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  PSYCHOTHERAPY

  BY

  HUGO MÜNSTERBERG

  M.D., PH.D., LITT.D., LL.D.
  PROFESSOR OF PSYCHOLOGY IN HARVARD UNIVERSITY


  NEW YORK
  MOFFAT, YARD AND COMPANY
  1909


  COPYRIGHT, 1909, BY
  MOFFAT, YARD AND COMPANY

  _All Rights Reserved_

  Published, April, 1909
  Second Printing, May, 1909


       *       *       *       *       *


  RECENT BOOKS BY THE SAME AUTHOR

  Psychology and Life, Boston, 1899

  Grundzüge der Psychologie, Leipzig, 1900

  American Traits, Boston, 1902

  Die Amerikaner, Berlin, 1904

  Principles of Art Education, New York, 1905

  The Eternal Life, Boston, 1905

  Science and Idealism, Boston, 1906

  Philosophie der Werte, Leipzig, 1907

  On the Witness Stand, New York, 1908

  Aus Deutsch-Amerika, Berlin, 1908

  The Eternal Values, Boston, 1909


       *       *       *       *       *


  TO

  MY FRIEND AND COLLEAGUE

  DR. FRANZ PFAFF

  PROFESSOR OF THERAPEUTICS IN
  HARVARD UNIVERSITY


       *       *       *       *       *


PREFACE


This volume on psychotherapy belongs to a series of books which I am
writing to discuss for a wider public the practical applications of
modern psychology. The first book, called "On the Witness Stand,"
studied the relations of scientific psychology to crime and the law
courts. This new book deals with the relations of psychology to
medicine. Others discussing its relations to education, to social
problems, to commerce and industry will follow soon.

For popular treatment I divide applied psychology into such various,
separated books because they naturally address very different audiences.
That which interests the lawyer does not concern the physician, and
again the school-teacher has his own sphere of interests. Moreover the
different subjects demand a different treatment. The problems of
psychology and law were almost entirely neglected. I was anxious to draw
wide attention to this promising field and therefore I chose the form of
loose popular essays without any aim towards systematic presentation of
the subject. As to psychology and medicine almost the opposite situation
prevails. There is perhaps too much talk afloat about psychotherapy, the
widest circles cultivate the discussion, the magazines overflow with
it. The duty of the scientific psychologist is accordingly not to stir
up interest in this topic but to help in bringing this interest from
mere gossip, vague mysticism, and medical amateurishness to a clear
understanding of principles. What is needed in this time of faith cures
of a hundred types is to deal with the whole circle of problems in a
serious, systematic way and to emphasize the aspect of scientific
psychological theory.

Hence the whole first part of this book is an abstract discussion and
its first chapters have not even any direct relation to disease. I am
convinced that both physicians and ministers and all who are in
practical contact with these important questions ought to be brought to
such painstaking and perhaps fatiguing inquiry into principles before
the facts are reached. To those who seek a discussion of life facts
alone, the whole first part will of course appear to be a tedious way
around; they may turn directly to the second and third parts.

One word for my personal right to deal with these questions, as too much
illegitimate psychotherapeutics is heard to-day. For me, the relation
between psychology and medicine is not a chance chapter of my science to
which I have turned simply in following up the various sides of applied
psychology. And still less have I turned to it because it has become the
fashion in recent years. On the contrary, it has been an important
factor in all my work since my student days. I have been through five
years of regular medical studies, three years in Leipzig and two years
in Heidelberg; I have an M.D. degree from the University of Heidelberg.
In my first year as docent in a German university twenty years ago, I
gave throughout the winter semester before several hundred students a
course in hypnotism and its medical application. It was probably the
first university course on hypnotism given anywhere. Since that time I
have never ceased to work psychotherapeutically in the psychological
laboratory. Yet that must not be misunderstood. I have no clinic, and
while by principle I have never hypnotized anyone for mere experiment's
sake but always only for medical purposes, yet I adjust my practical
work entirely to the interests of my scientific study. The limitations
of my time force me to refuse the psychotherapeutic treatment of any
case which has not a certain scientific interest for me, and of the many
hundreds whom I have helped in the laboratory, no one ever had to pay
anything. Thus my practical work has strictly the character of
laboratory research.

The chief aim of this book is twofold. It is a negative one: I want to
counteract the misunderstandings which overflood the whole field,
especially by the careless mixing of mental and moral influence. And a
positive one: I want to strengthen the public feeling that the time has
come when every physician should systematically study psychology, the
normal in the college years and the abnormal in the medical school. This
demand of medical education cannot be postponed any longer. The aim of
the book is not to fight the Emmanuel Church Movement, or even
Christian Science or any other psychotherapeutic tendency outside of the
field of scientific medicine. I see the element of truth in all of them,
but they ought to be symptoms of transition. Scientific medicine should
take hold of psychotherapeutics now or a most deplorable disorganization
will set in, the symptoms of which no one ought to overlook to-day.

                                                       HUGO MÜNSTERBERG.

  HARVARD UNIVERSITY, March 20, 1909.




  CONTENTS


  CHAPTER                                                             PAGE

     I. INTRODUCTION                                                     1


  PART I

  THE PSYCHOLOGICAL BASIS OF PSYCHOTHERAPY

    II. THE AIM OF PSYCHOLOGY                                            9

   III. MIND AND BRAIN                                                  27

    IV. PSYCHOLOGY AND MEDICINE                                         55

     V. SUGGESTION AND HYPNOTISM                                        85

    VI. THE PSYCHOLOGY OF THE SUBCONSCIOUS                             125


  PART II

  THE PRACTICAL WORK OF PSYCHOTHERAPY

   VII. THE FIELD OF PSYCHOTHERAPY                                     158

  VIII. THE GENERAL METHODS OF PSYCHOTHERAPY                           184

    IX. THE SPECIAL METHODS OF PSYCHOTHERAPY                           212

     X. THE MENTAL SYMPTOMS                                            239

    XI. THE BODILY SYMPTOMS                                            297


  PART III

  THE PLACE OF PSYCHOTHERAPY

   XII. PSYCHOTHERAPY AND THE CHURCH                                    319

  XIII. PSYCHOTHERAPY AND THE PHYSICIAN                                347

   XIV. PSYCHOTHERAPY AND THE COMMUNITY                                 370




I

INTRODUCTION


Psychotherapy is the practice of treating the sick by influencing the
mental life. It stands at the side of physicotherapy, which attempts to
cure the sick by influencing the body, perhaps with drugs and medicines,
or with electricity or baths or diet.

Psychotherapy is sharply to be separated from psychiatry, the treatment
of mental diseases. Of course to a certain degree, mental illness too,
is open to mental treatment; but certainly many diseases of the mind lie
entirely beyond the reach of psychotherapy, and on the other hand
psychotherapy may be applied also to diseases which are not mental at
all. That which binds all psychotherapeutic efforts together into unity
is the method of treatment. The psychotherapist must always somehow set
levers of the mind in motion and work through them towards the removal
of the sufferer's ailment; but the disturbances to be treated may show
the greatest possible variety and may belong to mind or body.

Treatment of diseases by influence on the mind is as old as human
history, but it has attained at various times very different degrees of
importance. There is no lack of evidence that we have entered into a
period in which an especial emphasis will be laid on the too long
neglected psychical factor. This new movement is probably only in its
beginning and the loudness with which it presents itself to-day is one
of the many indications of its immaturity. Whether it will be a blessing
or a danger, whether it will really lead forward in a lasting way, or
whether it will soon demand a reaction, will probably depend in the
first place on the soberness and thoroughness of the discussion. If the
movement is carried on under the control of science, it may yield
lasting results. If it keeps the features of dilettanteism and prefers
association with the antiscientific tendencies, it is pre-destined to
have a spasmodic character and ultimately to be harmful.

The chaotic character of psychotherapy in this first decade of the
twentieth century can be easily understood. It results from the fact
that in our period one great wave of civilization is sinking and a new
wave rising, while the one has not entirely disappeared and the other is
still far from its height. The history of civilization has shown at all
times a wavelike alternation between realism and idealism, that is,
between an interest in that which is, and an interest in that which
ought to be. In the realistic periods, the study of facts, especially of
the facts of nature, is prevalent; in idealistic periods, history and
literature appeal to the world. In realistic periods, technique enjoys
its triumphs; in idealistic periods, art and religion prevail. Such a
realistic movement lies behind us. It began with the incomparable
development of physics, chemistry, and biology, in the middle of the
last century, and it brought with it the achievements of modern
engineering and medicine. We are still fully under the influence of this
gigantic movement and its real achievements will never leave us; and yet
this realistic wave is ebbing to-day and a new period of idealism is
rising. If the signs are not deceitful, this new movement may reach its
historical climax a few decades hence, when new leaders may give to the
idealistic view of the world the same classical expression which Darwin
and others gave to the receding naturalistic age. The signs are clear
indeed that the days of idealistic philosophy and of art, and of
religion, are approaching; that the world is tired of merely connecting
facts without asking what their ultimate meaning is. The world dimly
feels again that technical civilization alone cannot make life more
worth living. The aim of the last generation was to explain the world;
the aim of the next generation will be to interpret the world; the one
was seeking laws, the other will seek ideals.

Psychotherapy stands in the service of both; it is the last word of the
passing naturalistic movement, and yet in another way it tries to be the
first word of the coming idealistic movement; and because it is under
the influence of both, it speaks sometimes the language of the one, and
sometimes the language of the other. That brings about a confusion and a
disorder which must be detrimental. To transform this vagueness into
clear, distinct relations is the immediate duty of science.

Indeed it may be said that psychotherapy is the last word of a
naturalistic age, because psychotherapy finds its real stronghold in a
systematic study of the mental laws, and such study of mental laws,
psychology, must indeed be the ultimate outcome of a naturalistic view
of the world. Realism begins with the analysis of lifeless nature,
begins with the study of the stars and the stones, of masses and of
atoms. At a higher level, it turns then to the living organism, studies
plants and animals and even brings the human organism entirely under the
point of view of natural law. When science has thus mastered the whole
physical universe, it finally brings even the mental life of man under
the naturalistic point of view, treats his inner experiences like any
outer objects, tears them in pieces, analyzes them, and studies them as
functions of the nervous system. A scientific psychology is thus reached
which is the climax of realism, because it means that even the ideas and
emotions and volitions of man are treated as natural phenomena, that
their causes are sought and that their effects are determined, that
their laws are found out. To apply this realistic knowledge of the mind
in the interest of therapy is merely to use it in the same way in which
the engineer uses his knowledge of physics, when he wants to harness
outer nature. As that is possible only when theoretical science has
reached a certain height of development, it can indeed be said that
practical psychotherapy on a scientific basis can be considered almost
as the ultimate point of a realistic movement; it cannot set in until
psychology has reached high development, and psychology cannot set in
unless biology has preceded it.

There is no doubt that we are still far from this last phase of the
realistic period. The practical application of scientific psychology is
still a new problem. Experimental psychology began about twenty-five
years ago; at that time there existed one psychological laboratory.
To-day there is no university in the world which does not have a
psychological workshop. But laboratories for applied psychology are only
arising in these present days, and the systematic application of
scientific psychology to education and law and industry and social life
and medicine is almost at its beginning. While the height of the last
realistic wave was in the period of the sixties, seventies, and
eighties, of the last century, its last phase, the practical application
of physiological psychology, including psychotherapy, is only at its
commencement.

But while this last great movement has not yet reached its end, the new
idealistic movement to come has not yet reached a clear self-expression.
A general philosophical interest can be felt, but a great philosophical
synthesis seems still lacking. A new sense of duty can vaguely be felt,
but great new tasks have not yet found common acknowledgment. Above all,
the unshaped emotionalism of the masses has not yet been brought into
any real contact with the new idealism which grows up on the higher
level of scholarly thought. But it is evident, if a new great mood of
idealism is to come, one of its popular forerunners must be the demand
that the spirit is real in a higher sense than matter, that the mind
controls the body, that faith can cure. In such unphilosophic crudeness,
no definite thought is expressed, as everything would depend on the
definition of spirit, of faith, of mind, of reality. Moreover, every
inquiry would prove that the idealistic value of such statements as are
afloat among the masses to-day is reached only by a juggling with words.
That faith can cure appears to point towards the higher world, as the
word faith has there the connotation of the faith in a religious sense;
and yet the faith which really cures a digestive trouble, for instance,
is the faith in the final overcoming of the intestinal disturbance, an
idea which belongs evidently in the region of physiological psychology,
but not in the region of the church. Yet, however clumsy such statements
may be, they are surely controlled by the instinctive desire for a new
idealistic order of our life, and the time will come when their
unreasoning and unreasonable wisdom will be transformed into sound
philosophy without losing its deepest impulse. The realistic conviction
that even the mind is completely controlled by natural laws and the
idealistic inspiration that the mind of man has in its freedom mastery
over the body, are thus most curiously mixed in the popular
psychotherapy of the day, and too few recognize that the real meaning of
mind is an entirely different one in these two propositions.

Of course the one or the other of these two elements prevails in the
systematic treatises on the subject; the realistic one in those written
by the psychiatrists, the idealistic one in those written by clergymen
or Christian Scientists. The literature indeed is almost entirely
supplied from these two quarters: and yet it is evident that neither the
one nor the other party can give to the problem its most natural
setting. The student of mental diseases naturally emphasizes the
abnormal features of the situation, and thus brings the
psychotherapeutic process too much into the neighborhood of pathology.
Psychotherapy became in such hands essentially a study of hypnotism,
with especial interest in its relation to hysteria and similar diseases.
The much more essential relation of psychotherapy to the normal mental
life, the relation of suggestion and hypnotism to the normal functions
seemed too often neglected. Whoever wants to influence the mind in the
interest of the patient, must in the first place be in intimate contact
with psychology. On the other hand, the minister's spiritual interest
brings the facts nearer to religion than they really are. That a
suggestion to get rid of toothache, or to sleep the next night, is given
by a minister, does not constitute it as a religious suggestion. If the
belief in religion simply lies alongside of the belief in most trivial
effects, and both are applied in the same way for curing the sick, it is
evident that not the spiritual meaning of religion is responsible for
the cure, but the psychological process of believing. But if that is the
case, it is clear that here again the psychologist, and not the
moralist, will give the correct account of the real process involved.
In short, it is psychology, psychology in its scientific modern form,
which has to furnish the basis for a full understanding of
psychotherapy. From psychology it cannot be difficult to bridge over to
the medical interests, on the one side, to the idealistic ones on the
other side.

Our task here is, therefore, to lay a broad psychological foundation. We
must carefully inquire how the modern psychologist looks on mental life
and how the inner experiences appear from such a psychological
standpoint. The first chapters of this volume may appear like a long,
tiresome way around before we come to our goal, the study of the
psychotherapeutic agencies. And yet it is the only possible way to
overcome the superficiality with which the discussion is too often
carried on; we must understand exactly how the psychological analysis
and explanation of the scientist differ from the popular point of view.
After studying in this spirit the foundation of psychotherapy, we shall
carefully examine the practical work, its methods and its results, its
possibilities and its limitations. We shall inquire finally into the
place which it has to take, looking back upon its history, criticising
the present status and outlining the development which has to set in for
the future, if a haphazard zigzag movement is not to destroy this great
agency for human welfare by transforming it into a source of
superstition and bodily danger.




PART I

THE PSYCHOLOGICAL BASIS OF PSYCHOTHERAPY




II

THE AIM OF PSYCHOLOGY


The only safe basis of psychotherapy is a thorough psychological
knowledge of the human personality. Yet such a claim has no value until
it is entirely clear what is meant by psychological knowledge. We can
know man in many ways. Not every study of man's inner life is psychology
and the careless mixing of different ways of dealing with man's inner
life is largely responsible for the vagueness which characterizes the
popular literature of psychotherapy. It is not enough to say that a
statement is true or not true. It may be true under one aspect and
entirely meaningless under another. For instance, a minister's
discussion of man's energies may be full of deep truth and may be
inspiring; and yet it may not contain the slightest contribution to a
really psychological knowledge of those energies, and would mislead
entirely the physician were he to base his treatment of human energies
on such a religious interpretation.

Can we not look from different standpoints even on any part of the
outer world? I see before me the ocean with its excited waves splashing
against the rocks and shore, I see the boats tossed on the stormy sea
and I am fascinated by the new and ever new impulses of the tumultuous
waves. The whole appears to me like one gigantic energy, like one great
emotional expression, and I feel deeply how I understand this beautiful
scenery in appreciating its unity and its meaning. Yet would I ever
think that it is the only way to understand this turmoil of the waters
before me? I know there is no unity and no emotion in the excited sea;
each wave is composed of hundreds of thousands of single drops of water,
and each drop composed of billions of atoms, and every movement results
from mechanical laws under the influence of the pressing water and air.
There is hydrogen and there is oxygen, and there is chloride of sodium,
and the dark blue color is nothing but the reflection of billions of
ether vibrations. But have I really to choose between two statements
concerning the waves, one of which is valuable and the other not? On the
contrary, both have fundamental value. If I take the attitude of
appreciation, it would be absurd to say that this wave is composed of
chemical elements which I do not see; and if I take the attitude of
physical explanation, it would be equally absurd to deny that such
elements are all of which the wave is made. From the one standpoint, the
ocean is really excited; from the other standpoint, the molecules are
moving according to the laws of hydrodynamics. If I want to understand
the meaning of this scene every reminiscence of physics will lead me
astray; if I want to calculate the movement of my boat, physics alone
can help me.

As long as we deal with outer nature, there is hardly a fear of
confusing the various attitudes; but it becomes by far more complex when
we deal with man and his inner life. We might abstract entirely from
æsthetic appreciation or from moral valuation, we might take man just as
an object of knowledge; and yet what we know about him may be entirely
different in accordance with our special attitude. Each kind of
knowledge may be entirely true, and yet true only from the particular
standpoint. Let us consider two extremes. If I meet a friend and we
enter into a talk, I try to understand his thoughts and to share his
views. I agree or disagree with him; I sympathize with his feelings, I
estimate his purposes. In short, he is for me a center of aims and
intentions which I interpret: he comes in question for me as a self
which has its meaning and has its unity. The more I am interested in his
opinions, the more I feel in every utterance, in every gesture, the
expression of his will and his purposes; their whole reality for me lies
in the fact that they point to something which the speaker intends; his
personality lies in his attitude towards the surroundings, towards the
world. Yet I may take an entirely different relation to the same man. I
may ask myself what processes are going on in his mind, what are the
real contents of his consciousness, that is, what perceptions and memory
pictures and imaginative ideas and feelings and emotions and judgments
and volitions are really present in his consciousness. I watch him to
find out, I observe his mental states, I do not ask whether I agree or
disagree; his will is for me now not something which has a meaning, but
simply something which occurs in his inner experience; his ideas now
have for me no reference to something in the world, but they are simply
contents of his consciousness; his memories now are for me not symbols
of a past to which he refers, but they are present pictures in his mind;
in short, what I now find is not a self which shows itself in its aims
and purposes and attitudes, but a complex content of consciousness which
is composed of numberless elements. I might say in the first place that
my friend was to me a subject whom I tried to understand by interpreting
his meaning, and in the second case, an object which I understand by
describing its structure, its elements, and their connections.

Both ways of looking on man are constantly needed. We might alternate
between them in any experience. In the heat of argument, my friend will
certainly be for me the subject with whose meanings I try to agree or
disagree, whose emotions carry me away, whose ideas open the world to
me. Yet in the next moment, I may notice that his ideas were shaped and
determined by certain earlier experiences; that they linked themselves
in memory according to certain laws of mental flow; that the vividness
of his ideas made him overlook certain impressions of the surroundings;
and that may turn my attention to an entirely different aspect of his
inner life. His feelings and emotions, his volitions and judgments now
have for me simply the character of processes which go on and which are
observed, which coincide and which succeed each other, which fuse and
overlap, and which are composed of smaller parts. My interest is now no
longer in the meaning and intentions of this self, but it belongs to the
structure and the connections in this system of mental facts. At first,
I wanted to understand him by living with him, by participating in his
attitudes, and by feeling with his will; now I want to understand him by
examining all the processes which go on in his consciousness, by
studying their make-up and their behavior, their elements and their
laws. In one case I wanted to interpret the man, and finally to
appreciate him; in the other case I wanted to describe his inner life,
and finally to explain it. The man whose inner life I want to share I
treat as a subject, the man whose inner life I want to describe and
explain I treat as an object.

I might express these two standpoints still otherwise. If my neighbor is
to me a subject, for instance, in the midst of an ordinary conversation,
he comes in question only with reference to his aims and meanings:
whatever he utters has a purpose and end. I understand his inner life by
taking a purposive point of view. On the other hand, the man whose inner
life is to me an object can satisfy my interest only if I understand
every particular happening in his mind from its preceding causes. I
transform his whole life into a chain of causes and effects. My
standpoint is thus a causal one. No doubt in our daily life, our
purposive interest and our causal interest may intertwine at any moment.
I may sympathize with the hopes and fears of my neighbor in a purposive
way, and may yet in the next moment consider from a causal standpoint
how these emotions of his are perhaps affected by his fatigue or by some
glasses of wine, or by a hereditary disposition, or by a suggestion; in
short, at one time I look out for the meaning of the emotion as a part
of the expression of a self, and at another time for the structure and
appearance of the emotion as a part of a causal chain of events. In both
directions I can go on with entire consistency, and there cannot be any
part of inner experience which cannot be fully brought under either
point of view. How far we have a right to mix the two standpoints in
practical life, we shall carefully examine; but it is clear that if we
want to understand the true meaning of the study of inner life, we have
no longer any right carelessly to mix the two standpoints without being
conscious of their fundamental difference. We must understand exactly
what the aim of the one and of the other is, and where each has its
particular value; science certainly has no right to throw together such
different views of life. And now this may be said at once: the causal
view only is the view of psychology; the purposive view lies outside of
psychology.

Such a separation does not at all aim to indicate that the one view is
more important than the other, or that the one has more scientific
dignity than the other; both yield us truth, and both may be carried
from the simplest and most trivial observations of daily life to the
highest elaborations of scholarship. To those who are inclined to give
all value and all credit only to the strictly psychological view, it may
be replied at once that surely our most immediate life experience is
carried on by the non-psychological attitude. If we love our family and
like our friends, and deal with the man of the street, we are certainly
moving in a world of purposive reality. We try to understand each other,
to agree and to disagree, to be in sympathy and antipathy, without
asking how those volitions and feelings and ideas of other people are
built as mental structures, and from what causes they arose; we are
satisfied to understand what they mean. In the same way with ourselves.
We live our lives by hinging them on our aims and purposes and ideas,
and do not ask ourselves what are the causes of our attitudes and of our
thoughts.

This purposive view has in no respect to disappear if we move on from
our personal intercourse to a scholarly study of reality. The historian,
for instance, who tries to understand the will relations of humanity, is
the more the true historian the more he sticks to this purposive view of
man. The truth which he seeks is to interpret the personalities, to
understand them through their attitudes, to make their will living once
more, and to link it by agreement and disagreement, by love and hate,
with the will of friends and enemies, groups and parties, nations and
mankind. It is only a loose popular way of speaking, if this purposive
analysis of a character is often called psychological. In a stricter
sense of the word, it is not psychological. If the historian really were
to take the psychological attitude, he would make of history simply a
social psychology, seeking the laws of the social mind, and treating the
individual, the hero, and the leader, merely as the crossing-point of
psychological law. For such a psychological view the mental life of the
hero would not be more important or more interesting than the mental
life of a scoundrel, and the psychology of the king would not draw his
interest more than the psychology of the beggar. The historian has to
shape all that from an entirely different standpoint: his scientific
interest depends upon the importance of men's attitudes and actions, and
such importance refers to the world of purposes.

In the same way, we have to stick to the non-psychological point of view
whenever man's life, his thoughts and feelings and volitions, are to be
measured with reference to ideals; that is in ethics and æsthetics and
logic, sciences which ask whether the volitions are good or bad, whether
the feelings are valuable or worthless, whether the thoughts are true or
false. The psychologist does not care; just as the botanist is
interested in the weed as much as in the flower, the psychologist is
interested in the causal connections of the most heinous crime not less
than in those of the noblest deed, in the structure of the most absurd
error not less than in that of the maturest wisdom. Truth, beauty, and
morality are thus expressions of the self in its purposive aspect.

We can go one step further. Those who narrowly seek every truth only in
the scientific understanding, ought to be reminded that this seeking for
causal connections is itself, after all, only a life experience which as
such is not of causal but of purposive character. "Life is bigger than
thought." In the immediate reality of our purposive life we aim towards
mastering the world by a causal understanding, and for this end we
create science; but this aim itself is then a purpose and not an object.
The first act is thus for us, the thinkers, not a part of the causal
events, but a purposive intention towards an ideal. Therefore, our
purposes have the first right; they represent the fundamental reality;
the value of causal connections and thus of all scientific and
psychological explanation, depends on the value of the purpose. Causal
truth can be only the second word; the first word remains to purposive
truth. From this point of view we may understand why there is no
conflict between the most consistent causal explanation of mental life
on the one side, and an idealistic view of life on the other side; yes,
we can see that the fullest emphasis on a scientific psychology--which
is necessarily realistic and, to a certain degree, materialistic--is
fully embedded in an idealistic philosophy of life, and that without
conflict. And we shall see how this consistency in sharply separating
the psychological view from the non-psychological, secures much greater
safety for true idealism than the inconsistent popular mixing of the
two principles, where scientific psychology is constantly encroached
upon by demands of faith and religion, and where faith and religion seem
constantly in danger of being overturned by new discoveries in
physiological psychology. We may, indeed, remove from the start the
mistaken fear that a consistent causal aspect of life leads to injustice
to the higher aims and ideal purposes of mankind. If we want to have
psychology,--and that means if we want to consider the mental life in a
system of causes and effects,--we must proceed without prejudices, and
without side-thoughts.

From a psychological standpoint our own mental life and that of our
neighbor, that of the man and that of the child, that of the normal and
that of the insane, that of the human being and that of the animal, are
to be considered as a series of mental objects. They are to be analyzed,
and to be described, and to be classified and to be explained, just as
we deal with the physical objects in the outer world. How are these
objects of the psychologist different from the objects of the physicist,
from the pebbles on the way and the stars in the sky? There is only one
fundamental difference and all other differences result from it. Those
outer objects which we call physical, are objects for everybody. The
star which I see is conceived as the same star which you see, the table
which I touch is the table which you may grasp, too. But every psychical
object is an object for one particular person only. My visual impression
of the star, that is, my optical perception, is a content of my own
consciousness only, and your impression of the star can be a content of
your consciousness only. We both may mean the same by our ideas, but I
can never have your perception and you can never have my perception. My
ideas are enclosed in my mind. I may awaken in your mind ideas which
have the same purpose and meaning, but they are new copies in your mind.
We both may be angry, but your anger can never be my anger, and your
volitions can never enter my mind. Every possible psychical fact thus
exists in one consciousness only, while every physical fact exists for
every possible consciousness.

The psychologist's final task is to explain the appearance and
disappearance, the connections and sequences of these mental objects,
the contents of consciousness. But before he can start on explanation of
the facts, he has to describe them, and describing means analyzing them
into their elements and fixating those elements and their combinations
for an exact report. Such descriptive work is in a way preparatory for
the further task of real explanation; yet it is in itself important,
complicated, and difficult. Of course, it may be easy to separate the
complex content into some big groups of facts, to point out that this is
a memory idea and this an imaginative idea and the other an abstract
idea, and this a perception and that a feeling, this an emotion and that
a volition. But such clumsy first discrimination does not go further,
perhaps, than does the naturalist's, who tells us that this is a
mountain and that a tree, this a pond and that a bird. The real
description would demand, of course, an exact measurement of the height
of the mountain and the geological analysis of its structure, or an
exact classification of the tree and the bird, with a complete
description of their organs, and in each organ the various tissues have
to be described, and in each tissue the various cells, and the
microscopist goes further and describes the structure of the cell.
Certainly in the same way the psychologist has to go on to resolve every
one of those complex structures; he has to examine the mental tissues
and the mental cells of which a volition or a memory idea or a
perception are composed. And while he cannot use a microscope for these
mental elements, yet his studies may cause elements to appear which the
naïve observation remains entirely unaware of.

Perhaps he finds in his consciousness the perception of the table before
him which lingers for a little while in his mind. He finds no difficulty
in analyzing it into color sensations and tactual sensations; and yet he
is aware of so much more in it. The table, for instance, has form for
him and he may find that these form perceptions involve the sensations
of the eye movements which he makes from one corner of the table to the
other; he may find that if the idea lasts in him, he becomes aware of
the time by sensations of tension; he finds that in his perception of
the table lies an idea of its use, and he discovers that that is made up
of elements which are partly memory reproductions of earlier
impressions, partly sensations of movement impulses; he also finds that
the table feels smooth, and he discovers by his analysis that this
impression of smoothness results from a special combination of tactual
sensations and movement sensations; and again those movement sensations
he analyzes further into sensations of muscle contraction and sensations
of pressure in the joints and sensations of tension in the tendons.
Before a zoölogist has completed his description of a bird in the
landscape, he has given account of hundreds of thousands of things; but
before the psychologist would complete the enumeration of the mental
elements which enter into the seeing of the table, he would have to give
account of by far more psychical elements. Every point in the surface of
the table has its own light value, perhaps different in its quality and
intensity and saturation, in its hue and tint and shade from the next
one, and at whatever point of the table's edge our attention is
directed, each one involves numberless shades in the vividness of all
the other points and numberless mental relations of space perception
among the various parts of the table. In the thorough analysis of the
describing psychologist, every single idea, and in the same way, every
single emotion or feeling or judgment becomes complex like a living
organism, an aggregate of thousands of mental tissues, and yet made up
from "the stuff that dreams are made of."

But there is one particular difficulty which makes the psychological
description so much harder than that of the physicist, and which gives
rise to many disagreements and discussions in psychological literature.
The psychologist has not only to tear the complex into pieces and thus
to seek the elements, but he has to fixate those elements for the
purpose of communication, as, of course, a scientific description
demands that he be able to give account to others of what he
experiences. The physicist has no difficulty whatever in that line
because, as we saw, the world of physical things is the world which all
men are sharing together. Every element which I find in it, I can show
to every other person, and if I cannot show that particular thing,
because I cannot yet carry the mountain to another place, then I can at
least measure it, as we share those standards of space. Thus natural
science has in its objective measurements the possibility of describing
every part of the physical world. The psychical world, on the other
hand, is as we saw, the world which is private property. Every effort at
description is thus entirely in vain as long as our mental facts cannot
somehow be linked with physical happenings. If I say that I have in my
mind sweetness or sourness, or bitterness or saltness, I cannot carry
any understanding to anyone else and therefore cannot give any
description until I have agreed that I mean by sweetness the sensation
which sugar gives me, and by saltness the sensation of salt. The sugar
and salt I can point out to my neighbor and only in that way I
understand what he means if he says that he tastes salt and sweet;
otherwise I should have no means whatever to discriminate whether that
which he calls a sweet taste sensation is not just what I call headache.
Where no such direct relation for a physical thing is known, description
of the mental element would remain impossible. Of course, every
perception of the outer world, all our seeing and hearing, and touching
and tasting, offers us at once such definite connection between the
inner experience and a piece of the physical universe. Our own organism
is also such a piece of physical nature: just as I describe my tasting
or touching, I may describe the perception of my arms and legs or my
inner organs. Thus everything which is material of perception gives us a
handle for a real psychological description. Psychology usually calls
the elements of these perceptions sensations. Whatever is composed of
sensations is thus describable.

On the other hand, no other way of description is open. If there were
mental states which are composed of other elements than sensations, they
would necessarily remain indescribable; we could not grasp them because
they would not have any definite relation to the common physical world.
We might say, for instance, that our mental content is made up of
sensations and feelings, but if such feelings were really entirely
different from sensations, they would have to remain for all time
mysterious and unknown. We could not compare notes. The feeling which I
call joy may feel just like the one which you call despair. The
consistent development of modern psychology and its emancipation from
vagueness and superficial analysis became possible only through the fact
that such recourse to indescribable elements has become unnecessary.
Modern psychology has been able to demonstrate more and more that the
same elements which constitute our perceptions are also the elements of
the other contents of consciousness. In other words modern psychology
has recognized that the volitions and emotions and feelings and
judgments, and the whole stream of inner life, are made up of
sensations. Millions of sensations in all degrees of vividness and
clearness, of intensity and fusion, in endless manifoldness of rhythms
and relations constitute their whole content. It is a discovery quite
similar to the one which chemistry made when it found that the same
elements which are part of the inorganic substances are also the only
possible elements of the organic world.

From a strictly psychological standpoint, the ideas and the not-ideas
contain thus nothing but sensations. Their grouping, their shading,
their combination, their succession decide whether we have before us a
perception or an imagination, a volition or an emotion. What are we
ourselves then for the psychologist? Evidently we ourselves belong also
to the inner experiences which we know; and psychology has succeeded in
analyzing this idea of our own self just in the same way as it analyzes
our idea of the moon. In this analysis, psychology finds its idea of the
self as a content of consciousness crystallized about the sensations
from the body. Every one of our bodily activities is represented in our
consciousness by movement sensations, and these sensations form the core
of the complex aggregate which develops into the idea of ourselves.
Organic sensations from our inner organs, pain sensations and pleasure
sensations fuse with the movement sensations, and the whole complex
shapes itself slowly into the idea of the personality of the self in
contrast to the idea of other personalities. We ourselves are for
ourselves a complex combination of sensations; and yet all our feelings
and emotions and volitions are only a part of it. Psychology thus
necessarily considers those experiences of feeling and will and
character simply as changes in the midst of that central experience of
personality which is itself made up of bodily sensations. Each bit of
will and emotion must be decomposed into its finest elements. There is
no passing mood, and no floating half-thought in our mind, no dream and
no intuition, no slightest change of attention, no instinct and desire
which cannot be analyzed thus into its sensation elements or rather
which must not be analyzed, if we are to describe it at all, and that
means if we are to give a psychological account. Psychology is endlessly
far from this ideal to-day. It has been claimed, not without justice,
that psychology has reached to-day only the level which physics attained
in the seventeenth century; but psychology must insist that its ideal
lies in this direction. No one takes a real psychological view of the
human mind who does not understand this endless complexity of the
material, and who does not see that even the simplest mental state
practically presents a most complex problem to scientific analysis. The
physician who really aims towards scientifically exact influence on the
human mind has reached the first step of his preparation as soon as he
understands that the content of consciousness is composed of hundreds
of thousands of elements. To treat the mind as if there were only a few
large pieces, one thing called memory and one thing called will and one
called emotion and so on, is as if a surgeon were to perform an
operation, knowing that there are arms and legs, but not knowing the
ramifications of the nerves and blood-vessels which his knife may
injure. Yet the description of these complex facts is only the beginning
of psychology. We saw that the real aim is their explanation.




III

MIND AND BRAIN


The central aim of the psychologist must be to explain the mental facts.
It is not sufficient to describe the procession of mental experiences in
us, we must understand the causes which determine that now this and now
that appears and disappears, and appears just in this combination of
elements. The astronomer is not satisfied with describing the stars, he
wants to explain their movements and to determine which movements are to
be expected. The psychologist, like the naturalist, aims towards
explanation, and it is this demand which forces him to look from the
psychical facts to the physical ones, from the mind to the brain. He is
under an illusion if he fancies that he can explain mental facts by
themselves. The purposive mind has its connection in itself, the causal
psychological mind demands for its connection the body. To understand
this necessity is the first step towards understanding the relation of
mind and brain.

The psychologist's problem of explanation is in one way entirely
different from that of the physicist. The physicist finds a world of an
unlimited number of atoms which are ultimately conceived as all alike,
but each one in a different place, and all the changes in the universe,
the movements of the stars, the waves of the ocean, are to be explained
by the causal connections of the movements of these atoms. The
psychologist, on the other hand, finds an endless manifoldness of
elements which are not in space, and which have no space form whatever.
My will is neither triangular nor oval; my emotion is neither shorter
than five feet nor longer; my memory image of a melody has no thickness
and no tallness; my contents of consciousness are as such not in space;
their elements cannot pass through any space movements like the atoms of
the physicist. Instead of it, the psychical atoms, the sensations, have
different qualities, are blue and green, and cold and warm, and sweet
and sour, and toothache and headache. The changes which go on in such a
system are thus not changes of position and movements, but changes in
kind and strength and vividness and fusion; and exactly such changes are
the processes which the psychologist wants to explain. He wants to make
us understand why this idea grows up and the other fades away, why this
impression stands out with clearness as an attended object while the
other lacks vividness and disappears, why this volition grows out of
that emotion, why this feeling leads to this imaginative thought.

The first step towards such explanation is, of course, in psychology, as
in all other sciences, the careful observation of regularities. It
quickly leads us to formulate some general laws. Psychology has known,
for instance, for two thousand years, that if we have perceived two
things together, and later we see the one again, the new perception
brings us a memory image of the other thing. If we saw a man's face and
heard at the same time his name, seeing his face may later awaken in us
the memory of his name, or the hearing of his name may later awaken in
us a reproduced memory image of his face. On such a basis, for instance,
we formulate some general laws of association of ideas, and as soon as
we have such laws laid down, we consider the appearance of such a memory
image by association as sufficiently explained. We feel that it gives us
sufficient basis to predict that in the future this idea will stir up in
us the other idea. Psychology has formulated plenty of such general
statements, and they serve well for a first orientation.

Yet can this ever be considered as a last word of scientific explanation
of psychical facts? Can psychology really in this way reach an ideal
similar to that of scientific astronomy or chemistry? Would the
scientist of nature ever be satisfied with this kind of explanation,
which is nothing but generalization of certain sequences? Does not the
explanation of the naturalist contain an entirely different element? He
does not merely want to say that this effect has sometimes been observed
and that there is thus probability that it will come again, when similar
causes are given. No, the physicist wants to understand those
connections of cause and effect as necessary ones. He tries to find
sequences which cannot be otherwise because they cannot be thought in
any other way. Therefore he is not satisfied with complex regularities,
but analyzes them until he can bring them down to simple physical
connections, and these physical connections finally to mechanical
processes, which realize for us logical necessities. That matter lasts
and cannot disappear is such a presupposition, which comes to us with
the necessity of logical thinking. We simply cannot think it otherwise.
And the whole idea of natural science is to conceive the physical
universe in such a way that all changes in the outer world can be
understood as the movements of its parts in accordance with such
necessary physical axioms. If we knew all the atoms of the present
status of the universe, and we knew every present movement of every
atom, we should be able to foresee the position of every atom in the
next moment and in the following moment and in all following moments,
and all that by the necessary continuation of the substance and its
energies. That alone is the background of all special physical inquiry,
and we rely on the special laws of physics and chemistry, because we
trust that this universe, as a whole, could be ultimately understood as
such a system of necessary changes in the positions of the lasting
atoms.

For the psychologist there is no hope of finding such necessity in the
mental processes. The point is not that psychology is to-day too far
removed from the fulfillment of such an ideal, the point is rather that
such an ideal would be meaningless for the psychologist. His materials,
the psychical contents of consciousness, are by their nature unfit to
enter into such necessary connections; they cannot do it because they
cannot last. The physical object, we saw, is the object which is common
property, which we all feel in common, which must thus exist for all
time. The things in nature may burn down or decay, but no atom of them
can ever disappear from the universe, each must enter into new and ever
new combinations and last through all changes. The psychical thing, on
the other hand, can exist only for the one immediate experience. Every
sensation which enters into my ideas or volitions or emotions is a new
creation of the instant which cannot last; each one flashes up and is
lost with the moment's experience. My will to-day may have the same aim
as my will of yesterday, but as psychical object, my will to-day is a
new will, is a new creation in every pulse beat of my life. I must will
it again, I cannot store it up. And my joy of to-day can never be as
psychical fact the same joy which I may have to-morrow. Mental objects
as such, as psychological material, are not destined to last. It has no
meaning whatever to think of their being kept over until another time.
It is a coarse materialism to conceive the mental contents like pebbles
which may remain on the road from one day to another. Our ideas and
feelings are mental appearances which have their existence in the act of
the one experience; each new experience must be an entirely new
creation.

If I remember my last year's perception, I do not dig it out from an
under-mind, in which it was stored up and buried, but I create an
entirely new memory picture, just as I may make to-day a speech which
says the same thing which I said last year, and yet my action of
speaking is not last year's speech movement. It is a new action, and the
movement did not lie over somewhere during the interval. Mental life is
produced anew in every moment. When the first experience is gone and the
second comes, nothing of the stuff from which the first was made still
has existence in the content of consciousness. By this fact it becomes
entirely impossible ever to conceive necessary connections in the sense
of physical necessity in the world of consciousness. The one idea may
bring to me another idea by association, but as long as I consider both
strictly as mental facts, I can never understand why this association
happens, I can never grasp the real mechanism of the connection, I can
never see necessity between the disappearance of the one and the
appearance of the other. It remains a mystery which does not justify any
expectation that the same sequence will result again. Whatever belongs
to the psychical world can never be linked by a real insight into
necessity. Causality there remains an empty name without promise of a
real explanation.

Only when we have recognized this fundamental difficulty in the efforts
for psychological explanation, can we understand the way which modern
psychology has taken most successfully. The end of this way is simply
this: every psychical fact is to be thought of as an accompaniment of a
physical process and the necessary connections of these physical
processes determine, then, the connections of the mental facts. Indeed
this has become the method of modern psychology. It has brought about
the intimate relation between psychology and the physiology of the
brain, and has given us, as foundation, the theory of psychophysical
parallelism; the theory that there is no psychical process without a
parallel brain process. But the real center of the theory lies indeed in
the fact which we discussed; it lies in the fact that we cannot have any
explanation of mental states as such at all, if we do not link them with
physical processes.

Is it necessary to express again the assurance that such statements of a
parallelism between mind and brain in no way interfere with an
idealistic view of inner life? Have we not seen clearly enough that
these mental facts which are conceived parallel to physiological brain
processes do not represent the immediate reality of our inner life, that
our life reality is purposive and as such outside of all causal
explanation, and that we have to take a special, almost artificial,
point of view to consider inner life at all as objects, as contents of
consciousness, and thus as psychological material? But since we have
seen that for certain purposes such a point of view is necessary, as
soon as we have taken it we must be consistent. Our inner life in its
purposive reality has therefore nothing to do with brain processes, but
if we are on the psychological track and consider man as a system of
psychological phenomena, then to be sure, we must see that our only
possible interest lies in the finding of necessary causal connections.
But these cannot be found otherwise than by linking the mental facts
with the physical ones, the psychological material with the processes of
the brain.

Of course, that mental experience stands in intimate relations to the
body is a knowledge which does not wait for such philosophical
arguments. That mind and body come in contact is a conviction which goes
with every single sense perception. I see and hear because light and
sound stimulate my sense organs, and the sense organs stimulate my
brain. The explanation of perception through causes in the physical
system seems the more natural as it is evident that in such cases there
are no psychical causes which might have brought forward the perception.
If I suddenly hear bells ringing, there was on the mental side nothing
preceding which could be responsible for my sound perception. And the
same holds true if the physical source lies in my own body, if perhaps
my tooth begins to ache, although no expectation preceded it.

In the same way it seems a matter of course that mind and body are
connected wherever an action is performed. I have the will to grasp for
the book before me, and obediently my arm performs the movement; the
muscles contract themselves, the whole physical apparatus comes into
motion through the preceding mental fact. The same holds true where no
special will act arouses the muscles. If a thought is in my mind and it
discharges itself in appropriate words, those words are after all as
physical facts the movements of lips and tongue and vocal cords and
chest; in short, a whole system of physical responses has set in through
a mental experience. But the same thought may be the starting-point for
many other bodily changes; it may make me blush, and that means that
large groups of blood-vessels become dilated; or I may get pale, the
blood-vessels are contracted. Or I may cry, the lachrymal gland is
working; or it may spoil my appetite, the membranes of my stomach cease
to produce; or my muscles may tremble, or my skin may perspire; in
short, my whole organism may resound with mental excitement which some
words may set up.

