Psychotherapy

The most difficult problem in this matter is the question of diagnosis. As a rule, the history is the most helpful for this. The patient tells of having found difficulty all his life whenever anything of special significance was placed on his shoulders. He is one of those who were born tired and remain so all their lives. It has been the custom to blame these people; they are rather to be pitied. If they are born in circumstances that allow of their living quietly in the country, they accomplish a certain amount of work quite successfully and live happy, contented lives. If they are born in the city where the hurry and bustle around them and the insistence of friends that they must take up responsibilities becomes poignant, they get discouraged and even despondent. It is from this class of patients that the "ne'er-do-wells" of modern life are recruited. They form the under-stratum of trampdom, the scions of good families with the wanderlust, the willing but incapable. Certain of them become vicious and criminal, either because they do not want to work or because their mentality is perverted in some way. Such patients cannot be treated with any hope of their becoming successful exemplars of the strenuous life, but they may be directed into the less exacting occupations of country life and so live quiet, useful and happy lives. For the congenital class we can do little except to prevent them from trying to do things that are beyond their mental capacity and helping them to see just what their limitations are.

Mental Exhaustion .—Many disturbances of mental energy are acquired. These may be either functional or organic. For the organic variety we cannot do much, since it is dependent on changes in organs that are permanent. We can, however, usually predispose the patient's mind to the recognition of the fact that he should no longer try to devote himself to occupations that constitute a special drain on his nervous energy. The man, for instance, who is already suffering from arterio-sclerosis must be warned that worry and work will surely hasten the process and that his nervous symptoms cannot be cured, but must be palliated. He must be advised to lessen his mental strain and to take up something which, while occupying his mind, does not make insistent calls on his vitality. In this matter it must be remembered that when a man over fifty develops nervous symptoms, as a rule there is no question of functional trouble but of organic change and usually heart or arteries or kidneys are at fault.

In recent years we have come to realize that typhoid fever often makes serious inroads upon a patient's vitality which can only be retrieved by care, not alone for some months but, if possible, even for some years, not to put an overstrain on the vital energy. Certain other diseases produce an even more lasting effect. A sufferer from well-developed tuberculosis will probably never be able to go back to the strenuous city life. If he attempts to do so, not only is there danger of a recurrence of his tuberculosis, but there may even be a development of neurotic symptoms. Syphilis is another disease that leaves patients in a condition in which it is dangerous for them to assume the serious responsibilities of an exacting occupation and especially anything that involves excitement and worry. Syphilitic patients should be warned of the danger of pursuing vocations that make such demands upon them. It is the actor, the broker, the speculator, and the strenuous business man generally, who is likely to suffer from parasyphilitic conditions, tabes, paresis and the like, much more than those who follow occupations that make less demands on them.

Functional Mental Incapacity.—In a large number of cases the incapacity to do things because of lack of mental energy is due to functional disturbances of the nervous system. These are the most important for the psycho-therapeutist because much can be accomplished for them. Nearly always the patient can be benefited by advice and suggestion, and very often some unfavorable factor at work, using up his mental energy to no purpose, will be discovered. In order to do good, however, careful study of the individual patient is the most important element. The most frequent functional disturbance of the nervous system, leading to exhaustion of mental energy, is over-attention to one's self and to one's occupations. Men can do many complicated things quite naturally and easily, but when they carefully watch themselves doing them, accomplishment is not so ready and the task is double. They tire much easier, for, as a rule, what they are doing could be accomplished automatically and they are using up energy attending to it. This is probably one of the commonest causes for the rather frequent development of that state called nervous exhaustion in our time. People watch themselves too closely and by so doing they not only use up energy unnecessarily in the surveillance, but also they hamper their powers to do things and so consume additional energy in overcoming this inhibition.

Morbidly introspective people watch almost ceaselessly everything they do. They not only watch themselves work and worry about it, but they watch themselves play and grow solicitous that it will do them good; they watch themselves divert themselves to see if it is giving them real recreation and so spoil the diversion; they watch themselves eat and disturb their appetite, and watch themselves digest and hamper digestion; they even try at least to watch themselves sleep and so interfere with sleep. Many of the cases of insomnia are really due to this over-attention. They fear they will not sleep, they worry about it, they keep themselves awake hoping that they will sleep, and in the more serious cases even during sleep itself they are so solicitous that their dreams become very vivid and a form of unconscious cerebration goes on with surveillance of themselves. They do not rest even in sleep. They wake feeling not rested, they get up with a consciousness that they are beginning a long day without being properly refreshed and they exhaust enough energy to complete a good part of the day's work in wondering whether they will be able to go on with their occupation for the day, whatever it may be.

