THE PRACTICAL WORK OF PSYCHOTHERAPY
THE PRACTICAL WORK OF PSYCHOTHERAPY
THE FIELD OF PSYCHOTHERAPY
We have discussed the psychological tools with which the psychotherapist has to work but we have not spoken as yet of psychotherapy itself. All that we have studied has been by way of preparation; and yet the right preparation is almost the most important factor for the right kind of work. To rush into psychotherapy with hastily gathered conceptions of mental life may be sometimes successful for the moment, but must always be ultimately dangerous. It is often most surprising what a haphazard kind of psychology is accepted as a basis for psychotherapy even by scientifically schooled physicians who would never believe that common sense would be sufficient to settle the problems of anatomy and physiology; as soon as the mind is in question, no serious study seems needed. Can we be surprised then that in the amateur medicine of the country within and without the church any fanciful idea of mental life may flourish? If we are to recognize the rights and wrongs of psychotherapy in a scientific spirit, a sober analysis of the mental facts involved was indeed at the very first most essential. Now we can easily draw the conclusions from our findings.
We recognized from the start the fundamental difference between two different attitudes which we can take towards the inner life of any personality, the purposive view and the causal. We recognized the sphere to which each belongs and we saw that all medical treatment demands the causal view, thus dealing with inner life as part of the causal chain of events. Each inner experience became therefore a series of so-called contents of consciousness. These contents can be described and must be analyzed into their elements. The basis of psychotherapy is therefore an analytic psychology which conceives the inner experience as a combination of psychical elements.
But the final aim was the causal connection. The appearance and disappearance of those millions of elements and their connection had to be explained. We recognized that such an explanation of the contents of consciousness was possible only through the connections between the accompanying brain processes. Every psychical change had to be conceived as parallel to a physiological change. The psychology which is to be the basis of psychotherapy had to be therefore a physiological psychology.
We recognized that these psychophysiological processes were processes of transmission between impressions and expressions, that is, between incoming nervous currents and outgoing nervous currents, between stimuli and reactions. Thus we have no central process which is not influenced by the surroundings and which is not at the same time the starting point of an action. We have normal health of the personality as long as there is a complete equilibrium in the functions of the organism which adjusts the activities to the surroundings. Every abnormality is a disturbance of this equilibrium. A psychology which is the basis of psychotherapy thus conceives every mental process in relation to both the ideas and the actions; it avoids all one-sidedness by which the mind is cut off either from its resources or from its effects. The relations to the impressions are usually the less neglected: and we must the more emphasize the fact that the psychology needed for psychotherapy knows no mental fact which does not start an action and that every change in the system of actions involves a change in the central experience. Wherever this equilibrium of adjusted functions is disturbed, some therapy of the physician has to set in: whether psychotherapy is in order depends upon the special conditions.
We have recognized that there are no mental facts outside of those which are in consciousness and that from a psychological point of view consciousness itself does not have different degrees and different levels, that all varieties of experience refer thus only to the special content and its organization. There is thus no subconscious. On the other hand, we saw that there is no conscious experience which is not based on a bodily brain process. By these two fundamental facts of scientific psychology, every possible psychotherapy gets from the start its clear middle way between two extreme views which are popular today. The one school nowadays lives from the contrast between consciousness and subconsciousness and makes all psychotherapy work with and through and in the subconscious. The other school creates a complete antithesis between mind and body and makes psychotherapy a kind of triumph of the mind over the body. Practically every popular treatise on psychotherapeutic subjects in recent years belongs to the one or the other group; and yet both are fundamentally wrong. And while, of course, this mistake is one of theoretical interpretation, it evidently has its practical consequences. The fantastic position allowed to a subconscious mind easily gives to the doctrine a religious or even a mystical turn and the artificial separation between the energies of the mind and those of the body leads easily to a moral sermon. Whether this amalgamation of medicine with religion or with morality may not be finally dangerous to true morality and true religion is a question which will interest us much later. Here we only have to ask whether it is not harmful to the interests of the patient and thus to the rights of medicine, and indeed that must be evident here at the very threshold. Both schools must have the tendency to extend psychotherapy at the expense of bodily therapy and to narrow down psychotherapy itself to a therapy by appeals which in the one case are suggestions to the subconscious and in the other case persuasions and encouragements to the conscious will. As soon as we have overcome the prejudices of those two rival schools and have recognized that both are wrong, that there is no subconscious and that there is no psychological fact which is not at the same time a physiological one, we see at once that this common procedure of both schools is unjustified and dangerous. Mental therapy and physical therapy ought to be most intimately connected parts of the same therapeutic effort and mental therapy includes by far more than mere suggestions and appeals. All that involves of course that its systematic application belongs in the hands of the well-trained physician and of nobody else, but on the other hand, it involves that every physician ought to be well schooled in psychology.
