Psychotherapy

TREATMENT

Strong Mental Impression.—In the treatment of these affections two periods are to be considered, one during, the other after the attacks. During the attack a strong impression must be made upon the patient's mind so as to divert the concentrated attention. We have well authenticated stories of the various expedients resorted to by physicians who were confident of their diagnosis in order to secure such a strong mental impression. I once knew an old physician who was summoned to a childless wife whose adoring husband was in manifest agonies of solicitude over her and whose mother and mother-in-law had been caring for her for days with all anxiety, walk into the room of the patient, take one of her hands in his, slap her on the cheek, tell her to get up and walk and she would have no more of that supposed inability to walk which had caused the family so much anxiety. He succeeded. It can be imagined what would have happened had he not succeeded. We know of cases where an alarm of fire or a burglar scare or some sudden emotion has produced a like result. We cannot prescribe these things, however, and at the most, after one or two successes in a particular patient, they would fail.

The only thing that we can do as a routine practice is to relieve by direct treatment the slight physical condition that is usually present and then try and influence the patient's mind. If a thorough examination is made in the course of which the physician is able to show the patient that he understands the condition and that he can demonstrate for himself and them that there is nothing serious the matter with important organs, he can make them feel that their pain or disability is entirely due to concentration of attention on a particular nerve or set of nerves. With many patients this will succeed, not at once, but after two or three seances of positive suggestion, even in the waking state. If the patients are bothering their relatives very much it may be necessary to give some opium as an adjuvant. As a rule, the needle had better not be used, but a suppository given. This is not nearly so attractive to the patient's mind as the use of the needle and is not likely to be called for so often. Every physician has had the experience that after giving opium two or three times, either per rectum or hypodermically, almost anything can be given, provided the patient is persuaded that the drug is being given again. A reasonably large dose may be used the first time, but certainly after the second or third time a much smaller dose will produce the same effect and often a simple gluten suppository, provided it looks like the other, will work just as well as an opium suppository.

After Treatment.—The after treatment of these cases is directed mainly to such alterations of the mental attitude and physical condition as shall prevent recurrences. The general condition of the patient must be improved in every case where there is indication for this. Many of these patients are under weight for their height. They must put on weight. Weir Mitchell's success with the "rest cure" consisted to a great extent in his power to cause these patients to put on weight. This supplies reserve energy, but, above all, replaces discouragement by hope and buoyancy. Gain in weight can be accomplished mainly by two methods. First, by seeing that the patient gets an abundance of air and, secondly, by dictating how much shall be eaten. In this matter details are important and it may be necessary to suggest the actual diet for each meal. This must be liberal and must consist of simple but particularly nutritious materials. Patients' dislikes need not be taken into much account, their likes are often helpful. When there is insistence on lack of appetite and decided objection to chewing, eggs and milk should be given in increasing quantities, until five or six eggs and some twelve glasses of milk are taken every day. Besides this, a good portion of meat should be eaten at one meal with some vegetables. By firm insistence, day after day, it will not be hard to get patients whose appetites are seriously inhibited to take this amount of food. To secure this, a good, firm, sensible nurse is invaluable. Appetite, as we have emphasized in the chapter on Appetite, is largely a matter of will, and anything that is eaten, provided it stays down, will do good unless there is organic disease.

A certain amount of exercise is important in these cases, but not nearly so important as an abundance of fresh air. Patients must not be allowed to overtire themselves. Riding in an open carriage or on the top of a bus, especially where there are distracting scenes and many human interests, is particularly beneficial. Automobiling is often likely to be more tiresome than is good for these patients when they are run down, though it is one of the best of therapeutic measures for those who are physically capable, that is, up to weight, even though they may complain of feeling weak.

Diversion of Mind .—It is in these cases particularly that diversion of mind is of prime importance. Many of these patients have either no serious interest or at most certain interests with which they may occupy themselves if they wish, but that are not engrossing and attention to which may be put off whenever they care to. Duties that are inevitable and that call for the occupation of so much time that the patient has little opportunity to think of herself are often the salvation of these patients. As I mention in the chapters on Occupation and Diversion of Mind, I have seen a number of cases and I am sure that every physician of reasonable large experience has seen similar cases, where women, particularly, who in the midst of prosperity have been constantly suffering from some form of psycho-neurosis, great or small, have, after some sudden turn of fortune, been completely relieved from their nervous symptoms by having to devote themselves seriously to some occupation for a livelihood.

