the modern theories of the origin of neurotic disturbances, all with entire sincerity and yet all shaped in a way which gives to the special case an especially harmless appearance. He may even enter into experimental proof that the patient is really accessible to autosuggestions. A very simple scheme for instance is to put some interesting looking apparatus with a few metal rings on the fingers of the subject and connect it with a battery and electric keys. The key is then pushed down in view of the patient and he is to indicate the time when and the place where he begins to feel the galvanic current. The feeling will come up probably very soon in the one or the other finger, and as soon as he feels sure that the sensation is present, the physician can show him that there was no connection in the wires, that the whole galvanic sensation was the result of suggestion.

Such a method demands patience and good will. The prejudices and deeply-rooted hypochondriac ideas, foolish theories of the patient and pessimistic emotions which have become habitual, must be removed piece by piece until the central symptoms themselves can be undermined and explored. It often takes hours of careful and fatiguing reasoning, in which at any time the patient may suddenly slip back to his old ideas. Yet if the explanatory arguments have once succeeded in making the patient himself believe firmly that his whole trouble resulted from suggestion only, the inhibitory effect of this idea may be an excellent one. The only serious defect of the method is that it often does not work. The credit which neurologists of today give to its effectiveness seems to me much too high. Even slight neurasthenic and psychasthenic disturbances remain too often in complete power when the patient is fully convinced that they originated with an emotional excitement which has long since lost its feeling value or that it resulted from a chance suggestion picked out from indifferent surroundings. The patient knows it and yet goes on suffering from the fruitless fight of his will against the intruder. Where mere reasoning is entirely successful, I am inclined to suspect that an element of suggestion has always been superadded. The authority of the physician has created a state of reenforced suggestibility in which the argument convinces, not by its logic but by its impressiveness.

This element of suggestion is quite obvious when the argument takes the form of persuasion, a psychotherapeutic method which has found its independent development. Whoever seeks to persuade relies on the mental fringe of his propositions. The idea is not to work by its own meaning but by the manner of its presentation, by its impressiveness, by the authority, by the warmth of the voice, by the sympathy which stands behind it, by the attractiveness with which it is offered, by the advantages which are in sight. Thus persuasion relies on personal powers to secure conviction where the logic of the argument is insufficient to overcome contradictions. But just for that reason persuasion is after all only a special kind of suggestion.

Other methods work on the same basis. Prominent among them is the psychotherapeutic effect of a formal assurance. The psychotherapist assures the patient that he will sleep the next night or that the pain will disappear or that he will be able to walk with such firmness that the counter-idea is undermined. It depends on the type of patient whether such suggestions of belief work better when it is assured with an air of condescension, spoken with an authority which simply ignores every possible contradiction, or with an air of sympathy and hope. Experience shows that it is favorable to connect such assurance with the entrance of a definite signal. "You will sleep to-night when the clock strikes ten," "The pain will disappear when you enter the door of your house," or perhaps, "Read this letter three times quietly in a low voice, and at the end of the third reading your fear will suddenly stop." Psychological insight will further decide whether it is wiser in the particular case to assure the patient of the resulting effect or rather of the power to bring about the effect. With some people, it works better to insist that the result will happen, with others to promise that they themselves can secure it; in the one case they feel themselves as passive instruments, in the other as real actors. To some hysterics, it is better to say: "You will walk," to others, "You can walk."

This belief in the future entrance of a change frequently demands an artificial reenforcement. There belongs first the application of external factors which awaken in the background of the mind the supporting idea that something has been changed in the whole situation or that some helpful influence has made the improvement possible. Medicines of colored and flavored water, applications of electric instruments without currents, in extreme cases even the claptrap of a sham operation with a slight cut in the skin, may touch those brain cells which words alone cannot reach with sufficient energy and may thus secure the desired psychophysical effect. The patient who by merely mental inhibition has lost his voice for weeks may get it back as soon as the physician has looked into his larynx with a mirror and has held an electrode without battery connection on the throat. Another way of helping by make-believe methods is to give the impression that a decided improvement is noticeable. The uneducated patient believes it easily when the physician at his very entrance into the office expresses his surprise about the external symptoms of a change for the better, perhaps seen in the color of the skin or the shading of the iris in the eye and reaffirmed by some pseudotests of the muscle reflexes. All that is not very edifying and the decent physician, who justly feels somewhat dragged down to the level of the quack in applying such means frequently, will abstain from them wherever possible. He knows that in the long run, even the psychasthenics are best treated with frankness and sincerity and he will therefore only in exceptional cases resort to such short-cut treatment by making believe. Yet that it is sometimes almost the only way to help the patient cannot be denied.

