Psychotherapy by Hugo Münsterberg (world of reading .TXT) 📕

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 reënforce 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 reënforced by the attitude of prayer. Even the physiological conditions of it, the clasping of the hands, the kneeling, and monotonous sounds reënforce 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