Occupation, particularly with children, with the weak and the ailing, with the poor and those who are unable to help themselves, is specially likely to be helpful to such patients when they are women. Such interests affect them deeply and by the sympathy they arouse through contact with real physical suffering, they prevent over-attention to themselves. I have seen the care of a cancer patient, and especially of a relative affected by cancer, do more for a psycho-neurotic sufferer than all that doctors had been able to accomplish in years. It is often difficult to find occupation and diversion of mind for these patients, but this is the therapeutic problem the physician must solve if he is going to secure relief from present conditions and prophylaxis against further attacks.

Oldtime Cures.—Many of the remedies for obscure abdominal conditions show how well the real character of the affection was duly recognized and appreciated in the past. It is in these cases particularly that the pillulae micarumpanis, the bread pills, of the olden times, were so commonly used with good effect. We have quoted examples in other chapters. Many of the drugs that are employed with reported success for these affections have a strong suggestive element in them. Valerian probably is a good tonic and yet there is no doubt that the suggestive quality of its nauseating smell and the almost inevitable eructations that occur after to emphasize it, are helpful in curing certain internal psycho-neuroses. Another drug that has been much used in the same way is asafetida, whose disgusting taste and odor have been excellent auxiliaries. Fresh pills of quinine and red pepper uncoated and therefore producing definite effects on the taste before swallowing and on the mucous membrane of the stomach after swallowing, often prove the best remedy for persistent vomiting or for enduring nausea. A drop of nux vomica, taken every half hour with the definite warning that the patient must by no means take more, and that the bottle must be carefully protected lest anyone else should be poisoned, is often very efficient. These remedies have a slight physiological action and a large psychic action, but that exactly corresponds with the etiology of the affection for whose treatment they are employed.

Dominant Ideas.—During the attack it is often possible to find either from the patient or from friends that there is some dominant idea which is bringing about the mental short-circuiting that leads to the concentration of attention. From the oldest times it has been recognized that in young women a disappointment in love may prove to be the occasion for a psycho-neurotic or, as they used to call it, hysterical attack. This is, however, not a specific cause. It is the disappointment much more than the sex element in the case, as a rule, that produces the unfavorable effect. It was easy to conclude that the sex factor was extremely important in older times when women's sphere of activity was largely limited to the home, and marriage was the one legitimate object of their ambition. Now that we have had more experience with the business woman, we know that serious disappointments of any kind have a tendency to initiate psycho-neurotic conditions in susceptible and especially suggestive individuals. A failure to secure promotion in a store, or to secure some position that is eagerly sought for, a loss of money in business, etc., especially when they have been preceded by weeks or months of solicitude and worry over the event that now happens, may lead to the development of a psycho-neurosis.

This is particularly notable with regard to educational interests of various kinds. Young women readily overdo application to study, or, rather, anxiety over it, and as a result get into a state of mind in which a failure to pass an examination, or to secure promotion, or even the failure to win a prize, may give rise to a highly nervous condition in which tears and laughter come unbidden and in which further developments may bring on a typical psycho-neurotic attack. All sorts of pains and aches and motor incapacities may occur in these states. The supreme occupation with the single idea present in their minds at all times, waking and sleeping, while they try to study, or when they read or even when they are supposed to be diverting themselves, finally precipitates a nervous explosion along nerves that have been irritated for some reason, though the pathological condition present may be quite insufficient of itself to explain the affection that ensues. These are the popular nervous breakdowns, not difficult to treat once their real character is diagnosed.

Sorrows of various kinds may produce a like effect. Worry or anxiety about the serious illness of a near relative, especially an inevitably fatal illness, such as cancer or tuberculosis or the disturbing mental affections, may have a similar result, but usually not in those who are occupied with the actual care of the patients. The mental states constitute the psychic elements underlying the neurotic condition that develops.

Almost needless to say, successful treatment must include a faithful attempt to lessen the significance of the mental state that is so important in the case. Usually the mere obtaining of the patient's confidence is enough to lessen greatly the irritation produced by the mental condition. A sorrow shared is halved. It is, above all, secretive individuals who become depressed over their sorrows. While the patient who insists on constantly sharing them with everyone becomes a nuisance, it is always a little dangerous not to have a confidant to whom worries and anxieties are entrusted. If they are kept to one's self they are nearly always exaggerated—they are seen out of proper perspective and have a much more depressing influence. Calm, judicious reasoning with the patient over the significance of the condition as presented, is often of great help.

Often these ideas, so potent for mental and bodily disturbance, are almost entirely unconscious or exist in the patient's subconsciousness and are recalled only under such special conditions as remove the bonds of the patient's occupation with himself or herself at the present time and allow memories to come back without interference. There are many curious stories of such cases. A child is frightened or very much disturbed by having a cat kill a favorite bird. The cat becomes a deterrent object. Gradually this deterrence grows. As a consequence, there may develop one of those intense dreads of cats which makes life miserable if near that animal. There may even be physical effects produced by the continued presence of a cat in the same room. Often in these cases the beginning of this mental attitude, or at least its occasion in the incident of the killing of the bird is forgotten, or at least not consciously referred to as an etiological element in the dread.