As soon as a disturbance to be cured is considered as a lack of equilibrium in psychophysical functions, every mental influence, every suggestion and appeal becomes itself an excitement or an inhibition of nerve cells. The sharp demarcation line between a psychical agency and a physical one disappears altogether; the spoken word is then considered as physical airwaves which stimulate certain brain centers and in the given paths this stimulation is carried to hundreds of thousands of neurons. The protracted warm bath or the cold douche influences, too, large brain parts by changing the blood circulation which controls the activity of those neurons; or the bromides absorbed in the digestive apparatus, or the morphine injected, also reach the neurons and again have a different kind of influence on them, and the electric current may stimulate the nervous system in still a different way. It may be, and under many conditions certainly is, essential to influence the brain cells just in that particular way which results from the spoken word, but there too the causal influence remains a function of the physical effect and thus by principle there is no sharp separation from other physical means. Thus to believe in psychotherapy ought never to mean that we have a right to make light of the other means which, as experience shows, may help towards the treatment of disturbances in the central equilibrium. Suggestions and bromides together may secure an effect which neither of them alone will bring about. It is most unfortunate that not without some guilt on the part of the physicians themselves, the large public has begun to believe that orthodox psychotherapy has to mean a rejection of drugs and a contempt for the doctors who prescribe them.
Of course a discussion of psychotherapy cannot enter into the study of these physical agencies of treatment, but at the threshold, we have to insist that there exists no opposition between psychophysiological and physiological means of influencing the brain. It may be true that drugs and baths and electricity have no influence on the subconscious, but the trouble is not that the drugs are inefficient but that they cannot influence what does not exist. In the same way disappears now that new boundary line for psychotherapy which wants to limit it to mere suggestion and appeal. If psychotherapy employs all the means by which we can influence mental states in the interest of the health of the personality, we have no reason to confine it either to a persuasion of the subconscious through suggestion and hypnotism or a persuasion of the conscious, in which it works as a moral appeal. Suggestion and hypnotism certainly must play a large part in psychotherapy and that part does not become smaller by the fact that we reject the subconscious interpretation of them and consider them entirely as psychophysical processes. And in the same way undoubtedly we have to acknowledge the psychophysiological effect of persuasion and of the appeals to the conscious intellect and will. But for us as psychotherapists all those factors have no moral value but only a therapeutic one, and thus stand in line with any other influence that may help, even though from a purposive point of view it stands on a much lower level. A mere mental distraction by enjoyment and play and sport, an æsthetic influence through art, a mere stimulus to automatic imitation, an enforced mental rest, an involuntary discharge of suppressed ideas, and many similar schemes and even tricks of the mental physician belong with the same right to psychotherapy.
It is really doubtful whether the moral and religious appeals are always helpful and not sometimes or often even dangerous for the health of the individual; and it is not doubtful that morally and religiously indifferent mental influences are often of the highest curative value. The more we abstract from everything which suggests either the mysticism of the subconscious or the moral issues of a mind which is independent of the body, the more we shall be able to answer the question as to the means by which health can be restored. This question is neither a moral nor a philosophical one but strictly one of experience. In this connection, we must remember that we also have had to give up the artificial demarcation line between organic and functional diseases. We recognized that every so-called functional disease has its organic basis too, and that it is entirely secondary whether we are able to find visible traces of the organic disturbance. We had to acknowledge, to be sure, the difference between reparable and irreparable disturbances, but such grouping expresses only in another form the fact that experience alone can show whether the methods of treatment which we know so far will be successful or not. Not a few disturbances of the equilibrium which appeared irreparable to an earlier time yield to the treatment of to-day, and no one can determine whether much which appears irreparable today may not be accessible either to psychotherapeutic or to physical therapeutic means to-morrow. If we were carelessly to identify the reparable troubles with those which we cannot recognize visibly, we should be at a loss to understand why, for instance, many forms of insanity are entirely beyond our psychotherapeutic influences. On the other hand, every physician who uses psychotherapeutic means is surprised to see the effective bodily readjustment where serious disturbances perhaps of the circulatory system or the digestive system existed. What the methods can do and what they cannot do must simply be left to experience, but of course to an experience which is eager to expand itself by ever new experimental curative efforts.