A neater way to secure the sufferer's belief in the possibility of a cure is by securing the desired effect at least once through little devices. As soon as it is once reached, the patient knows that it can be reached and this knowledge works as a suggestion. The hysteric who cannot speak when he thinks of his words, or who cannot walk when he thinks of his legs, may by the skillful physician be brought to a few words or steps before he himself is aware of it by completely turning his attention to something else and producing the stimulus toward the movement in a reflex-like way. Still more successful is the effort to resolve the inhibited action into its component parts and to show to the patient who cannot perform the action as a whole that he can go through the parts of it after all. As soon as he has passed through a few times, a new tactual-visual image of the whole complex is secured for his consciousness and this image works then as a new cue for the entire voluntary action, overcoming the associated counter-idea.

Another excellent way to overpower a troublesome idea or impulse or emotion is to reenforce the opposite idea by breaking open the paths for its motor expression. The effort to hold the counter-idea before consciousness may be unsuccessful so long as it is only an idea which tries in vain to produce any motor effect; but if the action itself has been repeatedly gone through, the idea will find it easier to settle and it becomes vivid in proportion to the openness of the channels of motor discharge. This holds true even for emotional states. A certain word perhaps picked up by the psychasthenic in a particular experience may produce whenever it is seen a shock and a depressing emotion. If we ask the patient to go artificially through the movements which express joy and hilarity, make him intentionally grin and open wide the eyes and expand the arms and inhale deeply, and after training this movement complex of joyful expression, speak the dreaded word at the height of the movement a new feeling combination clusters about the sound and may overcome the antagonism. Sometimes you will give to the desirable idea sufficient strength by mere repetition, sometimes you force the attention better by unusual accentuation, connecting the suggestion with a kind of shock. From here it is only one step to the suggestion in the form of a sharp order which breaks down the resistance just by its suddenness and loudness, supported perhaps by a quick arm movement which gives a cue for imitative reflexes. In the case of a youngster even a slap may add to the nervous shock; also a sudden clapping of the hands may favor effectiveness of the suggestive order.

Often it is wise to give the suggestion, not from without but to prescribe it in the form of autosuggestions. For instance, advise the patient not only to have the good will and intention of suppressing a certain fixed idea or by producing a certain inhibited impulse but to speak to himself in an audible voice, every morning and every evening, saying that he will overcome it now. Here, too, the autosuggestion may become effective by the frequency of the repetition or by the urgency of the expression or by the accompanying motor reactions. As a matter of course any associations which reenforce the idea may be used for assistance. Especially near-lying is the appeal to the man's conscience, but just such associations which touch the idea of the own personality and its deepest layers of feelings are always risky. They may touch and stir up old memories which interfere with success or they may awaken a feeling of contrast between duty and fulfillment which may disturb the whole equilibrium. If the physician knows that the good-will of the patient is insufficient to overcome the pathological disturbance, he ought not to make him feel ashamed or guilty, and that not only for moral reasons but also for strictly psychotherapeutic reasons.