But it is not only the impression of outer stimuli and the expression of
inner thoughts in which mind and body come together. Daily life teaches
us, for instance, how our mental states are dependent upon most various
bodily influences. If the temperature of the blood is raised in fever,
the mental processes may go over into far-reaching confusion; if hashish
is smoked, the mind wanders to paradise, and a few glasses of wine may
give a new mental optimism and exuberance; a cup of tea may make us
sociable, a dose of bromide may annihilate the irritation of our mind,
and when we inhale ether, the whole content of consciousness fades away.
In every one of these cases, the body received the chemical substance,
the blood absorbed and carried it to the brain, and the change in the
brain was accompanied by a change in the mental behavior. Even ordinary
sleep at night presents itself surely as a bodily state--the fatigued
brain cells demand their rest, and yet at the same time the whole mental
life becomes entirely changed. It is not difficult to carry over such
observations of daily life to the more exact studies of the
psychological laboratory and to examine with the subtle means of the
psychological experiment the mental variations which occur with changes
of physical conditions. We might feel, without instruments, that our
ideas pass on more easily after a few cups of strong coffee, but the
laboratory may measure that with its exact methods and study in
thousandth parts of a second, the quickening or retarding in the flow of
ideas. Every subjective illusion is then excluded, our electrical
clocks, which measure the rapidity of mental action and of thought
association, will show then beyond doubt how every change in the
organism influences the processes of the mind. Bodily fatigue and
indigestion, physical health and blood circulation, everything,
influence our mental make-up. In the same way it is the laboratory
experiment which shows by the subtlest means that every mental state
produces bodily effects where we ordinarily ignore them. As soon as we
apply the equipment of the psychological workshop, it is easy to show
that even the slightest feeling may have its influence on the pulse and
the respiration, on the blood circulation and on the glands; or, that
our thoughts give impulse to our muscles and move our organs when we
ourselves are entirely unaware of it.

Again we may turn in another direction. Pathology shows us how every
physical disablement of the brain is accompanied by mental processes.
If the blood supply to the brain is cut off, we faint; a blow on the
head may wipe out the memory of the preceding hours, and a hemorrhage in
the brain, the bursting of a blood vessel which destroys groups of brain
cells, produces serious defects in the mental content. A tumor in the
brain may completely change the personality; the bodily disease of
certain convolutions in the brain brings with it the loss of the power
of speech; paralysis of the brain dissolves the whole mental
personality. Physical inhibition in the growth of the brain involves, on
the mental side, feeble-mindedness and idiocy. Of course, all this is
not sufficient to bring out a definite parallelism between special
mental functions and special physical processes, as the phenomena are
extremely complex. If a patient who has suffered from a mental
disturbance dies, and his brain is examined, there is no simple
correlation before us. It may be difficult to diagnose exactly the
mental symptoms. If we have heard that the man was unable to read, we do
not know from that what really happened in his brain. He may not have
read because he did not see the words, or because the letters were
confusing, or because he had lost memory for the meaning, or because he
had lost the impulse to speak the words, or because he felt unable to
turn his attention, or because the impulse to read aloud was not carried
out by his organism, or because an inner voice told him that it is a sin
to read, or for many similar reasons; and yet each one represents
psychologically an entirely different situation. On the other hand, on
the physical side, the destruction is probably not confined to one
particular spot. Complications have crept over to other places or the
disturbance in one part works as inhibitory influence on other brain
parts, or a tumor may press on a far-removed part, or the disturbance
may be one which cannot be examined with our present microscopic means.
In short, we have always a complex mental situation and a complex
physical one, and to find definite correlations may be possible only by
the comparison of very many cases.

Other methods, however, may supplement the pathological one. The
comparative anatomist shows us that the development of the central
nervous system in the kingdom of animals goes parallel to the
development of the mental functions, and that it is not only a question
of progress along all lines. Any special function of the mind may have
in certain animal groups an especially high development, and we see
certain parts correspondingly developed. The dog has certainly a keener
sense of smell than the man--the part of the brain which is in direct
connection with the olfactory nerve is correspondingly much bulkier in
the dog's brain than in the human organism. Here too, of course,
research may be carried to the subtlest details and the microscope has
to tell the full story. Not the differences in the big structure, but
the microscopical differences in the brain cells of special parts are to
be held responsible. But comparison may not be confined to the various
species of animals; it may refer not less to the various stages of man.
The genetic psychologist knows how the child's mind develops in a
regular rhythm, one mental function after another, how the first days
and first weeks and first months in the infant's life have their
characteristic mental possibilities, and no mental function can be
anticipated there. The new-born child can taste milk, but cannot hear
music. The anatomist shows us that correspondingly only certain nervous
tracts have the anatomical equipment by which they become ready for
functioning. Most of the tracts at first lack the so-called medullar
sheath, and from month to month new paths are provided with this
physical equipment.

Finally we have the experiment of the physiologist. His vivisectional
experiments, for instance, demonstrate that the electrical stimulation
of a definite spot on the surface of a dog's brain produces movements
which we should ordinarily take as expressions of mental states,
movements of the front legs or of the tail, movements of barking or
whining. On the other hand, the dog becomes unable to fulfill the mental
impulses if certain definite parts of his brain are destroyed. The
physiologist may show from the monkey down to the pigeon, to the frog,
to the ant, to the worm, how the behavior of animals is changed as soon
as certain groups of nervous elements are extirpated. It is the mental
emotional character of the pigeon which is changed when the physiologist
cuts off parts of his brain. In short, stimulation and destruction
demonstrate, by experiments which supplement each other, that mental
functions correspond to brain functions.

There is thus no lack of demonstration from all quarters that mental
facts and brain processes belong together; and yet, however much we may
cumulate such popular and scientific observations, they would never by
themselves admit of the sweeping generalization that there cannot be any
mental state which is not accompanied by a process in the central
nervous system. Someone might say, to be sure, the perceptions and
memory images, the volitions and instincts and impulses, have their
physiological basis, but there remain after all acts of attention, or
decisions, or subtle feelings, or flights of imagination, which are
independent of any brain action. Here, indeed, observation cannot settle
such a general principle. Its real hold lies in the fact with which we
started: there is no causal connection in the mental states as such. If
we want to understand mental facts as such in a chain, of causal events,
we have first to conceive them as parallel to physical events. The
principle of psychophysical parallelism, that is, the principle that
every psychical process accompanies a physiological change is thus not a
mere result of observation. It is simply a postulate. Every science
begins with postulates and only that which fulfills such postulates has
the dignity of truth in the midst of that scientific realm. The
astronomer cannot find by observation that there is no star the
movements of which are not the effects of foregoing causes. He knows it
beforehand, he demands it, he does not recognize any movement as
understood until he has found the causes, he presupposes that such
causes exist, that no star moves simply by a magic power, and that
nowhere in the astronomical universe is the chain of causality broken.
He postulates it, and where he does not discover the causes, he is sure
that he has not solved the real problem.

In the same way the psychologist who aims towards explanation of mental
facts must postulate that there cannot be any mental state which is not
an accompaniment of a physical brain process, and is as such connected
through physical means with the preceding and the following events in
the psychophysical system. Only when such a general framework of theory
is built up by a logical postulate, is the way open to make use of all
those observations of the laboratory and of the clinic, of the zoölogist
and of the anatomist. It is the theory which has to give the right
setting to those scattered observations. However far we may be from
being able to point to the special brain process which lies at the
bottom of the higher mental state, we know beforehand that there is no
shadow of an idea, no fringe of a feeling, no suggestion of a desire
which does not correspond to definite processes in the brain. The
details may and must be material for diverging theories, but the
conflict of such hypothetical opinions has nothing to do with the
certainty of the underlying conviction that if we knew the whole truth,
we should recognize every single mental happening as parallel to
physical processes in the nervous system. To explain mental facts means
to think them as parallel to the brain processes which have their own
causal connections in the physical world.

We started, for instance, from the old observation that two impressions
which come to our mind at the same time have a tendency to reawaken one
another; and we saw that psychology was well able to formulate these
facts in general statements of the association of ideas. But we realized
that that in itself is not really explanation. If the odor which we
smell awakes in us the name of a chemical substance, and if we now bring
this under the general heading of association of ideas, an explanation
is not really given by it. That smell sensation itself is not really
understood as a cause of those sound sensations of the word. We have no
insight into the connection of those two happenings. But the situation
is entirely changed, if we consider the smell effect from the point of
view of the parallelistic theory. Now the association of facts would
indicate that we got the first two impressions together, because two
brain processes were going on at the same time. My nose brought me the
smell stimulus, my ear gave me the sound stimulus, each going on in a
particular center, or, to express it in a simplified schematic way, each
reaching particular brain cells, and the excitement of these brain cells
being accompanied by the particular sensations. The physiologist has
many possibilities of conceiving the further stages of the process, in
order to satisfy the demand of explanation. He may say the excitement of
each of these two brain cells, the one in the olfactory center, the
other in the auditory center, irradiates in all directions through the
fine branches of the brain fibers. Each cell has relations to every
other cell in the brain; thus there is also one connecting path between
those two cells which were stimulated at once. Now if the two ends of an
anatomical path are excited at the same time, the path itself becomes
changed. The connecting way becomes a path of least resistance, and that
means that if, in future, one of the two brain cells becomes excited
again, the overflow of the nervous excitement will not now go on easily
in all directions, but only just along that one channel which leads to
that other brain cell. A theory like this explains in real explanatory
terms, in ways which physics and chemistry can demonstrate as necessary,
that any excitement of the odor cell runs over into the sound cell and
vice versa. In short, the psychological association of ideas, which we
should simply have to accept as inexplainable fact, is thus transformed
into a connection which we understand as necessary; and the fact is
really explained.

This simple scheme of the physiology of association for a hundred years
has given a most decided impulse to the progress of psychology. As the
association process can so easily be expressed in physiological terms,
the aim was prevalent to understand the interplay of mental life more
and more as the result of association. The underlying thought of this
whole association psychology was thus a conviction that whenever two
mental experiences occur together, either of them keeps the tendency to
reawaken the other at a later time. Through the endless combination
which life's impressions awaken in the mind from the first hour after
birth, the whole stream of memory images and thoughts and aims and
imaginations is thus to be explained.

The whole theory of physiological associationism works evidently with
two factors. First, there are millions of brain cells of which each one
may have its particular quality of sensation, and second, each brain
cell may work with any degree of energy, to which the intensity of the
sensation would correspond. If I distinguish ten thousand different
pitches of tone, they would be located in ten thousand different cell
groups, each one connected through a special fiber with a special string
in the ear. And each of these tones may be loud or faint, corresponding
to the amount of excitement in the particular cell group. Every other
variation must then result from the millionfold connections between
these brain cells. Indeed, the brain furnishes all possibilities for
such a theory. We know how every brain cell resolves itself into
tree-like branch systems which can take up excitements from all sides,
and how it can carry its own excitement through long connecting fibers
to distant places, and how the endings of these fibers clasp into the
branches of the next cell, allowing the propagation of excitement from
cell to cell. We know further how large spheres of the brain are
confined to cells of particular function, that for instance cells which
serve visual sensations are in the rear part of the brain hemispheres,
and so on. Finally we know how millions of connecting fibers represent
paths in all directions, allowing very well a coöperation by association
between the most distant parts of the brain. The theories found their
richest development, when it was recognized that large spheres of our
brain centers evidently do not serve at all merely sensory states, but
that their cells have as their function only the intermediating between
different sensory centers. Such so-called association centers are thus
like complex switchboards between the various mental centers. Their own
activity is not accompanied by any mental content, but has only the
function of regulating transmission of the excitement from the one to
the other. Above all their operation would make it possible that through
associative processes, the wonderful complexity of our trains of thought
may be reached.

Yet even the highest development of the association theories did not
seem to do justice to the whole richness of the inner life. We may well
understand through those association processes that a rich supply of
memory pictures is at our disposal, that ideas stream plentifully to our
minds and enter into new and ever new combinations. But that alone is
not an account of our inner experience. If there is anything essential
for inner life, it is the attention which gives emphasis to certain
states and neglects others. And that means that certain mental contents
are growing not only in strength but in vividness and clearness, and
that others are losing their vividness, are inhibited and suppressed.
Here were always the real difficulties of the association theories; they
seemed so entirely unable to explain from their own means why certain
states become foremost in our minds and others fade away, why some have
the power to grow and others are neglected. These facts of attention and
vividness, inhibition and fading, worked almost as a temptation to give
up the physiological explanation altogether and to rely on some mystical
power, some mental influence which could pull and push the ideas without
any interference and help from the side of the brain. Yet since we have
seen that the truth of psychophysical parallelism has the meaning of a
postulate which we cannot escape unless we want to give up explanation
altogether, it is evident that such falling back into un-physiological
agencies would be just as inconsistent as if the naturalist should posit
miracles in the midst of chemistry or astronomy. If the facts which
cluster about attention cannot be understood by the simple scheme of
associationism, the demand must be for a better physiological theory.

The development of physiological psychology in recent years has indeed
shown the way to such a wider theory, which furnishes the physiological
accompaniment also for those experiences of attention and vividness
which form the weakness of associationism. This new development has come
up with the growing insight that the brain's mental functions are
related not only to the sensory impressions, but at the same time to the
motor expressions. The older view, still prevalent to-day in popular
writings, made the brain the reservoir of physical stimuli, which come
from the sense organs to the cortex of the brain hemispheres. There the
perceptions arose and through associative interplay the memory pictures
and the ideas of action and the feelings arose, and the whole inner life
was thus bound up with the processes in these sensorial spheres. When
the mind had done its work, finally an impulse was sent to some motor
apparatus in the brain which then sent off the impulse to some acting
muscles. That whole motor part was thus a kind of appendix to the brain
process. The psychical life had nothing to do with it but to give the
command for its action. The process in the motor part thus began when
the mental proceeding was completed. But it became clear that this view
was only the outgrowth of the strong interest which physiology took in
the sense processes. If a neutral fair account of the brain actions is
attempted, there can hardly be doubt that this whole sensorial view of
the brain is only half of the story and that the motor half has exactly
the same right to consideration. The cortex of the brain, the functions
of which are accompanied by mental processes, is always and everywhere
not only the recipient of sensory stimuli but at the same time the
starting point of motor impulses. That which is centripetal, leading to
the cortex, is therefore not more important for the central process than
that which is centrifugal, leading from the cortex. The cortex is the
apparatus of transmission between the incoming and the outgoing
currents, between the excitements which run to the brain and the
discharges which go from the brain, and the mental accompaniments are
thus accompaniments of these transmission processes. If the channels of
discharge are closed and the transmission is thus impossible, a blockade
must result at the central station and the accompanying mental processes
must be entirely different from those which happen there when the
channels of discharge are wide open. Here too all the special theories
are still in the midst of tumultuous discord. Yet this new emphasis on
the motor side of the psychical process seems to influence modern
psychology more and more.

Nobody can deny that first of all this is the necessary outcome of a
biological view of the brain. What else can be the brain's function in
the midst of nature than the transforming of impressions into
expressions, stimuli into actions? It is the great apparatus by which
the organism steadily adjusts itself to the surroundings. There would be
no use whatever biologically in a brain which had connections with the
sense organs, but which had no connections with the muscular system, and
on the other hand, a brain which had motor nerves and muscular
adjustment would be entirely useless if it had not sensory nerves and
sense organs connected with it. In the one case the world would be
experienced, but no response would be possible; in the other case, the
means for response would be given, but no adjustment could set in
because no experience of the surroundings would be possible. Adjustment
every moment demands the relation of the brain in both directions.
Through the sensory nerves the brain receives; through the motor nerves
the brain directs, and this whole arc from the sense organs through the
sensory nerves, through the brain, through the motor nerves and finally
to the muscles, is one unified apparatus of which no part can be thought
away. The brain in itself would be just as useless for the organism as
the heart would be without the arteries and veins.

We must keep this intimate and necessary relation between the sensory
and motor parts constantly in view, and must understand that there
cannot be any sensory process which does not go over into motor
response. Then only the ways are open to develop physiological views
which give a physical basis to the processes of attention and vividness
and inhibition, just as well as to the processes of memory and
association. Such motor theories take many forms. Perhaps we shall most
quickly bring the most essential factors together, if we say that full
vividness belongs only to those sensations for which the channels of
motor discharge are open, while those are inhibited for which the
channels of discharge are closed; and any channel of discharge is
closed, if action is proceeding in the opposite channel. If I open my
hand, the motor paths which lead to closing my fist are blocked; and if
I close my fist, the channels which lead to the opening of the hand are
closed. Now if only those ideas are vivid which find the channels open,
it is clear that all the ideas which would lead to the opposite action
have no chance for development; they remain inhibited, and just this
relation between the vividness of certain ideas and inhibition for those
ideas which lead to the opposite action is the characteristic of the
process of attention.

From such a point of view, the total mental life can be brought into the
psychophysical scheme. We now have not two variable factors, but three,
namely, the qualities of the elements, the intensities of the elements,
and, as a third, the vividness of the elements. The quality corresponds,
as we saw in the association theory, to the local position and
connection of the brain cells; the intensity corresponds to the energy
of the excitement; and the vividness, we may add now, corresponds to the
relation to motor channels. The whole mental life thus becomes the
accompaniment of a steady process of transmitting impressions and
memories into reactions. That every experience involves millions of such
elements we saw when we spoke of the description of mental life. The
effort to explain mental life shows us now that this millionfold
manifoldness belongs to a system of reactions of which all parts are in
steady correlation: a moving equilibrium of unlimited complexity. Surely
no one can reduce this wonderful manifoldness to those clumsy concepts
with which popular psychology is reporting the story of the mind and its
relations to the brain.

It may seem that such a psychological view of inner life annihilates
that which we feel as the most essential characteristic of our inner
experience, its unity and its freedom. In one sense that is certainly
true. In the real life which we live and fight through, where our duties
and our happiness lie, we know a unity and freedom of our personality
which psychology must destroy. Of course that does not mean that
psychology denies the truth of that freedom and unity. Moreover it would
condemn itself if it were to deny that which gives meaning to the
endeavors of our life and thus also to every search for truth.
Psychology claims only that we must abstract from it, when we take the
psychological standpoint towards life. Freedom of our real life means
that we must know ourselves in the midst of our life work as guided by
aims and obligations, and that in this purposive existence of ourselves
we do not feel ourselves as determined by causes. I will the fulfillment
of my ideals only because I will them. That this will itself may be the
effect of foregoing causes is an aspect which does not belong to my
naïve experience. Our freedom means that in our real life our will is
not related to causes, that the point of view of causality is thus
meaningless for the value of our achievements. And the other man's will
too comes in question for us as something to be interpreted and to be
appreciated, but not to be explained by connection with causes. As long
as we move in this sphere of purposive interest, we are free and deal
with free selves; but if in the midst of these free aims, the will
arises to consider the actions of others and of ourselves from the
standpoint of causality, then we have ourselves decided to enter a new
sphere in which it would be meaningless to seek for any will which is
not determined by causes. As soon as we have chosen the psychological
standpoint and are in the midst of the work of causal reconstruction,
any will which is not understood as determined by causes is simply an
unsolved problem. In the midst of a causal construction, absence of
causes would never mean real freedom.

In that purposive world of immediate life experience, we also are
unities inasmuch as we ourselves know us as the same in every new will
of ours. We remain identical with ourselves because every purpose is
posited in the midst of, and bound up with, the general purpose of
ourselves. And in this internal unity of meaning, nothing breaks
ourselves into pieces, and the whole manifold of experience is thus
expressed by a personality which knows itself in its purposive unity.
But this unity again is denied by our own intention as soon as we decide
to take the causal view of inner life. The purposive unity must now
transform itself into an endless complexity, and our own self becomes a
composite of hundreds of thousands of elements.

On the other hand, all this does not mean that psychology cannot have
its own consistent conception of the mind's unity and freedom. Our
psychological mind is a unity because its manifold is a system in which
all parts hang together. A change in any one part involves changes in
the whole system. The interrelation, to be sure, is not a strictly
psychical one, for we have seen that the causal connection as such
appears at the physical side. But, inasmuch as there is no psychical
process which does not belong to a physiological one, the
interconnection of the mental facts is complete and involves the
totality of neural processes of which after all a small part only has
its psychological record. We might compare those hundreds of millions of
neurons in each brain with the hundreds of millions of individuals who
make up the population of the nations, and the psychical accompaniment
we might compare with the written historical record of mankind. The
written records themselves have no direct interconnection, they are only
accompaniments of what happens in these millions of men. And again only
the higher layer of the neurons in the population sees its doings
recorded in the annals of history; and yet whatever those leaders of
action and thought and emotion may achieve is dependent upon and working
on the actions of those millions of subcortical population neurons. The
historical record has its unity through the interrelation of all parts
of historical mankind.

But after all the psychologist has no less a right to speak of freedom.
Of course his freedom cannot mean exemption from causality. Whatever
happens in the psychological system must be perfectly determined by the
foregoing causes. But the psychologist has good reason to discriminate
between those actions which result from the normal psychophysical
factors and such actions as result from broken machinery. If the brain
is poisoned by alcohol or in fever, if an infectious disease has
destroyed the brain cells, action is no longer the outcome of the
normal coöperation of the organs, and even those clusters of neural
activities which are accompanied by the consciousness of the own
personality lose their control of the motor outcome. The man in delirium
or paralysis acts without causal connection with his past; the action
is, therefore, not the product of his whole personality, and the
psychologist is justified in calling the man unfree. But, whenever the
motor response results from the undisturbed coöperation of the normal
brain parts, then the inherited equipment and the whole experience and
the whole training, the acquired habits and the acquired inhibitions
will count in bringing about the reaction. This is the psychological
freedom of man. The unity of an interconnected composite and the freedom
of causal determination through normal coöperation of all its parts
characterize the only personality which the psychologist has to
recognize.




IV

PSYCHOLOGY AND MEDICINE


We are now ready to take the first step towards an examination of the
problem of curing suffering mankind. So far we have spoken only of the
meaning of psychology, of its principles and of its fundamental theories
as to mind and brain. We have moved in an entirely theoretical sphere.
Now we approach a field in which everything is controlled by a practical
aim, the treatment of the sick. Yet our discussion of psychology should
have brought us much nearer to the point where we can enter this realm
of medicine. Everything depends on the right point of entrance. That an
influence on the inner life of man may be beneficial for his health is a
commonplace truth to-day for everybody. Every serious discussion of the
question has to consider which influences are appropriate, and in which
cases of illness the influence on inner life is advisable. The popular
treatises usually start this chapter by speaking of the "mental and
moral" factors; and this coupling of mental influences and moral
influences characterizes large parts of the discussions of the Christian
Scientists and the Christian half-scientists. Yet we must insist that
the right entrance to psychotherapy is missed if the difference between
morality and mentality is not clearly recognized from the beginning. The
confusion of the two harms every statement. To avoid such a fundamental
mistake, we had to take the long way around and to examine carefully
what psychology really means and what it does not mean.

We know now that inner life can be looked on from two entirely different
standpoints: a purposive one and a causal one, and we have seen that
these two ways of looking on inner life bring about entirely different
aspects of man's inner experience, serve different aims, and stand in
different relations to the immediate needs of our real life. We know
that the one, the causal aspect, belongs to psychology, while the
non-psychological, the purposive aspect, belongs to our immediate mutual
understanding in the walks of life. If the physician is to make use of
inner experience in the interests of overcoming sickness, he must first
decide whether to take the causal or the purposive point of view in
dealing with the patient's mind. This problem is too carelessly ignored
and through that neglect arises much of the popular confusion. Of course
just this carelessness becomes in some ways the ground for apparent
strength for many a superstition and prejudice. If the doors of the
causal mind and of the purposive mind are both open, and the spectator
does not notice that there are two, any trick on thought and reason can
easily be played. Whatever cannot pass through the causal door slips in
through the other, and whatever does not go in through the door of
purpose marches through the entrance of causality. With such methods
anything can be proved, and the most unscrupulous doctrines can be
nicely demonstrated. If we are to avoid such logical smuggling, we must
see clearly which attitude towards mental life belongs properly to the
domain of psychotherapy.

But what we have discussed now leaves little doubt as to the necessary
decision. The physician is interested in the mental life with the aim of
producing a certain effect, namely, that of health. Thus the mental life
of the whole personality comes in question for him as belonging to a
chain of causes and effects; whichever levers he may move, everything is
to be a cause which, in accordance with causal laws, is to produce a
certain change. Inner life is thus, in the interests of medical
treatment, necessarily a part of a causal system. This means the
standpoint of scientific psychology is the only adequate one. The
purposive view of inner life ought not to be in question when the
patient enters the doctor's office.

To characterize the difference, it may be said at once that it is a
purposive view which belongs to the minister. If the minister says to
his despairing parishioner, "Be courageous, my friend, and be faithful,"
nothing but a strictly purposive view gives meaning to the situation.
The word friend indicates it, that one subject of will approaches
another subject of will, with the intention of sympathy and
understanding of the attitude of the other; and the advice to be
courageous and faithful means an appeal which has its whole meaning in
the relation to aims and ends. The speaker and the hearer are both
moving in a sphere of will relations, purposes and ideals, sin and
virtue, hope and belief. To take the other extreme: if the neurasthenic
in his state of depression and in his feeling of inability seeks relief
from the nerve specialist, he too may say: "My friend, be courageous and
faithful," yet his words have an entirely different purpose. They are
not appeals to a common interest of belief; they are subtle tools with
which to touch and to change certain psychophysical processes, certain
states in mind and brain; there each word is a sound which awakens
certain mental associations, and these associations are expected to be
causes of certain effects and these effects are to inhibit those
disturbing states of emotional depression. If a few grains of sodium
bromide were to produce the same effect, they would be just as welcome.
The whole consideration moves in a sphere in which only physiological
and psychological processes are happening. Thus the physician may work
with the ideas of religious belief, but those ideas are then no longer
religious values but natural psychophysical material, which is to be
applied whenever it appears as the right means to secure a certain
effect.

On the other hand the minister also knows, of course, that every word
which he speaks has its psychological effect, but he abstracts from that
entirely, as his belief should appeal directly to the struggling will of
the man. As minister, he is thus not a psychologist. He works with
moral means; the physician, with causal means. The view which the doctor
has to take of the man before him is therefore thoroughly psychological;
whereas that of the religious friend is thoroughly unpsychological, or
better, apsychological. Indeed it is misleading, or at least demands a
special kind of definition, if people say that the minister has to be a
good psychologist. It is just as misleading as the claim, which we hear
so often, that for instance Shakespeare was a great psychologist. No,
the poet deals with human beings from the purposive standpoint of life
and the mere resolving of complex purposes into parts of purposes is not
psychology in the technical sense of the term. The poet makes us
understand the inner life, but he does not describe or explain it; he
makes us feel with other people, but he does not make those feelings
causally understood. The realistic novelists sometimes undertake this
psychological task, but they are then on the borderland of literature,
the analysis of their heroes becomes then a psychological one.
Shakespeare understood human beings better than anyone and therefore the
men and women whom his imagination created are so fully lifelike that
the psychologist may feel justified in using them as material for his
psychological analysis, but Shakespeare himself did not enter into that
psychological dissection; he kept the purposive point of view. In the
same way certainly the minister--the same holds true for the lawyer or
the tradesman or anyone who enters into practical dealings with his
neighbor--may resolve complex attitudes of will into their components,
but each part still remains a will attitude which has to be understood
and to be interpreted and to be appreciated, while the psychologist
would take every one of those parts as a conscious content to be
described and to be explained. But here we abstract from the purposive
relations. Our attention belongs now to the doctor's dealing with man;
for him cause and effect are the only vehicles of connection. Thus he
has to exclude the purposive interpretation of inner life and has to
understand every factor involved from a psychological point of view: his
psychotherapy must be thoroughly applied psychology.

The day of applied psychology is only dawning. The situation is indeed
surprising. The last three or four decades have given to the world at
last a really scientific study of psychology, a study not unworthy of
being compared with that of physics or chemistry or biology. In the
center of the whole movement stood the psychological laboratory with its
equipment for the most subtle analysis and explanatory investigation of
mental phenomena. The first psychological laboratory was created in
Leipzig, Germany, in 1878. It became the parent institution for
laboratories in all countries. At present, America alone has more than
fifty psychological laboratories, many of them large institutions
equipped with precious instruments for the study of ideas and emotions,
memories and feelings, sensations and actions. Still more rapid than
this external growth of the laboratory psychology was the inner growth
of the experimental method. It began with simple experiments on
sensations and impulses, and it seemed as if it would remain impossible
to attack with the experimental scheme the higher and more complex
psychical structures. But just as in physics and chemistry the triumphal
march of the experimental method could not be stopped, one part of the
psychological field after another was conquered. Attention and memory,
association and inhibition, emotion and volition, judgment and feeling
all became subjected to the scientific scheme of experiment. And that
was all supplemented by the progress of physiological psychology,
pathological psychology, child psychology, animal psychology. In this
way the last decades created a science which of course was by principle
a continuation of the old psychology, but yet which had good reason to
designate itself as a "new" psychology.

But in this whole development, until yesterday, the curious fact
remained that it was going on without any narrow contact with practical
life; it was a science for the scientist and measured by its practical
achievements in daily life, it seemed barren and unproductive.
Psychology was studied as palæontology and Sanscrit were studied,
without any direct relation to the life which surrounds us. And yet
after all it deals with the mental facts which have to enter into every
one of our practical deeds, if we are to consider mental life from a
psychological point of view. The psychologists were certainly not to be
blamed for sticking to their theoretical interests. More than that,
they were certainly justified in their reluctance, as everything was in
the making, and incomplete theories can easily do more harm than good.
But slowly a certain consolidation has set in; large sets of facts have
been secured, and psychology seems better prepared to become serviceable
to the practical tasks. On the other hand, it has been noticeable for
some time that not a few of the psychological results have gone over
into unprofessional hands and have been thrown on the market places and
have been brought into many a home where no one knew how to deal with
them rightly. Thus the need seems urgent that the psychologists give up
their over-reserved attitude and recognize it as their duty to serve the
needs of the community.

It is not sufficient for that end, simply to take odds and ends of
psychology and to hand them over to anyone who can see some use for
them. We must have a systematic scientific work done for the special
purpose of adjusting psychological knowledge to the definite practical
tasks and of examining the psychological facts with that practical end
in view. A science must be developed which is related to psychology as
engineering is related to physics and chemistry. Just as the
technological laboratories of the engineer bring out many new problems
which the physicist would never have approached, in the same way we may
expect that special institutions for applied psychology will shape the
psychological inquiry in a new way.

Such a new science of applied psychology of course has before it a
field just as large and manifold as the field of technology, where
physical engineering, chemical engineering, mechanical engineering, and
electrical engineering and so on are separated. Such a future
psychological technology would deal, for instance, with
psychopedagogical problems. There belongs everything which refers to the
psychology of memory or attention, of discipline, of fatigue, of habit,
of imitation or effort; in short, all those mental factors which have to
be considered whenever the schoolchild is looked on from a causal point
of view. Further there is the psycholegal field where the memory and the
perceptions, the suggestibility and the emotions of the witness are to
be studied, where the psychological conditions which lead to crime, the
means to tap the hidden thoughts of the criminal, the inhibitions for
the prevention of crime, the mental effects of punishment and similar
causal processes must be determined. There are the psychoscientific
problems referring to psychological influences on the observations and
judgments and discriminations of the scholar who watches the stars or
who translates an inscription. There are the psychoæsthetic problems
where the task is to examine causally the factors which lead to the
agreeable effects of beautiful surroundings, and from the height of the
psychology of æsthetics in painting and sculpture, the inquiry may go to
the psychology of the pleasant effects in dress-making or cooking. There
are the large groups of psychotechnical problems where the effort refers
to the application of psychology in securing the best conditions for
labor and industry and commerce. It leads from the mental effects of
signals or the mental fatigue in mills to the secrets of advertisements
and salesmanship. There are especially important psychodiagnostical
studies where the aim is to determine the individual differences of man
by experimental methods and to make use of them for the selection of the
right man for the right place. There are psychosocial problems where we
examine the psychological factors which have to enter into public
movements, into social reforms, into legislation and into politics. In
this way new and ever new groups may be added; every time the central
thought is: how far can causal psychological knowledge help us to reach
a certain end? Together with these forms of applied psychology, we find
the psychomedical problems; here belongs everything which allows the
application of causal psychology in the interests of health.

It might be answered that this demand for a strictly causal point of
view can hardly be fulfilled, because, if I am acting,--it may be in the
interest of education or law or technique or medicine,--I must always
have an end in view and to select such an end belongs after all to my
system of purposes. If I am a teacher and have to deal with children,
then it may be said that after all, my knowledge of causal psychology
cannot help me if I am uncertain for which ideals I want to educate
these children. Psychology can tell me that I need these means, if I
want to reach certain effects, but I cannot find out by psychology which
effects are desirable. Psychology may tell me how to make a good
business man or a good scholar or a good soldier out of my boy, but
whether I want him to become a soldier or a merchant I must decide for
myself with reference to general aims, and that leads me back to the
purposive view of life. Such argument is entirely correct. Yes, it is
evident that it is in full harmony with our whole understanding of the
purpose of psychology. We saw that psychology with its causal treatment
of man's mind does not express the immediate reality, but is a certain
reconstruction which allows a calculation of certain effects. Thus it is
itself a system existing for a subject who has certain ends in view. The
whole causal view of man is thus a tool in the service of the purposive
man. This is the reason why it is indeed utterly absurd to think that
psychology can ever help us to determine which end we ought to reach.

In education, for instance, very many different ends might be reached;
psychology cannot decide anything. The decision as to the aims of
education must be made by ethics, which indeed takes not a causal but a
purposive attitude. Only after ethics has selected the aim, psychology
can teach us how to reach it. Of course this principle must hold for the
physician too. All his causal dealing with the mind presupposes that he
has selected a certain end in harmony with his purpose. The only
difference is that, in the case of the physician, there can be no
possible doubt as to the desirable end; what he aims at is a matter of
course, namely, the health of the patient. To desire the health of the
sufferer is thus itself a function which belongs entirely to the
purposive view of the world, and only in the interest of this purpose
does the physician apply his knowledge of psychology or of the causal
sciences of physics, physiology, and chemistry. Indeed only with this
limitation have we the right to say that the psychotherapist takes the
causal,--and that means the psychological,--view of his patient. As far
as he decides to take care of the health of his patient, this decision
itself belongs to the purposive world and to his moral system. The
physician is thus ultimately just like the minister and just like anyone
who deals with his neighbor, a purposive worker; but while the minister,
for instance, remains on this purposive track, the physician puts a
causal system into the service of his purpose. He knows the end, and his
whole aim is to apply his causal knowledge of the physical and psychical
world to the one accepted end of restoring the health of the patient. He
has to ask thus in general: what has psychology to-day to offer which
can be applied in the interests of medicine?

It would be an inexcusable narrowness to confine that chapter of applied
psychology which is to deal with the psychomedical problems to the work
of psychotherapy. Medicine involves diagnosis of illness as well as
therapeutics. Between the recognition and the treatment of the illness
lies the observation of its development and all this is preceded by
steps towards the prevention of illness. In every one of these regions,
psychology may be serviceable. Psychotherapy is thus only one special
part of psychomedicine. But the situation becomes still more complex by
the fact that the illness to be treated or the disturbance to be removed
may stand in different relations to the psychophysical processes. The
illness may be a disturbance in the psychophysical brain parts, or it
may belong to other brain parts which are only in an indirect way under
the influence of mental states or which are themselves indirectly
producing changes in the mental life. And finally the disturbance may
exist outside of the brain in any part of the body, and yet again
through the medium of brain and nervous system it may produce effects in
the mind or be open to the influence of the mind. Thus we have entirely
different groups of medical interests and it would be superficial to
ignore the differences.

Both psychodiagnostic and psychotherapeutic studies must be devoted to
cases in which the mind itself is abnormal, further to cases in which
the normal minds registers the abnormalities in other parts of the body,
and finally to cases in which the normal mind influences abnormal
processes in the body. These latter two cases have to be subdivided into
those where the bodily disturbance still lies in the brain parts and
those where it lies outside of the brain. But the situation becomes
still more complex by the mutual relations of those various processes.
The impulse to take morphine injections may have reached the character
of a mental obsession and thus represent an abnormality of the mind, but
yielding to it produces at the same time disturbances in the whole body
which thus become again external sources for abnormal experiences in
otherwise normal layers of the mind.

Of course the interest of the psychologist as such remains always
related to the psychological factor, but the relation of the
psychological factor itself to the total disturbance may be of most
different character. If I diagnose or treat the fixed idea of a
psychasthenic, the psychological factor itself represents the
disturbance. On the other hand, if I study the pain sensations of a
patient who suffers from a disease of the spinal cord, then the
sensations themselves, the only psychological factor in the case, are
only indications of a disease which belongs to an entirely different
physical region; the mind itself is normal. Or, on the other hand, if I
try to educate a sufferer from locomotor ataxia to develop his walking
by building up in his mind new motor ideas to regulate his coördinated
movements, the mind again is entirely normal but the physician needs his
psychology on account of the influence which the mind has on the bodily
system. Again, we must insist that psychomedicine covers this whole
ground. Wherever a psychical factor enters into the calculations of the
physician either by reason of its own abnormality or by its relation as
effect or as cause to a diseased part of the body in the brain or
without, there we have a psychomedical task, and as far as it is
therapeutic, we have psychotherapy.

The psychodiagnostic research lies outside of the compass of our book,
but we cannot emphasize sufficiently the great importance which belongs
to that work. Moreover, just in the field of psychodiagnostics, the
methods of the modern experimental psychological laboratory are most
promising and successful. Let us not forget that we deal with such
psychological factors even when we test the functions of eye and ear and
skin and nose by examining the sensations and perceptions. The oculist
who analyzes the color sensations of a patient and the aurist who finds
defects in the hearing of the musical scale and discovers that certain
pitches cannot be discriminated, is certainly dealing, for diagnostic
purposes, with the material that the psychological laboratory has sifted
and studied. Even that sensation symptom which enters into so many
diseases, the sensation of pain, belongs certainly within the compass of
the psychologist and it is only to be regretted that the systematic
study of the pain sensations, mostly for evident practical reasons, has
been much neglected in the psychological laboratory.

The psychologists have been at work all the more eagerly in the fields
of association and memory, attention and emotion, habit and volition,
distraction and fatigue. Here subtle methods have been elaborated,
methods which surely common sense cannot supply, and which showed
differences of mental behavior with the exactitude with which the
microscope reveals the hidden differences of form. If physicians are
slow in accepting the help which the psychological laboratory can
furnish, it may be in good harmony with the desirable conservative
policy in medicine, but finally the time must come when this
instinctive resistance against new methods will be overcome. The recent
attachment of psychological laboratories to certain leading psychiatric
clinics is a most promising symptom. Yet the diagnostic studies with the
means of the psychological laboratory cannot be confined to the cases of
mental disease. The mild abnormalities of the mind, and especially the
nervous disturbances which exist outside the field of insanity, demand
this support of psychology much more. And even the normal personality
will be more safely protected from disease and from social dangers for
its mental constitution if the resources of experimental psychology are
employed. The more we know of the psychological constitution of the
individual, the more we can foresee the development which is to be hoped
for or feared and which may be encouraged or retarded.

The psychologist may determine, for instance, the degree of attention
with its resistance against distracting stimuli, the power of memory
under various conditions and on various material, the mental
excitability and power of discrimination, the quickness and correctness
of perception, the chains of associations, the rapidity of the
associative process for various groups, the types of reaction, the
forming of habits and their persistence, the conditions of fatigue and
of exhaustion, the emotional expressions and the emotional stability,
the time needed for recreation and the resistance against drugs, the
degree of suggestibility and the power of inhibition: and every result
in any of these lines may contribute to the diagnosis and prognosis of
cases. The chronoscope here measures the reaction times and association
times in thousandths of a second; the kymograph, by the help of the
sphygmograph, writes the record of the pulse and its changes in
emotional states, while the pneumograph records the variations of
breathing, and the plethysmograph shows the changes in the filling of
blood vessels in the limbs which is immediately related to the blood
supply of the brain. Here belongs also the ergograph, which gives the
exact record of muscular work with all the influences of will and
attention and fatigue, the automatograph which writes the involuntary
movements, especially also the galvanoscope which may register the
influence of ideas and emotions on the glands of the skin, and thus lead
to an analysis of repressed mental states, and hundreds of other
instruments which are used in the psychological laboratory.

Yet it would be misleading to think only of complex apparatus when
experimental psychology is in question. An experiment is given whenever
the observation is made under conditions which are artificially
introduced for the purpose of the observation. Thus there is no need of
the physical instrument. If I bring a spoonful of soup to my mouth at
dinner and I become interested in the combination of warmth sensation
and touch sensation and taste sensation and smell sensation, then I have
performed an experiment if I take one more spoonful of soup just for the
purpose of the observation. The physician too may carry out important
psychological experiments, without needing the outfit of a real
laboratory. Association experiments, for instance, promise to become of
steadily growing importance. To make them serviceable to the problems of
his office, nothing but a subtle psychological understanding is needed,
inasmuch as any routine work schematically applied to every case alike
would be utterly useless. Give your man perhaps a hundred words and let
him speak the very first word which comes to his mind when he hears the
given ones. You call rose, and he may say red or flower or lily or
thorn; you call frog and he may answer pond or turtle or green or jump,
and if you choose your hundred words with psychological insight, his
hundred answers will allow a full view of his mental make-up. This is an
experiment which does not require any instruments at all but a man's
subtle analysis of the replies. That is not seldom sufficient to secure
the diagnosis of complex mental variations. The method yields still more
if the time for such a reply is measured, but there again not the costly
chronoscope of the laboratory is indispensable; a simple stop watch
which gives the fifths of a second would be fully sufficient for all
practical purposes. From such simple facts of the mental inventory the
association experiments may lead to complex questions which slowly may
disentangle the confused ideas, for instance, of a dementia præcox, and
thus lead to subtle differential diagnosis.

The psychological laboratory alone can also elaborate the methods of
studying, for instance, the feeble-minded with all the individual
variations. New and ever new methods have been tried; the memory was
tested by reading and repeating figures or letters, or colored papers
were shown or cardboards of different forms or nonsense syllables, and
the powers of remembering were studied. Or the accuracy of arm movements
was examined, or the quickness of understanding associated words, or the
success in planning a complex movement like throwing a ball at a target,
or the tapping of a key in the rhythm of a metronome, or the
discrimination and recognition of the pieces in the game of dominoes and
many another scheme. The laboratory has to analyze the conditions for
such methods and the psychologist has to prepare the means for the use
of the physician, just as the chemist has to prepare the sleeping
powders. In a similar way the laboratory may furnish means to analyze
the mental disturbances by a comparison with the experimental results of
artificial influences, for instance, of over-fatigue or half-sleep, of
drugs or alcohol, of poisons and emotional excitements. The
psychological resolving of the mental symptoms may of course, in the
same way, furnish the diagnosis where the mental variation is only a
distant effect of a bodily ailment. The changes in the emotions, for
instance, may lead to the recognition of a heart disease; lack of
attention may be a hint of the overgrowth of the adenoids; irritability
or apathy or delirious character of the mental behavior may indicate
whether uræmic acid is in the system or an infectious disease: anæmia
and undernutrition may be diagnosed and the psychology of fever demands
too a much closer analysis with the means of the psychological
laboratory than it has received so far.

We have not spoken as yet about those psychological methods which
themselves introduce abnormal mental states like hypnotism, and which
also not seldom are only means for diagnostic purposes. The hypnotic
state may bring to memory forgotten experiences of which the
physiological effects may have lasted in the brain and which may have
brought injury to the psychophysical system. Hypnotic inquiry can thus
lead to the recognition of the first causes in many hysterical states
and where hypnotism is not the best adjusted tool, a certain dreamlike
staring may be more effective. We have to return to much of that later
in full detail because just for instance in hysteria, the clear
recognition of the sources and of the character of the disease may at
the same time prove to be in itself the right starting point for
curative treatment.