From this point of view we can see clearly the general division of the whole field of possible psychotherapy. Psychotherapy influences psychophysical states in the interest of health. There are only two possibilities open: either the disturbance is in the psychophysical system itself or it is outside of it, that is in the other parts of the body which are somehow under the influence of the mind. In the first case when the disturbance occurs in the mind-brain system itself, we ought to separate two large groups, first those cases in which the system itself is normal and the disturbance comes from without, and second those in which the constitution of the system itself was abnormal and led to disturbances under conditions in which a normal system would not have suffered. We have to consider both groups somewhat more in detail, as each again allows a large variety of cases.
Thus we have before us, first the normal mind-brain system into which a disturbance breaks, injuring more or less severely and for a longer or shorter time the equilibrium of the psychophysical functions. Here belong any bodily processes which produce pain or any bodily defects which produce blanks in the content of consciousness; the pain of sciatica or of rheumatism, or the defect of the blind or of the deaf, certainly interferes in a disturbing way with the perfect harmony of psychophysical activities. But here also belongs the suffering which results from conditions in the surroundings, the loss of a friend, a disappointment in life, any source of worry and grief. Social and bodily conditions alike may thus work to break up the equilibrium. The pain sensation interferes with the normal flow of mental life and the grief may undermine the mental interests. The psychotherapeutic effort may be directed toward removing the source of the disturbance, bringing the patient under other conditions, curing the diseased organ, and where that is not possible, may work directly on the psychophysical state, inhibiting the pain, suppressing the emotion, substituting pleasant ideas, distracting the whole mind, filling it with agreeable feelings, until the normal equilibrium is restored.
The psychophysical system itself was not really harmed by such influences. In the following groups, such is no longer the case. We here think at first of those severe injuries which have their sources in abnormal processes outside of the brain. The anæmia of the patient or the low state of his nutrition or the fever heat of his blood impairs the harmony of the mental functions. Another and for the psychotherapist much more important group is that in which the impairment results from toxic influences. Alcohol, morphine, cocaine, tobacco, and many other drugs may have been misused and may have produced a most marked alteration in the mind-brain system. Desires may have developed which completely destroy the balance of the normal functions and yet the satisfaction of which increases the poisoning effect. But here belongs further the effect of poisons which the body itself produces: the toxic disturbance of uræmia or the coma in diabetes, or especially the grave disturbances resulting from the abnormal action of the thyroid gland, the source of cretinism. Many indications suggest that a near future will consider this group much larger than we are really justified in doing today, probably soon connecting a number of other mental diseases like dementia præcox with toxic effects of bodily origin. Experience shows that in this group not a few chances exist for successful psychotherapeutic influence. Yet the means may be various in character and their effect may be a direct or an indirect one. A psychical shock may remove directly the mental disturbance of the alcoholic state, but it is more important that mental suggestion can remove the alcoholic disturbance indirectly by suppressing the desire for alcoholic excesses. Even where cure by psychotherapeutic means is out of the question, as is the case with feverish delirium or uræmic excitements, no skilled physician ignores the aid which a well-adjusted mental influence can offer to the patient.