In certain easily recognizable cases, it is essential to give the suggestion with avoidance of any emphasis, only as a hint, passing as if the suggestion almost slipped from the tongue of the doctor without his real intention. The hysteric who is resisting the suggestion which is intentionally given to her is sometimes surprisingly trapped by a half-hidden suggestion, perhaps not spoken to the patient herself at all but spoken in a low voice to a colleague in the room. Sometimes we have to trick those who suffer by "negativism," that is by an obstinacy which exaggerates that of the ordinary stubborn man. In such cases the suggestion not to perform an action works best if we want the action performed. There is hardly an end to the list of such methods for bringing beliefs and attitudes with suggestive power to the mind of the sufferer. Definitely to describe the conditions under which the one or the other form ought to be applied would be no wiser than to tell a statesman what steps are to be taken in every possible diplomatic situation. The instinctive selection of the right means among the many possible ones characterizes both the true statesman and the true doctor.

So far we have spoken only about the character of the suggestion, presupposing that the receiver remains in his natural state. This presupposition is certainly often entirely correct, but as far as it is correct, the results of the suggestion vary greatly with the different individuals. On the whole, we might say that such suggestions given to the subject in his normal state are effective only when the subject is by nature a suggestible being. In considering the psychology of suggestion, we recognized at once that the degree of natural suggestibility varies excessively. The non-suggestible mind is only to a slight degree influenced by any of these proposed forms of suggestion as long as the suggestibility itself is not heightened. To be sure, the question whether the person is suggestible by nature or not cannot be settled simply by his own impression. Many of the most suggestible persons believe firmly that they are superior to any suggestive influence.

To bring suggestions to greater effectiveness and to exert their influence practically upon every possible subject, we have thus not only to give suggestions or to advise autosuggestion but in both cases we have to secure, especially for the naturally less suggestible patients, a somewhat heightened suggestibility. Yet no one can overlook that some of the methods which we described have in themselves the tendency to reenforce the mental suggestibility. Those methods of emphasis and order, of assurance and make-believe, of practical training and of awakening counter-ideas, of persuasion and even of reasoning, wherever they are in a high degree successful probably always gain a certain part of their success by the increased suggestibility which the whole situation brings with it.

This reenforcement of the psychophysical readiness for suggestions results indeed quite directly both from expectation of the unknown and of the half-way mysterious, and from the confidence in the doctor. Of course it can work very differently. The expectation can upset the nervous system and produce unrest instead of suggestibility and, instead of confidence, the patient may feel that discouraging diffidence which settles easily upon those who have tried one fashionable physician after another. But where there is real confidence, based perhaps on the fame of the doctor and on the reports of his powerful achievements, there the conditions for effective suggestions are greatly strengthened. Still better is it if this confidence in the man is combined with a sincere hope for recovery. To lie down on a lounge on which hundreds have been cured fascinates the imagination sufficiently to give to every suggestion a much better chance to overcome the counter-idea. The expectation that something wonderful will happen can even produce an almost hypnoid state. The effect will be the greater, the less the barriers of systematic knowledge hinder the entrance of suggested ideas. The uneducated will on the whole offer less resistance to suggestions, just as superstitions find the freest play in the minds of the untrained. It is not by chance that the earlier epidemics of pathological suggestibility have on the whole disappeared with the better popular education. In a similar way work fatigue and exhaustion. The resistance has grown weaker, the suggested idea goes automatically into activity.

Skillful artificial means can still surpass the effect of these natural conditions. Here belongs everything which accentuates the authority and dignity of the originator of the suggestion. The psychologically trained physician has no difficulty in heightening the effect by simple surprises, if he cares for such tricks. If the patient for whom a mental treatment is recognized as necessary shows himself too skeptical to submit to the powers of the psychotherapist, such captivation of his belief can easily be secured. Let the man perhaps fixate a penny on the table with his right eye, while the left is closed and you show him that you can make another penny suddenly disappear when you move it a certain distance to the right and appear again when you move it still further. As the man has never heard of the blind spot in the retina, he accredits you with a special power. Many similar psychological illusions can well be used to prepare the mind for unsuspected healing powers.