We have spoken so far only about the relations of psychology and
medicine from the point of view of diagnosis; the relations from the
point of view of therapy will make up the second part of this book. We
shall describe the methods and the results, the possibilities and the
limitations with manifold detail. That is the chief topic of this
volume. All that is needed to prepare for this principal problem is on
the one side a preparatory clearing up of some fundamental conceptions,
especially of those two which have played the chief rôle in the whole
discussion, namely the subconscious and suggestion. And on the other
side, we may consider at first some fundamental discriminations which
steadily influence the inquiries and controversies in the field. I think
of the difference between normal and abnormal mental states, between
psychical and physical facts in psychotherapy, between functional and
organic diseases, and to return to our starting point, between mental
and moral influences.

Every curative effort presupposes that the normal state of health has
been lost and that a diseased state has set in. Yet the mental analysis
suggests still less than the bodily inquiry, just where the normal
functioning is really lost. It would be easy to draw a demarcation line
if the pathology of the mind introduced any mental features which are
unknown in our normal existence, but the opposite is true. No mental
disease introduces elements which do not occur in the sphere of health.
A degenerated brain cell looks differently under the microscope from a
normal one, but the ideas of a paranoiac, the emotion of a maniac, the
volition of a hysteric, the memory idea of a paralytic is each in its
own structure not different from such elements in any one of us. The
total change lies thus only in the proportion; there is too much or too
little of it. The pathological mental life is like a caricature of a
face--each feature is contained, as in the ordinary portrait, but the
proportion is distorted, there is too much or too little of chin or of
nose. But who can indicate exactly the point where the distortion of the
features constitutes a caricature? Every grotesque change in the
relations ruins the healthy state: what makes us sure that the harmony
of health is spoiled?

Certainly we cannot settle it by mere statistics. The norm never means
merely a majority. Even if the overwhelmingly larger part of mankind
suffered from phthisis, the few who were free from it would be
recognized as well and all the others would be considered ill. In mental
life still more, no one ought to propose that the exceptional function
is the symptom of disease. The few persons who never had a dream in
their lives differ much in their mental experience from the large
majority and yet their peculiarity is certainly not a symptom which
needs curative treatment. The only real test of health is the
serviceableness to the needs of life. We have an unhealthy state of the
personality before us wherever the equilibrium of the human functions is
disturbed in a way which diminishes the chances of existence, and the
seriousness of the ailment depends upon the degree of this diminishing
power. Seen from a strictly psychological point of view, we must expect
thus a broad borderland region between the entirely normal well-balanced
mental life and that unbalanced disorder of functions which really
interferes with the chance for self-protection and effectiveness. That
the melancholic who declines to take any nourishment, or the paranoiac
who misjudges his surroundings, is unable to secure by his own energies
the safety of his life cannot be doubted. The balance is completely
destroyed and the will and the intellect of the physician and of the
nurse must be substituted for his own mental powers, if his life is to
be prolonged at all. But the misjudgment and the depression of the
insane are only an exaggeration of that which may occur in any man.

There are therefore thousands of steps which lead from the normal error
or regret to the destructive disturbance. Everyone knows persons whose
pessimistic temperament makes them inclined to an over-frequent
depression, or others whose silly disposition brings out constantly
those emotional tendencies which the maniac shows in an exaggerated
degree. The stupid mind shows those lacks of association and connection
which reach their maximum degree in the mind of the idiot. We know from
daily life the timid, undecided man who cannot come to a will impulse;
the hasty man who rushes towards decisions; the inattentive man who can
never focus his consciousness; and the overattentive man who can never
dismiss any subject; the indifferent man on whom nothing produces
evident impression and feeling; the over-sensitive man who reacts on
slight impressions with exaggerated emotion; and yet every one of such
and a thousand similar variations, needs only the projection on a larger
scale to demonstrate a mental life which is self-destructive. The silly
girl and the stupid boy, the man who has the blues and the reckless
creature, are certainly worse equipped for the struggles of existence
than those who are intellectually and emotionally and volitionally
well-balanced. They will take wrong steps in life, they may be
unsuccessful, their stupidity may lead them to the poorhouse, their
recklessness may lead them to the penitentiary. And yet we do not speak
of them as patients because their disproportionate mental features may
be sufficiently corrected by other mental states which are perhaps more
strongly developed.

Further, inasmuch as human life just in its mental functions is related
to its social surroundings, much must depend on the external conditions,
whether the disproportion and abnormality has to be treated as
pathological. The mind which may find perhaps its way under the most
simple rural conditions would be unable to protect life under the
complex conditions of a great city. The man who in certain surroundings
may appear a crank has to be treated as a patient in a different set of
life conditions. Wherever psychotherapeutic work is in question, perhaps
nothing is more important than to keep steadily in mind this continuity
between normal and abnormal mental features. The mental disturbance must
constantly be looked upon as a change of proportions between functions
which, as such, belong to every normal life. We have to train and to
develop, and thus to reënforce, that which is too weak, and we have to
drain off and to suppress and to inhibit that which is too strong.

Yet just this functional view of disease must remind us strongly from
the beginning that it would be utterly in vain to draw any demarcation
line between psychical disturbances and physical ones. We have seen from
the start that from the point of view of physiological psychology,
there can be no psychical process without an accompanying physiological
process in the brain. Every disturbance in mental actions is thus at the
same time a disturbance in the equilibrium of nervous functions. Yet
that alone would not exclude the possibility of considering some
diseases, for instance, exclusively from the mental side, and we should
be justified in doing so if those parts of the brain which are the seat
of the mental processes could remain in the diseased state without
influence on other parts of the nervous system and of the whole body. In
such a case it would indeed be sufficient to consider the psychophysical
disturbance from the psychological point of view only, that is, to speak
of the disease as a disorder of intellect, of emotion or will, without
thinking of changes in the brain cells. But such isolation does not
exist in nature. Not only the bodily factors like nutrition and
circulation and sexual functions have a thousandfold influence on the
psychophysical processes, and these in turn change the vegetative
functions of the body, but especially the other parts of the brain and
nervous system can be affected in most different ways. If we want to
consider whether a certain variation of the personality demands curative
treatment, we certainly cannot confine ourselves to the mental
variations. They are after all only parts of the whole group of changes
in the organism and are thus symptoms of a disease which has to be
studied in its totality. The mental symptoms alone may be relatively
slight variations, which in themselves might be sufficiently balanced
not to disturb the equilibrium of life, and yet they may be symptoms of
a brain disturbance which as a whole must interfere with the safety of
life. On the other hand, mental life may appear like a chaos and yet the
disturbance may be the symptom of merely a slight brain affection and
the treatment of the mental symptoms in their apparent severity would be
a useless effort. The mental disturbance, for instance, of the
intoxicated or the hashish smoker, even the delirium of the feverish,
does not suggest a fight against the mental symptoms during the attack.

On the whole, there is a far-reaching independence between the apparent
mental variations and the seriousness of the brain affection. Light
hysteric states may produce a strong absenting of the mind while severe
epileptic conditions of the brain may be accompanied by very slight
mental changes. Every neurasthenic state may play havoc with mental
life, while grave brain destructions may only shade slightly the
character or the intellect. To deal with the mental changes as if they
belonged to a sphere by itself, to the soul which is well or ill through
its own independent alterations without steadily relating the changes to
the total organism, leads therefore necessarily to failure. The mind
reflects only symptoms of the disease; the disease itself belongs always
to the organism. Psychotherapy has suffered too much from the belief
that the removal of mental symptoms is a cure of disease.

Certainly the psychophysical symptoms may often stand in the foreground
of the disease, and in that case it may be left to the special needs
whether we deal with them as psychical or as physical changes. Even the
patient may be made to see them in one or the other way in accordance
with his special needs. To tell him that his brain cells are in disorder
and that they can be cured will be the right thing for him who takes
only the introspective view of his suffering and is in despair because
his own will seems powerless to overcome those mental changes. For the
next patient, the opposite may be wiser. The belief that his brain is
ill may have induced him to give up effort of the will instead of
helping along by steady self-suggestion. He will be helped more if he
understands that his mind is working wrongly. But the full truth is that
both mind and body are in disorder; the function of the disturbed brain
cells accompanies the ineffective will, and to reënforce the will means
to bring into equilibrium again the disturbed brain cells. For the
psychotherapist the temptation of giving the attention to the mental
symptoms only is strong. The more firmly the physician sticks to the
standpoint of psychophysiology, the better he will see ailment and cure
in their right proportion.

This demand for the consideration of the whole personality, mind and
body, ought not to be influenced by the popular separation between
organic and functional diseases. If we call organic diseases of the mind
those in which the mental disturbance is the accompaniment of a brain
disturbance, and functional those in which no brain disturbance exists,
we leave entirely the ground of modern psychology. As soon as we
believe that the mind can be disturbed without a change in the functions
of the brain, we give away all that which has brought scientific order
into the study of psychological existence. Every mental disturbance
corresponds to a disorder in the brain's functions. But there cannot be
a change in the functions of the brain without a change in its
structure. Thus we must claim that all those so-called functional
disturbances like neurasthenia and hysteria, fixed ideas and obsessions,
phobias and dissociations of the personality, as well as the typical
insane states of the maniac or paranoiac have their basis in a
pathological change of the anatomical structure of the brain. This
postulate cannot be influenced by the fact that the microscope has been
unable to detect the character of most of these changes.

Of course all this does not exclude its being perfectly justifiable to
separate those diseases for which a definite destruction of the brain
parts can be detected, as in paralysis of the brain, from those where
that is impossible. We may also expect that those disturbances in the
brain which we cannot as yet make visible, may allow more easily an
organic repair and thus a restoration to the normal functions. Just as a
disjointed arm may be brought to function quickly again, a broken arm
slowly, an amputated arm never, each brain cell too may suffer lesions
which are reparable in different degrees. But it is evident that it
remains then an entirely empirical question whether the invisible damage
allows repair or not. We have no right to say that where the
destruction cannot be seen under the microscope there is no organic
change and the disturbance is therefore only a psychical one and can be
removed by mental means. All changes are physical and experience has to
decide whether they are accessible to psychological influences or not.
States like epilepsy may not allow any recognition of definite brain
destruction and are yet on the whole inaccessible to mental influence,
while many a brain disturbance with visible alterations, resulting
perhaps from anæmia or hyperæmia, may be caused to disappear. If on the
other hand we say that we can cure with psychotherapeutic means only the
functional brain diseases and define as functional simply those diseases
which can be cured by such means, we move, of course, in the most
obvious circle and yet just that is the too frequent fate of the
discussions in certain quarters.

Every psychical disturbance is organic inasmuch as it is based on a
molecular change which deranges the function. Some of these changes are
beyond restitution; some can be brought back to a well-working structure
by strictly physical agencies like drugs or electricity; others can be
repaired by physiological stimuli which reach directly the higher brain
cells through the sense organs and which we call psychical under one
aspect, but which certainly remain physiological influences from another
aspect. And these psychophysiological influences of the spoken words or
similar agencies are thus indeed for therapeutic effect entirely
coördinated with the douche and the bath and the electric current and
the opiate. It is a stimulation of certain brain cells, an inhibition of
certain others: a subtle apparatus which must be handled with careful
calculation of its microscopical causes and effects. That these words
from an entirely different point of view may mean a moral appeal and
have ethical value, point to moral and religious ideas and reënforce the
spiritual personality, lies entirely outside of the psychotherapeutic
calculation. As long as the curing of the patient is the aim, the faith
in God is not more valuable than the faith in the physician and the
moral appeal of no higher order than the influence through the galvanic
current. They come in question only as means to an end and they are
valuable only in so far as they reach the end. That they can be related
to an entirely different series of purposes, to the system of our moral
ideas, ought not to withdraw the attention of the psychotherapist from
his only aim, to cure the patient. The highest moral appeal may be even
a most unfit method of treatment and the religious emotion may just as
well do harm as good from the point of view of the physician.
Psychotherapy has suffered too much from the usual confusion of
standpoints.




V

SUGGESTION AND HYPNOTISM


Psychotherapy has now become for us the effort to repair the disturbed
equilibrium of human functions by influencing the mental life. It is
acknowledged on all sides that the most powerful of these influences is
that of suggestion. This is an influence which is most easily
misunderstood and which has most often become the starting point for
misleading theories. Before we enter into the study of the practical
effects of suggestion and the psychotherapeutic results, we must examine
this tool in the hand of the psychotherapist from a purely psychological
viewpoint. The patient may perhaps sometimes profit from suggestion the
more, the less he understands about its nature, but the physician will
always secure the better results, the more clearly he apprehends the
working of this subtle tool. Of course, that does not mean that any
psychology is able to explain the process of suggestion to a point where
all difficulties are removed, but at least the mysteries can be removed
and the effects can be linked with other well-known processes.

Let us be clear from the start that suggestion is certainly nothing
abnormal and exceptional, nothing which leads us away from our ordinary
life, nothing which brings us nearer to the great riddles of the
universe. There is no human life into which suggestion does not enter in
a hundred forms. Family life and education, law and business, public
life and politics, art and religion are carried by suggestion. A
suggestion is, we might say at first, an idea which has a power in our
mind to suppress the opposite idea. A suggestion is an idea which in
itself is not different from other ideas, but the way in which it takes
possession of the mind reduces the chances of any opposite ideas; it
inhibits them. It is indeed the best result of any successful education,
that the teachings have taken hold of the mind of the young in such a
way that all the opposite tendencies and impulses and wishes do not come
to development. The well-educated person does not need to participate in
a struggle between good and bad motives, for that which has been
impressed upon his mind does not allow the other side to come up at all.
Our life would be crowded with inner conflicts if education had not
secured for us from the start preponderance for the suggestions of our
educators.

The love of family and friends, of our country and our party are in the
same way such suggestions. We may hear arguments for the other side,
arguments which easily convince the man of the other party, but they do
not appeal to us: they are emasculated before they enter our minds; they
have no chance to overcome the resistance because suggestions stand in
their way. No argument will overwhelm the suggestion which religion has
settled in our inner life, and from this strongest suggestion which can
stand against any temptation of life small psychological steps lead down
to the little bits of suggestion with which our daily chance life is
over-flooded. Every advertisement in the newspaper, every display in the
shop-window, every warm intonation in the voice of our neighbor has its
suggestive power, that is, it brings its content in such a way to our
minds that the desire to do the opposite is weakened. We do buy the
object that we do not need, and we do follow the advice which we ought
to have reconsidered. And what would remain of art if it had not this
power of suggestion by which it comes to us and wins the victory over
every opposing idea? We believe the painter and we believe the novelist,
if their technique is good. We do not remember that the inventions of
their genius are contrary to our life experience; we feel sympathy with
the hero and do not care in the least that he has no real life. The
suggestion of art has inhibited in us every contrary idea.

Such daily experience shows us that suggestive power may belong to
different men in different degree. There are lawyers whose arguments and
whose presentation open our mind, it seems, to any suggestion: while
others leave us indifferent; we understand their idea, we follow their
thoughts, and yet we remain accessible to opposite influences. There are
teachers whose authority gives to every word such an impressiveness and
dignity that every opposite thought disappears, while others throw out
words which are forgotten. On the other hand, the readiness to accept
suggestions is evidently also quite different with different
individuals. From the most credulous to the stubborn, we have every
degree of suggestibility, the one impressed by the suggestive power of
any idea which is brought to his mind, the other always inclined to
distrust and to look over to the opposite argument. Such a stubborn mind
is indeed not only without inclination for suggestions, but it may
develop even a negative suggestibility; whatever it receives awakens an
instinctive impulse towards the opposite. Moreover we are all in
different degrees suggestible at different times and under various
conditions. Emotions reënforce our readiness to accept suggestions. Hope
and fear, love and jealousy give to the impression and the idea a power
to overwhelm the opposite idea, which otherwise might have influenced
our deliberation. Fatigue and intoxicants increase suggestibility very
strongly. To look out on a wider perspective, we may add at once that an
artificial increase of suggestibility is all which constitutes the state
of hypnotism.

At first, however, we want to understand the ordinary process of
suggestion in that normal form in which it enters into every hour of our
life and into every relation of our social intercourse. But if we begin
to examine the structure of the process, we can no longer be satisfied
with the vague reference to ideas and their opposites. What does it mean
after all if we speak of opposite ideas? Can we not entertain any ideas
peacefully together in our consciousness? From a logical standpoint,
ideas may contradict each other, but that refers to their meaning. As
mere bits of psychological experience, I may have any ideas together in
my consciousness. I can think summer and winter or day and night or
right and left or black and white or love and hate in one embracing
thought. As mere mental stuff, the one idea does not interfere with the
other. On the other hand, this is evident: I cannot will to turn to the
right and to turn to the left at the same time. There may be a wrangling
between those two impulses, but as soon as my will stands for the one,
the other is really excluded. Any action which I am starting to do thus
crowds out the impulse to the opposed action.

In the sphere of psychological facts, we have here indeed the only
relation between two happenings which necessarily involves an
opposition. We could never understand why one brain cell might not work
together with any other brain cell, but we do understand that nature
must provide for an apparatus by which the impulse to one action makes
the impulse to the opposite action ineffective. There is no action which
has not its definite opposite. The carrying out of any impulse involves
the suppression of the contrary impulse, and the impulse not to do an
action involves the suppression of the impulse to do it. When we spoke
of the relations of mind and brain, we mentioned that such a corelation
of mental centers indeed exists. Physiological experiments have
demonstrated that the activity of those centers which stimulate a
certain action reduce the excitability of those brain parts which awaken
the antagonistic action. As far as the world of actions is concerned,
the mechanism of the process of suggestion thus seems not inaccessible
to a physiological understanding.

Various ideas of movements to be carried out are struggling for control
in the cortex of the brain. That is the normal status which precedes any
decision. The channels of motor discharge are open for both
possibilities; we may turn to the right or to the left. Then the play of
associations begins. A larger and larger circle of ideas surrounds the
idea of the one and of the other goal. Those ideas awaken emotions. On
the one side may call our duty and on the other side our pleasure.
Larger and larger parts of the central content of our consciousness, of
our own personality, become involved; our principles and maxims, our
memories, our hopes and fears, enter into the battle until deeper strata
of the idea of ourselves enter into a firm association with the one
side, reënforcing, perhaps, the idea of the goal at the right. This
opens wide the channels of discharge for the movement to the right and
inhibits thereby the excitability of the center which leads to the
opposite action. The channel of discharge to the movement towards the
left becomes closed, the idea of that movement fades away and becomes
inhibited: we are moving towards the right. The outcome was the product
of our total personality.

But this result would have been different, if from the start the
channels of discharge had not been equally open for both possible
movements, and if thus the relative resistance to the impulse had not
been equal on both sides. If, for instance, we had gone from the given
point frequently to the left, as a result of the habit and training, the
impulse to the left would have found less nervous resistance. The
channels would have become widened by the repetition and the opposite
channels would have been somewhat closed by the lack of use. Or if
instead of such previous habit, we should see at the decisive moment
others turning to the left, the impression would have become the
starting point for a reaction of mere instinctive imitation. While we
might not have followed that imitative impulse at once, yet the channels
would have been widened, the discharge in the direction would have been
prepared by it, the resistance would have been lowered and the chances
for the opposite movement would have been decreased. Those people who
moved to the left gave us by their action the same kind of an impulse
which they would have furnished if they had begged us with words, or if
they had ordered us to follow them with authoritative firmness. In each
of these cases, the influence would have amounted to a suggestion.
Whether we watched the movements of other people or whether their words
made an impression on us, in either case the way became prepared for a
certain line of action and therefore the way for the opposite action
became blocked. The final outcome was thus no longer an entirely free
play of motor ideas, but there was a little inequality in play. The one
had from the start a better chance, the other was from the start
laboring under difficulties. The suggestion of actions is thus nothing
but making use of the antagonistic character in the nervous paths which
start from the motor centers. That all such phrases as the opening and
the closing, the widening and blocking, of channels of discharge are
only metaphors hardly needs special emphasis. Instead of such
comparisons, we ought rather to think of chemical processes which offer
various degrees of resistance to the propagation of the nervous
excitement.

We see from here the direction in which many psychotherapeutic efforts
must lie, efforts which are entirely within the limits of the daily
normal experience, and belong to the medical practice of every
physician, yes, to the helpful influence of every man in practical life.
The intemperate man may suffer from his inability to resist his desire
for whiskey. The idea of his visit to the saloon finds the channels of
discharge open. We argue with him, we tempt him by attractions which
lead to other ways, we suggest to him that he spend those evening hours
perhaps with friends or with books for which we awaken his interest; we
do it as impressively as we can, we appeal to his friendly feeling for
us; and if again the hour comes in which the desire for the artificial
stimulation sets in with a motor impulse towards the bottle, the
channels for discharge have now been blocked. The idea of the opposite
action arises, it associates itself with the emotions which we stirred
up in his mind, it associates itself with the respect for the adviser,
and thus new clusters of thought reënforce that idea of action which we
suggested, and this opposite line of action now finds a minimum
resistance because our appeal has opened beforehand the gate. The desire
for the book works itself out into action while the desire for the cup
finds increased resistance.

Just this is the kind of suggestion with which we correct faulty action
everywhere in our social circle; and yet small steps lead on from here
to the case where perhaps the desire for alcohol has reached that
pathological intensity in which the equilibrium is entirely disturbed
and cannot be repaired without suggestions of a much more powerful
character, given in a state of artificially increased suggestibility--in
hypnotism. The principle of opening certain channels of discharge for
the purpose of closing the opposite channels remains in the extreme case
the same as in the more ordinary cases. The impulse to drink is a
positive one, but the principle is not different where the impulse is
negative. A friend who comes from the quiet country may feel unable to
pass the busy square of the city. The fear of an accident holds back his
steps, he cannot give the impulse to walk through the crowded rush of
vehicles. Now either by words of advice, by persuasion or by showing the
way, we may apply our suggestion, we open the channels of discharge for
the necessary movements and thus decrease the excitability of those
centers in which nervous fear was playing. And again small steps lead
from here to the case of the psychasthenic sufferer whose phobia does
not allow him to cross any square and where reënforced suggestion has to
break open the ways for the walking movement when the square is reached.

Thus we are not far from a causal understanding of suggestive influences
wherever actions are concerned, where movements are to be reënforced or
to be suppressed and where antagonism of the motor paths is involved.
But that does not seem to lead us nearer to the much larger group of
states in which the whole suggestive process concerns apparently the
interplay of ideas alone, where not actions but impressions are
controlled by suggestion, where not impulses but thoughts are
strengthened or inhibited. Here lies the real psychophysical problem
which has been by far too much neglected in scientific psychology and
has almost been hidden and made to disappear in the wonderful accounts
of the hypnotists. But all those mysterious stories as to the
achievements of suggestion cannot help so long as we do not understand
the working of the process, and we shall have the better chance to
understand it the more we keep away from the uncanny and mysterious
results which refer to the most complex conditions, and rather seek to
analyze the state in its simplest forms and compare it with other simple
mental processes. The psychology of suggestion has suffered too much by
the fascination which its most complex forms exert on a trivial
curiosity.

Yet the problem of suggestion in the field of ideas stands after all not
isolated. Instead of connecting it with the weird reports of mystic
influence from man to man, let us rather link it with the simple
experience of attention. There is no pulse-beat of our life in which
attention does not play its little rôle. But does not attention share
with suggestion the characteristic feature that some contents of
consciousness are reënforced and others are suppressed? This negative,
this suppressing character of attention is not a chance by-product, it
is most essential. There is no attention without it. If I am studying, I
do not hear the conversation around me, and if I listen to the
conversation, my studies in hand become inhibited. If I enjoy the play
on the stage and give to it my full attention, my memories of the day's
work are suppressed; if I think of the happenings of the day, I am not
attentive to the play and hardly notice what is going on. The inhibited
impression may often disappear entirely. While I am reading I am not at
all aware of the tactual and muscular sensations in my legs, and if I am
completely absorbed by my book, I may not even notice that the bell
rings. In short, we have here as the most characteristic relation, just
as in suggestion, the fact that one mental state becomes vivid, and that
others are losing ground, become less vivid, are inhibited and perhaps
disappear entirely.

Of course, to point to the similarity between suggestion and attention
is not a real explanation. It may be answered that attention simply
offers the same difficulties once more. How can we explain in the
attention process the fact that one idea, the one attended to, becomes
vivid and that others evaporate? The difficulty evidently cannot be
removed by simply saying that only one sensorial process can be
developed in the brain at one time. The popular descriptions of
attention easily make it appear as if such were the solution of the
problem. If one sensorial brain part is intensely engaged, the remainder
of the brain is condemned to a kind of inactivity. Yet such a dogma is
hardly better than the old-fashioned one that the soul can have only one
idea at a time. We know too well now that the psychophysical system is
an extremely complex equilibrium of millions of elements. Thus every
change must be explained with reference to this complex manifold. Above
all, the facts simply contradict such an over-simple explanation,
inasmuch as it is not at all true that only one content of consciousness
can become vivid. Our attention does not focus upon one point at all but
may illuminate a large field and thus give vividness to various complex
groups. If I am thinking about a scientific problem, an abundance of
reminiscences of previous reading and imaginative ideas of possible
solutions, associative thoughts and conclusions are with equal vividness
before my mind and the forthcoming thought may be influenced by this
total combination. I have no right whatever to say that the idea of a
certain solution excludes there in my mind the consideration of the
books which I have read and of the discussions which I have heard.
Emotions may be superadded. In short, a world of mental states may be
held together by one act of attention. And new and ever new thoughts
are shooting in, and all still find place there in the field attended
to, while on the other hand my slight headache is inhibited and an
appointment is forgotten. At a gay banquet, my attention may be given to
the whole hall with all its color effects and its flowers, and to all
that the table offers and to the music from the orchestra and to the
jokes of my neighbors. It is not true that any one of those parts
suppresses the vividness of the others, they seem rather to maintain and
to help one another; and yet in the next moment, my neighbor may bring
me news which absorbs my mind entirely and leaves no room for the
flowers and the music and the meal. How far can psychology do justice to
these characteristics of attention?

There seems to be but one way. The attended-to idea does not exclude
every other idea, but it does exclude the opposite idea, and opposite to
each other is here again that pair of ideas which lead to opposite
actions, to opposite psychophysical attitudes. We must remember here the
psychomotor character of our brain processes which we so fully
discussed. We recognized the fundamental truth that there is no
sensorial state which is not at the same time the starting-point for
motor reaction. We recognized that the brain is by its whole
psychological development a great switchboard which transfers incoming
currents into outgoing ones and that its biological meaning lies in the
fact that it is the center piece of an arc which leads from the sense
organs to the muscles. We cannot conceive of those relations as complex
enough; we know, of course, that millions of nerve fibers lead from the
periphery to the highest psychophysical apparatus in the cortex of the
brain and that millions of fibers bring about the interrelation between
these central stations, but we must never forget that millions of fibers
also represent the outgoing paths and that they too lead down to lower
central motor instruments which are again in numberless corelations. Any
impression is thus a starting point for attitudes and reactions and it
is an empty abstraction to consider it otherwise. An idea is never,
psychophysically considered, the end of the process, it is always also a
beginning. No external action may follow, but the mental impulse to such
is nevertheless starting in the highest center.

If we look at the landscape, every single spot of color, reaching a
nerve fiber in our eye and finally a sensory cell in our brain, is there
the starting point for an impulse to make an eye movement in the
direction of the seen point. The eye may remain entirely quiet as the
impulse to move to the right and to the left, to move up and to move
down, may be equally strong, but those thousands of impulses work in the
motor paths and only their equilibrium results in the suppression of the
outer movement. With such motor scheme, we begin to understand the
selective process in attention. An impression may be accompanied by
other stimuli and associations, by thoughts and ideas, and thousands of
sensory excitements may thus arise in the cortex, but only those have a
chance for full vividness of development which coöperate in the motor
action already started. Those impressions which would lead to the
opposite actions have no chance because their motor paths are blocked
and their own full development is dependent upon their possibility of
expression. To close the path means to inhibit the idea which demands
such action. We can attend to a hundred thoughts together, if they all
lead to the same attitude and deed. We can look at the opera, can see
every singer and every singer's gown, can listen to every word, can have
the whole plot in mind, can hear the thousands of tones which come from
the orchestra; and yet combine all that in one act of attention, because
it all belongs to the same setting of our reactive apparatus. Whatever
the one wants is wanted by the others. But if at the same time our
neighbor speaks to us, we do not notice it; his words work as a stimulus
which demands an entirely different motor setting as answer. Therefore
the words remain unvivid and unnoticed.

To attend means therefore to bring about a motor setting by which the
object of attention finds open channels for discharge in action. Which
particular action is needed in the state of attention cannot be
doubtful. Attention demands those motor responses and those inner steps
by which the object of attention shows itself more fully and more
clearly. When we give attention to the picture we want to see more
details, when we give attention to the problem we want to recognize more
of the factors involved, when we give attention to the banquet we want
to grasp more of the pleasurable features. This aim of attention
involves that, as part of such reactions, the sense organs become
adjusted; we fixate the eyeball, we listen, and in consequence the
object itself becomes clearer, and through the easy passage into the
motor channels the whole impression becomes vivid. At the same time, all
those associations must be reënforced and become vivid too which lead to
the same action. On the other hand, the opening of the one passageway
closes the path to the opposite action and inhibits the impressions
which would interfere with our interest. Every act of attention becomes,
therefore, a complex distribution in the reënforcement and inhibition of
mental states.

Now let us come back to suggestion. It shares, we said, with attention,
the power to reënforce and to inhibit. But if we examine what is
involved in the suggestion of an idea, we find surely more than a mere
turning of the attention towards one idea and turning the attention away
from another idea. That which characterizes and constitutes suggestion
is a belief in the idea, an acceptance of the idea as real and the
dismissal of the opposite idea as unreal. Yes, we may say directly that
it is meaningless to speak of suggesting an idea; we suggest either an
action or, if no action is concerned, we suggest belief in an idea. If I
suggest to the fearful man at twilight that the willow-tree trunk by the
wayside is a man with a gun, I do not turn his attention to an abstract
idea of a robber nor do I simply awaken the visual impression of one,
but I make him believe that such an idea is there realized, that he
really sees the person. If I suggest to him that he hears distant bells
ringing or that he feels a slight headache, he may not be suggestible
enough to accept it, but if he accepts it he is not simply attending to
the idea which I propose but he is convinced of its real existence. The
same holds true with the negative; if I suggest to him that the slight
headache of which he complained has disappeared or that the smell which
he noticed has stopped, I do not simply invite him to think of the
absence of such sensations. It becomes for him a suggestion only if he
becomes convinced that these disturbances have now become unreal. The
same holds true for all those suggestions of ideas which belong to our
practical life, the suggestions which art imprints on our minds, or
which politics and religion impart. As long as we are under the
suggestion of the novelist, we really believe in the existence of the
heroine; we really believe in the validity of the political party
principle; it is not an argument to which we simply give our attention,
it becomes a suggestion only when the belief in its objective existence
controls our minds. We may say in general that suggestions which are not
suggestions of actions are without exception suggestions of belief.
Actions and beliefs are the only possible material of any suggestion.

Yet what else is a belief than a preparation for action? I may think of
an object without preparing myself for any particular line of behavior.
Here in the room I may think of rain or sunshine on the street as a mere
idea, but to know that it now really rains or shines means something
entirely different. It means a completely new setting in my present
attitude, a setting by which I am prepared to act along the one or the
other line, to take an umbrella or to take a straw hat, when I am to
leave the house. I may think of the door of this room as locked or
unlocked without transcending the mere sphere of imagination, but to
believe that it is the one or the other means a new setting in my motor
adjustments. If it is locked I know that I cannot leave the room without
a key. Every belief means the preparation for a definite line of action
and a new motor adjustment in the whole system of motor paths, an
adjustment by which my actions in future will be switched off at once
into particular paths. And there is theoretically no difference whether
my belief refers to the proposition that the door is locked or that a
God exists in Heaven.

But if every belief is such a new motor setting, then we are evidently
brought back to the mechanism which was essential for every suggestion
of action on the one side and for every process of attention on the
other side, namely, the mechanism of antagonistic movements. To prepare
ourselves for one line of action means to close beforehand the channels
of discharge for the opposite. The suggestible mind sees the man with a
gun on the wayside because he is preparing himself in his expectation
for the appropriate action; he is ready for the fight or ready to run
away, and every line of the tree trunk is apperceived with reference to
this motor setting. The smell, on the other hand, has disappeared under
the influence of the suggestion because a new motor adjustment has set
in, in which he is prepared to act as if there were no smell.

The difference between suggestion and attention lies thus only in this:
the motor response in attention aims towards a fuller clearness of the
idea, for instance, by fixating, listening, observing, searching; while
the motor response in suggestion aims towards the practical action in
which the object of the idea is accepted as real. In attention, we
change the object in making it clearer; in suggestion, we change
ourselves in adapting ourselves to the new situation in which we
believe. If you consider attention as a psychophysical process open to
physiological explanation, you have surely no reason to seek anything
mysterious in the process of suggestion; and no new principle is
involved, if we come from the effect of the smallest suggestive hint to
the complex and powerful suggestions which overwhelm the whole
personality.

The two great types of suggestion, the suggestion of actions and the
suggestion of ideas, have now come nearer together since we have seen
that the suggestion of ideas is really a suggestion of the practical
acceptance of ideas, and that means, of a preparation towards a certain
line of action. In the one case I suggest the idea of a certain action
and this motor idea leads to the action itself, and in the other case I
suggest a certain preparatory setting for action and that will lead to
the appropriate action whenever the time for action comes. Every
suggestion is thus ultimately a suggestion of activity. The most
effective suggestion for an action results, of course, if both methods
are combined, that is, if we suggest not only the will to perform the
action, but at the same time the belief that the end of the action will
be real. Suggestion reaches us usually from without. Yet there is again
no new principle involved, when the new motor setting results from one's
own associations and emotions. Then we speak of auto-suggestion. It is
the same difference which exists between the attention called forth
through an outer impression and the attention directed by our own will.
Loud noise demands our attention, and even a whispered word may awaken
associations which stir up the attention. In both cases the channels for
adjustment become opened without our intention. But if we are expecting
something of importance, if we start to watch a certain development and
to find something which we seek, we open the channels by our own effort
beforehand and produce our own settings thus through a voluntary
attention. In this way suggestion too may start from without,--by a
spoken word, by a movement, by a hint; or may start within us and may
give us our caprices and our prejudices.

We must not neglect one other feature of the suggestion. Not every
proposition to action or to belief can be called a suggestion. Essential
too remains the other side of it, the overcoming of the resistance. A
mere request, "Please hand me the book on the table," or a mere
communication, "It rains," may produce and will produce the fit motor
response, the movement towards handing over the book or opening of the
umbrella, and yet there may be no suggestive element involved. We have a
right to speak of suggestion only if a resistance is to be broken down,
that is, if the antagonistic impulse, or the motor setting for the
antagonistic action is relatively strong. If I say to the boy, "Hand me
the book," when he was anxious to hide the book from my eyes and thus
had the wish not to hand it to me and the tone of my request overwhelmed
his own intention, then to be sure suggestion is at work. The stronger
the resistance, the greater the degree of suggestive power which is
needed to overcome the motor setting. If I say to the normal man, "It
rains," while he sees the blue sky and the dry street, his impression
will be stronger than my suggestion; but if he is suggestible and I tell
him that it will rain, he may accept it and take an umbrella on his
walk, even if no indication makes a change of weather probable. The
present impression of the dry street was strong enough to resist the
suggestion, the imaginative idea of that which is to be expected in the
next hour was too weak, and was overwhelmed by the suggestion of the
weather prophecy.

It is clear that the whole suggestive effect, being one of a new motor
setting, depends thus entirely on the equilibrium of the personality
which receives the suggestion. Every element which reaches the mind
through sense organs or through associations must have influence in
helping the one or the other side, that is, in opening the channels of
action in the suggested direction or in the antagonistic one. The
results appear surprising only if we forget how endlessly complex this
psychomotor apparatus really is. If we disregard this complexity we may
easily have the feeling that one person has an unexplainable influence
over another, as if the will of the one could control in a mysterious
way the will of the other. But as soon as we see that every action is
the result of the coöperation of hundreds of thousands of psychomotor
impulses which are in definite relation to antagonistic energies, and
that the result depends upon the struggling and balancing of this most
complex apparatus, then we understand more easily how outer influences
may help the one or the other side to preponderance: as soon as the
balance turns to the one side, a completely new adjustment must set in.
And we understand especially that there is nowhere a sharp demarcation
line between receiving communications and receiving suggestions. By
small steps suggestion shades over into the ordinary exchange of ideas,
propositions, and impressions, just as attention shades over into a
neutral perception.

To be suggestible means thus to be provided with a psychophysical
apparatus in which new propositions for actions close easily the
channels for antagonistic activity. Such an apparatus carries with it
the disadvantage that the personality may too easily be guided contrary
to his own knowledge and experience. He will be carried away by every
new proposition and will accept beliefs which his own thoughts ought to
reject. On the other hand, it has the advantage that he will be open to
new ideas, be ready to follow good examples, never stubbornly close his
mind to the unaccustomed and the uncomfortable. It is easy to determine
the degree of suggestibility. Take this case. I draw on the blackboard
of a classroom two circles of an equal size, and write in the one the
number fourteen and in the other the number eighty-nine, and ask the
children which is the larger circle. The suggestible ones will believe
that the circle with the higher number in it is really larger than the
other, the unsuggestible children will follow the advice of their senses
and call both equal, and there may be a few children with negative
suggestibility who would call the circle with the higher number the
smaller circle. What happened to the suggestible ones was that the
higher number brought about a motor attitude which faced that whole
complex as being more imposing and this new motor setting was with them
strong enough to overcome the motor adjustment which the circles alone
produced. Such experiments of the psychological laboratory can be varied
a thousandfold, and it might not be unwise to introduce them into many
practical fields. Everybody knows for instance how much may depend upon
the suggestibility of the witness in court. The suggestible witness
believes himself to have seen and heard what the lawyer suggests. The
memory picture which such a witness has in mind offers, of course, much
less resistance to the opposite action and attitude and belief than the
immediate impression. If I show the witness a colored picture of a room
and close the book and ask him whether there were three or four chairs
in the picture and whether the curtain was green or red, the suggestible
man will decide for one or the other proposition, even if there were
only two chairs and a blue curtain. The perception would have resisted
the suggestion, the fading memory image cannot resist it. Thus
suggestibility is really a practical factor in every walk of life. And
it is in the highest interests of psychotherapy that this intimate
connection between suggestion and ordinary talk and intercourse, between
suggestion and ordinary choice of motives, between suggestion and
attention be steadily kept in view and that suggestion is not
transformed into a kind of mysterious agency.

To be sure, the importance of suggestion for psychotherapy is not
confined to these suggestive processes of daily life. They play a rôle
there, as we shall see, and we shall claim that even the mere presence
of the physician may have its suggestive power and so may every remedy
which he applies. But no doubt many of his suggestive effects depend on
a power which far transcends the suggestions of our daily life. Yet the
psychologist must insist again that no new principle is involved, that
even in the strongest forms of suggestion, in hypnotism, nothing depends
upon any special influence emanating from the mind of the hypnotizer or
upon any special power flowing over from brain to brain; but that
everything results from the change of equilibrium in the psychomotor
processes of the hypnotized, and thus upon the interplay of his own
mental functions. All that is needed is a higher degree of
suggestibility than is found in the normal life. In a more suggestible
mind even the direct sense impressions may be overwhelmed by the
proposition for an untrue belief and the strongest desires may yield to
the new propositions of action. This library may then become a garden
where the hypnotized person picks flowers from the floor, and the wise
man stands on one leg and repeats the alphabet, if the hypnotizer asks
him to do so. Let us consider at first this extreme case. By a few
manipulations I have brought a man into a deep hypnotic state. He is now
unable to resist any suggestion, either suggestion of impulse or
suggestion of belief, and as every one of the hypnotic phenomena can be
explained in this way, we may claim that the hypnotic state is in its
very nature a state of reënforced suggestibility. Whether I say, "You
will not move your arm," or whether I say, "You cannot move your arm,"
awakening in the one case the impulse to the suppression of the
movement, in the other case the belief in the impossibility of the
movement, in either case the result is the same; the arm remains stiff
and any effort of his to move it is inhibited. I may go to the extreme
and tell him that our friend by my side has left the room; he will not
see him, he will not even hear a word which the friend speaks. If I take
a hat in my hand and put it on the friend's head, the hat appears to
hang in the air. Every impression of sound or sight or touch which comes
from the friend is entirely inhibited. The direct sense impression of
eye and ear is thus completely overwhelmed by the suggestion.

What has happened? Are the manipulations which I applied sufficient to
produce the changes by their physical influence? Certainly not; they are
of the most different kinds and yet all may have the same effect.
Perhaps I may have used the easy method of making the subject stare at a
shining button held in front of his forehead. Or I may have used slight
tactual impressions, while he was lying with closed eyes, or I may have
produced the abnormal state by monotonous noises of falling waterdrops,
or I may have simply spoken to him and asked him to think of sleep and
to relax and to feel tired, while I held my hand on his forehead or
while I held his hand in mine. Or I may have relied upon mild talking
without touching him at all; and yet every time the result was reached
in the same degree. There is thus certainly no special physical energy
which like a magnetic force flows over. It cannot even be said that my
will is engaged. I have often hypnotized without even thinking of the
subject before me, going through adjusted manipulations while my
thoughts were engaged in something else. I have even hypnotized over the
telephone; and a written note may be substituted with the same result. I
write to the patient that two minutes after receiving this letter by
mail, he will fall into hypnotic sleep. The effect sets in; and yet at
that time, I may not remember sending the note at all.

It is thus entirely evident that the hypnotic effect results only from
the mental conditions of the subject. Whatever may stimulate his mind
to the right kind of reaction will produce the desired result. The
increased suggestibility thus sets in by his own imagination which may
be stirred up by slight visual or tactual or acoustic stimuli or by
monotonous words or by feelings of relaxation and especially by words
which encourage sleep. But just because it is the play of his own
imagination, the most essential factor certainly is the will and
expectation of the subject. No one can really be hypnotized against his
own will. And to expect strong hypnotic effect from a certain hypnotist
is often in itself sufficient to produce hypnotic sleep. Thus there is
no special personal power necessary to produce hypnotism. Everybody can
hypnotize. And almost with the same sweeping statement it may be said
everybody can be hypnotized, provided that he is willing to enter into
this play of imagination. The young child or the insane person is
therefore unfit.

Of course, not everybody can be hypnotized to the same degree. Just as
the normal suggestibility showed itself very different with different
persons, the degree of artificial reënforcement varies still more.
Practically everybody can be brought to that breakdown of the
resistance in which he can no longer open the eyes against the order of
the hypnotist, but rather few can be brought to the point of seeing
extended hallucinations, or accepting the disappearance of persons who
are speaking, or of yielding to the impulse to a dangerous action. The
highest reported degree, in which even criminal actions are performed
by honest men, exists in my opinion only in the imagination of
amateurs; it is certainly not difficult to produce sham crimes for
performance sake, with paper daggers and toy pistols, but that is no
proof at all that the hypnotized person would commit a crime under
conditions under which he has the conviction that he faces a real
criminal situation. But if we abstract from real crime, we certainly
have to acknowledge that actions can be performed which appear in
striking contrast with the habits and character of the normal
personality, upset his knowledge, and are based on beliefs which would
be immediately rejected under ordinary conditions. These higher degrees
of hypnotic state are easily followed by complete loss of memory for all
that happened during the abnormal state.

How have we to interpret such a surprising alteration of mind? It lies
near to compare it with sleep. The brain seems powerless to produce its
normal ideas, the associations do not arise, the normal impulses have
disappeared and a general ineffectiveness has set in; in short, the
brain cells seem unable to function. Of course, the explanation of sleep
itself may offer difficulties. Is it a chemical substance which poisons
the brain during the sleep, or are the brain cells contracted so that
the excitement cannot run over from the branches of one nerve cell into
those of another? Or are the blood-vessels contracted so that an anæmic
state makes their normal function impossible? But whatever the physical
condition of sleep may be, have we really a right to emphasize the
similarity between sleep and hypnosis? After all that we have discussed,
we ought rather to recognize that the hypnotic state too comes much
nearer to the process of attention than to the process of sleep. We saw
that in every act of attention the process of inhibition is essential.
All that is not in harmony with the attended idea is suppressed. Yet we
should hesitate to say that in attention parts of our brain are asleep.