We come to a third group. Some outside cause has harmed the central nervous system directly, and has left it in a disabled state after the cause itself has disappeared. Such causes may have been at first purely functional: for instance, a neglect of training, or a wrong training, or an over-activity, but the ill-adjusted function which involved, of course, every time an ill-adjusted organic activity or lack of activity, has led to a lasting or at least relatively lasting disturbance in the system of paths. The neglect of training, for instance, in periods of development may have resulted in the retardation which yields the symptoms of a feeble-minded brain, or the wrong training may have created vicious habits, firmly established in the mind-brain system and gravely disturbing the equilibrium. Above all, the overstrain of function, especially of emotional functions, may lead to that exhaustion which produces the state of neurasthenia. It is true that not a few would doubt whether we have the right to class neurasthenia here where we speak of the harm done to the normal brain. Many neurologists are inclined to hold that neurasthenia demands a special predisposition and is therefore dependent upon a neurotic constitution of the brain itself. But if defenders of such a view, as for instance, Dubois, acknowledge that "we might say that everybody is more or less neurasthenic," we can no longer speak of any special predisposition. Certainly there exists a constitutional neurasthenia sometimes but we have hardly a right to deny that overstrain in the brain activity may produce a series of neurasthenic symptoms in any brain, and the special predisposition is responsible rather for the particular selection among the innumerable symptoms.
Neurasthenia certainly is the classical ground for the psychotherapist. The patient’s insomnia and his headache, his feeling of tiredness and his disgust with himself, his capricious manias and his absurd phobias, his obsessions and his fixed ideas all may yield to the "appeal to the subconscious," and as a neurasthenic easily believes in the existence of various organic diseases in his body, Christian Science can perform here even "miracles." In the case of retardation, the psychical influence will have to be in the first place one of training. Yet it would be narrow to overlook that in neurasthenia, too, suggestion has to be only a part of the psychical treatment. Training and rest, distraction and sympathy and many other factors have to enter into the plan. Incomparably small, on the other hand, is the aid which psychotherapy can offer in cases of real destructions in the brain, as in the case of tumors, hemorrhage, paresis or the degeneration by senility. More effective may be its work in concussion of the brain and especially with traumatic neuroses, as in the case when a railroad accident has put the mind-brain system out of gear.
So far we presupposed that the central system itself was normal. No sharp separation line, however, lies between all these disturbances and the equally large group of psychophysical disabilities resulting from a defective constitution of the brain. The normal brain shades over by smallest differences into the abnormal one; yes, even the varieties of temperament and character and intellectual capacity and industry and energy represent, in the midst of our social surroundings, large deviations from the standard. That which might still pass as normal under certain conditions of life would be unadjusted and thus abnormal under other conditions. In the same way, we certainly cannot point out where the natural constitution of a brain ceases to be fit for its organic purposes and where the structural variations are ill-prepared for the struggle for existence. Just as we claimed that an entirely normal brain might be brought by an emotional overstrain to a state of exhaustion and disability, we may claim on the other side that a brain which nature has poorly provided may yet be protected against damage and injury. The inborn factor does not alone decide the fate. Psychophysical prophylaxis may secure steadiness of equilibrium to a system which inherited little resistance. Yet this large borderland region, where an ill-adjusted brain may be saved or lost in accordance with favorable or unfavorable circumstances, shades off again to the darker regions where the inner evolution leads by necessity to disaster even under favorable conditions.
We might begin this large group of the constitutional disturbances with that neurasthenia which develops on the basis of inherited disability. Lack of energy resulting from a feeling of tiredness, a quick exhaustion, a mood of depression, an easy irritation, even despair and self-accusation, sullenness and fits of anger, cranky inclinations and useless brooding over problems, headache and insomnia characterize the picture which everyone finds more or less developed in some of his acquaintances. If we classify symptoms, we may separate from it that which we nowadays are inclined to call psychasthenia. An abnormal suggestibility for autosuggestions stands in the foreground. Fixed ideas and fixed emotions, especially fears, trouble the patient. He may pick up his obsession by any chance experience and no good-will liberates him from the intrusion perhaps for years. The patient is perfectly well aware that his ideas and his emotions are unjustified, he himself does not believe in them, and yet they come with the strength of an outer perception and with the vividness of a real attitude, and his whole mental equilibrium may be upset by the continuous fight against these involuntary interferences. In the light cases, sometimes the one and sometimes the other autosuggestion may hold the stage; in the severe cases, mental life turns more and more around certain definite fears and yet it may all still be in the limits where the daily work can go on and the world may not know of the hidden tortures. Here belongs the fear of open places or the fear of touching certain objects, the fear of doing harm to others or the fear of deciding actions wrongly, the fear of destroying valuable things or the fear of being the center of public attention, the fear of crowds or of closed doors, of altitudes or of bridges. And in all cases emotional reaction may set in with anxieties, and bodily symptoms such as palpitation of the heart may result, whenever an effort is made to disregard the nervous fear. There is perhaps no group of patients which so much deserves the most careful efforts of the psychotherapist. Still more than the hysterics they suffer from the fate of seeing their ills counted as not real. For them everybody has the good advice that they ought to overcome their fancies; and yet they feel their life ruined with their endless fight against the overpowering enemy. And if anywhere, it is here that the psychotherapist is successful. Psychasthenic fear can be removed, while the developed melancholic depression, for instance, is entirely beyond the reach of psychical influence.