Patients have been known to develop states of mind which made them object to certain figures or names because of earlier associations with them that were unpleasant. There is the story of a man who would never take a car with an odd number though this was sometimes a source of annoyance and delay and who could not explain to himself or his physician how this objection had developed, until his memory was searched and it was found that, years before, he had witnessed the death of a child under the wheels of a car with an odd number. He had completely lost the sense of the direct influence of this, but it existed in subconscious memory and proved the source of much annoyance to him, for if with a friend he were not able to avoid taking an odd numbered car he would feel quite miserable during the ride. Frights of various kinds may produce this same effect. I have in my notes the case of a man who is unable to sleep at night without a light in his room, because of a fright. Once while asleep in the dark, he awoke conscious that someone was in the room and sat up and demanded who was there. The answer was a revolver shot and a bullet, passing not far away from him, pierced the head of the bed. As he sank back the burglar leaped from the window and escaped. He realized that this was the cause of his fear of the dark, but lesser incidents might easily become subconscious yet continue their influence.

Psycho-Analysis.—In recent years Freud has suggested that in many puzzling cases of psycho-neurosis, where, so far as is known, there seems to be no dominant idea bringing about the concentration of attention, careful analysis of the patients' memories will bring out the fact that there is a subconscious idea as the underlying substratum of these affections. Freud has developed what is called the process of psycho-analysis in order to bring out these ideas which are sometimes exerting their influence unconsciously to the patient. The subconscious is one of the fads of the hour, so that Freud's announcement attracted much attention. Psycho-analysis, however, is not advanced so confidently even by its inventor as a positively curative measure, as it was at the beginning. It has been found that after the dominant idea in the subconsciousness has been found and neutralized with a consequent amelioration of the psycho-neurotic symptoms, there may be a relapse, when another dominant idea will have to be found, and that there seems to be the possibility, in some cases at least, of an almost endless succession of such ideas to account for further and further relapses.

Undoubtedly psycho-analysis has its place in psychotherapy and is of great value in certain cases. There is no doubt, however, in my mind that in most of these cases reported as cured after psycho-analytic methods had been employed, what really happened is that the patient's mind became diverted to another idea—that of marvelous cure through mind searching which relieved the previous concentration of mind underlying the psycho-neurosis. These are the cases that used to be cured by hypnotism. Before hypnotism was developed they were cured by mesmerism. Before mesmerism they were cured by magnets or by the Leyden jar, and during the past century they have been cured by electrical methods or by osteopathy or by Eddyism. Many of the cures were effected by stroking and touches, the use of Perkins' tractors, or Greatrakes' methods, or anything else that attracted attention very strongly. They were given a new idea which occupied them very much and so saved them from that preoccupation with themselves and their feelings and whatever slight ailment might be present that was the physical occasion for psycho-neurotic symptoms. This happened with psycho-analysis. When it was absolutely new and the operator had great confidence in it, this confidence was imparted to the patients, with the consequent cure or decided amelioration of their psycho-neurosis, just as that used to be brought about by our previous method of treating such cases by some strong suggestion.

As I emphasize in the chapter on Dreams, the examination of the dreams in order to get a hint of the dominant idea, is particularly interesting, because it represents a return to the oldest methods of suggestion of which we have record. The fact that sexual ideas seem to represent a great many of the dominant ideas in these cases is of interest for a similar reason. It represents the tendency constantly recurring to refer most nervous ailments, as indeed most other ailments, to something pathological in the sexual or genital sphere. The old idea embodied in the word hysterical exemplifies this very well. The "vapors" or "tantrums" or fits which were supposed to be due, to some extent at least, to suppressed sexuality by medical writers of three or four generations ago, have come back to us under another form and with other terms. Psycho-analysis gives occasion for instruction in so far as it helps the patient to get rid of old persuasions and exploded ideas as to disease and diet and the various functions of the body and the mind that have often almost unconsciously been acquired and secured a dominance. It is surprising how often it will be found that people are taking too much or too little water at meals, too many or too few vegetables, too much or too little of salt or of other condiments as the result of habits and notions acquired when they were young and under influences that they may now forget. In the same way habits of life with regard to bathing, clothing and the like may be the source of unfavorable conditions in mind and body that need only to be discovered to be corrected. Their correction will often bring about the relief of symptomatic conditions that have proved quite obstinate to treatment. We have emphasized this in the chapters on the Individual Patient and the necessity for acquiring just as much knowledge as possible about both his occupations and his mental attitude in order to be able successfully to treat chronic disease.

SECTION XVIII

DISORDERS OF MIND