We should feel reluctance to group such inhibition together with sleep
because it would be a sleep which at any moment can pass from one part
of the brain to others and which certainly leaves at every moment most
of the cell groups unaffected. We saw that attention does not at all
focus on one narrow point, but that an abundance of impressions, of
ideas and associations, of thoughts and emotions can enter the field of
attention, if they all lead to one and the same motor attitude, and that
only the one part is inhibited which involves the opposite action. Such
a jumping sleep which at every moment selects a special part would be,
of course, just the contrary of that which characterizes the sleep state
of the fatigued brain. But exactly these characteristics of attention
belong to hypnotism too. It is not true that the mind of the hypnotized
is asleep and that perhaps only one or the other idea can be pushed into
his mind. On the contrary, his mind is open to an abundance of ideas,
just as in the normal state. If I tell him that this is a landscape in
Switzerland, he sees at once the mountains and the lakes, and his mind
provides all the details of his reminiscences, and his imagination
furnishes plenty of additions. His whole mind is awake; the feelings and
emotions and volitions, the memories and judgments and thoughts are
rushing on, and only that is excluded which demands a contrary attitude.
This selective process stands decidedly in the center of the hypnotic
experience and makes it very doubtful whether we are psychophysically on
the right track, if we make much of the slight similarity between
hypnosis and sleep.

This has nothing to do with the fact that hypnosis is best brought about
by suggesting the idea of sleep, that is, the belief that sleep will
set in. This belief is indeed effective in removing all the ideas
which are awake in the mind which would interfere with the willingness
to submit to the suggestions of the hypnotizer. But the fact that
belief in sleep and expectation of sleep bring with them the hypnotic
state is not a proof that the hypnotic state itself is sleep. Even
the mental experiences which can remain in sleep, the dreams, are
characteristically different from the hypnotic experience. Thus the
dreams show that unselective awakening of ideas which is to be expected
from a general decrease of functioning. The hypnotic variation is
characterized just by its selective narrowing of consciousness. For the
same reason, hypnotism is strikingly different from such diseases of the
mind as dementia. Certainly in dementia too, many associations are cut
off, but it is not a selective inhibition, it is a haphazard destruction
resulting from the degeneration in the brain.

The fundamental principle of the hypnotic state lies in its selective
character. Inhibited and cut off are those states which are antagonistic
to the beliefs in the suggested ideas, and as their antagonism consists
in their connection with opposite actions, the whole is again a question
of motor setting. No doubt, such new motor setting can precede the
normal sleep too; thus the sleeper may be insensitive to any surrounding
noises, but perhaps awake at the slightest call from a patient who is
intrusted to his care. In that case, one special feature of hypnotism is
superadded to sleep but the sleep itself is not hypnotic. Again sleep
may go over into a state which shares many characteristic features with
hypnotism, that is, somnambulism, and it may be said with a certain
truth that hypnotism is artificial somnambulism. But somnambulism, while
arising in sleep, is not at all a feature of sleep.

While sleep is characterized by a decrease of sensitiveness and of
selective powers, the selective process of hypnotism rather reënforces
sensitiveness and memory in every field which is covered by the
suggestive influence. Stimuli may become noticeable which the normal man
is unable to perceive, and long-forgotten experiences which seem
inaccessible to the search of the waking mind may reproduce themselves
and may vividly enter consciousness. Again we have there symptoms which
rather characterize the state of over-attention than the state of sleep.
We might add further that we know states with all the characteristics of
hypnotism in which even the subjective idea of sleep is entirely
absent, for instance, all those which are usually called states of
fascination. A certain shining light or a glimpse of an uncanny eye may
startle and upset the imagination of the subject and throw him into a
state of abnormally increased suggestibility. It is well known that
whole epidemics of such captivation have occurred and have resulted in
hysterias of the masses in which the subjects become the slaves of their
impulse, perhaps to imitate what they see or hear, or to realize ideas
in which they believe without logical warrant. They surely are not
asleep, are not even partially asleep. Every center of their brains
would be ready to work, if the captivated attention were not forcing the
mind in one direction and selectively suppressing every impulse to
opposite actions. The developed hypnotism finally shades off into
innumerable states of hypnoid character in which the sleeplike symptoms
are entirely in the background.

Thus the increased suggestibility of the hypnotic state will result not
from a partial sleeplike decrease of functioning but the decrease of
function is a motor inhibition which results from over-attention. In the
ordinary attention, our motor setting secures only an increase in
clearness and vividness of the attended ideas, but in an abnormal
over-attention the new motor setting produces a complete acceptance with
all its consequences. Abnormal or heightened attention thus goes
directly over into the belief and into the impulse without resistance.
There is no hypnotism which does not contain from the first stage this
definite relation to certain objects of attention, usually to a
particular person. All the manipulations, passes, fixation, monotonous
speaking, and so on narrow the contents of consciousness but hold the
idea of the hypnotizing person steadily in the center of attention. The
awakened expectation of sleep, the associated feeling of tiredness all
help to cut off attention from the remainder of the world, but as no
real sleep sets in, this cutting off from the remainder reënforces the
focusing of attention on the one central idea of the hypnotizing
personality. Every word and every movement of this personality become
therefore absorbed with that over-attention which leads at once from a
mere perceiving and grasping to a complete sinking into the suggested
idea with the suppression of all opposites, and thus to a blind
acceptance and belief. We saw before that such belief is indeed nothing
else but a motor setting in which certain ways of action are prepared.
We are to think in accordance with the belief in the suggested idea and
the channels for discharge in the opposite direction are closed. Even
the ordinary life shows us everywhere that the step from attention to
belief is a short one. The effort to grasp the object clearly works as a
suggestion to accept that which we are seeking as really existing, and
that from which we are to abstract and which we are to rule out through
our attention, we believe to be non-existent. The prestidigitator does
his tricks in order to sidetrack our attention, but he succeeds in
making us believe that we see or do not see whatever he wishes.

That the motor setting alone determines those changes and that a real
sleeplike inability of the centers does not set in, can also be
demonstrated by the results of later hypnotizations. I ask my hypnotized
subject not to perceive the friend in the room; he is indeed unable to
see him or to hear him. Yet his visual and acoustic centers are not
impaired, the defect is only selective, inasmuch as he sees me, the
hypnotizer, and not the friend. But even this selection inhibits only
the attitude and not the sensorial excitement. If I hypnotize him again
to-morrow and suggest to him now to remember all that the friend did and
said during yesterday's meeting, he is able to report correctly the
sense impressions which he got, which were inhibited only as long as
they contradicted the suggestion, but now rush to consciousness as soon
as the suggestion is reversed. As a matter of course, he must therefore
have received impressions through eye and ear in his hypnotic sleep of
yesterday from all that happened, only he was not aware of it because
the channels of the accepting attitude were blocked.

As soon as the over-attention has produced the acceptance of the belief,
all further effects are automatic and necessary. If I tell the
hypnotized person that he cannot speak and he absorbs this proposition,
with that completeness in which he accepts it as a fact, not speaking
itself unavoidably results. The motor ideas with which the speech
movement has to start are cut off and the subject yields passively to
the fate that he cannot intonate his voice. Thus a special influence on
the will is in no way involved. If the idea is accepted, and that means,
if the preparatory setting for the action has been completed, the ideas
of opposite activity must remain ineffective; the suggested idea must
discharge itself in action without resistance. As a matter of course the
new line of action will then surround itself with its own associations
and will thus give to the subject the impression that he is acting from
his own motives. As soon as the psychophysical principles are
understood, there is indeed no difficulty in going from the simplest
experience to those spectacular ones where we may suggest to the
profoundly hypnotized person that he is a little child or that he is
George Washington. In the one case, he will speak and cry and play and
write as in his present imagination a child would behave; in the other
case, he will pose in an attitude which he may have seen in a picture of
Washington. There is nothing mysterious and his utterances are
completely dependent upon his own ideas, which may be very different
from the real wisdom of a Washington and the real unwisdom of a child. I
may suggest to him to be the Czar, by that he will not become able to
speak Russian. In the same way I may suggest changes of the
surroundings; he may take my room for the river upon which he paddles
his canoe, or for the orchard in which he picks apples from my
bookshelves.

Finally there is no new principle involved, if the action which is
prepared by any belief has to set in after the awaking from hypnotic
sleep, the so-called post-hypnotic suggestion. As a matter of course,
just these have an eminent value for psychotherapy. I may suggest to-day
that the subject will overcome to-morrow his desire for the morphine
injection, or that he will feel to-night the restfulness which will
overcome his insomnia. But if the suggestion of an idea means belief,
and if belief means a preparation for action, we have indeed no new
factor before us if the action for which we prepare the subject is from
the start related to a definite time. If we do not link it with the
consciousness of a special time or of a special occasion which will
occur later, the suggestion soon fades away. That my library is an
orchard is forgotten perhaps within ten minutes, if I have not come back
to it in the conversation. But if I say that after awaking as soon as I
shall knock on my desk three times, you will be in the orchard again,
the psychophysical apparatus is prepared, a new setting has set in, the
three knocks will bring about the complete transformation. In short the
difficulties disappear as soon as we are consistent in interpreting all
suggestive influences as changes in the motor setting and as the result
of the antagonistic character of all of our motor paths.

We say the difficulties disappear. Of course, that is meant in a
relative sense only. It means essentially that we are able to bring the
complex state of hypnotism down to the similar state of attention and
motor adjustment, but of course we must not forget that we are far from
a satisfactory explanation of the process in attention itself. We know
that the opening of motor channels in one direction somewhat closes the
channels for discharge in the opposite direction, but what mechanism
does that work is still very obscure. Whichever principle of
hypothetical explanation we might prefer, it certainly leads to
difficulties in view of the extreme complexity of attention in states of
suggestion and hypnotism. We might think of a mechanism which through
the medium of the finest blood-vessels should produce a localized anæmia
in those centers which lead to the antagonistic action. Or we might
fancy that by extremely subtle machinery the resistance is increased in
those tissues which lie between the various neurons, or we might even
think of toxic and antitoxic processes in the cerebral regions; and any
day may open entirely new ways of explanation. We may add that even if
the mechanism of attention were completely explained, we are also still
far from understanding the physiological changes which go on in the
sphere of the blood-vessels or of the glands and the internal organs. We
understand easily that the idea of the subject that he cannot move his
arm keeps the arm stiff; but that his idea to blush really dilates the
blood-vessels of his cheek is much less open to our causal
understanding; still less that in very exceptional cases perhaps a part
of the skin becomes inflamed, if we make believe that we touch it with a
glowing iron. And yet here too we see that we move in the same direction
and that we have to explain these exceptional and bewildering results by
comparing them with the simpler and simpler forms, that the process of
attention contains all the germs for the whole development.

In claiming that hypnotism depends upon the over-attention to the
hypnotizing person, we admit that the increased suggestibility belongs
entirely to suggestions which come from without. Only that which at
least takes its starting point from the words or the movements of the
hypnotizer finds over-sensitive suggestibility. Ideas which arise merely
from the associations of the subject himself have no especially
favorable chance for acceptance. But surely we also know states in which
the suggestibility for certain of one's own ideas is abnormally
increased. Great individual differences exist in that respect in normal
life. There are normal hypochondriacs who believe that they feel the
symptoms of widely different diseases under the influence of their own
ideas, and others who are torturing themselves with fears on account of
unjustified beliefs. But the abnormal increase of suggestibility
parallel to that of hypnotism for suggestions from without exists for
suggestions from within, mainly in nervous diseases, especially in
neurasthenic, hysteric, and psychasthenic states. Within certain limits,
we might almost say that this increase of suggestibility for
autosuggestion is the fundamental characteristic of these diseases, just
as increase of suggestibility for heterosuggestions characterizes
hypnotism.

Especially in earlier times, the theory was often proposed that hypnosis
is an artificial hysteria. Such a view is untenable to-day; but that
hysteria too shows abundant effects of increased suggestibility is
correctly indicated by such a theory. The hysteric patient may by any
chance pick up the idea that her right arm is paralyzed or is
anaesthetic and the idea at once transforms itself into a belief and the
belief clings to her like an obsession and produces the effect that she
is unable to move the arm or that she does not feel a pinprick on the
skin. These autosuggestions may take a firmer hold of the mind than any
suggestions from without, but surely such openness to selfimplanted
beliefs must be acknowledged as symptomatic of disease, while hypnosis
with its impositions can be broken off at any moment and thus should no
more be classed among the diseases than are sleep and dreams. The
hysteric or psychasthenic autosuggestion resists the mere will of
breaking it off. Here, therefore, is the classical ground for strong
mental counterinfluences, that is, for psychotherapeutic treatment.
Experience shows that the strongest chance for the development of such
autosuggestive beliefs exists wherever an emotional disposition is
favorable to the arriving belief. But emotion too is after all
fundamentally a motor reaction. The whole meaning of emotion in the
biological sense is that it focuses the actions of man into one channel,
cutting off completely all the other impulses and incipient actions.
Emotion is therefore for the expressions of man what attention is for
the impressions. An emotional disposition means thus in every case a
certain motor setting by which transition to certain actions is
facilitated. It is thus only natural that a belief can settle the more
easily, the more it is favored by an emotional disposition, as the motor
setting for the one must prepare the other. Hypnosis and hysteria thus
represent the highest degrees of suggestibility, the one artificial, the
other pathological; the one for suggestions from without, the other for
suggestions from within. But between these two and the normal state
there lie numberless steps of transition. The normal variations
themselves may go to a limit where they overlap the abnormal artificial
product, that is, the suggestibility of many normal persons may reach a
degree in which they accept beliefs hardly acceptable to other persons
in mild hypnotic condition. Thus there is no sharp demarcation between
suggestions in a waking state and suggestions in a hypnoid state. And
the expectation of coming under powerful influence may produce a
sufficient change in the motor setting to realize any wonders. Moreover
probably every physician who has a long experience in hypnotizing has
found that his confidence in the effectiveness of the deep hypnotic
states has been slowly diminished, while his belief in the surprising
results of slight hypnotization and of hypnoid states has steadily grown
and has encouraged him in his psychotherapeutic efforts.




VI

THE SUBCONSCIOUS


The story of the subconscious mind can be told in three words: there is
none. But it may need many more words to make clear what that means, and
to show where the misunderstanding of those who give to the subconscious
almost the chief rôle in the mental performance sets in. The psychology
of suggestion, for instance, which we have now fully discussed without
even mentioning the word subconscious, figures in most popular books in
the treatises of both physicians and ministers as a wonderful dominance
of the subconscious mind. The subconscious mind alone receives the
suggestions and makes them effective, the subconscious mind controls the
suggestive processes in consciousness, and the subconscious mind comes
into the foreground and takes entire hold of the situation when the
hypnotic state sets in.

But we are always assured that there is no need of turning to the
mystery of suggestion and hypnotism to find that uncanny subpersonality
in us. We try to remember a name, or we think of the solution of a
problem; what we are seeking does not come to consciousness and now we
turn to other things; and suddenly the name flashes up in our mind or
the solution of the problem becomes clear to us. Who can doubt that the
subconscious mind has performed the act? While our attention was given
over to other questions, the subconscious mind took up the search and
troubled itself with the problem and neatly performed what our conscious
mind was unable to produce. Moreover in every situation we are
performing a thousand useful and well-adapted acts with our body without
thinking of the end and aim. What else but the subconscious mind directs
our steps, controls our movements, and adjusts our life to its
surroundings? And is not every memory picture, every reminiscence of
earlier experiences a sufficient proof that the subconscious mind holds
its own? The poem which we learned years ago did not remain somewhere
lingering in our consciousness, and if we can repeat it today, it must
be because our subconscious mind has kept it carefully in its store and
is ready to supply us when consciousness has need for it.

Surely if we think how this, our subconscious mind, is able to hold all
our memories and all our learning, and how it transacts all the work of
controlling our useful actions and of bringing up the right ideas, we
may well acknowledge that compared with it our conscious life is rather
a small part. It is as with the iceberg in the ocean; we know that only
a small part is visible above the surface of the water and a ten times
larger mountain swims below the sea. It seems, therefore, only logical
to attach this whole subconscious mental life to a special subconscious
personality. Then we come to the popular theory of the two minds in us,
the upper and the lower, of which we can hardly doubt that the lower one
has on the whole the larger part of the business to perform. And we
certainly have no right to give to the word lower mind the side-meaning
that the activity is of a lower order. The most brilliant thoughts of
the genius are not manufactured in his upper consciousness, they spring
suddenly into his mind, their whole creation belongs thus to the
assiduous work of the subconscious neighbor. There the inventor and
discoverer gets his guidance, there the poet gets his inspiration, there
the religious mind gets its beliefs. In short, the constitution of the
mental state allows on the whole to the upper consciousness a rather
decorative part while the real work is left for the lower house.

Yet it must be acknowledged that the scholars somewhat disagree as to
the dignity of the lower mind. Considering the usually accepted fact
that in hypnotism the lower mind comes entirely over the surface, just
these hypnotic events can indeed suggest two different views of the
subconscious and this doubleness is reënforced if we still add the
entertaining material which comes to light by the automatic writing of
mediums in their trance. The hypnotized person is ready to perform any
foolishness, is not influenced by any considerations of tact and taste
and wisdom and respect, and thus some of the chief believers in the
subconscious personality stick to the diagnosis that the lower mind in
us which shows up in hypnotism is a rather brutal, stupid, lazy,
cowardly, immoral creature which ordinarily rather deserves to be
subdued by our noble and wise upper personality. And the automatic
writings of the mediums indorse this disrespectful view, for it is
difficult to gather more idiotic slang than the emanations of these
letters of the planchette. On the other hand, the hypnotized person
shows an increase of sensitiveness and hyperæsthesia in which perhaps
optical impressions or smells may be noticed which the ordinary man
cannot perceive. Moreover the memory of the hypnotized is, as we saw,
abnormally sharpened. Entirely forgotten experiences may awake again.
The same holds true for the hysteric in whom also, of course, the
subconscious takes hold of the inner life. Thus it seems entirely safe
to say that the powers of the subconscious personality far surpass those
of the upper conscious fellow, and that agrees with all those facts as
to the subconscious origin of the work of the genius. Further, has it
not been found again and again that the hypnotized and the hysteric
cannot only remember long-forgotten parts of the past but have
telepathic knowledge for distant events and even mysterious premonitions
of the field of occurrences of the future?

Hypnotism is essentially the same as the old mesmerism, and mesmerism
was widely acknowledged as clairvoyance, and all that harmonizes again
with the experiences of the mediums whose subconscious mind in trance
enters into contact with the spirits of the dead. The subconscious
personality is thus really a metaphysical power which transcends the
limitations of the earthly person altogether and has steady connection
with the endless world of spirit and the inner soul of the universe.
Most popular books, it is true, do not demand from their readers the
choice between the one or the other type of the lower personality,
between that brutal, vicious, ignorant creature and that far-seeing,
inspired, powerful soul. They simply mix the two and adapt the special
faculties of this underground man to the special requirements of the
particular chapter, the subconscious being unusually wise or unusually
stupid in accordance with the special facts which are just then to be
explained. Even that does not always settle all difficulties. They may
discover, for instance, that the subconscious mind with which we deal in
the hypnotized person has again itself a subconsciousness. If we tell
the hypnotized person not to see a certain picture on the wall, this
subconscious personality perceives the whole room with the exception of
the picture. Yet after all someone sees this picture, because if we
hypnotize him the next time and ask him what the picture contained, he
now knows its contents. Thus they must have been recognized in a
sub-subconsciousness, and we therefore come to a personality which lives
on a floor still below the basement. But experiment can demonstrate that
even this most hidden personality has still its secrets which are handed
downwards. In short, we finally have not merely two but a number of
personalities in us.

But now let us leave these fantasies of psychological fiction. Let us
turn to the concrete facts, let us see them in the spirit of modern
scientific psychology, let us try to explain them in harmony with the
principles of psychological explanation, and let us discriminate the
various groups of facts which have led to that easy-going hypothesis of
the subconscious. Discrimination indeed is needed, as it would be
impossible to bring the whole manifold of facts under one formula, but
there is certainly no unification reached by simply putting the same
label on all the varieties and behaving as if they are all at once
explained when they are called the functions of the subconscious. Two
large groups may be separated. Facts are referred to the subconscious
mind which do not belong to the mind at all, neither to a conscious nor
to a subconscious one, but which are simply processes in the physical
organism; and secondly, facts are referred to the subconscious mind
which go on in the conscious mind but which are abnormally connected.
Thus the subconscious mental facts are either not mental but
physiological, or mental but not subconscious.

What does the scientific psychologist really mean by consciousness? We
must now think back to our discussion of the principles which control
the fundamental conceptions of modern psychology. We saw clearly that
the psychology which is a descriptive and explanatory science of mental
phenomena can by no means have the ambition to be a full interpretation
of the inner reality. Our inner life, we saw, is not a series of
phenomena, is not a chain of objects which we are aware of and which we
therefore can describe, and which finally we can explain. But in its
living reality, we saw that it is purposive, has a meaning and aim, is
will and intention, and can thus be understood in its true character,
not by describing and explaining it but by interpreting it and
appreciating it. This is the life attitude towards personalities when we
deal man to man. We do not at first consider ourselves or our fellows as
mental objects to be explained but always as subjects to be understood
in their meaning. If we pass from this primary attitude to the attitude
of the scientific psychologist we gain, as we saw, an artificial
perspective. We must consider then our inner experience of ourselves
with all our states as a series of objects made up of elements connected
by law. Instead of the real things which in our real life are objects of
will and purpose, tools and means for us, the psychologist knows only
objects of awareness, objects which have no meaning, but which simply
exist and which are no longer related to a will but are connected with
other objects as causes and effects. Now we deal no longer with the
chairs and tables before us but from a psychological point of view they
become perceptive ideas of chairs and tables, ideas which are not in the
room but in our own minds. While these objects of our will and of our
personality become mere ideas, our will and personality themselves
become, too, a series of phenomena. Our self is now no longer the
purposive will but is that group of sensations and ideas which clusters
about the perception of our organism and its actions; in short, our
self itself becomes an object of awareness.

Our whole inner experience thus becomes a manifold of objects. Our self
and the actions of our self are thus alike for the psychologist mere
phenomena, mere objects which are perceived. Will and emotion, memory
idea and thought--they all are now passing appearances like the sunshine
and rain, the flowers and waves. By this transformation the immediate
will character of real life is given up, but instead of it a system of
objects is gained, that allows description and explanation. If we are to
deal at all with inner life not from a purposive but from a causal point
of view, we are obliged to admit this reconstruction. Without it we
cannot have any science of the mind, without it we can understand the
intentions of our neighbor and appreciate the truth and morality of his
meanings but we cannot causally explain his experiences or determine
which effects are to be expected. It is thus not an arbitrary
substitution but a procedure just as necessary and logically obligatory
as the work of the chemist who substitutes trillions of invisible atoms
for the glass of water which he drinks. The possibility of causal
explanation of the successive facts demands this remolding of the outer
and of the inner world. We have discussed that before and now only have
to draw the consequences.

Thus for the psychologist the mental world is a system of mental
objects. To be an object means of course to be object of some subject
which is aware of it. What else could it mean to exist at all as object
if not that it is given to some possible subject? But the world of
objects is twofold; we have not only the mental objects of the
psychologist but also the physical objects of the naturalist. Science
must characterize the difference between those two and we pointed once
before to the only fundamental difference. Physical objects are those
which are possible objects of awareness for every subject; psychical
objects are those which are possible objects of awareness for one
subject only. The tree which I see is as physical tree object for every
man, it is the same tree which you and I see; my psychical perception of
the tree is object for one subject only. My perception can never be your
perception. Our perceptions may agree but each has his own. As to the
physical objects, we can entirely abstract from such reference to the
subjects. We say simply: the tree exists or is part of nature; and only
the philosopher is aware that we silently mean by it that it exists for
every subject and that it is therefore not necessary to refer to any
particular subject. But the perception of the tree which is either your
idea or my idea evidently gets its existence only if it is referred and
attached to a particular subject which is aware of it. Such subject of
awareness is that which the psychologist calls consciousness and all the
ideas and volitions and emotions and sensations and images which make up
the mental life are then contents of the consciousness or objects of the
consciousness. To have psychical existence at all means thus to be
object of awareness for a consciousness. Something psychical which
simply exists but is not object of consciousness is therefore an inner
contradiction. Consciousness is the presupposition for the existence of
the psychical objects. Psychical objects which enjoy their existence
below consciousness are thus as impossible as a wooden piece of iron.

If consciousness is nothing but the subject of awareness for the
individual objects, we see at once certain consequences which are too
often forgotten in the popular, haphazard psychology. In the scientific
system of psychology, consciousness has for instance nothing whatever to
perform, that is, consciousness itself is in no way active. The active
personality of real life has been left behind and has itself been
transformed into that self which is merely content of consciousness. The
person who acts and performs the deeds of our life is then only a
central content of our consciousness which is crystallized about the
idea of our organism. It has thus become one of the contents of which
consciousness itself is passively aware. Consciousness is an inactive
spectator for the procession of the contents. Thus consciousness itself
cannot change anything in the content nor can it connect the contents.
No other function is left to consciousness but merely that of awareness.
Every change and every fusion and every process must be explained
through the relations of the various contents to one another.
Consciousness has, therefore, not the power to prefer the one idea or to
reject the other, to reënforce the one sensation and to inhibit the
other. From a psychological point of view, we have seen before that
even attention does not mean an activity of consciousness but a change
in the content of consciousness. Certain sensations become more
impressive, more clear, and more vivid, and others fade away, become
indistinct and disappear, but all that goes on in the content of
consciousness and the spectator, consciousness itself, simply becomes
aware of those changes. Consciousness has also in itself no special
span, ideas appear or disappear not because consciousness expands or
narrows itself but because the causal conditions awaken or suppress the
various contents.

Consciousness has in itself no limit; all organization belongs to the
content. Whatever psychical states are attributed to one organism belong
thus to its consciousness but all the connections are entirely
connections of the content. We, therefore, have not even the right to
say that consciousness, as such, has unity. Unity too belongs to the
organization of the content. One part of the content hangs together with
the other parts but consciousness is only the constant condition for
their existence. Where there is no unity, there it cannot have any
meaning to speak of the double or triple existence. There may be a
disconnection in the various parts of the content and a dissociation by
which the normal ties between the various contents may be broken but
consciousness itself cannot fall asunder. Thus consciousness cannot have
any different degrees. The same consciousness experiences the distinct
clear content and the vague fading confused content. Thus also
consciousness can never be aware of itself and the word
self-consciousness is easily misleading. In psychology, it can never
mean that the consciousness which is a subject of all experience is at
the same time object of any experience. Its whole meaning lies in its
being the passive spectator. That of which consciousness becomes aware
in self-consciousness is the idea of the personality, which is certainly
a content. The personality, the actor of our actions, is thus never
anything but an object in psychology, and consciousness never anything
but a subject. Consciousness itself is thus in no way altered when the
idea of the personality is changing. Only if all this is carelessly
confused, if consciousness is sometimes treated as meaning subject of
consciousness, and at another time as meaning the content of
consciousness, and again at another time the unified organization of the
content, and at still another time the connection of the content with
the personality, and if finally all that is confused with the purposive
reality of the immediate personal life--only then, do we find the way
open to those tempting theories of the subconscious personality.

       *       *       *       *       *

If, instead, we stick to the scientific view, we find the following
facts. First, we have everywhere with us the fact that the earlier
experiences may again enter into consciousness as memory images or as
imaginative ideas, that is, in the order in which they are experienced a
long time before or in a new order, either with a feeling of
acquaintance or without it. Certainly at no time is the millionth part
of what we may be able to reproduce present in our consciousness. Where
are those words of the language, those faces of our friends, those
landscapes, and those thoughts; where have they lingered in the time of
their seclusion? Scientific psychology has no right to propose any other
theory as explanation but that no mental states at all remain and that
all which remained was the disposition of physiological centers. When I
coupled the impression of a man with the sound of his name, a certain
excitement of my visual centers occurred together with the excitement of
my acoustical centers; the connecting paths became paths of least
resistance, and any subsequent excitement of the one cell group now
flows over into the other. It is the duty of physiology to elaborate
such a clumsy scheme and to make us understand in detail how those
processes in the neurons can occur and it is not the duty of psychology
to develop detailed physiological hypotheses. Psychology has to be
satisfied with the fact that all the requirements of the case can be
furnished by principle through physiological explanation. Least of all
ought we to be discouraged by the mere complexity of the process. If a
simple sound and a simple color sensation, or a simple taste and simple
smell sensation, can associate themselves through mere nervous
conditions of the brain, then there is nothing changed by going over to
more and more complex contents of consciousness. We may substitute a
whole landscape for a color patch or the memory of a book for a word,
but we do not reach by that a point where the physiological principle of
explanation, once admitted, begins to lose its value. Complexity is
certainly in good harmony with the bewildering manifoldness of those
thousands of millions of possible connections between the brain cells.

Every experience leaves the brain altered. The nerve fibers and the
cells have gone into new stages of disposition for certain excitements.
This disposition may be slowly lost. In that case the earlier experience
cannot be reproduced; we have forgotten it. But as long as the
disposition lasts--it is quite indifferent whether we conceive it more
in terms of chemical changes or physical variations, as processes in the
nerve cells or between the nerve cells--the physiological change alone
is responsible for the awakening of the memory idea under favoring
associative conditions. Of course, someone might reply: can we not fancy
that there remains on the psychical side also a disposition? Each idea
which we have experienced may have left a psychical trace which alone
may make it possible that the idea may come back to us again. But what
is really meant and what is gained by such a hypothesis?

First, do not let us forget that such a proposition could only have one
possible end in view, namely, the explanation of the reappearance of
memories. But when we discussed the basis of physiological psychology,
we convinced ourselves that mental facts as such are not causally
connected anyhow. Our real inner life has its internal connections,
connections of will and purpose, but as soon as we have taken that great
psychological step and look on inner life as merely psychological
objects, then the material is connected only through the underlying
physiological processes and we can never explain causally the appearance
of an idea through the preceding existence of another idea. We may
expect one after the other, but we have no insight into the mechanism
which makes the second follow after the first. Such insight into
necessary connection we find only on the physical side, and we saw that
just here lies the starting point for the modern view of physiological
psychology. If that holds true for the connections between idea and
idea, of course it holds true in the same way for the connection between
mental disposition and the corresponding memory. We can understand
causally that a chemical disposition in the nerve fibers brings about a
chemical excitement in those neurons, but how a mental disposition is to
create mental experience we could not understand; and to explain it
casually, we should need again a reference to the underlying
physiological processes. The hypothesis of mental dispositions would
thus be an entirely superfluous addition by which we transcend the real
experience without gaining anything for the explanation.

Secondly, if we really needed a mental disposition for each memory
picture, in addition to the physiological disposition of the brain
cells, can we overlook that exactly the same thing would then be
necessary for every perception also? The outer impression produces,
perhaps through eye or ear or skin, an excitement of the brain cell and
this excitement is accompanied by a sensation; and no one fancies that
the appearance of this sensation is dependent upon a special disposition
for it on the mental side. No one fancies it, because it is evident that
such a hypothesis again would be entirely useless. If every new
perception needed such a special mental disposition, we should have to
presuppose dispositions for everything which possibly can come into our
surroundings. Every smell, every word, every face which comes anew to us
would need its special ready-made disposition. In other words, our mind
would contain the disposition for every possible idea and that would
mean that these dispositions would be in no way helps for explanation.
If the disposition exists for everything, no one particular thing can be
explained by the existence of that disposition. Again we should have to
rely entirely upon the physiological brain excitement for explaining
that this word or that word is perceived by our mind. But if the brain
excitement alone is sufficient to explain the new perception in the
mind, then no reason can be found why the renewed brain excitement would
not be sufficient to renew the mental experience. Thus there is nowhere
room for mental dispositions below the level of consciousness.

Thirdly, what could we really mean by such mental dispositions? A
physiological disposition for a physiological action is certainly not
the action itself. The finger movement in piano playing finds only a
disposition in my brain centers, in case I am trained; the movement
itself does not last. But the disposition is at least itself a change
in the physical world. The molecules are somehow differently placed, the
disposition has thus as much objective existence as the resulting
movement. Nothing at all similar can be imagined in the sphere of
psychical contents. Such mental dispositions would have to exist
entirely outside the world of concrete mental experiences and, if we
scrutinize carefully, we soon discover that such theories are only
lingering reminiscences of the purposive view of life, and do not fit at
all into the causal one. If we take the purposive attitude, then every
idea and every will contains indeed all that its meaning involves and
everything which we can logically develop out of it is by intention
contained in it. All mathematical calculations are then contained in the
thought of figures and forms, but they are contained there only by
intention, they are logically inclosed; psychologically the
consciousness of the figures and forms does not contain any disposition
for the development of mathematical systems. We indeed have no right to
throw into a psychological subconsciousness all that which is not
present but involved by intention in the ideas and volitions of our
purposive life.

If thus the memory idea is linked with the past experience entirely by
the lasting physiological change in the brain, we have no reason to
alter the principle, when we meet the memory processes of the hypnotized
person or the hysteric. It is true their memory may bring to light
earlier experiences which are entirely forgotten by the conscious
personality, but that ought to mean, of course, only that nerve paths
have become accessible in which the propagation of the excitement was
blocked up before. That does not bring us nearer to the demand for a
subconscious mental memory. The threshold of excitability changes under
most various conditions. Cells which respond easily in certain states
may need the strongest stimulation in others. The brain cells which are
too easily excited perhaps in maniacal exultation would respond too
slowly in a melancholic depression. Hypnotism, too, by closing the
opposite channels and opening wide the channels for the suggested
discharge, may stir up excitements for which the disposition may have
lingered since the days of childhood and yet which would not have been
excited by the normal play of the neurons. Quite secondary remains the
question of how these reproduced images finally appear in consciousness,
that is, whether they appear with reference to earlier happenings and
are thus felt as remembrances, or whether they enter as independent
imaginations, or whether they finally, under special conditions, take
the character of real, new perceptions. The latter case is well-known in
crystal-gazing, where long-forgotten memory ideas project themselves
into the visual field like hallucinations. But for the theory of the
subconscious, even these uncanny crystal visions do not mean more than
the simplest awakening of the experience of a landscape image of
yesterday.

We turn to a second group of facts and again we have no fault to find
with the observation of the facts, even of the most surprising and
exceptional ones. Our objection refers to the interpretation of them.
This second group contains the active results of such physiological
nervous dispositions. In the first group, the dispositions come in
question only as conditions for a new excitement which was accompanied
by mental experience. In this second group, the dispositions are causes
for other physiological processes which either lead to actions or to
influences on other mental processes. The dispositions are here working
like the setting of switches which turn the nervous process into special
tracks. In the simple cases, of course no one doubts that a purely
physiological basis is involved. The decapitated frog rubs its skin
where it is touched with a drop of muriatic acid in a way which is
ordinarily referred to the trained apparatus of his spinal cord, as no
brain is left, and the usefulness of the action and its adjustment is
very well understood as the result of the connecting paths in the
nervous system.

From such simple adjustment of reactions of the spinal cord, we come
step by step to the more complex activities of the subcortical brain
centers, and finally to those which are evidently only short-cuts of the
higher brain processes. That we react at every change of position with
the right movements to keep our bodily balance, that we walk without
thinking of our steps, that we speak without giving conscious impulse
for the various speech movements, that we write without being aware of
the motor activity which we had to learn slowly, that we play the piano
without thinking of the special impulses of the hands, that we select
the words of a hasty speech, if we have its aim in mind, without
consciously selecting the appropriate words--all that is by continuous
transitions connected with those simplest automatic reactions. And from
here again, we are led over gradually perhaps to the automatic writings
of the hysteric who writes complex messages without having any idea of
their content in consciousness. It is in such cases certainly a symptom
of disease that the activity of these lower brain centers can go over
into the motor impulse of writing without producing secondary effects in
the highest conscious brain centers; it is hysterical. But that the
message of the pencil can be brought about by such operation of lower
brain centers, or at least with imperfect coöperation of the higher
brain centers, is certainly entirely within the limits of the same
physiological explanation.

On the other hand, nothing is changed in the theoretic principles of the
case if the effect of these automatic processes in the nervous system is
not an external muscle action at first, but an influence on other brain
centers which may furnish the consciousness with new contents. We try to
remember a name, that is, a large number of neuron processes are setting
in which normally lead to the excitement of that particular process
which furnishes us the memory image of the name. But those brain cells
may not respond, the channels may be blocked somehow or the excitability
of those cells may be lowered. Now new excitements engage our
psychophysical system. We are thinking of other problems. In the
meantime, by the new equilibrium in the brain the blockade in these
first paths may slowly disappear or the threshold of excitability may be
changed. The physiological excitement may now be carried effectively
into those tracts. The cell response sets in and suddenly the name comes
to our mind. This purely physiological operation in our brain paths must
thus have exactly the same result which it would have had, if more parts
of the process had been accompanied by conscious experience. And again
from mere remembering a forgotten name, we come by slow steps to the
solution of a problem, to the invention, and finally to the creation of
the genius.

Superficiality of thought is easily inclined to object to such a
physiological interpretation and perhaps to denounce it pathetically as
a crude materialism which lowers the dignity of mental work. Nothing
shows more clearly the confusion between a purposive and causal view of
the mind. In the purposive view of our real life, only our will and our
personality have a meaning and can be related to the ideas and higher
aims. Nature is there nothing but the dead material which is the tool of
our will and which has to be mastered by the personality. In that world
alone lie our duty and our morality. But as soon as we have gone over to
the causal aspect of our life and have taken the point of view of the
psychologist, making our inner life a series of contents of
consciousness, of psychical phenomena, we have transformed our inner
experience in such a way that it has become itself nothing but nature.

It is mental nature, nature of psychical stuff, but each part of it is
nothing but a mental element, a mental atom without any meaning and
without any value; nothing but a link in the chain, nothing but a factor
in the explanation of the whole, nothing to which any ethical or
æsthetic or logical or religious significance can any longer be
attached. The psychical sensations and the physical atoms are equally
material for naturalistic explanation. To understand causally a certain
effect, for instance the creation of a work of art, of a discovery or a
thought or a deed as the product of psychical processes, is thus in no
way more dignified or more valuable than to understand it as the product
of physiological brain processes. The one is not more dignified than the
other because both alike have nothing whatever to do with dignity. Both
alike are the necessary results of the foregoing processes, and to
attach a kind of sentimental preference to the explanation through
conscious factors is nothing but a confused reminiscence again of the
entirely different purposive view of life. And surely nothing is gained
for the higher values of life if this confusion sets in, because if the
popular mind becomes unable to discriminate between the secondary,
causal, artificial aspect of science and the primary, purposive aspect
of life, the opposite effect lies still nearer: the values of the real
life suffer and are crowded out by the knowledge of the scientific
facts. Man's moral freedom is then wrongly brought in question, as soon
as it is learned that every action is the product of brain processes.
Life and science alike will gain the more, the more clearly the
purposive and the causal point of view are separated and the more it is
understood that this causal aspect itself is demanded by certain
purposes of life. The oratory of those who denounce the physiological
theories as lacking idealism in reality undermines true moral
philosophy. There is no idealism which can really flourish merely by
ignoring the progress of science and confusing the issues. The true
values of the higher life cannot be safely protected by that thoughtless
idealism which draws its life from vagueness and which therefore has to
be afraid of every new discovery in scientific psychology. Our real
ideals do not lie at all in the sphere in which the problem of causally
explaining the psychological phenomena arises.

Our conscious experiences are thus indeed not only here and there, but
usually the products of chains of processes which go on entirely on the
physiological side. We have no reason at all to seek for those preceding
actions any mental accompaniment outside of consciousness, that means,
any subconscious mental states. Then, of course, this physiological
explanation also covers entirely those after-effects of earlier
experiences, especially emotional experiences, which the physician
nowadays likes to call subconscious "complexes." We shall see what an
important rôle belongs to these facts, especially in the treatment of
hysteria and psychasthenia, but the interpretation again ought to avoid
all playing with the conception of the subconscious. Emotional
experiences may produce there some strong stable dispositions in the
brain system which become mischievous in reënforcing or inhibiting
certain thoughts and actions without awakening directly conscious
experiences. The whole psychological switch system may have been brought
into disorder by such abnormal setting of certain parts, but the
connection of each resulting accident with the primary emotional
disturbances does not contradict the fact that all the causes lie
entirely in disturbances of the central paths. It is a change in the
neurons and their connections. To discover it we may have to go back to
early conscious experiences, but in the process itself there is no
mental factor, and therefore no subconscious emotion is responsible for
the mischief carried out.

Both groups of facts which we have studied so far, have dealt with
processes which were indeed not conscious but which we had no right to
call subconscious inasmuch as they contained no mental process at all
but only physiological dispositions and actions. We turn finally to the
other smaller and more abnormal group of so-called subconscious facts in
which the facts are mental indeed and not only physiological, but not at
all outside of consciousness and thus again not subconscious. A
conscious fact may easily suggest the appeal to subconscious theories to
those who have accepted such theories for other reasons. There are, for
instance, plenty of mental experiences which we do not notice or which
we do not recognize. Yet if we find later that they must have influenced
our mind, we are easily inclined to refer them to subconscious activity.
But it is evident that to be content of consciousness means not at all
necessarily to be object of attention or object of recognition.
Awareness does not involve interest. If I hear a musical sound, I may
not recognize at all the overtones which are contained in it. As soon as
I take resonators and by them reënforce the loudness of those overtones,
they become vivid for me and I can now notice them well even when the
resonators are removed. I surely was aware of them, that is, had them in
consciousness all the time but there were no contrast feelings and no
associations in consciousness which gave them sufficient clearness to
attract attention.

In this way I may be again led by gradual stages to more and more
complex experiences. I may overlook and yet include within my content of
consciousness most various parts of my surroundings; and yet the
neglected is not less in consciousness itself than the attended. Much
that figures in literature as subconscious means indeed nothing else but
the unattended. But it belongs to the elements of psychological analysis
to recognize that the full content of consciousness is always larger
than the narrow field of attention. This narrow field on the other hand
has certainly no sharp demarcation line. There is a steady shading off
from the most vivid to the least vivid. We cannot grasp those least
vivid contents of consciousness, we cannot fixate them as such, because
as soon as we try to hold them, they move from the periphery of the
content into its center and become themselves vivid and clear. But as we
are surely aware of different degrees of clearness and vividness in our
central mass of contents, we have no difficulty in acknowledging the
existence of still lower degrees of vividness in those elements which
are blending and fusing into a general background of conscious
experiences. Nothing stands out there, nothing can be discriminated in
its detail. That background is not even made up of whole ideas and whole
memories and whole emotions and feelings and judgments and volitions,
but of loose fragments; half ideas and quarter ideas, atoms of feelings
and incipient impulses and bits of memory images are always mixed in
that half-dark background. And yet it is by principle not less in
consciousness, and consciousness itself is not different for these
contents. It is not half-clear consciousness, not a lower degree of
awareness, only the objects of awareness are crumbled and fading.

Whether these background objects really exist can only be made out by
studying carefully the changes which result under different conditions,
the influences which those loose parts have on the structure of the
whole, and the effect of their complete disappearance. I may never
really notice a little thing in my room and yet may be aware that it has
been taken away. The visual image of it was an element of my mental
background, when I was sitting at my desk, but it never before moved to
the center of my conscious content. But this center itself is also
constantly changing. Sometimes the one, sometimes the other idea may
enter into it, but in this alternation that which is not in the focus
either remains in consciousness unattended or when it disappears from it
it loses its mental character altogether. If I attend a tiresome lecture
while my mind is engaged with a practical problem of my own life, there
may be a steady rivalry between the words which come with the force of
outer stimulus to my brain and make me listen and my inner difficulties
which claim my attention. I listen for a while, and then suddenly,
without noticing it, my own thoughts may have taken the center of the
stage and again without sudden interruption a word may catch my
attention. While I was thinking of my own problem the sounds of the
lecturer were really outside of my field of attention, yet some remark
now pushes itself again into the center. That does not mean that a
subconscious mind is listening while my lucid mind was thinking, but it
does mean that those words were unattended and remained in the periphery
of the field of consciousness. But when some of the sentences stirred up
in that peripheral field some important associations, they were strong
enough to produce a new motor reaction by which the mental equilibrium
became changed again and by which the lecturer overwhelmed my private
thoughts. Yet even this state of mind, without any break, can go over
into an absolutely physiological process. I may for a while really
inhibit the lecturer's voice completely and remain in the thoughts of my
own imagination. After a minute or two, the resistance against the
acoustical stimulus will certainly be broken and the sound will again
enter into my consciousness, but in that interval there was no
subconscious and not even any unattended mental function; there was no
mental process at all. The sound reached my brain but as the motor
setting was adverse, the sounds did not bring about that highest act of
physiological transmission which is accompanied by mental contents. Thus
it became entirely physiological. Yet of course every word reached my
brain and left traces there. If I were hypnotized after the lecture and
thus the threshold for the real awakening of brain excitements lowered,
it might not be impossible that some of the thoughts of the lecturer
which did not enter my consciousness at all, are now afterwards in the
hypnotic state stirred up in me. Yet even that would not indicate that
they had become mental and thus subconscious at the time of the lecture.