We have after all the same psychasthenic state before us when the obsession has impulsive character, from the mere abnormal impulse of lying, or making noise in a quiet place or crying in the dark, or touching certain places, to that of stealing, indecent speech, arson, and perhaps even murder. The symptoms might easily be mistaken for those of graver diseases. Yet the fact that the patient himself really does not will the effect at which he is aiming separates, mostly without difficulty, the diagnosis of psychasthenia from that of insanity. Quite nearly related to it are the manifold variations of abnormal and perverse sexual tendencies. The psychiatrists are perhaps too much inclined to bring all these pathological impulses and desires, fears and anxieties, into the nearest neighborhood to real insanity. The indisputable success of psychotherapy in these spheres ought to add a warning against these expansions of the strictly psychiatric domain. The psychologist will be more inclined to emphasize their relation to simple neurasthenia which itself imperceptibly shades over into our normal life.
All neurasthenic and psychasthenic disabilities show a certain emotional continuity and uniformity. It is the emotional instability and the quick alternation of symptoms which characterize hysteria or rather the hysterias. It seems as if science were near to the point of explaining the hysterical disease by one common principle, but certainly the symptoms are an inexhaustible manifold. The rapid changes of the intense moods of the patient usually stand in the center. Torturing obsessions, abnormal impulses, over-suggestibility, hypochondriac depressions, paralysis of arms or legs, anæsthesia and paræsthesia, a mental stupor and confusion, illusions and perceptions of physiological symptoms may work together in spite of his, or rather her clear intelligence. It is probably on a hysteric basis also that somnambulic states arise during the night, and from them a straight way leads to those mental attacks after which the memory is entirely lost, or for which fundamental associative connections are cut off. And from here we come to the exceptional cases of alternating personality. The more we recognize the myriad symptoms in the hysteric patient as products of the emotional instability, of autosuggestibility and of inhibition, the more we understand the almost miraculous result of psychotherapeutic treatment. Autosuggestions can be fought by countersuggestions, anæsthesia and paræsthesia can be removed often in an instant, dissociated personalities may be built up again through hypnotism, the most severe bodily symptoms may disappear by influences in a waking state. Hysteria alone would justify the demand that every physician in his student days pass with open eyes through the field of psychology. Quite near stand chorea and the epidemic impulses to imitative movements. And we might bring into this neighborhood also the disturbance in the equilibrium of the speech movements through all degrees of stammering and severe impairment. Up to a certain degree, though not often completely, they too yield easily to psychotherapeutic influence.
We enter now that region of constitutional disturbances in which psychotherapy is of small help. It leads from epilepsy to the periodic diseases, especially the maniacal depressive insanity, the paranoia which develops late, and finally to states of idiocy which cover the whole life. We are far from claiming that psychical influences are entirely powerless, the more as we insisted that psychotherapy goes much beyond mere suggestions and appeals. No psychiatrist will work without psychological tools when he deals with the exultations of the maniac and the depressions of the melancholic, with the hallucinations of persecution or the erotic insanities of the paranoiac. Still more the whole register of psychology has to be used, when we are to educate the idiot and the imbecile. But the disappearance of the disease or of the chief symptoms through the mental agencies is in all these cases out of the question. Only in incipient cases, especially of melancholia and mania, the psychotherapeutic work seems not entirely hopeless; and for epilepsy some distinct successes cannot be denied.