Still stronger is the effect of personal contact. The psychophysiology of love indicates the most complex influence which contact sensations have on the whole nervous system and especially on the vasomotor apparatus of the body. Probably such vasomotor effect enters in, changing the blood circulation in the brain, when a personal contact between the transmitter and receiver of the suggestion is brought about. If the physician's hand rests quietly on the forehead of the patient who lies with closed eyes, or if he holds for a long while the hand of the patient, he may secure a nervous repose and submission which gives to the suggestions the most fertile soil. Needless to say that here again everything depends upon the accessories. An unsympathetic doctor may be entirely powerless where his neighbor has complete success. Neither a lifeless hand nor an agitating one will bring the desired repose, neither a cold nor a rough one. There must be strength and energy and even discipline, and yet sympathy in the pressure of the fingers. Again a psychologically different effect and yet one often to be preferred results from mild stroking movements, the stroke always to be repeated in the same direction, never up and down. The slow change in the position of the tactual sensations evidently produces a rather strong influence on the equilibrium of nervous impulses, and here again vasomotor reflexes seem to arise easily. Another variety of such bodily influences is given by artificial changes of the positions, for instance by bending the head of the subject backward while the eyes are closed. It may be that a certain lack of balance sets in in which the self-equilibrium is disturbed and an external influence can thus more easily get control of the psychophysical system. Again a certain monotony of speaking may easily add to the increase of the suggestibility.

Everyone knows that another most fruitful cause of this change is any mystic inspiration, any emotion in which the individual feels himself in contact with something higher or larger or stronger. Of course, the church can secure this effect easily, and here again the maximum will be reached if a bodily contact with the symbol of religious exaltation can be established. The patient who can touch the relics of the saints or bathe in the waters of Lourdes or at least feel on his forehead the hand of the minister, is wrought up to a state of suggestibility which makes suggestions easily effective. The objective value of religion again has nothing to do with it, as exactly the same effect can result from the most barbarous superstition. The amulets of a gypsy might secure the same resetting of the psychophysical system which the most sacred symbols awaken, and even many an educated person is unable to cross the threshold of a palmist or an astrologist, or to attend the performance of a spiritist, or to sit down with a purchasable trance medium without feeling an uncanny mental state which is objectively characterized by an increased suggestibility. But finally, the same effect sets in when the symbols of other emotional spheres are applied, perhaps for the patriotic soldier the flag of his country.

All the states of increased suggestibility which we have characterized so far still remain within the limit of normal wakefulness. We may turn now to the methods of the psychotherapist which produce in the interest of the suggestions an artificial state. However we have no right superficially to claim that the effectiveness of the suggestions is always greater in such unnatural states. On the contrary, we know that sometimes well applied suggestions work on wide-awake persons with increased suggestibility more strongly than on hypnotized subjects. Here even the instinct of the experienced physician may easily go astray, and it may need practical tests to find out which way will be the most accessible to the particular case. Often a certain role belongs even to natural sleep. It cannot be denied that some people can be influenced to some degree by words spoken to them during sleep. Most adults either wake up or show no signs of influence beyond effects on their dreams. But some absorb especially whispered words in such a way that their power becomes evident after the waking of the sleeper. Much more is this true of children. A suggestion to give up vicious habits, perhaps in the sexual sphere, or to speak fluently and no longer stammer may thus be beneficial. Yet the danger of this method is not small and extensive use of it is certainly not advisable. The more easily it can be carried into every bedchamber and can thus give to every mother and nurse the tools of a rather powerful therapy, the more a danger signal ought to be displayed. Interference with the natural sleep by outer influences creates abnormal conditions which cannot be removed at will. The chances are great that many unintended bad effects slip in and that not a few hysterias may be created by a method at the first glance so startling. Much less objectionable is it to make use of the effect of that period of half-sleep which precedes the natural sleep, and which is for many a period of increased suggestibility for autosuggestions. A resolution or the formulation of a belief which would be ineffective in a wide-awake state seems to get an accentuated effect on the mind, if it is repeatedly expressed in this transitional state. The psychasthenic who in such a half-dozing stage assures himself that he will no longer be afraid of going over a bridge or hearing a thunderstorm or will feel a disgust for whiskey or will have the energy for work, has a certain chance that such autosuggestions become reality the next morning. With many others there seems no effect to be obtained and not a few seem unable to catch the right moment. As soon as they begin to speak they become wide awake or fall asleep before they talk.