The so-called subconscious, which in reality is fully in consciousness
but only unnoticed, easily shades over into that unconscious which is
also in consciousness but dissociated from the idea of the own
personality and thus somewhat split off from the interconnected mass of
conscious contents. Wherever we meet such phenomena, we are in the field
of the abnormal. The normal mental life is characterized by the
connectedness of the contents. Yet even that holds true, of course, only
if we think of those mental states which exist at one and the same
instant in consciousness. As soon as we consider the succession of
mental events, we cannot doubt that even normal experience shows breaks,
lapses, and complete annihilation of that which a moment before was a
real content in our consciousness. We may have looked at our watch and
certainly had in glancing at the dial a conscious impression, but in the
next moment we no longer know how late it is. The impression did not
connect itself with our continuous personal experience, that is, with
that chief group of our conscious contents which we associate with the
perception of our personality. Under abnormal conditions of the brain,
larger and larger parts of the completely conscious experience may thus
be cut off from the continuity of conscious life. But to be in
consciousness, and therefore to be not-subconscious, does not mean to be
through memory ties connected with the idea of our own personality.

The somnanbulist, for instance, may get up at night time and write a
letter, then go to bed again and not know anything of the event when he
awakes in the morning. We have no reason to claim that he had no
knowledge of the letter in his consciousness when he wrote it. It is
exactly the same consciousness from a psychological standpoint as the
one with which he wakes up. Only that special content has in an abnormal
way entirely disappeared, has not left a possibility of awakening a
memory image, and the action of the personality in writing has thus
become separated and cut off from the connected experiences of the man.
But while the nocturnal episode may be entirely forgotten, it was not
less in consciousness for the time being, than if a normal man should
leave his bed hastily to write a letter. Moreover under abnormal
conditions, as for instance in severe hysteric cases, those dissociated
contents may form large clusters of mental experiences in the midst of
which a new idea of the own personality may develop. Considering that
through such disconnection many channels of discharge are blocked, while
others are abnormally opened, it seems only natural that the idea of the
own acting personality becomes greatly changed. Thus we have in such an
episode a new second personality which may be strikingly different in
its behavior and in its power, in its memories and in its desires, from
the continuous normal one, and this secondary personality may now
develop its own continuity and may arise under special conditions in
attacks which are connected among one another by their own memory bonds.

The two personalities may even alternate from day to day and the normal
one may itself become pathologically altered. In that case the two
alternating personalities would both be different from the original one.
But again we have even in such most complex and exceptional cases only
an alternation in the contents, not an alternation in the consciousness
itself. Different ideas of the own personality with different
associations and impulses follow each other in consciousness and the
abnormality of the situation lies in the lack of memory connections and
of mutual influences, but consciousness remains the same throughout. It
remains the same, just as we do not change consciousness if we feel
ourselves in one hour as members of our family, in the next hour as
professional workers in our office, again later as social personalities
at a party or as citizens at a political meeting or as æsthetic
subjects at the theater. Each time we are to a high degree a different
personality, the idea of our self is each time determined by different
groups of associations, memories, emotions, and impulses. The
differentiation is to be considered as normal only because broad memory
bridges lead over from one to the other. The connection of the various
contents with the various ideas of the own personality constitutes thus
in no way a break of consciousness itself and relegates no one content
into a subconscious sphere.

Finally the same holds true, if the idea of the personality as content
of consciousness in the patient is split into two simultaneous groups,
of which each one is furnished with its own associations. Yet the
interpretation here becomes extremely difficult and arbitrary. Take the
case that a patient in severe hysteria at our request writes down the
history of her life. We should not hesitate to say that she is doing it
consciously but now we begin to talk with her and slowly the
conversation takes her attention while her pencil is continuing to write
down the connected story of her youth. Again the conversation by itself
gives the impression of completely conscious behavior. As both functions
go on at the same time, the person who converses does not know what the
person who writes is writing, and the writer is uninfluenced by the
conversation. Various interpretations are possible. Indeed we might
think that by such double setting in the pathological brain two
independent groups in the content of consciousness are formed, each one
fully in consciousness and yet both without any mutual influence and
thus without mutual knowledge. In the light of such interpretation, it
has been correctly proposed to speak of coconscious processes, rather
than subconscious. Or we may interpret it more in harmony with the
ordinary automatic writing or with other merely physiological reactions.
Then we should suppose that as soon as the conversation sets in, the
brain centers which control the writing movement work through channels
in which no mental factors are involved. One of the two characteristic
reaction systems would then be merely physiological. We saw before that
the complexity of the process is no argument against the strictly
physiological character of the event. That various activities can
coexist in such a way that one of them may at any time slide down from
the conscious centers to the merely physical ones, we all know by daily
experience. We may go home through the streets of the busy town engaged
with our thoughts. For a while the idea of our way and of the sidewalk
is in our consciousness, when suddenly we reach our house and notice
that for a long while we have no longer had any thought at all of the
way. We were absorbed by our problems, and the motor activity of walking
towards our goal was going on entirely in the physiological sphere. But
whether we prefer the physiological account or insist on the coconscious
phenomena, in either case is there any chance for the subconscious to
slip in? That a content of consciousness is to a high degree dissociated
or that the idea of the personality is split off is certainly a symptom
of pathological disturbance, but it has nothing to do with the
constituting of two different kinds of consciousness or with breaking
the continuous sameness of consciousness itself. The most exceptional
and most uncanny occurrences of the hospital teach after all the same
which our daily experience ought to teach us: there is no
subconsciousness.




PART II

THE PRACTICAL WORK OF PSYCHOTHERAPY




VII

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.




VIII

THE GENERAL METHODS OF PSYCHOTHERAPY


The psychological work of the physician does not begin with his curative
efforts. Therapy is always only the last step. Diagnosis and observation
have to precede, and an inquiry into the causes of the disease is
essential, and in every one of these steps psychology may play its rôle.
The means of psychodiagnostic are not less manifold than those of
psychotherapy. Moreover there the technique may be more complex and
subtle. The whole equipment of the modern laboratory ought to be put at
its disposal. Perceptions and associations, reactions and expressions
ought to be examined with the same carefulness with which the
conscientious physician examines the blood and the urine.

A particular difficulty of the task more or less foreign to every other
medical inquiry is the intentional or unintentional effort of the
patient to hide the sources of the trouble and to mislead as to their
true character. Too often he is entirely unconscious of the sources of
trouble or else he has social reasons to deceive the world and himself,
and ultimately the physician. And yet no psychical treatment can start
successfully so long as the patient is brooding on secret thoughts at
the bottom of his mind. The desire to hide them may often be itself a
part of the disease. It is surprising how often unsuspected vistas of
thoughts and impulses and emotions are opened by an inquiring analysis
where the direct report of the patient does not awaken the least
suspicion. In the field of insanity, naturally the physician at once
goes to an examination on his own account, but in the borderland regions
of the psychasthenics and hysterics and neurasthenics, the intellectual
clearness of the patient too easily tempts one into trusting the
sincerity of his story; and yet the most important ideas clustering
perhaps about love or ambition, about vice or crime, about business
failure or family secrets, about inherited or acquired diseases may be
cunningly withheld and may frustrate every psychotherapeutic influence.
Where suspicion is awake and mere confidential talk and persuasion seem
insufficient, the physician may feel justified in the interest of his
patient in drawing the thoughts out of their hiding-place by artificial
means. Skill, tact, and experience are needed there.

As a matter of course, in the overwhelming mass of cases the frankness
and the good will of the patient himself will support the physician and
accordingly his examination is not obliged to trap the patient but
simply to guide him to important points. But then begins the most
essential study of diagnostical differentiation. With all the means not
only of psychology but of neurology and internal medicine, he has to
separate the particular case from similar ones and to examine whether
he deals with, for instance, a hysteric or with a paranoiac, with a
neurasthenic or with a case of dementia præcox; and he will not forget
that there exist almost no symptoms of serious diseases which the
nervous system of the hysteric may not imitate for a time. Not ours is
the task of analyzing special methods of neurological and mental
differential diagnosis such as are used in the psychiatric clinic and in
the office of the nerve specialist. There the family history with
reference to nervous and other diseases, the history of the patient
himself, the infectious diseases which he has passed through, his habits
and anomalies, his use of alcohol and of drugs, his experiences in
social life, the demands of his profession, his recent troubles and
their first origin are to be recorded carefully. Then begins the
physical examination, the study of his sense organs and his nerves, of
the motor inabilities, the pains, the local anæsthesias and
paræsthesias, the disturbances of the reflexes, of the spasms, tremors,
convulsions, and incoördinations, of the vasomotor and trophic
disorders, and so on. In a similar way the psychical examination tests
the hallucinations and illusions, the variations and defects of memory
and attention, of judgment and reasoning, of orientation and
self-consciousness, of emotions and volitions, of intellectual
capacities and organized actions. But we do not have to enter here into
a discussion of such diagnostic means; our chief interest belongs to the
therapy.

The variety of the psychotherapeutic methods is great and only some
types are to be characterized here. But one rule is common to all of
them: never use psychotherapeutic methods in a schematic way like a
rigid pattern. Schematic treatment is a poor treatment in every
department of medicine, but in psychotherapeutics it is disastrous.
There are no two cases alike and not only the easily recognizable
differences of sex and age, and occupation and education, and financial
means, and temperament and capacity are decisive, but all the subtle
variations of prejudices and beliefs, preferences and dislikes, family
life and social surroundings, ambitions and prospects, memories and
fancies, diet and habits must carefully be considered. Every element of
a man's life history, impressions of early childhood, his love and his
successes, his diseases and his distresses, his acquaintances and his
reading, his talent, his character, his sincerity, his energy, his
intelligence--everything--ought to determine the choice of the
psychotherapeutic steps. As it is entirely impossible to determine all
those factors by any sufficient inquiry, most of the adjustment of
method must be left to the instinct of the physician, in which wide
experience, solid knowledge, tact, and sympathy ought to be blended.
Even the way in which the patient reacts on the method will often guide
the instinct of the well-trained psychotherapist.

It is therefore certainly not enough that the knowledge of the physician
simply decide beforehand on a definite course of psychical treatment and
leave the carrying out to a well-meaning minister or any other medical
amateur who schematically follows the indicated path. The finest
adjustment has to come in during the treatment itself and the response
of the patient often has to suggest entirely new lines of procedure.
More than in any other field of medicine, the physician himself has to
extend his influence far beyond the office hours and the strictly
medical relations. And yet, on the other hand, there is no department of
medicine in which the treatment might not profit by the
psychotherapeutic influence. With a few vague words of encouragement
mechanically uttered, or with a routine of tricks of suggestion by bread
pills and colored water and tuning forks, not much will be gained even
in the ordinary physician's practice. Subtle adjustment to the personal
needs and to the individual conditions is necessary in every case where
the psychical factor is to play an important rôle. It cannot be denied
that the one great obstacle in the work of the routine physician is the
lack of time and patience which is needed for successful treatment. To
prescribe drugs is always quicker than to influence the mind; to cure a
morphinist by hyoscine needs less effort than to cure him by suggestion.

The first method to bring back the psychophysical equilibrium is of
course the one which is also demanded by common-sense, namely, to remove
the external sources of the disturbance. External indicates there not
only the outer world but also the own body outside the conscious parts
of the brain. If we take it in the widest meaning, this would evidently
include every possible medical task from filling a painful tooth to
operating on a painful appendix, as in every case where pain results,
the mental equilibrium is disturbed by it and the normal mental life of
the patient reduced in its efficiency. But in the narrower sense of the
word, we shall rather think of those sources of trouble in the organism
itself which interfere directly with the mental functions. The
examination of any public school quickly leads to the discovery that
much which is taken for impaired mental activity, for lack of attention,
for stupidity, or laziness may be the result of defective hearing or
sight or abnormal growth of the adenoids. Growths in the nose may be
operated upon, the astigmatic or the short-sighted eye may be corrected
by glasses, the child who is hard of hearing may at least be seated near
the teacher; and the backward children quickly reach the average level.
No doubt in the life of the adult as well, often almost insignificant
and from a strictly physical point of view unimportant abnormities in
the bodily system, especially in the digestive and sexual spheres, are
sources of irritation which slowly influence the whole personality. To
be sure, the brain disturbance may have reached a point where the mere
removal of the original affliction is not sufficient to reinstate the
normal balance of mental energies, but wherever such a bodily irritation
goes on, it is never too late to abolish it in the interests of
psychotherapy.

The less evident and yet even more important source of the painful
intrusions may lie outside of the organism in the social surroundings
and conditions of life. Most of that has to be accepted. The physician
cannot bring back the friend who died or the fortune which was lost in
speculation or the man who married another girl. He will even avoid
suggesting far-reaching social changes in the private life of the
patient, changes like divorce in an unhappy marriage or the breaking of
the home ties, however often he may get the impression that such a
liberation would stop the source of the mental trouble. He will be the
more careful not to overstep his medical rights as he seldom has the
possibility to judge fairly on the basis of the one-sided complaint, and
the probability is great that the character and temperament of the
complainant may be a more essential factor of the ailment than the
personalities which surround him. Yet even the conservative physician
will find abundant opportunities for advice which will remove disturbing
energies from the social surroundings of the sufferer. Even a short
release from the burdening duties, a short vacation from the incessant
needs of the nursery, a break in the monotony of the office, may often
do wonders with a neurasthenic. Often within a surprisingly short time
the brain gathers the energies to overcome the frictions with
unavoidable surroundings.

Yet here the physician has to adjust the prescribed dose of outing very
carefully to the special case. We may be guided by the psychological
experiments which have been made in the interest of testing the fatigue
induced by mental work. If perhaps four hours of concentrated work are
done without pauses, experiment shows that the quality of the work
deteriorates, measured for instance by the number of mistakes in quick
calculation. If certain relatively long pauses are introduced, the
standard of work can be kept high all through. But if frequent pauses
are made, and each short, the result is with many individuals the
opposite. The experiment indicates that these frequent pauses are
working as interruptions which hinder the perfect adjustment to the work
in hand. That is suggestive. Our neurasthenic may complain about the
life which he has to live and yet after all he is frequently so
completely adjusted to it that it may not be in his interest to remove
him far away from the conditions which cannot ultimately be changed but
to which he has to return. The instinct of the physician has to find the
middle way between a temporary removal of irritation which really allows
a development of new energies and a mere interruption which simply
damages the acquired relative adjustment. Every cause of friction which
can be permanently annihilated for the patient certainly should be
removed.

This negative remedy demands its positive supplement. The patient must
be brought under conditions and influences which give fair chances for
the recuperation of his energies. Too often from the standpoint of the
psychologist, the prescription is simply rest. As far as rest involves
sleep, it is certainly the ideal prescription. There is no other
influence which builds up the injured central nervous system as safely
as sound natural sleep, and loss of sleep is certainly one of the most
pernicious conditions for the brain. Again rest is a great factor in
those systematic rest cures which for a long while were almost the
fashion with the neurologist. Experience has shown that their
stereotyped use is often unsuccessful, and moreover that the advantage
gained by those months spent in bed completely isolated and overfed is
perhaps due to the separation and changed nutrition more than to the
overlong absolute rest. Yet used with discrimination, the physiological
and the psychical effect of lying in bed for a few weeks has certainly
often been a marked improvement, especially with young women. But more
often the idea of rest in bed during daytime is not meant at all when
the nerve specialist recommends rest to his over-strained patient. It is
simply meant that he give up his fatiguing daily work, even if that work
is made up of a round of entertainments and calls and social
engagements. The neurasthenic and all similar varieties are sent away
from the noise of the city, away from the rush of their busy life, away
from telephones and street cars, away from the hustling business and
politics.

Indeed it is the dogma of most official and unofficial doctors that the
restlessness and hurry and noise which all are characteristic of the
technical conditions of our time are the chief sources of the prevailing
nervousness. There was no time in the history of civilization in which
the average man was overwhelmed by so many demands on his nerve energy,
no time which asked such an abundance of interests even from the school
child. The wild chase for luxury in the higher classes, reënforced by
the commercialism of our time, the hard and monotonous labor in our
modern mills and mines for the lower classes, the over-excitement
brought to everybody by the sensationalism of our newspapers and of our
public life all injure the brain cells and damage the equilibrium. That
is a story which we hear a thousand times nowadays. Yet it is doubtful
whether there is really much truth in such a claim and whether much wise
psychotherapy can be deduced from it.

We may begin even with the very justifiable doubt whether nervousness
really has increased in our time. Earlier periods had not so many names
for those symptoms and were not able to discriminate them with the same
clearness. Above all, the milder forms of abnormities were not looked on
as pathological disturbances. If a man has a pessimistic temperament, or
has fits of temper, or cannot get rid of a sad memory idea, or imagines
that he feels an illness which he does not have, or has no energy to
work, even today most people are still without suspicion that a
neurasthenic or a psychasthenic or a hysteric disturbance of the nervous
system may be in its beginning. Earlier times surely may have treated
even the stronger varieties of this kind as troublesome variations in
the sphere of the normal. On the other hand, there can be no doubt that,
for instance, the Middle Ages developed severe diseases of the nervous
system in an almost epidemic way which is nearly unknown to our time.

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 régime. 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
régime. 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 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
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
reënforce 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
reënforced 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 reënforcement. 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 reënforce 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 reënforce 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
reënforce 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 reënforcement 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 rôle 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.

Incomparably more value belongs to the artificial sleep, the mesmeric
state of earlier days, the hypnotism of our time. We have discussed its
theory and recognized that an abnormally increased suggestibility is
indeed its chief feature. We know hypnotism in most various degrees; the
lowest can be reached practically by everyone, the highest by rather
few. It is almost arbitrary to decide where those waking states with
high tension of suggestibility end and the hypnotic states begin, and
not less arbitrary to call the higher degrees only hypnotism and to
designate the lower degrees as hypnoid states. If we do it, we certainly
should acknowledge from the start that the hypnoid states are for
therapeutic purposes not a bit less important than the full hypnotic
states. Certainly the hypnoid states do not allow complex hallucinations
and absurd post-hypnotic actions, but they offer excellent starting
points for the removal of light obsessions and phobias and for the
reënforcement of desirable impulses, volitions, and emotions. Many
persons cannot under any circumstances be brought beyond such a hypnoid
degree. The physician who has not theoretical experiments but practical
success in view ought therefore never to trouble himself with the
inquiry exactly which degree has been reached. This advice is given
because nothing interferes with the progress of hypnotic influence so
badly as the constant testing. It must naturally often lead to a point
where the subject finds that he can very well still do what the
hypnotizer told him not to do. If the doctor assures him that he can no
longer move his arm and the patient is yet able to move it, the doctor
secures the very superfluous knowledge that this special degree of
suggestibility has not been reached, but the patient is sliding backward
and the lower degree which actually had been reached will be less
accessible later. The physician might rather resort to the opposite
course and assure the patient, even after the first treatment which
might have been a slight success, that he saw from definite symptoms
that hypnosis had set in. That will greatly smooth the way for real
hypnotic effects the next time.

The best method of hypnotizing is the one which relies essentially on
the spoken word, awakening through speech the idea of the approach of
sleep. If the hypnotizer assures the subject in monotonous words that a
feeling of fatigue is setting in, that he is feeling a tiredness
creeping over his shoulders and arms and legs, that his memories are
fading away and that he is now hypnotized, for not a few all is done
that is needed. The hypnotic state will come and will hold until the
verbal suggestion takes it off again. Perhaps the hypnotizer says that
he will count three and at three the subject is to open his eyes and
feel perfectly comfortable. It is wise to tell the patient beforehand
that he will not lose consciousness and that he will remember afterward
whatever happens as many people believe that loss of memory belongs to
the hypnotic state, and that they were not hypnotized if they can
remember what happened. Such a skeptical after-attitude can seriously
interfere with the success of the treatment.

Yet in most cases, it will be safer not to rely on words only but to
supplement them by manipulations which all converge towards the effect
of increasing the suggestibility and thus of overcoming the resistance
to the suggestions introduced. It is well known that for this purpose it
is advisable to begin the influence with some slight fatiguing
stimulations. The effect is most easily reached when the patient fixates
perhaps a shining button held over his eyes or listens to monotonous
sounds. A particularly strong effect belongs again to very slight touch
stimuli. If the subject with his eyes closed is touched perhaps by two
pencils at various and unexpected points of the face and hands, a
skillful playing on his tactual senses soon produces a half-dozing state
of hypnoid character. In the same group belong those so-called passes
which evidently have a reflex influence in the blood-vessel system. It
is advisable to combine the various elements in such a way that at first
physical stimuli upon eye or skin produce an over-suggestible state and
that only as soon as this state is reached the verbal suggestion sets
in, perhaps with the words, "I shall hypnotize you now." Under such
conditions every subject may soon be brought to that degree of
hypnotization which is accessible to him. Yet more than one treatment is
usually necessary for the higher degrees. Much less importance for
therapeutic purposes belongs to that hypnoid state which is reached
without the idea of sleep where the subject comes with open eyes into a
kind of fascination, produced perhaps by a sudden flash of light or by
the firm eye of the hypnotizer. It is a state which can lead to a strong
submission of will and which has its legal importance. Therapeutically
it can hardly secure an effect which cannot better be secured through
the real sleeplike hypnotism. Under certain conditions, chemical
substances may well prepare for the hypnotic treatment, for instance
bromides or alcohol. Others rely on the suggestive effect of flavored
water. But all that is unwise. The confidence of the patient is the best
preparation for the securing of the helpful degree of hypnotism.

Of course only a small part of the therapeutic usefulness is secured
during the hypnotic state itself. A pain may be removed, sleep be
secured, an idea be inhibited, a movement be reënforced in cases where
non-hypnotic suggestions would have found insurmountable obstacles.
During the hypnosis we may also open the storehouse of memory and bring
to light the ideas which disturbed the equilibrium of the suffering
mind. Further in those most complex hysteric cases of dissociated
personality, new memory connections may be formed during the hypnosis
by which a synthesis of the double or triple personalities into the old
one may be secured. Yet the general effect which the physician has to
hope for from hypnotic treatment is the post-hypnotic one. Not what
happens during the hypnosis but what the suggestion will produce after
hypnosis is essential to him. The fixed idea is to disappear forever,
the paralyzed limb is under control, the desire for morphine and cocaine
is gone for all future time, the perverse longing is annihilated, the
old energy is to remain again for all time. It is the post-hypnotic
after-effectiveness which gives to the hypnoid and to the hypnotic
states their importance for the treatment of the most exasperating
symptoms. To be sure, the treatment often must be a prolonged one. A man
who for years has used thirty grains of morphine a day cannot be rid of
the desire after two or three hypnotic sittings. In such a case the
treatment may cover three or four months, if it is to be of lasting
value and without any damage during the treatment.

Still we are not at the end of the psychotherapeutic methods and we may
turn to a fascinating group of curative efforts which has especially
come to the foreground in recent years. We mentioned before that
mischief cannot seldom be traced back to earlier experiences with a
strong unpleasurable feeling. In certain cases, the subject remembers
such particular experiences as the beginning of his discomfort; in
others, especially those of hysteric character, the starting point may
have long been forgotten, and yet that early impression evidently left
traces in the brain which produce disturbances in conscious life. The
psychotherapist nowadays calls these groups of traces "complexes." We
recognized clearly that there is no reason to refer such forgotten
remainders of the past to any subconscious mind; they are physical
after-effects which keep their influence over the equilibrium of the
psychophysical system. Now modern psychotherapy finds that the entire
disturbances which arise from such emotional disagreeable experiences,
forgotten or not forgotten, can often be removed by psychical means. Two
ways in particular seem open. As soon as the idea is fully brought back
to consciousness again, the patient must be made to express the primary
emotion with full intensity. Subtle analysis has repeatedly shown that
many of the gravest hysteric symptoms result from such a suppression of
emotions at the beginning and disappear as soon as the primary
experience comes to its right motor discharge and gains its normal
outlet in action. The whole irritation becomes eliminated, the emotion
is relieved from suppression and the source of the cortical uproar is
removed forever.

Practically still more important seems the other case which refers alike
to hysterics and psychasthenics and which is applicable for the
forgotten experience not less than for the well-remembered ones. This
second way demands that the psychotherapist bring this primary
experience strongly to consciousness and then by a new training link it
with new and more desirable associations and reactions. The disturbing
idea is thus not to be discharged but to be sidetracked so that in
future it leads to harmless results. The new setting works towards an
entirely new equilibrium. What was a starting point for abnormal fears
now becomes an indifferent object of interest and all its evil
consequences are cut off. It may be acknowledged that the full
elaboration of these methods still belongs to the future. Both methods,
the discharging, or the so-called cathartic one, and the side-tracking
method evidently demand the discovery of the starting point in the
service of the therapy and here again several methods are at the
disposal of the psychologist.

A promising way to this end is the inexhaustible association test which
we mentioned when we discussed the contributions of the psychological
laboratory to the medical diagnosis. A series of short words are spoken
to the patient and, as soon as he hears one, he is to pronounce as
quickly as possible the first word which comes to his mind. If we use
fifty words, we should be able to learn something as to the inner states
of the man and as to the working of his mind, if we analyze carefully
his particular choices. But two further conditions ought to be
fulfilled. The time of the association ought to be measured. Of course
there will be wide differences. A word which is often in a certain
connection will quickly bring the habitual association. Abstract words
will call forth their associations more slowly than concrete words,
familiar words more rapidly than unfamiliar words. To measure such
association time with fullest accuracy, as it is necessary for the
purpose of scientific investigations, delicate electrical instruments
are needed that indicate thousandths parts of a second. For the purpose
of the practical physician such accuracy would be superfluous. His
examination will be perfectly successful if it is carefully done with a
stop-watch which shows the fifth part of a second, like those which are
used at races. He speaks a word, presses at the same time the button of
the watch, and presses the stopper when he sees the lips of the patient
moving. He is thus able to examine not only the involuntary choice of
association but also the time of every associative process. But a second
condition ought also to be fulfilled. After some indifferent words,
others ought to be mixed into the series which touch in a tentative way
on various spheres corresponding to the possible suspicions. The groups
to which the hidden thoughts of psychasthenics, for instance, belong are
not many. As soon as our series of words strikes such a group, the
reaction of the mind may be discriminated. The effect may be a general
perturbation resulting either in an unusual delay of the fitting
association or in an effort to cover the sore spot by an unfitting
association. Sometimes the dangerous association may rush forward even
with unusual rapidity but, as soon as it is uttered, it gives a shock to
the mental system, brings the whole associative process into disorder,
and the result is that the next following associations are abnormally
delayed. The skilled psychologist will quickly take such a change as a
cue for the selection of the later words in his series. Of course, he
will at first return to neutral words, but as soon as he has found a
danger spot, he will approach it from various sides, perhaps in every
fourth or fifth word, and may then find out which particular experiences
are disquieting the patient. Words like women or money or career or
family or disease are often sufficient to get the first inkling of a
mental story.

With less diagnostic elegance we sometimes reach the same end by taking
careful records of pulse and breathing and involuntary movements during
an apparently harmless conversation. The instruments at the disposal of
the psychologist are those familiar to every psychological laboratory:
the pneumograph, which registers the movements of respiration; the
sphygmograph, which writes the pulsation of the artery in the wrist; the
automatograph, or other instruments, which register the slight
unintentional movements of the arm. If the examiner is skillful, he will
not fail to discover the changes in breathing and pulse and reaction as
soon as the painful groups of ideas are approached. More of theoretic
interest and too cumbersome for practical diagnosis is the unfailing
galvanic reaction from the skin in which the glands change their
activity and their resistance to the galvanic current under the
influence of hidden emotions. Yet all these methods, with exception of
the last, are essentially useful only if the starting experience is
still accessible to the memory of the patient. He may be unaware that it
had anything to do with his nervous symptoms but he recognizes the
experience still as soon as his attention is directed towards it. The
psychologically more interesting but probably more exceptional situation
is the one in which it is not only forgotten but cannot be recognized
when it is brought to consciousness. The shortest way to get hold of
such past impressions is the hypnotic one. The hypnotic state sharpens
the memory and experiences of early childhood or apparently
insignificant experiences of later life may be brought back when they
would have been inaccessible to any intentional effort of the attention.
Even still more surprising is the success if the association is left to
a dreamy play of ideas suggested perhaps by gazing into a crystal ball
or by a meaningless talking. Perhaps the patient lies with closed eyes
on the couch while the physician holds his hand. A few words are given
to him as a starting point and then he is thoughtlessly to pronounce
whatever comes to his mind, not only unfinished sentences but loose
phrases, single words, apparently without meaning and slowly ideas arise
which betray the original intrusion. At last memories and lost emotions
come again to the surface, and the watchful psychotherapist may discover
the complex, which is then to be removed by discharge or by
side-tracking. This is the so-called psychoanalytic method.

Finally the psychotherapist may go still one step further. After all it
often seems inexplainable that just this or that emotional experience
made such a deep and lasting impression while a thousand other
experiences passed by without leaving any mischievous after-effect. It
seems that indeed the conditions are still more complicated. That
emotional disturbance operated dangerously perhaps only because it
itself appealed to a suppressed desire and this seems to hold true
especially for suppressed emotions of the sexual sphere. The desire for
gratification in normal or abnormal channels was perhaps attached by the
mind to some group of objects. It was completely suppressed but it left
an abnormal tension in the central system. If now a chance experience
touches on this group of ideas, there results an explosive reaction; and
movements, convulsions, spasms, obsessions, and fears set in which get
their particular character not through the secondary intrusion but from
the primary desire. To discharge that intrusion leads therefore only to
the elimination of those symptoms which resulted from it, but the
primary disturbance goes on and any new chance intrusion will produce
new explosions. The psychotherapist should therefore go deeper and
relieve the mind from those primary desires which may belong to early
youth and which are entirely forgotten. Even the method of automatic
writing may here sometimes lead to an unveiling of those deepest layers
of suppressed desires. In the same way a careful, subtle analysis of
dreams may support the search for the hidden source of interference.

We have spoken of the technical methods of the psychotherapist. It would
be short-sighted to ignore the great manifoldness of secondary methods
which he shares with the ordinary intercourse between man and man, the
methods which the teacher uses in the schoolroom, which the parents use
in the nursery, which the neighbor uses with his neighbor, methods which
build up the mind, methods which train the mind, methods which reënforce
good habits and suppress unwholesome ones, methods which stimulate sound
emotions and inhibit a quarrelsome temper, methods which indeed are not
less important in the psychiatric clinic and in the hospital than in our
daily life, and which certainly have central importance in that
borderland region which is the particular working field of the
psychotherapist.




X

THE MENTAL SYMPTOMS


We have discussed both the psychological theory and the practical work
of psychotherapy in a systematic order without any reference to personal
chance experience. After studying the fundamental principles, we have
sketched the whole field of disturbances in which psychotherapeutic
influence might be possible and all the methods available. It seems
natural that our next step should be an illustrating of such work by a
number of typical cases. Here it seems advisable to leave the track of
an objective system and to turn to the record of personal observation.
As this is not a handbook for the physician, dealing with the special
forms of disease, we emphasized before that we avoid even any attempt in
such a direction because it would have to introduce not only the
questions of diagnosis, but above all the highly important questions of
treatment by physical agencies. We saw that for us nothing else can be
desirable, but to show the way in which the various symptoms which
suggest mental treatment occur, and how they yield to the psychical
methods. We had also agreed beforehand that for a first survey we might
separate the mental from the bodily symptoms and group the mental ones
with reference to the predominance of ideational, emotional, and
volitional factors. And finally it may be said that we abstain from
everything which is exceptional or even unusual, and confine ourselves
to the routine observations with which the psychotherapist comes in
contact every day and the simplest country physician surely every week.

Thus I turn from systematic objectivity to my unsystematic reminiscences
of many years. Of course, they abound with eccentric abnormities and
startling phenomena. As I have devoted myself to psychotherapeutics,
always and only from scientific interest, as a part of my laboratory
studies and therefore have refused to spend any time on cases which
offered no special psychological interest to me, the striking and
sensational cases have prevailed in my practice even to an unusual
degree. Yet they are unessential for our purposes here, the more as
their interest lies mostly in the complex structure of the mental state
while the curative features are in the background. Our purpose of
demonstrating practical cases as they occur in every village, and as
they ought to be understood and treated by every doctor, thus rules out
just those experiences which would be prominent in a theoretical study
of abnormal psychology. We want to select only simple commonplace cases.
Only those who have not learned to see are unaware that such cases are
everywhere about them.

As a matter of course, I also leave out everything which refers to
insanity, that is, every mental disturbance which lies essentially
outside of the domain of psychotherapy. The helpful influence which
psychical factors can exert in the asylums for the insane is, as we
emphasized, entirely secondary. The psychotherapeutic methods in the
narrower sense of the word are in the present state of our knowledge
ineffective in the insane asylum. I should also be unable to speak of
laboratory experience with insanity, as I insist on sanitarium treatment
in every such case. The question of how to differentiate the diagnosis
of insanity from that of the other mental abnormities is not our
question at this moment. I select the few illustrations which seem to me
desirable for the purpose of making more concrete our abstract
discussion of methods, essentially from the class of neurasthenics,
psychasthenics, hysterics, and so on.

In all these reports, I shall confine the account to the few points
which are to illustrate the psychical factors, thus abstaining entirely
from the further details which any medical history of the cases would
demand and from all results of further examination and other
particulars. As a matter of course, I exclude the possibility of
identifying the patient. I may start with a typical case of obsessing
ideas of simplest character and with simple routine treatment
illustrating the emphasis on antagonistic ideas.

     A man of mature age, well educated, well built and in every respect
     in good health, without nervous history and without other nervous
     symptoms, suffered vehemently by the persistent recurrence of a
     visual image which entirely absorbed his attention. He knew
     exactly the development of his trouble. A woman acquaintance of his
     had committed suicide by poisoning herself. He knew her slightly
     and the emotion of personal loss played hardly any rôle in the
     case. But he had met her at a gay dinner a short time before her
     death. The news of the suicide came to him when he was overtired
     from work. The idea of the contrast between seeing his friend
     partaking of the dinner and imagining her drinking the poison gave
     him a strong shock. There was hardly any grief mixed in. He
     remembers that he shivered at the thought of the contrast, and in
     that moment the visual image of the woman raising a glass of poison
     to her mouth flashed into his mind and thus became almost a part of
     the shock. From that time on, the memory image of this scene
     returned more and more frequently. At first it associated itself
     with any chance mentioning of death or suicide and to a very slight
     degree with the idea of a meal. More and more any element of a meal
     and of social life, the word soup or meat, the word gown or dance,
     brought up at once the picture of the woman, which had in the
     meantime lost every element of personal relation. Any sad thought
     of her ending had faded away. It remained merely a troublesome
     impression. The man fought against it by trying to suppress the
     idea but the more he fought against it, the more insistently it
     rushed forward through new and ever new association paths. Any
     advertisement in the newspaper referring to food, anything in a
     shop window referring to ladies' dresses, any household utensils
     related to a meal, and especially the meals themselves, forced the
     visual image into the centre and captured the attention to such a
     degree that a confusing distraction from the real surroundings
     resulted. The struggle against the idea became more and more
     exasperating, made life a torture, almost suggested despair, even
     faint thoughts of suicide, and especially a growing fear that it
     was a symptom of the beginning of insanity.

     When he came to me, a number of physical cures, especially bromides
     and electricity, had been tried in vain by the physician. Some
     weeks in the country had not changed the distress. He came to me
     with the direct request as a last resort to try hypnotic treatment.
     I found in spite of the fact that he and his physician had
     constantly spoken of visual hallucinations that the visual image
     had no hallucinatory character at all, that is, he never believed
     that he saw the image of that woman as if it were actually present,
     he never took the product of his imagination for reality, nor had
     it the vividness and character of reality. It was hardly more vivid
     than any landscape which he tried to remember, only that it
     controlled the interplay of ideas in such a persistent way. I found
     that he was a strong visualizer and easily suggestible. I told him
     beforehand that I should hypnotize him only to a slight degree,
     that he would not lose consciousness, that he would remember
     everything which I told him. Then I asked him to lie down and had
     him gaze on a crystal only for half a minute, then close the eyes.
     I asked him to relax and to think of sleep. With the two blunt
     points of a compass, I touched his two cheeks at corresponding
     places, then his forehead. And now I told him that I would begin
     with the hypnotic influence. I put my hand on his forehead and
     spoke to him in a monotonous way, saying that he felt a fatigue in
     his shoulders, and in his arms, creeping over his whole body and
     assured him that he was now fully hypnotized. To what degree he
     really was hypnotized cannot be said as no effort was made to test
     it by any experiments, thus avoiding any possible reaction against
     the feeling of submission. Expression and breathing indicated a
     slight hypnoid state. Then I removed my hand and spoke to him in a
     warm and assuring way.

     I told him that in future he would give his full attention to his
     meal, and not give the slightest attention to any image of his
     friend. If he should think of the friend the memory would appear
     indifferent, he would not even notice the image and would give his
     whole mind to the objects with which he was engaged. In the same
     way, when he should be reading newspapers or looking in
     shopwindows, his whole attention would belong to that which he
     really perceived. Any passing inner image would be ignored. Then I
     awoke him from his sleep. He was unwilling to believe that he had
     been in hypnosis at all. I told him that the effect would prove it
     and in his fully wakeful state I explained to him why there was not
     the slightest fear of insanity justified, that it was a
     psychasthenic state resulting from fatigue and shock and from a
     wrong attitude of his attention during the past months, and then I
     asked him to return the next day. Intentionally I had not given the
     suggestion that the image would disappear. I could not expect it
     would disappear entirely after a first treatment and even a faint
     appearance of it would have at once fascinated the attention and
     brought about the whole disturbance of the equilibrium which might
     become habitual. Instead of it I gave the impulse to the
     counter-idea, that is, I reënforced the attention towards that
     which he really saw around him and thus withdrew the attention from
     the rival image in the mind. The success was complete. He came the
     next day in a much happier frame of mind, reporting that he still
     had seen the image of the woman every few minutes, especially
     strongly at the breakfast table, but it had no longer troubled him.
     It was more in the background of consciousness, sometimes it
     appeared transparent, it no longer held his attention, and he felt
     free to give his full attention to the actual surroundings.

     On that basis I hypnotized him the second day and he had hardly
     heard me saying that he ought to try to sleep when he was evidently
     in a much deeper hypnotic state than the first time. Again I
     suggested only the opposite attitude, the positive turning to the
     surroundings and the complete neglect and indifference for the
     possible memory image. This time the effect was still stronger. On
     the third day he reported that he still saw the image but he no
     longer minded it, as it was like a veil through which he looked at
     real objects and that left him entirely indifferent. His mind was
     hardly engaged with it any more. The real spell of the attention
     was broken. On the basis of this situation, I took the last step
     and suggested that the image of the woman would disappear
     altogether and would not trouble him any more. In the next
     twenty-four hours, it still returned two or three times, but
     colorless and faint. The following day I was able to eliminate it
     altogether. Even when the last trace of the inner struggle between
     the memory and the perceived surroundings had disappeared, I went
     on with two hypnotic sittings to give stability to the new
     equilibrium, to insist that the image would not come back and to
     settle completely that inner repose with which every fear of
     possible disease evaporated. I feel sure that the cure would not
     have been reached so quickly, possibly not at all, if the second
     suggestion, the disappearance of the image, had been given at the
     first step. The improvement was secured because the antagonistic
     process itself was used for the suggestion. On the other hand,
     there was no doubt that in this case the strong will of the patient
     or suggestion in a normal state would not alone have been
     sufficient. The hypnotic treatment was indicated by the symptoms
     and justified by the results.

I may take another typical case in which also the obsession was brought
about by an idea without emotional value or at least by an idea which
had lost its emotional character; the idea came somewhat nearer to
hallucination, but had its chief elements on tactual ground where the
transition from image to hallucinatory perception is easier. I add this
case to demonstrate that hypnosis is not the only open way of treatment
in such cases and that the variations must always be adjusted to the
special conditions. The case gains importance by the fact that the
patient was himself a physician well trained in mental observation.

     The patient is a highly educated physician of middle age. He
     reports that he had been neurasthenic all his life with slight
     ever-changing symptoms. He has always been troubled by the
     "perseveration" of tactual images which had a strong feeling tone
     and which were associated with seen or heard reports of the
     experiences of others. For instance, when he read in a newspaper
     that someone had hurt his hand with a pin, or that someone had cut
     his foot on a nail, he immediately felt a not directly painful but
     uncomfortable sensation at the particular place in the hand or in
     the foot, together with a shrinking of the whole body and such
     tactual sensation usually returned during the following days in
     fainter and fainter form until it faded away. Most troublesome had
     always been the reading of any torture processes in historical
     books or in fiction. Yet there had never been a case in which the
     sensations really had the vividness of hallucinations and never a
     case in which the after effects had not disappeared at least in a
     few weeks.

     This time the effect had already lasted four months and it became
     more and more troublesome. The patient had not the slightest fear
     of mental disease and no anxiety, but he felt a very serious
     disturbance by the instinctive effort to get rid of the intrusion.
     The place of the disturbance was the wrists. The starting point was
     a definite experience. On an unusually hot summer day the physician
     had listened for a long time to the complaints of a female patient
     who suffered vehemently from a nervous fear of scissors and knives
     and who was afraid that she would cut her artery at the wrist. He
     believes that it was the exhausting heat of the day which weakened
     him to a point where the story of his patient affected him very
     strongly and made him think of it all the time. Yet there was no
     sensation element involved. A few hours later, he sat in a hotel at
     his dinner. Just in front of him a butler started to carve a duck
     with a long, sharp knife. In that moment he felt as if the knife
     passed through the wrists of both arms. He felt for a moment almost
     faint; arms and legs were contracted and an almost painful
     sensation lingered in the skin, and did not disappear for hours.

     From that day at the sight of knives or razors, not only in his
     hands or his direct neighborhood, but also in a store and finally
     in a picture, stirred up at once the optical image of that carving
     knife cutting into the skin of the wrist, only with the difference
     that it seldom was found in both arms, usually in the one or the
     other. The sensation became a strictly tactual one with optical
     overtone, but there was no emotion in it. The pain element had
     disappeared. Also the shock, which still recurred in the first days
     slowly disappeared. The longer the symptom lasted, the more the
     optical factor faded away, and the tactual factor came into the
     foreground after three or four weeks. Perhaps seeing a razor in a
     store window or a pocket knife open no longer stirred up the image
     of cutting the wrist, but simply a strong tactual sensation, as if
     the skin of the wrist was scratched and pinched. Finally, after
     about two months, the association character disappeared to a high
     degree and the scratching and cutting sensation in the skin became
     independent and automatic. The patient awoke in the morning with a
     vivid tactual hallucination of being cut without associating with
     it any picture of a knife. Throughout the day, in the midst of work
     and in the midst of conversation, sometimes one and sometimes the
     other wrist became the center of the exasperating sensation, easily
     bringing with it involuntary reactions as if to withdraw the arm.
     This became more and more frequent and more and more vivid.