We have reviewed the whole field of psychophysical disturbances, those produced through external conditions in the normal brain and those resulting from abnormal brain constitution. We have seen that the work of the psychotherapist is of very unequal value in different parts of the field; in some, as in neurasthenia, in psychasthenia, in hysteria and similar regions most effective, in others like paresis or paranoia reduced to an almost insignificant factor. Where it can help and where not we recognize as a mere question of experience. Certainly the severity of the symptoms alone does not decide it. As the treatment is entirely empirical, no one can foresee whether or not the situation may change to-morrow. We may find psychotherapeutic schemes by which epilepsy or maniacal depressive insanity or traumatic neuroses may become accessible. We simply do not know why we may remove stammering or synthesize a dissociated personality or overcome an inborn sexual perversity, while we are unable to remove the depression of the melancholic. Certainly the symptoms of the circulatory insanity disappear completely in the free intervals; there is no reason to give up hope that psychotherapy might find the way to hasten the appearance of such a normal period.
But we have emphasized from the start that the psychotherapeutic work has not only to set in when the disturbance itself lies in the psychophysical system. We may utilize the influence which the mind-brain system has for the whole body and thus may apply the psychical tool to work on the disturbances in the bodily apparatus. We may discriminate a direct and an indirect influence in the psychical treatment of bodily diseases. Transition from the foregoing group of psychical disturbances offers itself perhaps most easily through the state of insomnia.
The causes of sleeplessness may still lie in the psychophysical sphere; restless thoughts may inhibit the idea of sleep. The effect of sleep is again in the sphere of the mind, the annihilation of conscious contents. But the center which regulates and creates the sleep, probably by contracting the blood-vessels, lies outside of the psychophysical system in the lower centers of the brain. The real disturbance thus lies in the inactivity of this purely bodily apparatus and mental influence which is to create sleep has therefore to work downwards from the mind to a bodily organ. In the same way many other non-psychical centers of the brain may be brought to efficiency through psychophysical regulation.
But the therapeutic effect is certainly not confined to the central nervous system. Whithersoever the centrifugal nerves lead there the mind-brain system may have its curative influence. In the most startling way that is true for the digestive apparatus. The secretions of the stomach, the activity of the intestines can be influenced to a decree which it is difficult to explain. Important also is the relation to the circulatory system, especially the disturbances of the heart: innervation may be corrected, abnormal dilations and contractions of blood-vessels may be regulated. The bladder, uterus, even the pancreas and the liver seem to be influenced by the peripheral effects of the central excitement. And while no warning can be serious enough against the absurd belief that diseases like cancer or tuberculosis can be cured by faith, it must be admitted that psychical influences under special conditions may have a retarding influence on any pathological process in the organism. Much of that certainly is indirect influence but the physician would be reckless if he should ignore the aid which may result from such indirect assistance. Even if psychotherapy could not do more in the treatment of bodily diseases than to secure a joyful obedience to the strict demands of the physician, it would yet have to be accredited with an extremely important service.
In a parallel line comes the effective aid by the stimulation of hope and the suppression of fear, by suggestion of a feeling of encouragement and the inhibition of the emotions of worry. This is a field where even the average physician is most easily inclined to play the amateur psychotherapist. He knows how convalescence is disturbed by psychical depression and how much more quickly health returns, if it is confidently expected; he knows how many dangerous operations are disturbed by despondency and helped by bravery; he knows what a blessed change has come into the treatment of tuberculosis since a psychical factor of social interest has set in; he knows how many ills disappear when regular occupation and interesting work are established or the strain of distasteful work removed. Even the mere suppression of the pain works backwards on the bodily disease which produces it. The pain was a starting point for disturbing reactions; with its disappearance through psychotherapeutic influence, the reactions of the irritated brain come to rest, the diseased body can carry on its struggle without interference and may win the day. Often the psychical influence may not even change the symptoms at all but may remove other troublesome effects. The sufferer from locomotor ataxia may learn to walk again through mental education without any restitution of his spinal cord. In short, there are endless ways in which psychical influence may work towards the general health and towards the victory over bodily disease; and all that may be acknowledged without the slightest concession to the metaphysical creeds of mental healers and Christian Scientists. But to make use of those means and to harness such influences, it cannot be enough to rely on the common-sense of the physician any more than we should trust the common-sense of the surgeon to use his knife without condescending to the study of anatomy. The psychological study of the anatomy of the soul shows a not less complicated system of mental tissues and mental elements.