Inhibitory Surveillance .—People become afraid that they cannot or that they may not do things well and set a guard over themselves. This is illustrated very well in the doubts about accomplishment because of which they keep going back to see what they have done and how it was done, though usually it was accomplished quite well without any conscious attention. Dreads form another phase of this attitude of mind. For those who are affected with them they make a thing hard to do before it is begun, and harder to accomplish after it has been entered upon because of the suggestion that it may lead to some serious results, or they even inhibit their activities to a marked extent by their solicitude with regard to them. They worry about things before the event and thus consume energy uselessly. Worry has been defined as anxious solicitude about what we have to do next week at the same time that we occupy ourselves with what we are doing now and have to do in the next hour or two. The solicitude about next week is quite useless, as a rule, until the time comes, and it merely disturbs what we are doing now, making it harder to do and making errors in it almost inevitable, and so preparing ourselves for discouragement because of mistakes that have been made and still further adding to the difficulty of accomplishment.

Inhibition of Automatism .—These introspective people disturb themselves by over-attention to things that need no attention, that are accomplished automatically, and that are not done nearly so well if they are attended to. Not only is it true that it is harder to do work that ought to be accomplished automatically if much attention is given to it, but also nature resents the surveillance. Not only the brain does not work so well if watched to see whether perhaps it is working too much, or whether there are too many feelings in our head while we are doing things, but even the stomach resents being watched and does not do its work as well. The same thing is probably true for every one of our organic functions. In the chapters on the heart we call attention to the fact that surveillance makes a perfectly healthy though nervous heart miss beats. There is a dual waste of nervous energy then. We are employing our attention watching things done that need not be watched, and by that fact we are inhibiting natural processes and requiring that more energy shall be put into them for their accomplishment, and even then accomplishing them with discouraging imperfection.

Mental Short-Circuit .—The reflex mental process that particularly affects many individuals in our time and makes it hard for them to do their work, has been well described under the figure of a short-circuit in an electrical dynamo. The short-circuit diverts the current so that instead of acting outside the dynamo and performing useful work, it is discharged within the machine, brings about deterioration of its elements and soon leads to a reduction in the amount of electrical energy that that particular dynamo can develop.

Association Fibers Diversion.—Prof. Michael Foster in the Wilde Lecture for 1898, "The Physical Basis of Psychical Events,"43 has many valuable suggestions with regard to the mechanism of mental operations on the neuron theory. He has particularly dwelt on the function of the association fibers in connection with mental operations, or with the raising of sensation to the plane of mentality. A portion of the brain that is originating impulses, instead of sending them down to the periphery, through the projection fibers, to lead to the accomplishment of external work, may have its messages diverted through the association fibers to other portions of the brain and thus do harm rather than good.

Occurrence of Psychasthenia.—It must not be thought that these curiously interesting conditions occur only among people of low intellectual caliber, or in those of narrow intellectual interests, mere specialists who may have acquired a reputation for doing one thing well. They are frequent among the most intellectual classes. Brain workers of all kinds, unless they are careful to vary the interests of life, unless, as suggested in the chapters on Occupation of Mind and Diversion of Mind, they have a hobby besides their usual occupations, are likely to suffer in this way. As a matter of fact, many intellectual people have had what are called nervous breakdowns of this kind. A biographical dictionary shows any number of them. Dr. Gould's Biographic Clinics furnish many documents for the study of these conditions. A typical instance, told by the sufferer himself, the distinguished Sir Francis Galton, is of special significance for the psychotherapeutist. I quote because it illustrates the fact that such breakdowns do not portend a short or subsequently listless life, for Sir Francis, a most successful scientific investigator, lived well beyond fourscore years in the full possession of health of mind and body.