     The doctor, fully aware of the borderland character of this
     experience, felt sure that his inner fight against the disturbance
     would get control of it. The usual tonics did not show any
     influence. On the other hand, there were no other nervous symptoms
     and, with his most acute analysis, he did not find the slightest
     trace of emotion any longer. When the symptoms reached a point at
     which they seriously interfered with his comfort, he asked me for
     psychotherapeutic treatment, under the condition that I was not to
     apply hypnotism. He was absolutely averse to the use of hypnotism
     in his own case because he was afraid that to be hypnotized would
     mean for him a certain disposition to fall into hypnotic sleep by
     auto-suggestion, as he knew the vividness of his imaginative
     sensations. He wanted to avoid that the more as his own
     professional work might sometimes demand hypnotizing in his own
     practice. In any case he had an aversion to it and asked for other
     means.

     Under these circumstances, it seemed to me the most logical
     conclusion that the counter idea with its antagonistic reactions
     might be reënforced by direct perception. The abnormal tactual
     sensation forced on consciousness the idea of the cutting of the
     wrist. The necessary counter action would be to force to
     consciousness the idea of the uninjured wrist and the corresponding
     reactions. As the wrist can be easily made accessible to sight and
     as I anticipated that the visual sensations would be more forceful
     than the tactual ones, I told him to look straight at his own
     wrists for ten minutes three times a day after waking, after
     luncheon, and before going to bed. He had to hold his two forearms
     close in front of his eyes and stare at them, giving his full
     attention to the visual impression of the smooth, uninjured skin of
     the wrist. If during this process, the tactual counter-sensations
     were vivid, he had to go on with the staring at both arms, both
     held near together until the perception had crowded out the rival
     touch sensation. When this performance had been carried out six
     times, he did not notice the coming up of the tactual sensation
     with vividness any longer. From the third day it had disappeared
     entirely. I told him to go on with the process still every morning
     for some weeks. The physician himself considered the cure as
     complete.

Our first case dealt with hypnosis, our second case removed the
intruding idea by a perception in a waking state. To point at once to
the variety of methods which we sketched, we may turn again to a case of
emotionless idea removed by the method of switching off and
side-tracking the originating and physiological "complex."

     The patient is a school-teacher in the Middle West, a nervous,
     thin-looking woman of about twenty-five. Her only complaint is a
     persistent idea that she may at any time get a child. She has had
     this idea "as long as she can remember," according to her first
     expression. She never had any intimate acquaintance with any man,
     she was never engaged, she hated bitterly every thought of
     immorality, she knows and has assured herself by much reading that
     it is entirely impossible that she might get a child without sexual
     contact. Yet this thought recurs to her all the time, even when she
     is talking with other people. It embarrasses her in school, in
     spite of her teaching only girls in a private institution. This
     thought keeps her away from company and the effect of its
     embarrassing occurrence depresses her, but she is sure that the
     thought itself does not include any emotion. It is a mere thinking
     of it with a full consciousness that it is absurd, and yet she
     cannot suppress it.

     I began at once to try to find the origin of her queer obsession.
     After some efforts to pierce into her memories, we came to an
     experience of her youth. When she was about thirteen years of age,
     a young girl whom she had admired much for her beauty, living in
     the neighborhood of her parents, suddenly got a child which died
     after a few days. At that time no thought of immorality seems to
     have entered into that news. It was evidently mere sadness about
     the quick death of the child which gave to the experience its
     emotional tone. She was at that time completely naïve. She received
     an intense shock in the thought that an unmarried girl may suddenly
     get a child which would then quickly die. She cannot tell whether
     the thought that she herself would get a child had ever entered her
     mind before this occurrence in her neighborhood, nor can she say
     that it occurred immediately or very soon after it. She now knows
     only that she has always had that thought, but whether that means
     more than ten years, she does not know.

     I considered it a justifiable hypothesis that this strong emotional
     experience early in life had become the starting point for that
     secondary absurd thought. I considered that primary experience as
     cause for a deep physiological brain excitement which had
     irradiated towards the ideas of her personality. It had stirred up
     there associations which kept their psychological character while
     the primary disturbance had long lost its psychical accompaniment.
     It worked its mischief in a physiological sphere but was probably
     still the starting point for the persistent obsession. My aim was
     to remove this cause. It would have brought little improvement
     simply to suppress the freak idea as long as that physiological
     source was active. On the other hand I should not have the means to
     stop the physiological after-effects of that real experience: I had
     to sidetrack it and to secure thus a reduction. I decided therefore
     to work on the basis of that hypothesis, to accept that
     physiological complex as existing, but to switch it off by linking
     it with appropriate associations, thus setting it right in the
     whole system of her thoughts.

     For that purpose I brought her into a hypnoid state, bending her
     head backwards and speaking to her with slow voice until I saw that
     a slight drowsy state was reached. In this state I asked her to
     think back as vividly as she could of that experience of her youth,
     to fancy herself meeting that pretty girl, her neighbor, once more.
     She is to imagine that she speaks with her. Now I make her talk
     with me and she assures me that she sees the scene distinctly. She
     believes she sees the girl on the street. I ask her to tell the
     girl how indignant she feels over her behavior; she is to tell her
     that she understands now all which she did not understand in her
     childhood, that she knows now that she must have lived an immoral
     life; that she must have had a friend and that a pure girl like
     herself could never under any circumstances come into such a
     situation, that no pure girl could suddenly have a child. She is to
     express to the other girl her deepest disapproval of such conduct
     and her own feeling of happiness that anything like that could
     never happen to her. In accordance with my demands, she worked
     herself entirely into the scene: without using audible voice, she
     internally spoke with great vividness to her neighbor. When I awoke
     her from her drowsy state, she was quite exhausted from the
     excitement. I repeated that scene with her four times. She assured
     me that she felt it every time more dramatically. The power of the
     obsession weakened from the first day. After the fourth time, it
     had disappeared. The subcortical complex had evidently found its
     normal channels of discharge.

In discussing this method of side-tracking the complex, we mentioned
that in other cases the result is reached by bringing the memory of that
first experience to a vivid motor discharge, without substituting any
other ideas. For that purpose no direct personal influence is necessary.
Treatment might just as well be performed "by correspondence," provided
that the right starting point is discovered and that right suggestions
are given. As an illustration, I may choose a case which shows at least
the maximum distance treatment by mail, from Boston to Seattle. This
particular case presented no difficulty in getting hold of the starting
point as my correspondent, whom I have never seen, himself at once
pointed to the original source of his obsessing idea.

     The patient who lived with his family in Seattle wrote to me the
     following: "----I shall undertake to describe in a few words a
     condition which the writer has fought against for about eight years
     and which has subjected him to untold mental anguish.----I was
     backward in a social way but altogether happy. After working in a
     bank about a year, was discovered one evening by the cashier
     smoking a cigar in the basement, was unable to look him in the face
     at the time. Went home that night and thought very little about it,
     but on the following morning during the regular course of business,
     I stepped up to him to ask some question, and as usual,
     unconsciously looked him in the face. His glance was questioning
     and suspicious, and that was the beginning of a life of anguish for
     me. At first I could not look him in the eyes, then when looking at
     some other person, I happened to think of it and so on, until in
     two or three days it was impossible to look at anyone who came to
     my window. The cashier did everything he could for me. No use: I
     quit my position, lost most of my friends, had to leave a happy
     home and came to Seattle to work for an old school friend. In the
     first year, owing to new environments, I managed to conceal my
     mental condition to a certain degree. All of a sudden, I was again
     plunged into the depths of black despair. It took me about two
     years to (partially) forget it, when the same thing occurred again,
     and I lost my grip. The last time about eighteen months ago was
     almost more than I could stand. These three or four instances I
     speak of were cases of extreme despondency, but my usual mental
     condition is extremely unhappy. If occasions arise where I have to
     sit and talk to anyone for ten minutes, controlling myself is such
     an effort that it leaves me with a case of the blues.... I shall
     come and see you as the relief would give me a new lease on life."

     This letter was written on the twenty-third of January, 1908. I
     replied to him at once that he certainly ought not to come from the
     Pacific to the Atlantic, but that I wanted him to write to me much
     more about that first occurrence. As he was evidently right in
     considering that episode as the starting point of his troublesome
     associations, I supposed that these associated ideas had not yet
     become independent but were still the effect of that first
     "complex." Therefore I wanted to bring that to complete discharge.
     Accordingly I wrote him to think himself once more into that
     happening of years ago, to pass through it with all the power of
     his imagination, to describe it to me then in as full a statement
     as possible and to express in the letter also his conviction that
     there was no reason to avoid the eyes of his superior, that he
     might have looked straight into his face. As soon as he got my
     reply, he wrote to me on the sixth of February a description of
     that first episode, filling nineteen pages, telling me all about
     his relations to those various men and every minute detail was
     brought clearly to consciousness again. I did not add anything
     further, but the expected occurred. On the eighteenth of February,
     he writes to me: "In the last week or ten days, the writer has
     noted a decided improvement regarding mental condition. The result
     is a new interest in life. If you can spare the time, would like to
     have you write me a few lines. Gratefully yours." At the end of the
     month he writes: "Received your letter about half an hour ago.
     Hasten to assure you with a great deal of pleasure that I am
     feeling much better. Since sending you the letter regarding the
     first case, I have noticed day by day an improvement." On the
     eighth of March: "Since writing you last I have noticed a gradual
     improvement. It has given me wonderful encouragement." On the tenth
     of March: "Just a line to say that I am still improving." On the
     twelfth of April: "I desire to say that since the taking up of
     treatment with you, life has had a far different appearance to me
     than it has had for the last ten years." On the twenty-first of
     April: "Since my first letter to you, there has been such an
     improvement that I have accepted a position which carries with it
     much responsibility."

This case leads over to the large group in which the obsessing idea
involves the relation to a particular person. I find in such cases
autosuggestion more liberating than heterosuggestion if the development
has not gone too far. Of course autosuggestion can never take hypnotic
character, but makes use with profit of the transition state before
normal sleep. The type of these cases which are everywhere about us may
be indicated by the following letter.

     The writer is a young woman of twenty-four, whom I did not know
     personally. She wrote to me as follows: "I am a writer by
     profession and during the last year and a half have been connected
     with a leading magazine. In my work, I was constantly associated
     with one man, the managing editor. This man exerted a very peculiar
     influence over me. With everyone else connected with the magazine,
     I was my natural self and at ease, but the minute this man came
     into the room, I became an entirely different person, timid,
     nervous, and awkward, always placing myself and my work in a bad
     light. But under this man's influence, I did a great deal of
     literary work, my own and his too. I felt that he willed me to do
     it. The effect of this influence was that I suffered constantly
     from deep fits of depression almost amounting to melancholia. This
     lasted until last fall, when I felt that I should lose my mind if I
     stayed under his influence any longer. So I resigned my position
     and broke away. Then I felt like a person who, having a drug to
     stimulate him to do a certain amount of work, has that drug
     suddenly taken away, and without it I am unable to write at
     all...." I wrote to the young lady that she could cure herself
     without hypnotism and without my personal participation. I urged
     her simply to speak to herself early in the morning and especially
     in the evening before going to sleep, and to say to herself that
     the man had never helped her at her work, but that she did it
     entirely of her own power, and that he had never had any influence
     on it, and that she can write splendidly since she has left the
     place, and much better than before. A few months later, she came to
     Cambridge and thanked me for the complete success which the
     auto-suggestive treatment had secured. She was completely herself
     again and was fully successful in filling a literary position in
     which she had to write the editorials, the book reviews, the
     dramatic criticisms, and the social news. As a matter of course,
     such treatment had removed only the symptom. The over-suggestible
     constitution had not been and could not be changed. Thus it was not
     surprising that in the meantime, while her full literary strength
     had come back, she had developed some entirely different symptoms
     of bodily character which I had to remove by hypnotism.

As soon as the obsessing idea of the influence of another person takes
still a stronger hold and develops systems, the suspicion of insanity
always lies near; especially when hallucinations are superadded, the
probability is great that we then have to do with the delusions of a
paranoiac, and thus no case for psychotherapeutic treatment. Yet it is
always wise to keep a psychasthenic interpretation in view as long as
the insanity is not evident. I may mention such an extreme case.

     The patient, a man of middle age, highly educated, for years had
     heard voices calling his name. A man with whom he had some personal
     quarrel, had, as he believed, hypnotized him from a distance and
     made him act queerly or do things which he really did not want to
     do, by telepathic influence. It is a development which is found
     quite frequently. Abnormal organic sensations or abnormal impulses
     and inhibitions which the patient cannot account for by his own
     motives become connected with some vague ideas which are in the
     air, like wireless telegraphy or telepathy or hypnotism from a
     distance or electrical influence, or magnetism or telephoning,
     these then attached to an acquaintance who stands in a certain
     emotional relation. Here, too, some organic sensations evidently
     had been the starting point and the idea of the man with whom he
     quarreled had been secondarily attached. From this starting point
     more and more detail was reached. Every action was brought into
     connection with the powerful enemy who controlled more and more
     even the normal and reasonable doings of the patient. My first
     impression was decidedly that of a paranoiac. Yet in some ways the
     case suggested another view. There had remained an insight into the
     unreality of the obsession. The patient did not really believe the
     theory of the telepathic hypnotic influence. He felt it more as an
     idea which he could not get rid of and he did not know clearly
     himself whether he requested hypnotic treatment on my part for the
     purpose of counteracting the hypnotic power of his enemy or for the
     purpose of liberating him from his exasperating fixed idea.
     Moreover, I found that his voices had no hallucinatory character,
     but were merely sound images. I decided to make the experiment
     without great hope of success.

     I hypnotized the man deeply and suggested that no one can have
     power over his actions, that he is the responsible originator of
     everything that he does and that no one can influence him and that
     from that hour he would feel free from any telepathic intrigue. The
     effect of the very insistent and urgently repeated hypnotic
     suggestion during the first rather long treatment was such a
     surprisingly good one that I decided to continue the
     psychotherapeutic cure. I hypnotized him daily for two weeks. The
     belief in the real wrong doings of an enemy disappeared entirely
     from the first. It was at once apprehended as a mere obsessing idea
     in the own mind and this idea itself began to be resolved. It lost
     its unity; the absurd impulses were still felt but they became less
     and less connected with the idea of another man, and as soon as
     they were rightly understood as doings of the own mind, the
     opposite motives gained in strength. A stronger and stronger appeal
     to his own power made these motives more and more influential.
     Slowly the association of the influence of the other man faded away
     entirely. I intentionally had not given any attention to the
     pseudo-voices, inasmuch as they had not taken any relation to the
     ideational delusion. I therefore did not include them in my
     suggestions, as I consider it wise to confine hypnotic suggestions
     always to as few points as possible. Yet these voices decreased
     too. At a certain point in the cure I substituted--to save my own
     time--an autosuggestive influence, or rather a mixed one, inasmuch
     as I had him read ten times a day a letter of mine which contained
     appropriate suggestions. After about six weeks, all the
     disturbances for which he had sought my advice had disappeared.

Obsessing ideas of such personal influence involve of course always a
certain amount of emotional excitement and they may lead us to the
unlimited field of disturbances in which the persecuting idea is
surrounded by emotional attitudes. Analysis shows easily that the
emotion is an essential factor and that it persists in the disease while
the ideas to which it clings may change. Central is the emotion of fear;
nearest to it that of worry, but any emotion may give color to the
particular case. Again any number of methods may be applied and a few
illustrations with quite different ways of treatment may indicate more
fully the character of the trouble. There is no doctor in the city and
none in the remotest village who may not find such cases in his near
neighborhood. Of course slight degrees are easily hidden by the
patient's own inhibition of external expression. If such suppression by
the own will secures a real overcoming of the unjustified emotion, this
is surely better than to begin any medical treatment. But as the
suppression usually means simply lack of discharge and thus offers all
the conditions for an unhealthy inner growth of the trouble, the neglect
of such disturbances is most regrettable, and frankness of the patient
must be encouraged. Such situation demands a careful observation of the
whole case and a subtle adjustment of the treatment to the individual
needs. It may perhaps be helpful at first simply to indicate the
varieties of the more frequent disturbances of this kind by quoting from
various letters. Each case belongs to a type which can easily be removed
by psychotherapeutic influence, generally even by a skillfully directed
autosuggestion.

The writer is a young man.

     "I have always, as long as I can remember, been very nervous and
     sensitive. When about seven years of age, I was attacked by St.
     Vitus' Dance. Before that I cannot say whether I was particularly
     nervous or not. Afterward it was impressed upon me by the remarks
     of relatives that I was nervous, so that I soon took note of this
     condition myself. The manner in which this weakness has been
     especially troublesome is that it has caused me to be very shy. I
     shrank from new acquaintances and disliked being observed. Often in
     walking along on the street, I imagined myself closely noticed by
     the passerby and I always felt uncomfortable.

     "About three years ago I suffered from typhoid fever and after
     recovering, a new form of the old trouble showed itself. This time
     I imagined that when eating I chewed my food in a manner that was
     ridiculous and which made people hardly keep from laughter in
     observing me. Often I had to leave the table when half through
     because I felt I could not bear having critical eyes upon me any
     longer. About three months ago I determined to be troubled no
     further by my own foolish fancies and by constantly schooling
     myself I have improved very much. Still, however, when I walk alone
     along the street, I must fortify myself mentally before passing
     each group of people. If once I allow myself to think that they are
     looking at me, I feel almost paralyzed, my feet seem too heavy to
     lift, my arms do not seem to swing naturally, and in attempting to
     look placid and unconcerned, I feel that I am failing utterly. Also
     when at table, I must still tell myself before each mouthful that I
     have no need for fear, that my manner at table is equal and perhaps
     superior to the others beside me. I have gone a certain length in
     my self-training, and have relieved myself of a great deal of the
     mental distress, but now I believe I can advance no further. What
     seems needful now is to do away with the self-consciousness which
     brought on my worries, though whether this is possible is hard to
     say."

Here the letter of a young woman, the type which fills the army of the
mind healers and faith curists.

     "For years I have been seeking, or perhaps to be more accurate I
     should say waiting, for a mind to drift toward me; a mind that
     would understand my particular case of fear brought on by the
     constant bullying and nagging from my earliest childhood by those
     in my home. This fear of brutality has greatly depleted my nervous
     system and has unfitted me for the strong, useful, forceful life I
     should have expressed. If I could only rid my mind of the thought
     that I am always displeasing, or rather, going to displease people,
     for I hardly do displease them; if I could get rid of the fear of
     caring what the attitude of other minds toward me is, I feel that I
     should then strike out into a strong life of helpfulness to others.
     In other words I have always felt behind me a great force pressing
     me out into public work. When I was a child, it was so strong that
     I was sat down upon brutally, to so great an extent that I feared
     to voice my convictions and that fear still clings to me like a
     nemesis. It seems that every individual personality in a public or
     private audience rises up to overwhelm me, causing my tongue to
     grow heavy and my mind to become a blank. This enervating fear
     blends into every thought I have, whether sleeping or waking. I
     have fought with all my might to rid myself of it but so far in
     vain."

Here an expression of a very frequent variety. The writer is a
middle-aged man.

     "I am possessed of a fear that is constantly with me that something
     dreadful is going to happen and I do not seem to be able to
     overcome it. I am told by physicians that I am bodily sound,
     although very nervous, and that the fear is generated entirely by
     autosuggestion. When at its worst, it weakens and terrorizes me and
     in my better moments I am tormented with a fear of a recurrence of
     a bad spell. It is fear of a fear. A year ago at this time I had a
     very bad spell but got along fairly well through the summer, but I
     am afraid that I will soon again be in a bad condition and lose all
     that I may have gained."

The "fear of a fear" is indeed a symptom which the psychotherapist has
to fight extremely often, but as soon as he has really recognized it and
analyzed the whole mental condition, he will hardly have any difficulty
in uprooting it. I add a letter of a school-teacher in New York. He
writes:

     "I am teaching in a high school. I am of a nervous temperament and
     constitutionally limited in endurance. Often my work is done in a
     condition of greater or less exhaustion. I find that I blush very
     easily in purely freakish ways, when there is no occasion for it. I
     find this blushing connecting itself with certain of the girl
     pupils of my classes in a conspicuous way. It occurs hardly ever
     except when my class is facing me and I seem to be powerless to
     overcome it. I have always tried to live a careful moral life, but
     my early life was very much secluded. I lacked entirely the free
     intercourse young people usually have together and I felt awkward
     with others for a long time. In the matter of the blushing, it
     sometimes occurs in the case of girls who are especially pleasing
     to me but also not infrequently in the case of some who are not at
     all so. The whole thing might be passed over were it not that it
     has considerable effect in causing constraint toward my students
     and in some cases affecting them very strongly in an emotional way
     at the very time of life when such things can do most harm. I
     regard the matter as being so serious that it brings directly in
     question my right to teach, but I do not feel at all sure I could
     find other work that I could do if I give up my present position.
     The very thought that on a particular occasion it would be
     extremely awkward to blush makes it almost impossible for me to
     avoid it."

But we have rather now to consider the therapeutic side, and we may
begin again with a routine method of a simple hypnotic treatment.

     The patient is a young university professor. His intellectual work
     is perfect in all directions. There are no nervous symptoms, though
     there are some slight disturbances of digestion. He suffers as soon
     as he comes into a crowd of people and as soon as he is on any high
     place, where he has to look down; the worst when both conditions
     are combined, as for instance, at a concert or a theatre in a
     balcony seat. But every meeting of many persons, even at church,
     produces all the symptoms of nervous excitement. He was easily
     brought into hypnotic state by verbal suggestions. When he was in
     hypnosis, I reënforced the conditions for an opposite attitude. I
     told him that as soon as he was in a crowd of persons he would feel
     especially comfortable, would enjoy himself, would fully enter into
     the spirit of the occasion and feel especially secure in their
     presence. Whenever he should be on a high place, he would enjoy the
     safety of the ground on which he was standing or the seat on which
     he was sitting. I assured him that he would neglect entirely
     whatever he saw and would rely completely on his safe feeling
     resulting from his tactual impressions. After having hypnotized him
     three times the disturbance disappeared completely, and even an
     evening at the theatre in an exposed box on the balcony was enjoyed
     without any discomfort. After about a year, at a period of
     fatiguing work, some traces of the anxiety appeared again. This
     time two hypnotic sittings were sufficient to remove the
     disturbance of the equilibrium, which as far as I know has not come
     back. The same hypnotic treatments were used in a secondary way to
     remove the digestive trouble.

I again quote the case of a teacher, a profession in which the
psychasthenics are unusually frequent. It is a case of a young woman
from the Middle West.

     The young lady wrote me: "I come of a race of strong women and am
     not hysterical or easily frightened by many things that disturb
     women. Since my fifteenth year I have been seized by hallucinations
     of absurd or serious nature which no reasoning could explain away
     and which have gradually undermined my power of resistance to them.
     At the age of twenty-two, after a year of unusually hard work, my
     nervous endurance gave way, and with this breakdown came a sense of
     fear and a horror of crime that I have been unable to overcome. I
     have never felt the slightest inclination toward wrongdoing. It is
     a feeling rather that my shrinking from any mention of evil makes
     it impossible for me to listen or think rationally when such things
     are discussed. This feeling has seemed to change my whole attitude
     toward life and has left me without power to control my facial
     expression or carriage when it takes possession of me. I have been
     able to teach more successfully than I could hope, but it is only
     by cutting myself off from the friendships and pleasures incident
     to my life that I am able to accomplish my work. I have fought this
     trouble alone and will still do so if there is no help, but the
     thought that it is the source of great distress to those dear to me
     makes it very hard."

     A few weeks later the lady insisted on coming to Cambridge. I found
     that there had never been any hallucinations and that she used the
     word in her letter only to indicate some insistent memory images
     which had never taken the vividness of real impressions. In the
     presence of her friend, I hypnotized her deeply and strengthened
     through urgent suggestions her consciousness of her having done the
     morally right thing at every situation in her life and her
     conviction that she never did and never would commit a crime. Here
     as always, if possible, I left alone the emotional idea but
     reënforced the opposite. The effect was an immediate one. She felt
     freer the next day than she had felt for years. I repeated the
     treatment a few times and she assured me that the feeling had
     disappeared entirely.

I take the rather severe case of a woman of fifty.

     The highly educated and refined lady had lost her husband by an
     accident in Switzerland, which had been misrepresented by some of
     the newspapers as suicide. Two years later she wrote to me: "I feel
     as if I had received indelible photographs on my brain which have
     since greatly affected my health and from which I may never
     recover. This winter the symptoms I have been able to control
     returned and I have been ill. I unfortunately saw the newspaper
     headlines with my husband's supposed suicide. Though I exclaimed
     then, 'how outrageous,' I felt as if I had been struck and since
     then I can seldom read a paper without dread and apprehension, and
     the hearing of anyone's suicide fills me with terror. When I
     hurried to Europe, on the ocean a week from the day of my husband's
     death, I had a curious and overwhelming shock. On opening a drawer
     and seeing a pair of scissors, they looked to me like a dagger and
     suddenly the whole cabin seemed filled with implements of death.
     The doctors said that I would find it hard to get over such
     impressions but I told them I would, as I had courage and will. But
     I have been realizing in these two years that I may be suffering
     from something that may be beyond the control of will. I often
     become so nervously sensitive that scissors are unbearable for me
     to see, or a steel knife or anything that might express death. Our
     family physicians are still against hypnotism, and if I should go
     to a neurologist of my own selection, it might be to one who
     believed still only in nerve foods, baths, or a sanitarium."

     The lady came from the South, with her nurse, to Boston and
     insisted on being hypnotized by me. I cannot say whether a really
     deep hypnotic state was produced at once as I refrained from
     testing it. There was certainly no amnesia. Probably it began only
     with a slight drowsiness but at the fifth treatment I found a
     relatively deep hypnosis. It was a capricious case in which the
     improvement was fluctuating but clearly setting in from the first
     day. I trained her in hearing and seeing words like death and
     suicide with a reënforced feeling of strength and calmness; I
     forced her to see and touch scissors with an artificial attitude of
     strength and indifference. At the same time I reënforced her good
     mood and her enjoyment in life. When she left for England a few
     weeks later, she felt herself mentally cured, and throughout the
     summer her letters testified the wonderful change which the
     treatment had brought about. Half a year later, as the result of
     an exhausting physical local treatment, the psychophysiological
     symptoms came back to a certain degree. She requested me by a
     letter from England to give her some help by suggestion to suppress
     again the recurring intrusions. As I had observed her strong
     suggestibility, I sent her over the ocean a little pencil of
     mother-of-pearl which she had seen in my hand, and advised her to
     look at it until she counted twenty slowly and then to close her
     eyes and simply to sleep. The autosuggestive effect was unusually
     strong. She writes from London: "When I saw the enclosure of your
     letter I felt as if it would burn through my hand and the feeling
     became so overpowering that I locked it away with my jewels, but as
     the days ran into a week I felt I could not live with it in my
     apartment any more, and I felt almost ill, until it occurred to me
     I could seal it and take it to my bankers. I felt as dreamy and
     absent-minded and paralyzed as if you had just treated me."
     Nevertheless the effect was on the whole the desired one and she
     returned to America with a wholesome freedom of mind. I hypnotized
     her twice again and she writes in her last letter: "I can never
     repay you for what you have done for me. You have given me back my
     courage and my love of life in its vividness and interest and
     color, all that through the last years I had so entirely lost."

Even in cases where the disease itself is inaccessible to
psychotherapeutic treatment, the superadded grief and worry brought on
by the disease might yield to the mental influence and the whole
situation would to a high degree be transformed for the better by it. I
have often been asked to hypnotize in such cases, where the depression
was wrongly taken as a part of the nervous disease; sometimes I agreed
to do it in spite of feeling sure that the disease itself could not be
removed. I quote an instance.

     A young woman afflicted with epilepsy was brought up in the belief
     that she had only from time to time fainting attacks from overwork,
     and with them secondarily neurasthenic symptoms, especially spells
     of depression colored by a constant fear of the next fainting. She
     had heard voices all her life and they frightened her in an
     intolerable way. I produced a very slight hypnotic state. I
     concentrated my effort entirely on suggestions which were to give
     her new interest in life, and diminished the emotional character of
     the voices without even trying to make them disappear. I proceeded
     for several months. The young woman herself believed that the
     fainting attacks came less frequently afterwards; yet I am inclined
     to think that that is an illusion. But there was no doubt that her
     whole personality became almost a different one with the new share
     in the world. The epilepsy remained probably unchanged but all the
     superadded emotions were annihilated and she felt an entirely new
     courage which allowed her to control herself between her regular
     attacks. She had been unable to undertake any regular work before
     for a long while, but all that improved. More than a year
     afterward, she wrote me: "I have really worked most of the time
     this past winter and spring and I think I can see a steady though
     slow gain. I am reading quite a little and doing it for the most
     part easily. To be sure I have, after I have read, hard times with
     the voices but their character is usually less determined and
     fearful than formerly. Several times I have thought I must come
     again to you but each time I have started again to fight it out for
     myself, but now, as I am gaining, I can better estimate the great
     help your influence was to me at a juncture when everything seemed
     so hopeless and helpless."

Even in slight psychasthenic disturbances, the psychotherapeutic
influence is not always successful, especially if there is no time for
full treatment. But it is very interesting to see how even in such cases
the symptom is somehow changing, almost breaking to pieces. It becomes
clear that a protracted effort in the same direction would destroy the
trouble completely. Typical is a case like the following.

     An elderly woman has been troubled her life long by a
     disproportionate fear of thunderstorms with almost hysterical
     symptoms. As she had no other complaint, I hardly found it worth
     while to enter into a systematic treatment and could not expect
     much of a change from a short treatment, considering that her
     hysteric response had lasted through half a century. As she begged
     for some treatment, I brought her into a drowsy state and told her
     that she would in future enjoy the thunderstorms as noble
     expressions of nature. The whole procedure took a few minutes. Yet
     after some summer months she wrote me a letter which clearly
     indicated this characteristic compromise between the habitual dread
     and the reënforced counter idea. "I have the same sick dread at the
     sight of thunder clouds that I have always had, but I seem to have
     gotten somehow a most desperate determination to control my fear. I
     have done this to the extent of keeping my eyes open and looking at
     the storm. Is that hypnotism or pride?"

Another thunderstorm case may lead us to other methods of treatment.
Here again in the field of emotional response, we may consider the
methods of going back to primary experience, known or forgotten.

     A young married woman of the West had suffered always from
     hysterical attacks in response to any sharp sudden impressions,
     especially sudden loud noises. The banging of a door, but worst of
     all a thunderstorm, could produce hours of weeping and crying and
     desperate mental condition with all expressions of excitement. Her
     husband wanted me to hypnotize her but I preferred another way. I
     tried to get her memory back to the earliest case of which she
     could think of this hysterical response. As long as we were in
     ordinary conversation, she could not trace it beyond about her
     twelfth year. But when I brought her into a drowsy state, her
     memory revived older experiences and finally settled at a school
     experience in her seventh year of age. She then had an excitable
     country school-teacher who relied on whipping the children. Once
     her neighbor in the class did something forbidden. Her teacher
     mistook her for the culprit and began to whip her most forcibly
     before she could explain anything; and while the punishment was
     going on and she began to bleed from a wound, she all the time felt
     that she wanted to express her innocence and could not speak. After
     that, evidently the first attack of hysteric character followed.
     From that time on any sudden impression released the same group of
     reactions. The suppressed emotion had evidently become a
     psychophysical "complex." As soon as I had reached this starting
     point of her pathological history, I asked her to bring back to
     consciousness as many details as possible of that first incident.
     She told me all the names and described the classroom and brought
     herself vividly into the whole situation. Then I asked her to tell
     me the whole story once more and to express strongly her innocence
     and the wrongness of the punishment, and when she had completed her
     account, brought out with fullest indignation, I had her tell the
     whole thing once more and then a third and a fourth time, until she
     was quite tired out from it. That was all I did. Very soon after,
     the husband reported that there was a great improvement in every
     respect, no hysteric attacks, only slight discomfort. Most of the
     stimuli which had previously produced strong reactions now passed
     without any disturbance and even thunderstorms were experienced
     with relative ease. A year later they came once more to Cambridge,
     and she simply passed once more through the same process of
     discharge which seems now to have removed the symptoms still
     further.

By far more reliable, however, is the method of side-tracking the
starting experience into a new associational track.

     A gentleman with a decidedly psychasthenic constitution developed a
     tendency to hesitate in walking on the street. It was not a
     complete stumbling but a disturbing inhibition, which set in when
     he was walking alone and his attention was not absorbed by
     something on the street. He believed that it came on most strongly
     when he looked down at the pavement. He suffered from it vehemently
     and avoided going on the street alone. He was unable to connect it
     with any starting point. He interpreted it as merely a symptom of
     overwork. But going with him through all kinds of experiences which
     he had had on the street in previous years, we finally found that
     once he was running to catch a street car, when he suddenly saw
     almost immediately before him a big hole dug out for laying gas
     pipes. He was able to stop himself quickly enough not to fall into
     the hole but he got a strong emotional shock from the experience.
     He, himself, did not think that his walking troubles set in
     immediately after this shock. Yet the hypothesis seemed to me
     sufficiently justified that there existed a connection, even though
     some weeks lay between that first experience and the first
     observation of the abnormal inhibition in walking. On that basis I
     tried to train a new associative connection. I made him drowsy and
     asked him to think himself once more into the situation of his run
     for the car but as soon as he reached the hole to jump over it. He
     went through this motor feature on ten successive days with new and
     ever new energy and from that time up to the present the trouble on
     the street has disappeared entirely.

To mention at least one case of the large group in which suppressed
sexual emotion was the evident source of an anxiety-neurosis, I mention
the case of a woman who showed very strong symptoms of anxiety and
oppression and who was cured by a simple advice.

     The woman, aged thirty-two, was a saleswoman in a large store
     selling gentlemen's gloves and ties. She suffered from time to time
     by attacks of vague anxiety in which her heart showed vehement
     palpitation. There were paleness and perspiration and at the height
     a nervous trembling together with a feeling of despair. These
     attacks were not frequent, separated sometimes by weeks, sometimes
     by months, but troubling her exceedingly. She had been assured by a
     physician that her heart was normal and that she was probably
     overworked. She could find absolutely no source of the disturbance.
     After a long conversation, I was also unable to discover any direct
     or indirect causes until I worked on the basis of those theories
     which we have discussed, the theories which connect hysteric
     symptoms with chance intrusions which stand in relations to past
     suppressed emotions of sexual character. The patient absolutely
     denied any present sexual emotions. She had been engaged about
     eight years before and acknowledged that at that time there were
     strong sexual feelings connected with her fiancé, who broke the
     engagement. Psychoanalytic methods now brought it to full clearness
     that she had her first attack after selling a pair of gloves and
     fitting them to the hand of a male customer who had a certain
     similarity to her fiancé. It was not possible to trace this in the
     same way for later cases too, but it seems that bodily contact with
     a man by fitting gloves preceded every attack. All this was brought
     out partly by questions, partly by free ascending associations
     while she, herself, believed that she simply pronounced nonsense
     words as they came to her mind, and partly it was secured in a
     half-hypnotic state. I came to the conclusion that the suppressed
     sexual emotions at the breaking of the engagement were the primary
     cause of the disease. The similarity of the first customer together
     with the tactual sensations had evidently touched that complex and
     brought the suppressed emotion to an explosion which frequently
     takes the form of palpitation and similar symptoms. Later the mere
     tactual sensation alone produced by the contact with the hand of a
     man, possibly with a similar optical impression, perhaps also with
     the sound of the voice, brought back the reaction. Instead of
     giving treatment, I insisted that she change stores, and become
     saleswoman in a house where she would have to do only with women,
     and to sell articles which did not bring her into personal contact
     with customers. After more than six months of work in her new
     place, she reported that the attacks had not come back again.

Of course it may readily be acknowledged that this method does not allow
a sharp demarcation line between its various factors. It cannot be
denied that an element of straight suggestion may be included. The man
whom I train in the forming of a new antagonistic motor response feels
it of course all the time also as a silent suggestion to overcome the
old disturbance. It is thus to a certain degree impossible to say where
the effect of the discharge ends and where that of the hidden suggestion
begins. Yet there certainly cannot be any doubt that this revival of the
first experience and its improved discharge works directly towards the
removal of the troublesome symptom.

Abnormal fear is also the essential factor in most cases of stammering.
The patients usually know it themselves. For instance, a lawyer writes
to me:

     "I have been a stammerer the greater part of my life and have
     visited every stammering school in the country, but the relief
     obtained has been temporary and in most cases I was not benefited
     at all. I am convinced that stammering is due wholly to an abnormal
     mental condition, which consists of an unreasoning fear that takes
     possession of the individual when he attempts to utter certain
     sounds. It is simply a lack of confidence inspired by numberless
     failures to articulate properly and is not caused by any organic
     trouble, because, taking my own case for example, I can at times
     talk as fluently and easily as anyone. I am firmly convinced that
     stammering can be cured by hypnotic suggestion. If you could get me
     in the hypnotic state and suggest to me repeatedly that from
     thenceforth I would have easy fluent speech, I feel absolutely
     certain that such would be the case."

Or an engineer writes to me:

     "At times I stammer very badly. In an ordinary conversation it is
     scarcely perceptible, but it is almost impossible for me to make an
     explanation or relate an incident or tell an anecdote. I began to
     stammer when I was about seven years of age--I am twenty-nine
     now--and continued until I was seventeen, when I broke myself of it
     by reading aloud. It came back on me about a year ago, at which
     time I was laboring under a very severe nervous strain on account
     of business matters. I have since tried to break myself of it in
     the way that I did at first, reading aloud, but have been unable to
     do so. Can it be cured by hypnotic treatment or suggestion? Can any
     hypnotist of ordinary ability do it?"

I should affirm this question, which is one of the most frequent put to
the psychotherapist. And yet, if I myself have entirely given up the
cure of stammerers in recent years, it was not only because there was
little chance to learn anything new scientifically from it but also
because it was ultimately disappointing, as the severe cases cannot be
cured entirely. Every hypnotist can quickly secure a strong improvement.
In even new cases I found an almost surprising improvement in the first
two weeks, an improvement which stirs up the most vivid hopes of the
sufferers. Then the improvement becomes slower and finally it stops
before a complete cure is reached. The patient notices it and it easily
works back on his emotion and thus begins again to disturb the speech,
unless a very careful continuous counter-suggestion is given. Slight
disturbances, to be sure, can be removed entirely. The essential point
will always be to suggest to the stammerer the full belief that he is
able to speak every word and that he is able to speak it in every
situation. But where there is a limit for improvement, we must take for
granted that the disturbing fear is only superadded to an organic
trouble. In such cases, probably the inability of certain nervous paths
was primarily irreparable. These inabilities then became the source of
discomfort and of fear and this fear added greatly to the disturbance.
Hypnotism then quickly removes that part of the disturbance which had
been superadded by the mental emotion but it cannot remove that primary
factor, the objective inability, and every cure thus finds its limit
there.

Near the field of emotions stand also the many varieties of sexual
abnormities and perversities. I abstain from discussing any special
cases but it may be said that suggestive treatment is in this region
powerful to an almost surprising degree. Even homosexual tendencies
which go back to the beginnings of the memory of the individual yield,
as my experience shows, in a few weeks, if again the suggestion is not
so much directed towards the suppression as to the creation of the
antagonistic reaction, that means in this case, of the normal sexual
desire.

Both ideas and emotions, of course, lead to actions. Moreover we always
insisted that the resulting action is an essential part of the
psychophysical situation and that every mental experience has to be
characterized as a starting point for action. Yet this factor of
activity and of attitude sometimes stands in the foreground. The
controlling idea is then the idea of an end of action, the predominant
emotion, the emotion anticipated from a certain activity. Typical for
that are those disturbances in which an abnormal impulse or an abnormal
desire awakes perhaps a desire for ruinous drugs like morphine or
cocaine or an impulse to criminal deeds, like stealing. But the
disturbances of the psychomotor factor are not less present when the
central complaint is a lack of energy, the most frequent symptom of the
neurasthenic; and our whole discussion has made it clear that a mere
lack of attention belongs to the same category.

Of course, the abnormal impulse is psychophysically not different,
whether it leads to a legally important result like the impulse to kill
or leads to an indifferent result. The subjective suffering may be the
same in both cases. The starting point of the impulse may be any chance
experience. The psychasthenic may pick up such impulses from any model
for imitation or from any haphazard report. It may be entirely freakish
and yet beyond conscious control.

     A physician had read in a well-known book on hysteria about a case
     in which a girl was troubled by a constant effort to move the big
     toe in her shoes. This idea worked on him as a suggestion for
     several months. At my advice he fought it by auto-suggestion. He
     brought himself into a slightly drowsy state by staring into a
     crystal ball and assuring himself by spoken sentences with
     monotonous repetition for a long while that he has perfectly the
     power to hold the toe at rest. From the second day only a slight
     kinæsthetic sensation remained; the movement itself disappeared.

Or a more unusual case.

     A young lady once noticed in a man a different color in the two
     eyes. It gave her an uncanny feeling, together with the natural
     impulse to compare the two eyes. Accordingly she shifted her own
     eyes from one eyeball to the other in the man's face. The accent
     which this shifting impulse had received by the disagreeable
     feeling evidently forced her to repeat this movement with everyone.
     At first it became half a play, but soon a disturbing habit and
     finally an intolerable impulse. Whenever she talked with anyone,
     she lost control of her eyes and was obliged to enter into a kind
     of pendulum movement from eye to eye. The situation became so
     unendurable that the thought of suicide began to occur to her. I
     hypnotized her four times, suggesting to her complete indifference
     as to the face of those with whom she spoke and at the same time
     certain new habits of fixation. The impulse lost its hold and when
     I saw her last, it had completely disappeared.

By far more frequent than such neutral impulses are the desires, for
instance, of the alcoholist. On the whole it may be said that
psychotherapy can gain its easiest triumphs in the field of alcoholism
and a wide propagation of psychotherapeutic methods and of a thorough
understanding of psychotherapy would be fully justified, even if no
other field were accessible but that of the desire for alcoholic
intemperance. The moral disaster and economic ruin resulting from
alcoholic intemperance, the physical harm to the drinker and to his
offspring is so enormous, and the temporary cure of the victim is so
probable that the movement certainly deserves most serious interest. Yet
I speak of temporary cure and I refer here especially to the restriction
with which I introduced the psychotherapeutic methods in general. They
do not deal with diseases but with symptoms; and they certainly do not
deal with constitutions, but with results of the coöperation of
constitution and circumstances. That the given constitution may be
brought anew under conditions which again stir up similar symptoms is
always possible, and just with alcoholism the danger lies near unless
beneficial influences remain in power. Certainly no one has a right to
neglect such psychotherapeutic aid simply because relapses are possible.
Even a temporary relief can be a great blessing. Moreover, the temporary
relief is the safest basis to work towards the prevention of a
recurrence of the evil. Only in two directions is further restriction
needed. Psychotherapeutic methods are in my opinion of very small avail
in cases of periodic drinkers. Such periodic attacks of patients who
have not even a desire for alcohol in intervals between the attacks,
intervals which may last a quarter of a year, are related to epilepsy.
It seems that constant hypnotic influence during the interval has a
certain power to reduce the periodic impulse. I personally have not
seen any special improvement from it. The second restriction would be
that the drinker has to be under constant supervision during the first
days of hypnotic treatment. No patient, not even the morphinist, is so
skillful in deceiving his friends and even the physician. Even the most
emphatic gestures of sincerity ought to be distrusted.

     Only a short time ago I dealt with a young man whom his parents and
     a chauffeur had accompanied to Boston, exclusively for the purpose
     of watching him constantly while I was to attempt to cure him from
     excessive whiskey drinking. The chauffeur accompanied him from his
     room in the Boston hotel to the threshold of my laboratory. All
     through the day he was with his parents, and at the hotel the
     management had given the strictest orders not to sell any drink to
     the young spendthrift. He was an earlier student of mine and had
     attached himself to me with such an apparent sincerity as removed
     every possible doubt of his pledge. Intentionally I had not even
     asked him for a pledge not to drink but only for a pledge to
     confess to me the next day if he ever should take any alcohol. In a
     tentative way I suggested to him in a half hypnotic state on the
     first day that he would feel disgust for whiskey. I did not expect
     much of an improvement before at least three or four treatments. I
     was therefore most surprised when he most solemnly assured me the
     next day that he awoke in the morning with an assured feeling that
     he should never touch whiskey again and that he had not the
     slightest desire for it. Instead of a systematic development of
     suggestions, I confined myself therefore to a mere repetition of
     the treatment of the first day and as every morning the same
     assurance came forth, there seemed to be no need for any
     variation. It was not before the fifth day that I discovered that
     he had taken from the start a pint of whiskey every day. When he
     first arrived he had bribed a laundress of the hotel to bring to
     his room every day the whiskey hidden in the laundry and he drank
     it during the night. Then I declined any further participation.