To enter into the full richness of this whole, large field of course lies entirely beyond the scope of our short discussion, which seeks as its only aim a clear recognition of the principles. Yet it seems essential to illustrate at least this sketch of the field by a more detailed account of actual developments. Various ways of procedure might appear in order and the most natural one would be, of course, to pass down from disease to disease and sketch special cases from diagnosis to cure. We might go through the various stages of neurasthenia and then through psychasthenia and then through hysteria and so on. And if we had to write a handbook for physicians, it would certainly be the desirable way, in spite of the too frequent repetitions which would become necessary. But as our aim is only a discussion of principles of psychotherapy, we have no right to use this method. Moreover, such a method would suggest the misleading view that the psychotherapist is called and is able to treat diseases. All that he treats are symptoms and he ought not to pretend that he can do more, as long as he abstracts from all other therapeutic agencies. Psychotherapeutic influence may remove the phobia of a psychasthenic or the obsession of a neurasthenic or the emotion of a hysteric, and thus may bring not only momentary relief but a change which may be favorable for general improvement, but certainly the neurasthenia and psychasthenia and hysteria are not really removed by it. Of course, even the treatment of symptoms demands a constant reference to the whole background of the disease. The depression of the neurasthenic must not be treated like the depression of the melancholic, the obsession of the psychasthenic must not be mixed with the fixed ideas of a paranoiac, the hysteric inability to walk must not be confused with an injury of the motor nerves; in short, each symptom has to be treated as part of a complete situation. The efforts of the psychotherapist will move over as large a part of the disease as possible and cover, perhaps, the causes of the disturbance as far as they are of psychical origin. Yet it would remain dilettanteism if we were to accept the popular view that the mere psychotherapeutic aid is a sufficient treatment of the whole disease. The physician has to be much more than a psychotherapist. Our discussion only seeks to point out that whatever else he may be, he must be also a psychotherapist.
The more conservative method which befits us may be, therefore, the method of dealing with symptoms only and abstracting from the more ambitious plan of discussing the diseases entire. We simply separate the mental symptoms and the bodily symptoms which the psychotherapist is to remove. And just in order to classify somehow the manifold mental symptoms, we might separate those in the sphere of ideas, those in the sphere of emotions, and those in the sphere of volitions. Of course, nothing is further from such a plan than the old-fashioned belief that intellect, feeling, and will represent three independent faculties of the soul. Modern psychology has not only substituted the millionfold phenomena for the schematic faculties, but emphasizes above all the interconnectedness of the mental facts. There is no experience into which ideas, and feelings, and impulses do not enter together. And correspondingly we emphasized that on the physiological side too, every sensory excitement is at the same time the middle point of central irradiation and the starting point of motor activity. Thus there can be no disturbance of ideas which does not influence feeling and will, and vice versa. Yet it would be artificial to deny that any one of those various sides of the psychical process may come to prominence, sometimes the impulse, sometimes the emotion, and sometimes the interplay of ideas. The separation means only an abstraction, but it is an abstraction which is justified and suggested by the actual experiences. Thus we shall deal with the psychical treatment of ideational, emotional, volitional, and bodily symptoms.
Common to our discussions will be only the effort to avoid everything which is exceptional and by its unusual complications apparently unexplainable and mysterious. The greater complexity of the case certainly adds much fascination. Yet since we do not want to stimulate mere curiosity but clear understanding of the elements, we avoid every startling record. We confine ourselves carefully to those perhaps trivial experiences which daily enter into the view of those who come in contact with suffering mankind. There will be no startling stories of dissociated personalities, such as appear perhaps every few years on the horizon of the medical world, but we shall speak of those who every day in every town carry their trouble to the waiting room of the doctor and who might return more happily if he had more well-trained interest in the psychotherapeutic factors. Yet before we analyze some typical symptoms, it might be wise to review the whole series of means and tools which the psychotherapist finds at his disposal.