It was during my third year at Cambridge that I broke down entirely in health and had to lose a term and go home. I suffered from intermittent pulse and a variety of brain symptoms of an alarming kind. A mill seemed to be working inside my head; I could not banish obsessing ideas; at times I could hardly read a book, and found it painful to look at even a printed page. Fortunately I did not suffer from sleeplessness, and my digestion failed but little. Even a brief interval of mental rest did me good, and it seemed as if a long dose of it might wholly restore me. It would have been madness to continue the kind of studious life that I had been leading. I had been much too zealous, had worked too irregularly and in too many directions, and had done myself serious harm. It was as though I had tried to make a steam-engine perform more work than it was constructed for, by tampering with its safety-valve and thereby straining its mechanism. Happily the human body may sometimes repair itself, which the steam-engine cannot.

The physician with experience in such cases would be much more apt to say, "Happily we can learn to control our mental energy and not let it go to waste by foolish persistence at one set of ideas constantly, nor be dissipated in surveillance of functions that work automatically if left to themselves."

Etiological Factors.—This form of mental incapacity develops particularly in people after they have gone through a prolonged period of hard work and then have come to a time when they are much freer than they were before. They are prone to think that they exhausted their nerve force during the preceding period of labor and that now they are paying for it. Almost invariably what is really happening is that they now have much more time to occupy themselves with themselves and about themselves and to worry over their ills, real and imaginary. This is the typical nervous breakdown, as it used to be called, of elderly retired merchants or bankers. They have looked forward all their lives to a time when they could enjoy themselves doing nothing. They retire from business and then their troubles begin. It is no wonder that the old proverb, "A machine rusts out much sooner than it wears out" should have been so often quoted with regard to this condition. A man who has been working busily at something all his life cannot stop all at once and do nothing. He cannot learn to occupy himself with trivial things. Commonly, he has few, if any, interests apart from his business and he very soon wears the novelty off these and then introspection comes to make him exaggerate the significance of every feeling that he has, every stiffness that occurs, every muscle twinge due to change in the weather, until he becomes supremely miserable.

As a rule, these patients are simple, practical, common-sense, business men, and it is hard for the physician to think that there is nothing more than a functional neurosis present. It is even more difficult for the patient to be made to appreciate that his ills are mainly due to his own over-attention to himself in this idleness that he has looked forward to with so much pleasure. Ordinary medicines fail to relieve and the regular professional man seldom succeeds in doing these patients much good. They constitute the richest material for the quack and the charlatan. Much occupied with their ills they tell their friends all about them. Whenever a strong impression is produced on their mind by a promise to cure them with some new wonderful remedy they are favorably influenced, often get better and then are walking advertisements for the particular quack who has happened to benefit them. It is this class of people that has given more trouble to legislative committees of medical societies than any other. Some of them appeal to legislators whenever a bill for the admission of some new form of practitioners of medicine comes up with the story of how much benefit they derived from the treatment. Since they have been successful business men their word carries weight. It is curious how little the making of money, though often presumed to be so, is a test of real intelligence. It is often the man of one idea with no intellectual breadth who is the best money-getter.

These conditions develop almost entirely in predisposed individuals who, for some reason, are trying to overdo the energy they possess, and who, as a consequence, have lost a certain control over themselves. At times, of course, they occur in persons who have so little occupation of mind that thoughts of various kinds along these lines become insistently suggestive and cannot be thrown off because the patients' interests are not sufficiently deep or sufficiently varied to occupy their attention. The rational treatment of them, then, must be founded on a careful study of individual cases, the recognition of the special cause, and also the occasions at work in each case, a neutralization of unfavorable suggestion and a provision of such favorable suggestions and occupation of mind as will enable the patient to rid himself of the annoyance occasioned by these and the physical symptoms that so often develop as a consequence. In a certain number of cases a history of corresponding or equivalent affections in preceding generations will be found. In many patients, however, there is no such history, though there is usually the story of symptomatic mental conditions of one or other of the types mentioned, earlier in life. When in good health physically the patient has very little bother from them. When run down in weight or when worried or anxious about business or from the stress of important responsibilities these symptoms may become bothersome mentally and physically. Often it will be impossible to obliterate them entirely, but always they can be greatly improved and the patient can be made to realize that they are not seriously significant, that in mild form they are rather common and that, above all, they are not so peculiar to the individual as he is likely to think, with consequent increase of the unfavorable suggestion.