The danger of deceit is of course less imminent when not the family but
the patient himself takes the initiative. Yet even here distrust is
wise. The patient has sometimes the most sincere intention to be cured,
but under pressure of his craving he admits compromises which he hides
from the physician. Having reduced the large quantity of alcohol to
which he was accustomed, he hides the fact that he yet takes a few
drinks, which he thinks cannot prevent the cure. Yet inasmuch as a
complete cure has to rely on psychical factors, this consciousness of
deceiving even with small transgressions interferes badly with progress
and, inasmuch as the cunningness of the patient is itself a symptom of
the disturbance, the strongest possible precaution is advisable at the
beginning. For that reason it is also not best to begin at once with
complete prohibition, but to lead to a total abstinence in about one
week. But certainly in the case of every drunkard, total abstinence is
the only desirable goal. A pronounced drinker ought never to be
transformed simply into a moderate one. The return to intemperance would
result rapidly. On the other hand it would be unfair to deny that
psychotherapy has cured the symptom if the desire really once
disappeared completely, even if, after years, new temptations develop a
new desire. I myself had diphtheria three times in my life; my
constitution is thus probably especially favorable to that disease but I
do not estimate less the fact that I was perfectly cured the second
time, in spite of the fact that I caught it a few years later a third
time. To be sure, such experiences of relapse cannot be spared any
psychotherapist. I may give a typical instance.

     A well-known professional man of fifty years, through a long
     bachelorhood, was accustomed to close his work at four o'clock and
     then to sit comfortably in his study with a book and an unlimited
     supply of brandy. He took one cognac after another and every
     evening he was completely intoxicated. He married a young wife and
     felt the need of changing his habits, the more as he himself saw
     symptoms of his excess which alarmed him. When he came to me, I saw
     that he was seriously wishing to give up, and he understood himself
     that there was only the one way, namely, complete abstinence. He
     felt that he could not reach it by his own will power alone and
     sought my aid. I hypnotized him six times, suggesting at first a
     reduction to four drinks, then to two, then to one and then to pure
     mineral water. I concentrated my effort on stirring up the
     antagonistic attitude, the dislike of the smell of brandy and the
     aversion to its taste. The effect was excellent. After the fifth
     time the mental torture which he had felt in the first afternoons
     had completely disappeared. I considered further hypnotizing
     superfluous and felt sure after the sixth time that the man was
     cured. For about a year he remained abstinent, but in the meantime
     his professional life brought severe disappointments, and with cool
     consideration he decided that he might have at least some pleasure
     from life and forget its miseries. Accordingly after a year he
     determined again to take some brandy in his study, and of course,
     that led rapidly to an increase of the dose and today he is
     probably at the old point. And yet it may be said with correctness
     that psychotherapy had done its duty. If at the right moment before
     he took the first step again, even the slightest counter-suggestion
     had been applied, the disastrous second development could have been
     easily avoided.

My experience indicates the best results where the suggestions are from
the start directed as much against the unfavorable social conditions,
with their temptations and impulses to imitation, as against the
alcoholic beverages themselves. On the whole it is easier to break the
vicious drinking habits of the social drinker than those of the lonely
drinker, a point which ought to be well considered in settling the
complex problem of prohibition versus the temperance movement.

The situation of alcoholism repeats itself in still more ruinous forms
with morphinism and cocainism, vices which grow in this country to an
alarming degree. The psychotherapeutic treatment of such drug habits
demands much patience and much skillful adjustment to the psychological
conditions. Its general difference from the treatment of alcoholism is
given by the circumstance that any too rapid withdrawing of the drug is
certainly dangerous, if the organism is adjusted to a relatively strong
dose. On the other hand, I may say that I have not seen a single case
in which a really patient and insistent treatment of morphinism has not
been successful, even if the destructive dose of forty grains a day had
become habitual. The condition is only that the patient himself have the
best will, a will which yet is not strong enough to win the fight
without psychotherapeutic help. But no one ought to expect that the
psychotherapist can secure miracles like some of the pill cures which
treat the drug fiend in three days. Moreover neither physician nor
patient ought to believe that the worst is to come at the beginning. On
the contrary, it is the end which is hardest, the reduction of the small
dose to nothing. As illustration, I give an extreme case.

     A man who was formerly station master on a railroad had been
     operated on in a hospital after an accident, and as some pain in
     the hip remained which disturbed his sleep, the physician of the
     hospital gave him some morphine and provided him with the material
     for morphine injection after leaving the hospital. Then began the
     usual story. He became more and more dependent upon his injection,
     the dose was steadily increased, he found unscrupulous physicians
     who yielded to his demand for morphine prescriptions; he lost his
     position with the railway by the growing effects of the morphine
     poisoning, he became divorced, sank lower and lower, his daily dose
     fluctuating between thirty-five and forty grains a day, and when he
     came to me, he presented a picture of the lowest type of hopeless
     manhood. He spent practically the whole day in bed and was only
     able to totter slowly along with a cane. He assured me that life
     was hell for him. He could not sleep, he could not eat, he could
     not think, he had made up his mind to commit suicide if I could not
     help him. I foresaw that it would in the best case demand months of
     insistent energy to make a man out of that unfortunate wreck. He
     had gone through three different morphine cures in three
     sanitariums and none had helped him, and every physician whom he
     had consulted had declared his case as beyond any physical cure. I
     decided to make the somewhat disproportionate sacrifice of time in
     order to study whether even such an extreme case of morphinism is
     accessible to psychotherapeutic treatment. Four months later, he
     left my laboratory looking like an athlete, strong and vigorous,
     joyful and energetic. For three weeks he had not received any
     morphine, had good appetite, slept well, and had happily married.
     As his wife was a trained nurse, she will take good care that no
     new slip shall ever occur.

     There was nothing remarkable in those four months of treatment. He
     was easily hypnotized, and I hypnotized him at first every day,
     then every second day, then every week. It was without difficulty
     that I reduced the forty grains to about six grains a day. Then the
     struggle began. To test the case as a strictly psychological
     problem I left the effort entirely to his own will, that is, I did
     not deprive him of the morphine supply but left the regulation in
     his own hands. During that whole winter he had a bottle with a
     thousand morphine tablets standing on his desk. Thus he would have
     been entirely able to satisfy any craving, but by his own will he
     followed my suggestions and never took more than I permitted. It
     meant a terrible struggle. The tortures which he had to pass
     through were perhaps worse than those which he had experienced at
     the time of his lowest downfall. They came to a focus when he tried
     to go from five grains to three grains a day and then again when
     he approached half a grain. From there he had to move to a fourth
     of a grain, then to an eighth, and even that had still to be
     divided into four different doses which were then reduced to three,
     to two, and finally to one dose and ultimately to injections of
     warm water. A rapid increase in general strength and a return of
     appetite for food began when he had reached the five grain limit. I
     did not allow on any occasion the introduction of a substitute. On
     the other hand, I added every day suggestions covering the various
     secondary symptoms, especially the pains in the stomach and the
     feelings of faintness and the emotional depression.

There, is no doubt that under favorable conditions, especially if the
dose of morphine is not too strong, autosuggestion can bring about a
similar effect. A reduction of ten per cent every week can be carried
through, if a pledge is given to one's self in a drowsy state. The great
value of autosuggestion showed itself not seldom in the fact that
morphinists who had applied to me by mail for a cure in the mistaken
belief that I do work in a professional way for payment and who got from
me a written reply that I could not receive them, but that they can help
themselves, wrote to me that my letter gave them strength to reduce
their dose considerably.

Quite similar is the situation with cocainism or with the combination of
morphine and cocaine which is so frequent nowadays with young
physicians. I have repeatedly seen cures where the case already gave the
impression of insanity. Again I give a rather extreme case.

     A physician had acquired the habit of using and misusing cocaine
     for the treatment of a disease of his nose. The habit grew to a
     craving for cocaine while the cocaine itself poisoned the brain.
     Acoustical hallucinations began; he heard voices from every corner
     of the room, and on the street the voices took persecutory
     character. He connected them with his brother living in Europe,
     heard his voice in the denunciations, and developed a pathological
     system of ideas around the central thought that his brother had a
     telepathic influence on him. His reason succumbed, he lost all
     consciousness of delusion, and believed himself really to be under
     the control of the absent brother. When he came to me he had been
     without sleep and without food for several days, and he was not
     seeking my help to get rid of the mental disturbance but to
     overcome the power of his older brother. He did not connect the
     fear at all with his misuse of cocaine. When I discovered the rôle
     which the cocaine played, I determined to try the suggestive
     influence, the more as I found that he was in a half-hypnotic state
     as soon as he had entered my room. I suggested to him to sleep and
     to take food and to reduce the cocaine dose by a fourth. The next
     day he was an entirely different man by the effect of ten hours'
     sleep and a large breakfast. Now I concentrated my efforts on the
     reduction of the cocaine. After ten days of hypnotic treatment he
     gave up cocaine entirely, after three weeks the voices disappeared
     and slowly the other symptoms faded away. The pathological idea of
     the telepathic influence lasted a while after the voices had gone
     until this idea, too, yielded to suggestion. It still took six
     weeks before he himself felt that he was entirely normal.

The way in which the average physician nowadays neglects the simple tool
of suggestive treatment, when it can be used for the protection of
society, is perhaps nowhere so reckless as in the case of the morphinist
and cocainist. To give a typical case of this neglect I may mention that
of a highly intelligent young man who had been in the habit of using
both cocaine and morphine for ten years when at his own request he was
sent to a New York hospital. He had been taking alternately morphine for
a year or two, then cocaine for a year or two, and had sometimes
alternated and sometimes combined both in an irregular way. When he
entered the hospital in May, 1908, he was in a cocaine period and was
taking the enormous dose of one hundred and eighty grains of cocaine
every day. In the hospital they withdrew the drug altogether. During the
first weeks, he was entirely sleepless. They energetically refused him
any substitutes and after six weeks he began to feel comfortable. He
gained steadily in weight and after three months, when he left, he had
gained fifty pounds, felt entirely comfortable, and seemed in all
respects normal again. Before twelve hours had passed after leaving the
hospital, he had again taken thirty grains of cocaine and ten grains of
morphine, and this dose rapidly grew until after a few weeks it again
reached a hundred grains of cocaine and up to sixty grains of morphine a
day. Then came the complete breakdown. If that man in the last two or
three weeks of the hospital treatment, when he felt entirely comfortable
and normal and had gained his normal weight, had received even a slight
suggestive treatment suppressing any desire for cocaine or morphine, he
would easily have been saved. To let such a man after a drug career of
ten years go out again to the places of his old associations, where the
desire had to be stirred up, is inexcusable at a time when
psychotherapeutics has won its triumphs in this field. It might have
been sufficient to give him preventive treatment at least for the first
three days of his freedom. And such a case is typical of hundreds.

The overstrong impulse and overstrong desire finds its counterpart in
the abnormal lack of energy and lack of attention. The patient--and it
is especially the neurasthenic patient--has lost his usual strength, he
shrinks from every undertaking, he cannot decide upon any action, he
needs a disproportionate effort for the smallest task, and cannot
concentrate his attention in spite of his best will. The varieties of
this lack of power and inertia are familiar to every physician. They
certainly often need much more than merely psychotherapeutic treatment,
although on the physical side no schematic method is admissible. The
laziness of the anæmic needs a different treatment from the laziness of
the exhausted but in every case psychological factors can be of decisive
influence, whatever the physical and chemical treatment besides them may
be. A few letters may again illustrate the varieties. Here again there
is no sharp demarcation line between the normal and the abnormal.
Letters like the two following, for instance, are hardly letters of
patients. They show a variation which is still entirely within normal
limits and yet a source of suffering; it is a disturbance which usually
can be removed by psychotherapeutic means.

     "I do almost everything with effort, nothing spontaneously. I have
     been writing for five years but am a mood writer of the worst type.
     The mood comes at such uncertain times that I seem to be absolutely
     at the mercy of caprice. This might not in itself be a misfortune
     but writing is my only calling and I suffer the proverbial torments
     of lost spirits when I am idle. The necessity of driving myself to
     every piece of work, aggravated by the fact that my parents allowed
     my constitutional inertness to have full play, has hitherto
     prevented me from forming any regular habit of labor. I am now
     thirty-eight. Would you suppose that if I kept my nose to the
     grindstone for one, two or three years, I might yet hope to work
     with some ease and regularity? That is, if I compelled myself to
     write a certain number of hours every day as a discipline,
     regardless of the quality of matter I produce, is there any
     probability that I might ultimately overcome the fearful paralysis
     that so often grips my faculties? Can constitutional indolence be
     overcome by determination? I put in a little time on a couch every
     day. When worried I get neurasthenia and all kinds of phobias. Just
     now I am afraid to look at the newspapers on account of the cholera
     in St. Petersburg, and I have seen the time when I found it
     difficult to drink water after I had boiled it myself."

Also the next man is familiar to all of us.

     "Plainly we are told every man is born into the world to fill some
     purpose, or at least be of some benefit to himself or his
     fellowmen. For some reason I do not make friends among men. I have
     not the zeal or ambition to carry or even begin a conversation
     that will interest the individual man. I worry a great deal. I have
     never been able to concentrate my mind to study and figure out
     problems. I can read them zealously but apparently do not get to
     the bottom and cannot retain what I do read. If I could just get
     hold of the power of thinking and dig out that tangible something
     that holds me back, I could go forward and make myself what I know
     I should be. But I feel that so far I am a total failure. If I only
     had that one great gift, the power of concentration and will power,
     I would make what I so much desire, a success of myself."

A similar effect and yet psychologically a different condition exists
where the lack of energy results from the suggestive power of the
opposite, producing a constant indecision.

     "I am thirty years old and nearly all my life since childhood I
     have been fearfully troubled with the habit of indecision and
     regretting whatever I do. It has grown into a habit so fixed that
     at times I am fearful of losing my mind. I feel anxious to do
     something and decide to do it, then as soon as it is done, I nearly
     go wild with regrets until I have to undo it, if possible, and then
     only to regret that. I am this way about the most trifling things
     and about the most serious. I can't perform any duty well. In
     business and in social affairs, it is always with me. It has me in
     its clutches, a horrible monster dragging me down. My friends
     misinterpret me and wonder what I mean by doing so when all the
     time I want to do what is for the best and cannot for this tyrant
     who is ever present with me. I will plod for hours and hours at a
     time, and at every turn I am handicapped. I am intelligent
     naturally and appear a perfect fool."

From the report of such chronic cases we may turn to the acute ones.
Here a characteristic letter of, a typical neurasthenic young modern
poet.

     "These are my plans but I hardly think that I can carry them
     through, although perhaps you can help me by suggestion. I have the
     feeling that through the whole of last year my development did not
     go forward but backward. It is as if by a mental or physical
     overstrain, my whole personality has entered into a transition. I
     have no joy in life, no sensation in love, no satisfaction in
     labor. My will has become weak where it was strong. I am lazy, up
     to an absolute dislike of everything, while I have been energy
     itself. Often I have only the one desire, to end my life from mere
     fatigue. If there had been any external reason for ending my life,
     I should perhaps have done it long ago. I am so apathetic that I no
     longer take myself seriously. My successes do not please me; the
     idea of writing anything gives me anxiety. I have become less
     resisting, more sweet, more soft, I should almost like to say, more
     feminine. I became infatuated with a girl, simply because I knew
     that she hates all men. The inaccessible is still the only thing
     which can stimulate me somewhat. I have even written a poem on her,
     but nothing can satisfy me in love. I consider my state a disease
     of the will as a result of nervous exhaustion. I must find some one
     who, with kindly power, reënforces my will system. I need a strong
     mind--it may be a man or a woman. It would even be possible in the
     latter case that I might marry her.

     "Even the writing of this letter has fatigued me so much that I
     should like best to sleep. In moments like the present I should
     like best to throw myself down on the street or ... quickly ...
     sink ... into the ocean. (I regret having made the little points.
     They look as if my expressions are a pose.) Yet there are moods in
     which I am entirely normal and no one fancies what I am passing
     through. I have even become superstitious lately. Are there perhaps
     beings which can absorb our energy? Perhaps another being has drunk
     up my energy."

Authors run easily into such states. Here is another.

     "I am a neurasthenic, and I am beginning to believe, a professional
     one. My object in writing is to ask concerning the advisability of
     my visiting you for treatment. I am ready to take the next train if
     you say the word, if you believe you can help me. It seems that the
     regular practitioner, who is very irregular, cannot. If there is
     one good doctor I have not consulted, I would like to know his
     name. I was doing editorial work in X and broke down. Still the
     doctor said that if I liked my work, I should go back to it and
     pitch in. I did. It lasted a few days and then I had to give up
     altogether, couldn't grind out another word. Then to another
     doctor----also the best in the city. He told me to give up all
     work, which I did, and then I went on a farm for six months. That
     did not help me either. Later I went west and spent some time in
     the mountains. I felt no better there. Then I went to Arizona and
     lived in a tent out on the desert; that did not help me. There was
     always a sensation of exhaustion and any physical exertion put me
     on my back, even when it was light and pleasant exercise. Then I
     went to California; it did me little good. It is a perfect paradise
     for anyone who has not got neurasthenia. I still have not got
     myself in hand. I cannot do or say or write just what I wish, and
     cannot concentrate my thoughts. To try to read a book is punishment
     because I forget as fast as I read." And so on.

     I answered him certainly not to come but tried to induce some
     autosuggestions. A few weeks later, he wrote me: "Ever since you
     wrote me, I am now feeling somewhat improved." Yet I cannot judge
     how far the improvement belonged to the psychical factor only,
     inasmuch as I had advised him also to take some bromides. The
     really effective treatment would have been heterosuggestion and I
     had no time to enter into the case.

Where direct suggestion is used, the effect is often surprising.

     A young lawyer after a period of overwork had come to a state of
     complete lack of energy. He could not find strength to write a
     letter and he came to me at a day when he did not see any way but
     suicide open for himself. He complained that, as soon as he began
     to grasp a thought, it was evaporating. He stared absently about
     the room and felt sure that he would never again achieve anything.
     He had not even the energy to read the newspaper. I hypnotized him
     three times, each time waking in him the pleasure in a definite
     piece of work, at first simply in a novel which he was to read,
     then in some letters which he was to write, and then in his
     professional work. There was always an interval of three days. The
     fourth time he declared himself that the hypnotic influence was
     unnecessary, as he felt that he was again in the midst of his work.

As a rule the effect is a much slower one, but if all personal factors
are well considered and especially physical disturbances are excluded,
the result is usually satisfactory.

Very different from such neurasthenics, of course, is the lack of
attention in the feeble-minded, and suggestion of the ordinary type is
hardly advisable, but it is surprising how much can be reached by a
systematic psychical régime. I give one typical instance, representative
of many.

     A boy of twelve years when he was brought to me showed the mental
     powers of a stupid child of four. In a silly way he repeated every
     question which he heard without answering it; he talked steadily to
     himself in a nonsensical manner, mostly repeating nursery rhymes
     without end, never holding his attention to anything in the room,
     giving the impression that there was no attention whatever. The boy
     was a child of rich parents; he had his own teachers, but was for a
     large part of the year under the influence of the parents only, who
     very naturally yielded to every desire of the unfortunate child. I
     insisted on a complete change of the education. It was my effort to
     build up the mind by a rigorous training and by development of the
     power of inhibition. I absolutely forbade any meaningless material
     like the nursery rhymes, insisted that the child should never be
     allowed to talk to himself, and whenever he began to speak to
     himself he was to be addressed sharply, and if he yet went on, to
     be slapped on his hands. In the same way he was not allowed to
     repeat a question, but the question was repeated until he answered
     it, the question always formulated in simple words. He was forced
     to go through simple reading and writing without being allowed to
     make his silly diversions. His whole life was brought under strict
     discipline and no parental indulgence was permitted. Six months
     later the child was completely changed. It seemed as if he had gone
     through an improvement of three years. I regulated the whole of
     his elementary studies in accordance with the successful principle.
     The training of inhibition stood in the foreground and every
     haphazard reaction was severely rebuked. The summer vacations spent
     with the parents in the fashionable surroundings, to be sure, had
     always a retarding influence, but the main part of the year in
     which it was possible to carry through the strict discipline showed
     such steady and inspiring progress that the boy, while of course
     feeble-minded for life, can yet live externally a harmonious life.

A systematic training of the power of inhibition is indeed the
fundamental factor in all psychotherapeutic treatment when the
disturbance is in the volitional sphere, but the inhibition is secured
most safely by reënforcement of the antagonistic attitude. From these
volitional variations on the one side, from the ideational disturbances
on the other, only a few steps lead to those dissociations of the
personality which are characteristic of many graver cases of hysteria.
But to give to them any adequate analysis, it would be insufficient to
refer in this brief way to particular cases. Psychopathological
literature possesses some excellent analyses of such complex
disturbances. As I said before, I abstain entirely here from such
complex phenomena, as they enter too seldom into the sphere of the
practitioner and as the bewildering manifoldness of their symptoms does
not allow us so easily to recognize the fundamental principles which
alone were to be illustrated by our short survey of practical cases.




XI

THE BODILY SYMPTOMS


The discussion of the bodily symptoms which may yield to
psychotherapeutic treatment, naturally forms only a short appendix to
our discussion of the mental symptoms. Our interest was from the
beginning essentially a psychological one. I shall have to be the more
brief as my personal experience in the treatment of bodily diseases
through mental therapy is entirely secondary and accidental. The
psychological laboratory would, of course, be an entirely unfit place to
struggle with diseases of which the chief symptoms are not
psychophysical. Yet in spite of frequent testimonies of well-known
physicians to the contrary, I am still inclined to think that this is
also the situation at large. I think that in medicine in general the
psychophysical effect of mental treatment is by far more important and
by far more extended than the healing effect on diseased peripheral
organs. Of course these peripheral parts of the body may be favorably
influenced in an indirect way by the mental treatment; we shall have to
take notice of this important result but that is strictly not a
therapeutic effect on the bodily symptoms. Moreover, purely psychical
effects may give an impression as if the bodily symptom itself has been
removed.

To begin with the latter case, it is especially the inhibition of pain
which easily makes one believe that a bodily disturbance is successfully
treated. I have repeatedly seen cases in which I tried by suggestion to
soften the pain resulting from a peripheral disturbance like
inflammations, rheumatism, decayed teeth and so on. The effect was often
such a total disappearance of the pain that the patient himself was
inclined to believe that the objective disease had been ended, while in
reality the state of the diseased organ was not changed at all. It has
often happened that I tried to cure a person of certain mental symptoms
by suggestion, ignoring entirely the existence of some pain resulting
from a bodily disease with which I had nothing to do. Yet the suggestion
of improvement seemed almost to irradiate and the pain disappeared in
spite of having been ignored by the hypnotizer. For instance, I treated
a woman who suffered from psychasthenic obsessions, fearing all the time
that something would happen to her child. I did not give any direct
attention to the fact that she had had for years a painful disease of
the bladder for which she was constantly treated by a specialist. But
while I did not mention the bladder in my hypnotic suggestion, yet the
abdominal pain disappeared together with the obsession and the situation
might easily have suggested that the bladder trouble was a nervous one
which had been cured by the hypnotic sleep. The fact was that the
bladder disease was not influenced by the mental treatment at all, and
needed a continuation of the same local treatment. It was only the
psychophysical pain in the brain which had been inhibited.

Quite parallel to the disappearance of the organic pain sensation is the
arising of a general feeling of improvement. This organic sensation of
general betterment may again be a strictly mental occurrence without any
objective reference to a real improvement in the bodily conditions. Yet
again that easily gives the impression of an important change in the
bodily conditions themselves. The miraculous cures of various diseases
through mystic agencies generally belong to this category. There is no
doubt that often the migrating charlatans who advertise themselves by a
free treatment of the sick and invalids on the theater stage of small
towns, produce momentary effects which are sufficient to deceive. The
quack handles the diseased organ, perhaps a goiter or a leg crippled by
rheumatism, with a cruel rudeness and overwhelms the suggestible mind so
completely that the first autosuggestion is that of a complete change,
and that means cure. The disastrous results follow later. But from such
barbarisms we come by gradual steps to the suggestion of improvement
where the feeling of betterment can be in itself an important factor for
the cure. Yet even there we must not mistake the possible secondary
effect of a mental change from a psychotherapeutic cure of the bodily
disease.

Not seldom the removal of physical disability seems secured as soon as
certain mental disturbances are removed. There is no reason to believe
for instance that suggestion can have an important influence on a
diseased sense organ, and yet hypnotic influence and even autosuggestive
influence can under certain circumstances greatly improve seeing and
hearing. Especially in the field of hearing the central factor is of
enormous importance. Hyperæmic and anæmic conditions in the brain
centers of hearing control the vividness of the received sound. The
patient who cannot hear a certain watch more than one foot distant may
be able to hear it after some glasses of wine at a distance of three or
four feet. Thus it is only natural that a hypnotic influence can produce
similar changes on the psychophysical centers in such cases in which the
source of the trouble is a psychophysical laziness in the acoustical
center. Sometimes even this laziness itself is the result of psychical
autosuggestion which can be fought by counter-suggestion. I saw, for
instance, a distinct improvement in hearing in the case of a young woman
who had increasing deafness while the aurists declared that the ears
were in proper condition. I found that she lived with a father who
suffered from a severe middle-ear catarrh and that she was simply
controlled by a hidden fear that she might have inherited the ear
disease of her father. I removed this fear, partly by reasoning, partly
by suggestion, and partly by tricks which surprised her, for instance,
making her hear her watch with unaccustomed strength when she took it
between her teeth and closed both ears. The autosuggestive fear was
uprooted by these and the central ear organs slowly came to normal
functioning.

The purely psychical character is still more evident in the frequent
hysterical anæsthesias. No one doubts that here the sensations are
inhibited only and that the mental influence removes this inhibition
without any influence on the sense organs proper. Frequently also
organic troubles like stomach diseases appear cured when in reality
hysterical disturbances are at the bottom. The stomach may be sensitive
to any pressure and may produce severe pains and vomiting on taking any
food and everything may indicate a serious local disturbance. Yet
hypnotic treatment may quickly remove the symptoms because the whole
reaction may have resulted from the shock which perhaps a too hot piece
of potato caused. The removal of this mental starting point results in a
cure of the apparent stomach disease. Again in other cases, the
appearance of a physical cure is given by the creation of psychophysical
substitutes. I do not believe that hypnotism or suggestive treatment can
influence the brain parts which have suffered from a hemorrhage. Yet the
paralysis of the arm, for instance, which resulted from such a breaking
of a blood-vessel in the brain may be to a high degree repaired by
building up new motor images in the psychophysical system, which become
starting points for a new learning of movements. The patient did not
understand how to make the most out of those motor paths which had been
left. The destruction of the chief channels of discharge had inhibited
in his mind the idea of possible movement. He no longer believes that he
can move and it needs new suggestions to overcome this inhibition. The
curative effect on bodily disabilities is thus often an illusory one.

That does not mean that the field in which psychotherapeutics may work
directly on the body is not after all a large and interesting one.
Theoretically it is still little open to real understanding. The
explanation has essentially to rest on the acceptance of a given
physiological apparatus. A certain psychophysical excitement produces by
existing nerve connections a certain effect, for instance, on the
blood-vessels or on the glands of a certain region, or on a certain
lower nervous center. That such apparatus exists, the physiological
experiment with persons who are hypnotized to a high degree can easily
demonstrate. Their nose bleeds at a command; a blister may arise on a
part of the skin which is simply covered with a penny, when the
suggestion is given that the penny is glowing hot. With some subjects,
the pulse can become slower and quicker in accordance with the
suggestion; with some even the bodily temperature can change on order.
Our understanding of these indubitable facts indeed does not go further
than the acknowledgment that the paths for such central connections
exist. That means we simply describe the facts once more in the terms of
anatomy. But after all in the same way we rely on the nervous
connections, if a thought makes us blush and ultimately if our will
moves our arm or if our ideas move our speech apparatus. We do not
choose the muscles of our arm, we hardly know them; we know still less
in speaking, of the movements of our vocal cords, and in blushing of the
dilated blood-vessels. That ideas work on the lower centers of our
central nervous system, centers which regulate the actions of our
muscles and blood-vessels and glands, must simply be accepted as the
machinery of our physiological theory. The connection of such theories
with purely physical facts is given by the experience that an electrical
stimulation of the nerve may have the same influence as ideas. The
electric current, too, can regulate the beat of the heart, or contract
and dilate the vessels, or reënforce and relax the contraction of the
muscles, or strengthen and weaken the functions of the glands.

Nearest to the psychophysical processes stands the bodily symptom of
insomnia. There is no doubt possible that the work of the
psychotherapist can be very beneficial in producing sleep by suggestion.
That autosuggestions for sleep play an important rôle is popularly
accepted. Next to the most immediate means such as lying down, or
cutting off sense stimuli, or trying not to think, or avoiding
movements, certainly the most well known factor is the expectation of
sleep with the belief that sleep will come. This belief may be
reënforced to strong autosuggestion which may then overcome other
factors that hinder sleep. For instance, I have repeatedly received
letters from strangers containing expressions of gratitude with news
which under other circumstances would at least not flatter an author.
They wrote to me that immediately after reading one or another essay of
mine on hypnotism, they fell into deep sleep. Yet as they were always
patients who had suffered from insomnia, I was pleased with this
unintended effect of my writings. But in most cases a real cure demands
heterosuggestion.

There is room for any variety of effects; often they enter immediately.
The other day I gave sleep suggestion to a young woman who had
overworked herself in literary production. For months she had not slept
more than three or four hours a night and even that only after taking
narcotics. I intentionally did not allow her to come into a hypnotic
sleep but kept her fully awake, increasing her suggestibility while her
eyes were wide open. I suggested to her to take a walk, then to eat her
dinner, and after that to go to bed at once. She went to bed at seven
o'clock and slept without waking until ten o'clock the next morning, and
after fifteen hours' sleep she was like a different being. A regular
eight hour sleep is sometimes secured, even where no immediate direction
has been given for it. On the other hand, I cannot deny that I have
sometimes been entirely unsuccessful in securing better sleep by the
first three hypnotic treatments. When the first three treatments were
unsuccessful, I always gave it up on account of lack of time. Yet the
experience of others shows that in such cases, often after a long
continued hypnotic treatment insomnia yields to suggestion. One of the
great factors which work against the mental treatment is the habit of so
many sufferers of relying on their sleeping powders which, to be sure,
remain effective only by increasing the dose and thus finally by making
them dangerous. Every chemical narcotic has in itself suggestive power
and strengthens the belief of the sleep-seeker that he cannot find rest
without his dose. To overcome the monopoly of the opiates is one of the
most important functions of psychotherapy.

It is not surprising that the relations of psychotherapy to sleep show
such a great variety. The factors which coöperate in normal sleep are
many and the disturbance can have very different character. We had to
speak of the psychophysics of sleep when we discussed the theoretical
relation of sleep to hypnotism and insisted that it is misleading to
consider hypnosis simply as partial sleep. We claimed a fundamental
difference between the selective inhibition in hypnotism and the general
reduction of functions in sleep. To understand sleep, we have to
recognize it as one of the fundamental instincts, comparable with the
instinct for food or for sexual satisfaction. Every one of such
instincts has a circular character. Mental processes, subcortical
processes, and physical effects are involved in such a way that each
reënforces the others. The physical effect of the sleep instinct,
comparable with the pepsin secretion in the food instinct, or with the
hyperæmia of the sexual organs in the sexual instinct, is a change in
the cortex by which the sensory and motor brain centers are put out of
action. What kind of a change that is, is quite indifferent. It may be a
chemical one but more probably it is a circulatory one. Let us say it is
a contraction of blood-vessels which by the resulting anæmia makes the
sensory centers unfit for perception and the motor centers unfit for
action. In this way the brain becomes protected by sleep against the
demands of the surroundings. The mental reactions are eliminated and the
central nervous substance has an opportunity to build itself up. This
protective physical activity is now evidently itself controlled by a
subcortical center, just as secretion and sexual hyperæmia are
controlled. This center probably lies in the medulla oblongata.

Some theorists, to be sure, are inclined to think that the fatigued
brain cells enter directly through their exhaustion into the protective
sleep state. But that simplifies the situation too much. It is quite
true, as these theorists claim, that monotonous stimulation of the
senses produces sleep. But it is evident that the sleep occurs even then
not only in the particular overtired brain cells. A monotonous
stimulation of the acoustical center raises the threshold of perception
for all the senses and brings sleep to the whole brain. This control of
the whole apparatus is thus surely regulated by one definite center. But
this lower center, which controls the anæmia of the cortex, is itself
directly dependent again upon a mental condition, the mental experience
of fatigue. The fatigue sensation, which is possibly the result of toxic
processes, works on that lower sleep center, just as the appetizing
impression or the sensual images work on the centers of the other two
instincts. On the other hand this protective blood-vessel contraction
creates again as in the other cases a characteristic organic sensation,
the sensation of rest which arises when the threshold of perception and
activity is raised. The world begins to appear dim and far away, no
impulse for action excites us. This organic feeling of rest associates
itself with the fatigue feeling. The fatigue sensation, the subcortical
sleep center, the contraction of the vessels in the cortex, and finally
the rest sensation form together the complete circle. The difficulty
which arises in this case lies only in the fact that the cortex gone to
sleep annihilates also, of course, the fatigue sensation and the rest
sensation. For that reason the real circle can appear only in the
preparatory stages of sleep. As soon as sleep itself sets in, the circle
is broken. The circle character of every instinct must lead the physical
effect upward to a higher and higher degree. Not to become excessive,
the physical effect must be checked somehow. In all other spheres, it
finds its end in satisfaction, for instance, by eating or by the sexual
act. In sleep the circular process ends automatically by its own effect
as soon as complete sleep is reached. Its causes, the fatigue and the
rest feeling, are stopped, as soon as the effect, the anæmia, is
secured.

We see now how widely different starting points can lead to sleep and
can understand from it how widely different disturbances can prevent
sleep. Sleep must result when fatigue is coming, but sleep must also
result when the elements of the rest feeling are produced, and as we saw
that the components of the rest feeling were the sensations of decreased
sensitiveness and decreased activity, sleep must result when either the
sensations and associations are absent and actions are suppressed, or
when monotonous sensations and automatic actions raise the threshold.
Sleep must arise further if our will associates the mere idea of such
rest, and finally physical or chemical means may produce a sleep
bringing effect either on the lower center or on the blood-vessels and
cells of the cortex. Correspondingly sleep may be prevented by
disturbances in any one of these spheres. There may be no normal
fatigue, there may be no fatigue sensation, there may be no rest feeling
on account of perceptions, or on account of associations, or on account
of impulses to action; there may be no normal response in the
subcortical center, there may be no physical effect in the cortex on
account of an existing hyperæmia or on account of an abnormal condition
of the cells. The psychotherapeutic treatment must carefully analyze
which element would be fit to supply the last link in the circular
chain. Sometimes we need the suggestion of fatigue, sometimes the
inhibition of ideas, sometimes the suppression of impulses, sometimes
the suggestion of rest, and so on. A mere general suggestion of sleep is
on the whole effective only in the cases of those persons in whom this
idea in itself awakens those various components. Very often it is
entirely ineffective in this general form. Sometimes it is possible to
carry the hypnotic state itself directly over into sleep, but it seems
more in the interest of the patient to separate those two states
distinctly.

We are still confined to processes in the brain itself if we turn to
headache. If it were only a question of inhibiting the pain by mental
suggestion, the case would not be different from inhibiting the pain of
a peripheral organ without attempting to cure the diseased organ itself.
But in the case of headaches, it seems justified to claim that in
certain varieties of this multifold symptom, not only the pain is
suppressed but the disturbance itself is removed. Especially where the
headache seems to result from hyperæmia, the trouble seems to be
accessible to psychotherapeutics. On the other hand I have never seen
any lasting effect on the so-called sick headache or migraine. While
continuous headaches or headaches which occur daily yielded to my
influence, sometimes completely, I was unable to prevent even by
preparatory hypnotization any migraine which appears periodically, for
instance, simultaneously with menstruation.

A few words only as to the general diseases and disturbances for which a
very strong therapeutic effect has been claimed by masters of the craft
like Wetterstrand, Moll, Dubois, and others. From my own experience I
can affirm the often lasting effect in the disturbances of the functions
of the digestive apparatus. The stomach and the intestines seem to a
high degree under nervous influences which can be changed through
hypnotic suggestion. If we consider what intimate connection exists
between the functions of these organs and the normal emotions, it seems
hardly surprising that mental factors can regulate their disturbances.
Vomiting, diarrhea, and especially constipation, often yield to slight
suggestions, even in a superficial hypnotic state. Here, too, I have
seen repeatedly a complete regulation of a long-standing disturbance as
an unintended by-product of hypnotic suggestion directed towards the
cure of psychical troubles. Much value is claimed for hypnotic method in
the treatment of anæmic conditions. It is said that anæmia improves
after a few hypnotic treatments, the appetite becomes better, the cold
hands and feet grow warmer, the headaches disappear, the capacity for
work increases rapidly, and most surprising of all the leucorrhea
ceases. As to heart disease, we ought to think in the first place of the
disturbances of nervous innervation. I have seen repeatedly a remarkable
decrease of nervous palpitation of the heart through direct mental
influence, abstracting here from the secondary effect of suppressing
mental excitement and fear. Where organic heart diseases are surely
present, it seems that hypnotism can sometimes act beneficially if the
heart trouble is accompanied by anæmia and general debility; of course a
developed valvular disease cannot be removed. In the same way it seems
that in Bright's disease, certain painful symptoms may be suppressed,
but the kidneys certainly cannot be influenced. At least open to
serious suspicion are the insistent claims that diabetes can be cured by
suggestion. Dr. Quackenbos of New York, for instance, gives to some of
his diabetes patients a hypnotic suggestion by the following words: "If
your pancreas be crippled in its production of the natural ferment which
is given off to blood and lymph and which conditions the normal
condition of sugar in the body or restrains the output of sugar from the
liver tissues, you will see that it forthwith pours into your blood or
lymph the sufficient quantity of sugar oxidizing ferments." It certainly
transcends our present understanding if we are to believe that a
suggestion of this type will change the action of the pancreas. It is
hardly worth while to enter into the still more extravagant claims from
other sides like those for curing cancer and phthisis. On the other
hand, in the light of all that we have discussed, there is no difficulty
in understanding the easily observable influence in the regulation of
menstruation, in the cure of contractions, local congestions, and
incontinency of urine. I may mention finally the use of hypnotism for
helping in a safe and quick confinement.

But in addition to all this, we have the great help which psychotherapy
may bring indirectly in the treatment of physical diseases. I said, for
instance, that I do not believe in a real help by mere suggestion in
cases of diabetes. But no one ought to underestimate the value which may
result for the treatment from a suggestion of a well-adapted diet. The
patient who feels a craving for bread and potatoes and perhaps sweets,
and is too weak to resist it, is indeed brought into safety if
suggestion liberates him from such desires. The same holds true for
every other diet and for any medical régime of life which does not
harmonize with the natural instincts of the patient. For not a few
sufferers, reënforcement of the interdict against coffee and tea or
alcohol and tobacco is more important than any medicine. Hypnotic
suggestion can easily create dislike of the prohibited material and can
build up new desires and inclinations. In the same way it is indirectly
most important to stir up, for instance, the sensations and feelings of
appetite and thus to make normal nutrition possible. Also in cases of
anæmia or tuberculosis, such indirect assistance can produce some
beneficial consequences.

The same holds true of the power of the psychotherapist to secure sleep.
The fight against insomnia which we discussed referred only to that
sleeplessness which is itself an expression of the disease. But as a
matter of course, the loss of sleep can accompany most different
diseases, as an almost accidental result. To secure sleep means then not
to treat the symptoms of the disease but a by-product; and yet every
physician knows how much is gained if the lost energies are restituted
by a sound sleep. And finally we have the indirect help towards the cure
by the suggestive removal of pain. We have no right to say that it is a
pure advantage for the treatment of the disease if the pain is centrally
inhibited. Pain surely has its great biological significance and is in
itself to a certain degree helpful towards the cure, inasmuch as it
indicates clearly the seat and character of the trouble and warns
against the misuse of the damaged organ which needs rest and protection.
To annihilate pain may mean to remove the warning signal and thus to
increase the chance for an injury. If we had no pain, our body would be
much more rapidly destroyed in the struggle for existence. But that does
not contradict the other fact that pain is exhausting and that the fight
against the pain decreases the resistance of the organism. As soon as
the disease is well recognized through the medium of pain and the
correct treatment is inaugurated, not only the subjective comfort of the
patient but the objective interest of his cure makes a removal of pain
most desirable. While it would be absurd to say that hypnotism can cure
tuberculosis or cancer, it is fully justifiable to say that hypnotic
treatment in tuberculosis or cancer is to a high degree beneficial,
inasmuch as it can secure sleep, appetite, and freedom from pain, three
factors which indirectly help to fight the disease. The elimination of
pain may sometimes also play its rôle in slight operations where other
methods of narcosis seem for any reason undesirable, and very frequently
hypnotic suggestion has been used for this purpose at childbirth.

The same importance which belongs to the removal of bodily pain in the
treatment of a peripheral disease may be given to its mental
counterpart, to the worry, excitement, and emotional shock. They all
stand in the way of a real success in any cure. Even the chances of a
dangerous operation are entirely different for the patient who goes to
it with free mind and a happy mood, with full confidence in its success,
from those of a patient who has worked himself into a state of fear and
anxiety. Here again the depression and the excitement are not in
question as symptoms of a disease, as they were when we discussed the
phobias and despondencies of the neurasthenic and of the hysteric. They
are merely normal side-effects of the bodily disease, accentuated
perhaps by a suggestible temperament. To eliminate all these emotions
means to change most helpfully the whole atmosphere of the sick-room and
to deprive invalidism of its saddest feature. This negative factor
corresponds of course most directly to the positive feature of building
up new hope and joyful expectation. He who creates confidence makes
convalescence rapid and strengthens the power to overcome disease.

It would be medical narrowness if the physician were strictly to deny
that the effect of such emotional change may sometimes lead far beyond
the ordinary suggestive influences and that in this sense the miraculous
really happens. When out of a despondent mood in a suggestible brain an
absorbing emotion of confidence breaks through, a completely new
equilibrium of the psychophysical system may indeed result. In such
cases, improvements may set in which no sober physician can determine
beforehand. Central inhibitions which may have interfered a life long
with the normal functioning of the organism may suddenly be broken down
and in an entirely unexpected way the mental influence gives to the
forces of the body a new chance to help themselves. The reasoning of the
scientific physician may easily stand in the way there. He may be afraid
of such overstrong emotion because he knows too well that such
unregulated powers may just as well destroy the good as in another case
the bad; in short, that ruin may result just as well as health. But that
does not exclude the fact that indeed almost mysterious cures can be
made without really contradicting the scientific theories. Such are the
means by which the mystical cults earn their laurels. A chance letter of
the type which often swells the mail of the psychologist may illustrate
this effect. I choose it because it is evidently written by a skeptic. A
short quotation from the lengthy epistle is sufficient.

"My condition was horrible in the extreme. I had consumption of the
lungs and other supposedly fatal troubles, complicated by wrecked
nerves. At the present writing, I am robust and splendidly healthy,
looking twenty years younger than I did at the period previously
described. The Christian Scientist saw my condition but appeared
unconcerned and unafraid, I being absolutely hopeless, skeptical, and
deeply contemptuous meanwhile. On the third day of her treatment I was
desperate for sleep, she having forbidden drugs, and I deliberately took
an overdose of chloral, thinking to die at once and end it. My
condition justified the act. She brought me out of the coma of the
chloral after three hours of mental work, and the next day I felt
decidedly calmer and less afraid of the coming of night, should I live
to meet it, which seemed doubtful. At noon she left me to go to her home
to lunch. I was pondering seriously on her reiterated 'God is love and
fills the universe and there is nothing beside Him,' when I suddenly had
a sensation of being lifted up or rising slowly and becoming lighter in
body. A rush of power that I have no way of describing to you filled me.
I seemed to be a tremendous dynamo in the air several inches above the
ground and still ascending. When I noticed everything around me becoming
prismatic and more or less translucent, I could have walked on water
without sinking, and I had distinct understanding that matters seemed to
be disintegrating and dissolving around me. I was frightened but
self-conscious and quiet. I remained in this state for about three
hours, my consciousness seeming to have reached almost cosmic greatness.
I could have cured, I felt, any human ill, was filled with an absorbing
altruistic desire to help suffering. It was tremendous and totally
foreign to my everyday attitude. At the end of the day, towards
twilight, I became wearied of the tremendous throbbing and exalted state
in which I still remained and gave utterance to the thought aloud.
Almost before I had formulated it the condition left me, and like the
sudden dropping of a weight, I struck the ground, the same dull,
ordinary person of everyday experience, but with the vast difference of
perfect health, radiant and lasting to the present writing. My father
like myself is baffled and wondering. We are both pretty hard skeptics.
I want the truth, whether it be terrible or otherwise. I am profoundly
grateful to the Christian Scientist, if I regained my health through her
ministrations, but I have not so far been able to label myself and rise
in their church services to tell what has been done on me. The
performance repels me as crude and rather bad taste. I swear to you on
my honor as an American woman and a mother that what I have written you
is true, absolutely. If you can give me any light or if my experience
may perchance give you a helping ray, my renewed lease on life may have
had some purpose after all, which I have often questioned in my cynical
moods."

The unprejudiced psychotherapist will be perfectly able to find room for
such cures and, if it is the duty of the scientific physician to make
use of every natural energy in the interest of the patient's health, he
has no right to neglect the overwhelming powers of the apparently
mysterious states. Some of this power ought to irradiate from his eye
and his voice whenever he crosses the threshold of a sick-room. Some of
that power ought to emanate from him with every pill and drug which he
prescribes. The psychotherapeutic energies which work for real health
outside of the medical profession form a stream of vast power, but
without solid bed and without dam. That stream when it overfloods will
devastate its borders and destroy its bridges. The physicians are the
engineers whose duty it is to direct that stream into safe channels, to
distribute it so that it may work under control wherever it is needed,
and to take care that its powerful energy is not lost for suffering
mankind.




PART III

THE PLACE OF PSYCHOTHERAPY




XII

PSYCHOTHERAPY AND THE CHURCH


The belief in supernatural energies has cured diseases at all times and
among all peoples. Everywhere the patient sought help through the agents
of higher forces and everywhere these agents themselves utilized their
therapeutic success for strengthening the belief in their over-natural
power. The psychologist would say that it was always the same story, the
influence of suggestion on the imagination of those who suffer. Yet the
variety of forms is abundant. Not only the special symbols but the whole
attitude may take most varied character, and every special appearance is
intimately related to the whole mystical background and to the
religious, scientific, and social ideas of the time. If nevertheless,
even at the same time in the same country, very different forms of
religious suggestion are at work, it must not be forgotten that those
who live together in any nation and are united in many common purposes
represent, after all, different stages in the development of
civilization. It has always been true that those whose minds are
saturated with the real culture of their time are working together with
those whose culture belongs to earlier centuries and with others whose
minds are essentially of the type of the primitive peoples.

Let us glance at the life of the savages. In darkest Africa, we find a
special caste with its professional secrets which accepts new members
only after long tests. They are evidently persons with over-sensitive
nervous systems and liable to hallucinations. As soon as they have their
attacks of abnormal excitement, they are conceived to be agents of
superhuman powers, and on account of this they are able to prescribe the
cure of any diseases. In Australia, therapeutic power belongs to the
koonkie, a man who as a child had a vision of a demonic god. From him he
received the power to heal the sick. He goes to the patient, touches the
painful parts and rubs them and after a few minutes, he shows a little
piece of wood which he had hidden in his hand and which he claims to
have extracted from the body of the sufferer. The native feels actually
cured after such manipulation of the koonkie, who evidently believes
himself in his power. In Siberia, we find shamanism. The shaman stands
between man and the gods. These shamans are excitable persons with
epileptic tendencies, or at least over-suggestible men or women who by
autosuggestion and imitation can bring themselves into ecstatic
convulsions. They alone know from the gods the means to treat diseases
and their personal influence overcomes the ailment. In early America,
before the European discovery, the cure of disease belonged in the same
way to the middleman between the gods and human beings. In the Antilles,
for instance, the bohuti heals the diseases which are regarded as
punishments of the gods for human neglect. The priest by inhaling a
certain powder brings himself into an ecstatic condition, then presses
the painful organs of the patient, sucks at various parts of his body
until he finally produces some little bone or piece of meat which until
then he kept hidden in his mouth. The disease disappears, and the
extracted bone is used as an amulet which secures good harvests. Other
Indians had their piachas. They were selected from among the boys of
about ten years old and were then sent to lonely forests where they had
to live for years upon plants and water without any friends, seeing only
at night the older priests from whom they learned the ceremonies for
curing the sick. Here too their art consisted mostly in touching the
painful parts of the body with the lips and sucking them to bring the
evil saps out of the body by their supernatural power. In short, at the
most primitive stages in Africa and Asia, in America and Australia,
therapy was acknowledged to be a special power of men who had superhuman
forces derived from good or evil gods.

All this repeats itself in the so-called half-civilizations. Among the
masses of China, mental and bodily diseases were ascribed to the fox,
which plays such a large part in the superstitions of eastern Asia. The
priest has the power to banish the fox by mystical writings which he
pastes on the wall of the sick-room, and the patient recovers, as the
fox has to leave his body. In old Japan the mountain monks, who
inherited their superhuman powers from a martyr of the fifth century,
can remove the diseases which have magical origin or which are induced
by the devil. They also supply the magical papers covered with writings
and pictures of birds, to prevent the appearance of smallpox and
pestilence and to cure a number of diseases. India, the classical land
of suggestion and hypnosis, shows the most extensive connection between
religious and magical powers among which the cure of diseases is only
one feature. Such cure may be with medicaments or without, but the
essential part always belongs to the prayers which make the good and
evil spirits obedient to the healer. These prayers were often spoken in
Sanscrit, which the people did not understand and which thus added to
the mystic solemnity of the procedure. This suggestive influence of the
use of older languages for religious solemnities, known only to the
priests, repeats itself also at all times and among all nations. In
Assyria and Babylonia, too, medicine was exclusively a branch of
mysticism and essentially in the hands of the priests, who by words and
magical beverages annihilated the influence of the malevolent demons. It
is well known how the Old Testament reports the same traits of belief
among the Jewish nation. We hear there that Miriam became leprous,
white as snow, and Moses cried unto the Lord, saying: "Heal her now, oh
God, I beseech thee." And after seven days Miriam was cured in
consequence of Moses' prayer. And again, "The Lord sent fiery serpents
among the people and they bit the people and much people of Israel
died.--And Moses prayed for the people.--And Moses made a serpent of
brass and put it upon a pole and it came to pass that if a serpent had
bitten any man, when he beheld the serpent of brass, he lived."

Among the old Egyptians, it was especially Isis who discovered many
remedies and had been much experienced in medicine, and after having
become immortal, it was her greatest pleasure to cure the sick and to
announce the right remedies in dreams to those who came to sleep in her
temples. Many who could not be cured by any physician, and who had lost
their sight and hearing or could not move their limbs, became well again
when they took refuge in her temples. The same holds true for the
Serapis temple; even the best known men go there to sleep to get from
the goddess cures for themselves or for their friends. It is well known
again that in other ways the old Greeks attached medical influence to
temples and sacred springs and rivers and tombs. There were sacred
springs which cured everybody who drank from them, there were statues
which removed every disease when offerings were brought to them. Here
again the most frequent is the cure of paralytic symptoms and of
obsessions. The Orphic priests of old Greece most nearly resembled the
shamans of the savages.

Those who are inclined to give to the life of Christ a rationalistic
interpretation have often pointed out that the therapeutic effects
described in the Gospels might also be understood as effects of
suggestion by word and tactual impressions, produced especially on
hysterics, epileptics, paralytics, and psychasthenics. Such
rationalistic interpretations could also explain in the same way through
the suggestive influence in the minds of the sick, those cures which
Christ effected through others without being present himself. Here
belongs perhaps the cure of the servant of the centurion in Capernaum or
the cure of the daughter of the woman of Canaan. "And when he had called
unto him his twelve disciples, he gave them power against unclean
spirits to cast them out and to heal all manner of sickness and all
manner of disease." The Acts give us the full details of how Peter and
Paul cured the lame and how special miracles were performed by their
hands. No doubt this belief in the curative effect of the disciples and
their successors fills the first centuries after Christ. Eusebius tells
us how they healed the sick by laying on of hands. The forms were
frequently changing through the history of Christianity but the essence
remains the same. Sometimes more emphasis is laid on the personal factor
of the priest, sometimes more on the sacred origin of the symbol as in
the case of the relics, sometimes more on prayer and godly works, but it
is always the religious belief which cures. Typical are the therapeutic
wonders of Francis de Assisi. He banishes devils, cures gout, lameness,
and blindness. The traditional means of suggestion, prayer and the
laying on of hands, had in the meantime been supplemented by the sign of
the cross which the church had added. Moreover whatever he had only
touched became a remedy for the sick. Protestantism brought no change in
this respect. Martin Luther writes: "The physicians consider in the
diseases only the natural causes from which a disease results and want
to remove them by their medicines, and they are quite right in it. But
they do not see that the devil often sends to one a disease which has no
natural causes. Therefore there must exist a higher medicine, namely,
the religious belief and the prayer through which the spiritual medicine
can be found in the word of God."

The broad undercurrent of religious cures, especially in the Catholic
Church and in the Greek Church, but with fewer symbols also outside of
them, has up to the present time never ceased to flow. But independent
of it the therapeutic belief has again and again been focused on certain
individuals or certain sects or certain schools, in the midst of the
steady progress of scientific medicine and sometimes synthesizing the
religious claims with new-fashioned scholarly ideas. In the seventeenth
century, for instance, the Irish nobleman Greatrakes became a famous
center of attraction. He felt himself to be the bearer of a divine
mission and healed the sick, appealing to their belief by laying on of
hands and by movements which we nowadays call passes. Much more
influential in the eighteenth century was Pastor Gassner in Germany.
Gassner succeeded in producing with his religious psychotherapy such a
tremendous stir that many thousands who needed cure from functional
diseases, and thousands of curious people, too, streamed to his church
in Ellwangen, and his methods of cure spread almost contagiously among
the ministers of the country: an Emmanuel Church Movement of the
eighteenth century. Gassner, too, discriminated between the diseases
which have natural causes, that is the organic diseases, which he did
not treat, and the functional ones, which were obsessions of the devil.
To determine to which group the disease belonged, he ordered the devil
to produce the symptoms of the sickness. When in this way the
obsessional character of the disease was recognized, the minister began
with his suggestive influences to banish the devil. He demanded firm
confidence in the name of Christ, reënforced his effectiveness by
narration of the cures he had perfected, used further certain
manipulations such as the rubbing of the skin and passes on the head,
and finally gave his suggestions with authoritative firmness. Many
ministers who became his pupils treated like him with skillful
combination of religion and hypnoid influences the spasms, catalepsies,
neurasthenias, paralysis, and deafness, of neurotic patients.

There is no need to follow in detail the frequent similar occurrences
between Gassner's time and our own. We all know where we are to-day.
The medical profession and the medical science with its bacteriology
and serum therapy, its Roentgen rays and its organic chemistry is far
away from the church and without concession to religious aspects. On the
other hand there are the yearly processions of thousands and thousands
who make their pilgrimage to the sacred waters of Lourdes, guided by the
Catholic priests, half-hypnotized by the hope that the Virgin will cure
them. In every niche of the Catholic churches in all Europe, there are
kneeling before the burning candles those who pray for nothing but their
health; and their belief will sometimes yield almost miraculous cures.
In England the Society of Emmanuel was founded by men and women to whom
it seemed necessary to bring back to the minds of Christians the
undoubted fact that Christ taught and worked for physical heath and to
revive this sense of power over disease. Thousands were treated and the
results have been "most encouraging." Among the cases successfully
treated may be mentioned "one of cancer in which case the specialist
called in had given the sufferer only three months to live while by
means of the laying on of hands in prayer, a complete cure was
effected."

Not dissimilar in its proceedings, though much more elaborate in its
metaphysics than this movement in the midst of the Church of England, we
find in America the Christian Science movement started by Mrs. Eddy. It
was new as a therapeutic system, however old its philosophic elements.
Mrs. Mary Baker Eddy writes: "In the year 1866 I discovered the Christ
science or divine laws of life and named them Christian Science. God had
been graciously fitting me during many years for the reception of a
final revelation of the absolute divine principle of scientific being
and healing." The disease is cured for the Christian Scientist by the
belief in God because a true belief in God includes the insight that God
is all reality and that reality therefore cannot include the ungodlike,
that is, error and sin and disease. Disease is thus recognized as unreal
and if it has become unreal, of course it has disappeared as part of our
real life. Thousands and thousands have been cured under this symbol.
And as the latest chapter of this history of five thousand years, we
find the movement which Dr. Worcester has started in Boston and which,
too, spreads rapidly over the continent and awakens the ambition of many
a minister in every denomination in the land. The aim is to cure the
patient by reënforcing in him through religious persuasion, through the
contact with the symbols of the church and with godly men and through
religious suggestion, a confident belief which gives new unity and
through it new strength to the mind of the sufferer until it overcomes
the functional disease of the body. The physician at first examines
whether or not an irreparable organic disease has attacked the body, but
if he does not find such organic destruction, then the patient is to be
handed over to the minister, who will take care that through his
religious belief and inspiration the mind will triumph over the weakness
of the body.

Whoever looks in this way over the history of mankind can no longer
doubt that belief in supernatural powers is really an agency for the
overcoming of disease. We may be interested in it from the standpoint of
religion or from the standpoint of psychology or from the standpoint of
ethnology. In every case we have to acknowledge that he who believes may
be cured. If we abstract first from the religious point of view and
consider the problem as a scientific one, we have to interpret all those
curative effects of belief as results of suggestion. The attitude of the
one who gives the suggestion has gone in the history of mankind through
all possible variations. He may have been filled with fervent belief,
rejecting any interpretation except the religious one, or he may have
produced the suggestion of belief almost with the intentions of a
physician who simply relies on the physiological effects of any
suggestion; and between these two extremes any number of steps is
possible. Moreover the suggestion may have been detached from any
personality and may have belonged to any symbol of religious energies,
like the relics of the Catholic Church. Even the most skeptical of
ethnologists ought to acknowledge that very little in this history of
religious psychotherapy points to a conscious fraud. Those shamans of
the savages from Siberia to South Africa, from Australia to Mexico, are
in ecstasies which make them really believe in the mysterious power of
their manipulations. The ethnologist finds indeed as most common
characteristics of all those primitive movements that those who cure
are chosen from among neurotics who by epileptic attacks or
hallucinations and obsessions are predisposed to feel themselves as
bearers of a higher mission.

Yet whether the attitude of the transmitter is religious or
half-scientific, is inspired or insincere, the receiver of the
suggestion is always in the same condition: he is believing in his cure
through religious influence and through his belief he is helped, if he
is helped at all. This uniformity does not exclude the fact that the
patients too may show a manifoldness of mental states. They may remain
in a completely waking state with reënforced suggestibility, or they may
go over into a drowsy or hypnoid state or deeply into a hypnotic state,
or may receive the suggestions as we saw even in sleep. Further their
minds may be entirely filled with fine religious emotions and the
therapeutic effect be only an appendix or, on the other hand, this
confident expectation of the relief from pain may be their central
content of consciousness and may control the whole mental interplay. The
practical problem of the scientist is to consider how far these
religious energies ought to be used today in the interests of the cure
of diseases.

From a scientific standpoint such a discussion can hardly be fruitful
with those who consistently take the religious point of view only. A
view of the world which demands the faith that religious belief moves an
almighty power to cure a diseased organ, or that the disease has no
reality for one who lives in God, is invulnerable to merely scientific
arguments. The sick woman who kneels between the candles before the
picture of the Virgin, praying that her heart, which the physicians
declare incurable on account of a valvular disease, be cured, moves in a
sphere of thought which lies entirely outside of the medical study of
causes and effects. The same holds true, for instance, of Christian
Science. This statement is in itself no criticism and no argument; it
only acknowledges that any possible exchange of opinions has to be
carried over from the scientific psychological ground to that of
metaphysics and philosophy. It is quite different with modern movements
of the type of the Emmanuel Church Movement, where the religious thought
is intertwined with the psychological theory and where an actual
coöperation of physician and minister is sought. Here church and science
really meet on common ground, and it is important to examine objectively
whether it is wise and beneficial to encourage the spreading of this
tempting enterprise. The movement has reached the large cities between
the Atlantic and the Pacific and is beginning to captivate the ministers
of the small towns and villages. It seems as if an epoch has come for
the church--the church which too long has ministered only to the
spiritual needs of the community will at last remember again that Christ
healed the sick, that mind and body are one, that the personality must
be understood in its unity, and that endless fields of blessed influence
may again be opened to the church when the minister becomes the
physician of his congregation. Whoever knows the suggestive power of
such a social movement, and considers the ease with which triumphant
successes may be reached in this field and the disappointing and
discouraging reduction of power which the church shows everywhere in its
purely spiritual hold on the community, can foresee that all the
conditions are favorable for a rapid spread and that the church clinics
will become the American fashion of the near future.

It cannot be denied that the Christian church takes in hand there once
more a work which belonged to it through centuries. But they were
centuries in which the priest was in a certain degree the physician,
just as he was the educator and teacher, simply because in the church
there was centered all cultural influences which the community knew. The
complexity of modern times has for centuries demanded the opposite
system. Centralization is allowed only to the purely administrative
influence of the state, while all the active functions are divided among
specialists. We rely on the expert in education, we demand the expert in
medicine: is more gained or lost if the religious leader now again
suddenly undertakes a part of the functions which belong to the
physician? It is true that the ministers of this school do not propose
to undertake the physician's work to its full extent. They leave to him
the first and in some respects most important step, the diagnosis, and
abstain from the treatment of such cases as the physician declares
inaccessible to psychical influences. They do not heal cancer and
phthisis like the Emmanuel Movement in England or like the mental
healers in America.

But is not perhaps just this compromise dangerous in another direction,
inasmuch as it awakens a feeling of safety in those who feel in sympathy
with scientific medicine? They have passed the hand of the physician and
believe accordingly that because their illness is recognized as
functional, the minister can really perform all that ought to be done.
Is this belief justified? At the threshold, it occurs to every one that
such a diagnosis by physicians may be erroneous and that the chances for
such error are under the conditions of the church clinic much greater
than under the conditions of a regular medical treatment. The
diagnostician who treats the patient himself has ever new chances to
remodel his diagnosis and to correct it under the influence of
therapeutic effects. The danger is great that under the proposed
conditions, the activity of the physician will be superficial, because
he is deprived of his chief means, the constant observation. But we may
abstract from this possibility of error. Does the fact that the disease
is one the symptoms of which may yield to psychical treatment really
make it advisable that the further treatment be handed over to the
clergyman? To begin at the beginning, the usefulness of psychical
treatment does not at all exclude the strong desirability of physical
treatment at the same time. The emphasis which is laid on religious
persuasion and inspiration, on prayer and spiritual uplift practically
excludes the use of baths and douches, of massage and electricity, of
tonics and sedatives. And yet it is not caprice or sham when every
well-schooled medical specialist applies such means in the treatment of
these so-called functional diseases of the nervous system. The minister
applies and can apply only one of many possible methods for cure and
yet, if we really want to make use of the resources of modern knowledge,
we have to adapt most carefully all possible means to the individual
case. If we take the strictly religious standpoint the situation is of
course different, but if we speak of psychophysiological effects, we may
acknowledge the healing influence of prayer and yet rely in the special
case still more on bromide or strychnine. Yet the religious
psychotherapists not only neglect the physical help but usually
emphasize the antagonism. Some of the strongest supporters proclaim it
as a non-drug healing, thus deciding adversely about a medical method
regarding which they have no means at all to judge.

Parallel to this neglect of physical theory goes, of course, the neglect
of the physical factors in the disease. The physician may have justly
diagnosed that the case is "merely" neurasthenia or hysteria and not a
brain tumor or paralysis of the brain. Yet that does not mean in the
least that a real treatment which remains in harmony with the progress
of modern medicine ought to ignore the hundred physical elements which
enter daily into the disease. There are the most complex digestive
problems involved which demand a thorough understanding of chemical
metabolism, there are still more complex problems of the sexual organs
which the minister certainly ought not to discuss with his female
parishioners, there are bacteriological questions, there are questions
of the peripheral nervous system and sense organs; in short, questions
which belong to a world into which the minister as minister has never
looked. Even if he believes he might gather in an amateurish way some
information as to those questions which lie so far from his experience
as student of divinity, how can his half-baked knowledge compare with
the experienced study of the regular physician? Such physical questions
cannot be settled by the preparatory examination of the physician; they
come up every day during the treatment and what the spiritual diet which
the minister offers may help, may at the same time be ruined by the
physical diet about which the minister without chemistry cannot judge.

But let us abstract from the bodily aspect. Is the situation really very
different for the mental one? The appeal to the religious emotion, the
reënforcement of religious faith is from the religious point of view
certainly the one central effort from which everything has to irradiate.
The unity of this controlling thought is the glory of such inspiration.
But as soon as we handle this thought as a psychotherapeutic remedy,
destined to restitute the disturbed psychological equilibrium, it
becomes evident that the very uniformity of it makes it a clumsy,
inadjustable pattern. If there is anything which impresses the careful
student of psychology, it is the over-rich manifoldness, the complexity
of mental life. Even the simplest content of consciousness is a tissue
woven from millions of threads and any stereotyped influence means
crudeness and destruction. The minister's attitude towards inner life is
there directly opposite to that of the psychologist. He cannot enter
into those endless interplays of associations and memories, or
inhibitions and sensations and impulses, he cannot examine from which
remote psychological sources those ideas have arisen, how the feelings
become disturbed and the judgments sidetracked. He should not analyze
even if he could, because his whole aim is to synthesize. He asks for
the meaning and not for the structure, for the aims and not for the
elements. His therapeutic effort is therefore not even directed towards
a careful rebuilding of the injured parts of the mind, but it is nothing
more than a general stimulation to the mind to help itself. By touching
on one of the deepest emotional layers of the mind, the layer of
religious ideas, the minister gives to the soul an intense shock and
expects that in the resulting perturbation, everything will be shaken
and may then settle itself by its own energies in a healthful way. It is
a fact that that can sometimes happen and under certain conditions the
chances for it are even favorable. Under many other conditions the
chances are unfavorable and the result does not happen at all.

But whether or not a cure results, in any case it is certainly not an
effort which can be said to be in harmony with modern science. The idea
of science is always to understand the complex from its elements and to
restore the disturbed complex object by recognizing the disturbances in
the elements and by bringing those disturbed elements into right shape
again. Certainly the psychologist, too, in examining carefully the
injured mental mechanism may discover emotional injuries which might be
cured by the introduction of religious ideas, but he will not give to
them a value different from the introduction of any other ideas and
emotions, for instance, those of art and music and poetry, those of
social company or civic interest, of travel or sport or politics. Each
may have its particular value and to cure every mind with religious
emotion would be from a psychological point of view as one-sided as it
would be to cure every disturbed stomach by milk alone. Moreover in very
frequent cases, for instance, of neurasthenia or hysteria or
psychasthenia, such wholesale remedies can form only the background of
the treatment, but all the details have to be furnished with reference
to a most subtle analysis of the special symptoms, and a particular
organic symptom or a particular memory idea or a special inhibition by a
well-selected counter-idea will do much more than any great emotional
revival.

Stereotyped religious appeal is not only insufficient in an abundance of
cases--it must never be forgotten that those who nowadays go to the
minister for their health are already selected cases more open to
religious suggestion than the average--but can easily be decidedly
harmful. Of course that holds true for every physical remedy too, and
the judgment of the exact limit is one of the chief duties of the
physician. It holds also for the other mental factors like sympathy. A
certain amount of sympathy may save a neurasthenic from despair, and
only a little more may make his disease much worse and may develop in
him a consciousness of misery which makes him a complete invalid. Still
more is it true for the religious emotion, from the standpoint of
nervous physiology the strongest next to the sexual emotion, that it can
be the healing drug or the destructive poison. Everything depends upon
the degree of the intrusion and upon the resistance of the
psychophysical system. From a purposive point of view there cannot be
faith enough, from a causal point of view there can easily be too much
of the faith emotion. Religious fervor has at all times helped to create
hysteria and to develop psychasthenias. It cannot be otherwise. A group
of ideas which has such tremendous power over man must easily be able to
produce inhibitions and exertions which become dangerous to a nervous
system the constitution of which is pathological. To leave such a
dangerous and powerful remedy entirely in the hands of men who by their
profession must aim towards a maximum dose of religious influence can
certainly not be in the interests of the patients or of the community.

Even the whole technique of this movement awakens the fear of possible
harmful consequences. On the one hand we have the movement itself as a
popular suggestion for the suggestible masses. The patient who seeks the
help of a scientific neurologist hardly becomes a center of psychical
contagion, but the church services for the sick offer favorable
conditions for an epidemic development of hysterical symptoms. But more
important are the influences on the individual patient. The whole
purpose of the treatment demands the highest possible degree of
suggestibility brought about by the ministerial persuasion. But it is
evident that this degree of suggestibility means at the same time the
most fertile soil for every chance suggestion and for influences which
are perhaps entirely unintended. The physician and the psychologist,
considering the mental state with reference to its elements, will make
most careful use of those accessory influences. The minister, who
necessarily has his spiritual aim in mind, cannot even become aware of
all the involuntary influences which reach the mind in its most
suggestible state. There can be no doubt that it would often need
psychological art to avoid the creation of new pathological symptoms in
such half-hypnotized patients. Yet the minister even goes so far as to
make use of the sleeping mind without any consideration of the possible
damage which may be done to his subject. He goes to the bedside of a
sleeping girl and whispers his suggestions and is satisfied when they
show their effects the next day. It does not lie in his horizon to
consider the grave consequences which such suggestions during sleep may
produce during future years in the brain the sleep of which has been
transformed into such half-somnambulic relations. Hysterias may be
created by such methods. No one can blame the minister for his
remoteness from such doubts and problems, but the physician is to be
blamed if he encourages the belief that all this still belongs to the
proper sphere of the ministerial worker in abnormal psychology.

Those engaged in such work were not long in finding out that the mere
emotional inspiration is often no sufficient remedy, and the development
went along the same lines in which it has gone everywhere for some
thousands of years. Not to disappoint the sufferers, the religion had to
become in very many cases simply an inactive side issue and the real
cure was performed by the same methods with which any worldly
neuropathologist would go to work. If the woman who cannot sleep is
cured from her insomnia by being made to listen to the beats of a
metronome, it may sometimes be effective, however crude, but it is
certainly no longer religion, even though the metronome stands in a
minister's room. The more the movement spreads to those who have no
psychological training and knowledge, the more it must be necessary for
them to import the whole claptrap of the quack hypnotist and soon the
minister may discover that in certain cases physical means and drugs
help still better. Thus he simply enters into competition with the
regular physician, only with the difference that he has never studied
medicine. The chances are great that in his hands even such remedies and
drugs may do harm and finally, even if they were effective, is not the
question justified: will not religion suffer?

Indeed we have so far considered the question from one side only. We
have confined ourselves to the question of how far such a movement is
sound for the interests of the patient; but can we be blind to the other
side and overlook the not less important problem of whether it lies in
the interests of religion and of the church to amalgamate its spiritual
work with a medical one? We are not thinking of those widespread, unfair
arguments to the effect that this whole movement is undignified because
it is instituted by the desire to fill the empty pews or to make
competition with the success of Christian Science. That is utterly
unjust. But there are intrinsic factors in the movement which interfere
with the true aims of religion. First of all it cheapens religion by
putting the accent in the meaning of life on personal comfort and
absence of pain. The originators of the Emmanuel Movement stand well
above such error, but their national congregations do not. Certainly the
longing for pleasure and a well feeling and the abhorrence of pain and
illness pervades our practical life and keeps in motion all our
utilitarian efforts. But if there is one power in our life which ought
to develop in us a conviction that pleasure is not the highest goal and
that pain is not the worst evil, then it ought to be philosophy and
religion. It is only the surface appearance if it seems as if the
religious therapeutics minimizes the importance of pain; in truth it
does the opposite. It tries to abolish pain, but not because it thinks
little of pain; on the contrary, because it thinks so much of pain that
it is willing even to put the whole of religion into the service of
this strife for bodily comfort. The longing for freedom from pain
becomes the one aim for which we are to be religious. In a time which
denies all absolute ideals, which seeks the meaning of truth only in a
pragmatic usefulness, it may be quite consistent to seek the meaning of
religion in its service for removal of pain, and personal enjoyment. But
in that case the ideal of both religion and truth is lost. It is finally
not less undignified for religion to seek support for the religious
belief in effects which it shares and knows that it shares with any
superstitious belief on earth. Granted that the church can cure: the
shaman of Siberia can cure too, and the amulets of Thibet not less. The
psychologizing church knows, therefore, that it is not the value of the
religion which restores the unbalanced nervous system; and yet it wants
to provide for the spreading of true belief by the miraculous cures
which it exhibits.

This situation naturally produces the desire of the church to substitute
a religious explanation for a psychological one. It is claimed that
after all it is not the mental effect of the prayer, but the prayer
itself, not the psychophysical emotion of religion, but the value of
religion which determines the cure. Yet in that moment the whole
movement in its modern shape comes into a still more precarious
position. If the cure results from the inner value of the religion how
can we confine it to the so-called functional diseases and abstain from
any hope in organic diseases? Luther, from his religious point of view,
still had the right to separate the two groups because only those
functional diseases were effects of the devil, obsessions which could be
banished by the minister and by prayer, while the other diseases did not
result from the devil, but merely from natural causes. Such a definition
does not fit into the modern system. To-day from a really religious
point of view, both groups of diseases must be acknowledged to be
natural or with Mrs. Eddy, as the work of the unholy spirit. Christian
Science is indeed by far more consistent. If the cure results through
the meaning and value of religion, there is no reason whatever why
cancer and diphtheria and paralysis should not be cured as well as
psychasthenia. And if, on the other hand, organic diseases cannot be
cured because the psychophysical process of the religious emotion has no
influence over diphtheria bacilli, then the whole process is removed to
the causal sphere and it is acknowledged that the purposive meaning of
religion is not in question at all. The whole system of such religious
psychotherapeutics is therefore in its inner structure contradictory. It
contains causal and purposive elements without any possibility of
unifying them. They are loosely mixed, and the power of prayer means on
one page something entirely different from what it means on another. In
these respects Christian Science is by far more unified and in harmony
with itself; its therapeutics is really anchored in a system.

From a scientific point of view, its dangerousness is of course much
greater inasmuch as it extends its methods over every organic disease
and thus applies merely psychical treatment where from a standpoint of
scientific medicine, physical treatment would be absolutely necessary.
Moreover its philosophy is after all only a pseudophilosophy; its
tempting equations of disease and error and sin and unreality are
ultimately a mere playing with conceptions. If we were to point to the
root of the misunderstanding in Christian Science, we should say that
everything depends on the philosophical commonplace that the objects
with which we deal in our life are ideas and that our whole experience
is mind. "Christian Science reveals incontrovertibly that Mind is
All-in-All, that the only realities are the divine mind and idea." But
now silently this mental character of the real world is identified with
the mental experience which stands in contrast to the physical
experience. There results the impression that physical experience
therefore, does not belong to the world of reality. It is evident,
however, that mental in contrast to physical means something entirely
different from mental in the philosophical sense. In the latter meaning
of the word, we all agree that the world is mental; the word mental
indicates there that the world has reality not in itself but only as
experience of subjects. In the second sense, mental or psychical means
that it is experience for one particular subject only and not for every
possible subject. The physical thing, for instance this table, is indeed
different from my mental memory idea of a table, inasmuch as every
possible subject can experience this table while my mental memory image
belongs to me alone. The physical table and the mental memory image of
it are both equally mental in the philosophical sense, inasmuch as the
physical which is object for every possible subject and in this sense
not mental is therefore not less given to subjects. Every physical body
with its disease is thus in one sense taken as something not mental
while in another sense as mental; if we use the same word in two
entirely different meanings, it indeed cannot be difficult to
demonstrate any metaphysical consequences.

But we do not have to deal here with the metaphysics of "Science and
Health." If it is brought down to the concrete application, we stand
before the same confusion which characterizes all compromises. Causal
effects are sought in a sphere which belongs to purposive values. The
psychological effects of the emotion of faith are sought and are
misinterpreted as the emanations of religious powers. Religious
psychotherapeutics in all its forms seeks to demonstrate to us the
triumph of the soul over the body, while in reality it deals only with
the mental mechanism which as such belongs to the chain of causal events
in the same natural way as the organism. The soul, as spiritual agency
in its sphere of purposes and ideals, does not enter the machinery of
psychotherapy, and the psychological material on which psychotherapy is
applied is not freer and not better and does not stand higher than the
material of the bodily cells and tissues. The Emmanuel Movement
deserves the highest credit for bringing about a systematic contact
between religious faith cure and scientific medicine, but the time in
which the minister himself undertook the medical treatment had to be a
time of transition. It had to lead to a new relation in which the
ministerial function is confined to the spiritual task of upbuilding a
mind while the therapeutic function remains entirely in the hands of the
physician. Where the physician believes that the psychomedical treatment
demands a new equilibrium of the patient to be secured by religion,
there the minister should be called for assistance. Psychotherapeutic
hospitals would offer the most favorable conditions for such
coöperation. But the minister ought to enter even such a hospital with a
strictly spiritual aim, and he should never forget that the task of the
church stands much higher than the utilitarian task of removing pain
from the sick room. But if those psychotherapeutic hospitals will
flourish and the physicians will at last make use of psychical factors
in their regular practice, they ought not to forget on their part that
the important step forward was taken under the pressure of popular
religious movements. The ministers first saw what the physicians ought
to have seen before, but the physicians will see it more fully and more
correctly.




XIII

PSYCHOTHERAPY AND THE PHYSICIAN


Every thought of the physician moves in a world the structure of which
is determined by the thought forms of cause and effect. He knows the
effect which he wants to produce; it is the restitution of the organic
equilibrium. He studies the causes which can secure that end. And again
the disturbance of the equilibrium itself, the disease, is for him an
effect which he seeks to understand by an analysis of the preceding
causes. The means which he applies can therefore be valued only in
reference to their efficiency; no other point of view belongs to his
world. The religiously valuable may be indifferent or even undesirable
in the interplay of causes, and the morally indifferent may be most
important for the physician's interests. The religious emotion
accordingly has to stand in line with any other mental excitement or
with a hundred physical means which the laboratory and the drug store
supply. The physician will welcome the methods of treatment without
reference to metaphysical systems or to religious beliefs. To him it is
an empirical fact that many disturbances of mind and body which
interfere with the equilibrium of life can be repaired by influences on
certain psychophysical organs. A part of these repairing influences he
finds in the sense stimuli, for instance, of spoken or written words
which reach the brain and awaken associative and reactive processes. He
finds further that these influences can be reënforced in their
effectiveness by certain general conditions of the nervous system and
again finds that these can be secured partly by sense impressions, and
once more especially by words.

It is a matter of course to the physician that application of any sense
influence on the brain demands a most subtle analysis of the
psychophysical situation. Therefore he gives no less attention to the
disentangling of the whole history of the individual brain, to its
stored-up energies and to its mental possibilities. If he knows the
psychophysical status, and finally if he knows the means of influencing
those psychophysical organs which stimulate or inhibit the disturbed
central parts, he can foresee the psychophysical effects with a certain
definiteness. Thus everything depends upon the sharpest possible, almost
microscopic, mental analysis, together with a most thorough examination
of the whole nervous system and the most careful calculation of the
mental influences applied. The vagueness of the religious appeal
transforms itself into an exact calculation and the unity of the soul
which seeks spiritual uplift transforms itself into a mental mechanism
of bewildering complexity, and yet not more complex than the physical
organism, to which for instance, the chemical means of the physician
administer. To-day medical science is certainly only in the beginning of
this great movement. Especially the analysis of the psychophysical
conditions still lacks a sufficient refinement of method. But at least
the causal principle is now fully recognized and the scientific man of
today no longer doubts that this whole play of psychotherapeutic
processes goes on as a causal process in the psychophysical system of
the individual without any mysteriousness, without any magnetic
influences, without any miraculous interference, without any agencies
except those which are working in our ordinary mental life in attention
and reaction, in memory and sleep.

It is surprising how late this recognition appeared in the history of
human knowledge. It occurred here as in so many places in the history of
human civilization that the simple is the late outcome of the complex.
Just as in technique the apparatus often began in a complex, cumbersome
way and then became steadily simplified, so it is with explanations. The
complex machinery of cosmic influences and obsessions by demons and
magnetic mysteries was at first necessary until the simple explanation
was found that all the results depend upon the working of the mind
itself. Yet in technique and explanation alike, such progress to the
simpler means always at the same time the making use of much richer
knowledge. To explain an obsession or a sleep state by the agencies of
evil spirits or magnetic fluids is certainly an unnecessary side
conception. But to understand it from the working of the mind
presupposes after all the whole modern physiological psychology, and
thus had to be the latest step.

The effects themselves were certainly observed in all times. Even the
phenomena of hypnotism date probably back some thousands of years,
however difficult it may sometimes be to discriminate between the
artificial hypnotic states and hysteric or hystero-epileptic occurrences
in the past. Certainly it may be acknowledged that the Yogi in India
cultivated in the most remote times the methods of autosuggestion which
evidently led to hypnotic states, and everywhere around the
Mediterranean, antiquity knew the hypnotizing effect of staring on
polished metals and crystals. So in Egypt, so in Greece and Rome; and it
has often been claimed that the priestesses of Delphi and the sibyls of
the Romans were in states of hystero-hypnotic character. As to the
therapeutic use, especially the Greek physicians applied hypnotic means.
Excited patients were brought to repose by methods of stroking. The
efforts to explain scientifically the mysterious powers which men can
gain over the mind and will of another begin at the end of the Middle
Age and were developed quite naturally from the prevailing astrological
doctrines. Astrology worked on the theory that the human fate depends
upon the stars. These stars have an effect on the human organism. That
proves that an influence can exist between distant bodies. It is,
therefore, not more surprising that one organism can also have an
influence on another organism. Well known since antiquity were such
influences from one object to another, as in the case of the magnet.
Thus there may be a kind of magnetic power which creates relations
between all objects in the universe.

Pomponnazi explained thus at the end of the fifteenth century the
therapeutic effects of the human soul by the mutual influence which
stars and men have on each other. This theory comes to much more
important development in the writings of the physician Paracelsus. One
individual by the power of his effort can influence the will of another
individual, can fight with it, and suppress it; and all through energies
which are analogous to the magnetic power which binds stars and men. In
the middle of the seventeenth century, Helmont connects this power of
magnetic attraction and repulsion with an ethereal element which
penetrates all bodies and keeps them in motion. Through it man, too, can
by his mere imagination work on other men. This will can also be
effective on drugs which get through it a special therapeutic power.
Somewhat different was the theory of a Scotch physician, Maxwell, in the
second half of the seventeenth century. The ethereal spirit, which is
identical with light, can be artificially cumulated in any organism and
that secures its health. As one man can influence this vivifying ether
in any other man, he can produce cures even from a great distance. All
diseases are merely reductions of this ethereal spirit in the organism.

But the general stream of the explanation continued in the direction of
the magnetic doctrine. It was especially Mesmer in the eighteenth
century who, in a long life of fantastic mysticism and yet of universal
serious study, surely contributed much to the development of the theory.
He had started to use, like others, the magnet in his medical practice.
But he discovered that the same therapeutic successes could be gained
without applying the magnet itself, but by simply using his own hands.
The patients became cured when he moved his hands slowly from their
heads to their feet. The magnetic power was therefore evidently in man
himself. It was an animal magnetism in opposition to the mineral one
which belonged to the magnet and to the stars. He believed further that
he was able to infuse this magnetic power into any lifeless thing, which
would then have curative influence on the nerves. There can be no doubt
that, whatever may have been the value of his theories, he cured a large
number of patients, evidently producing a state which we would call
today a hypnoid state and often simply appealing to the natural
suggestibility of the impressionable minds. Among his pupils, usually
called mesmerists, was Puysèyur, who discovered, in 1784, the state
which was called artificial somnambulism, a kind of sleep in which the
ideas and feelings of the magnetized can be guided by the magnetizer.
Here evidently was the first recognition of the psychotherapeutic
variation which we call today hypnotism. There followed a period in
which the scientific interest of the physicians was somewhat sidetracked
by an unsound connection of these studies with mystic speculations and
with clairvoyance. But especially in Germany animal magnetism in
Mesmer's form and in the form of artificial somnambulism grew in
influence through the first decades of the nineteenth century and
succeeded in entering the medical schools. The reaction came through
popular misuse. At about the third decade of the century, interest
ceased everywhere.

The Portuguese Faria insisted in 1819, practically as the first, that
all those so-called magnetic influences, including the delusions, the
amnesias after awaking, and the actions at a command, did not result
from a magnetic power but from the imagination of the subject himself.
He believed that the effect depended upon a disposition of the
individual which resulted from a special thinness of blood. He abstained
therefore from the magnetic manipulations and produced the somnambulic
state by making the patients simply fixate his hands and by ordering
them to sleep. Thus he is the first who understood these changes as
results of mental suggestion. The next great step was due to the English
surgeon, Braid, who in the forties studied the magnetic phenomena and
like Faria insisted on the merely mental origin of the abnormal state.
He proved that a person can bring himself into such an artificial state
and that it is therefore entirely independent of energies from without.
He examined especially the influence of staring at a shining object, a
method which not seldom was called Braidism. He also introduced the
word hypnotism. In America mesmerism was generally known under the
name of electrobiology; and Grimes in particular came to results
similar to those of Braid. Yet the influence of these movements on
the medical world remained insignificant until a new great wave of
psychotherapeutics by means of suggestion began in France in the
sixties.

Of course this development from astrology to magnetism and from
magnetism to hypnotism represented only one side of psychotherapy.
Parallel to it goes the progress in the treatment of the insane. In the
first half of the eighteenth century, they are still on the whole thrown
together with the criminals but the more the disease character of the
disturbance is acknowledged, and the more special hospitals for the
insane are created, and finally the more the humane treatment in them
supersedes the brutal, the more psychotherapy enters into the work.
England showed the way. Especially Arnold, Crichton, and Perfect became
influential; and soon Pinel and Esquirol followed in France; and Reil
and Langermann in Germany. Reil recognized clearly at the threshold of
the nineteenth century that "Both psychical and physical diseases may be
cured by psychical means, but at the same time psychical diseases may
also be cured by physical means." And in his "Rhapsodies," rhapsodies on
the application of psychical methods in the treatment of mental
disturbances, he declared, "that the medical Faculties will soon be
obliged to add to the two existing medical degrees still a third,
namely, the doctorate in psychotherapy." This stream became broader and
broader and every new development of psychiatry in the last hundred
years did new justice to the influence of psychological means in the
treatment of mental diseases; to be sure, without allowing up to the
present day the hope that mental factors as such can cure the grave
forms of insanity. The borderland cases and the incipient mild forms
alone allow the hope of a cure. Outside of them the work of
psychotherapy in the insane asylum meant essentially improvement and
relief only. Again, in another direction, the general dietetic influence
of sound mental life may be called a part of psychotherapy and this
engaged not a few of the leading medical thinkers in all countries
during the last century, especially the nerve physicians who gave
serious attention to the wholesome engagements of the mind. Finally,
might not much be attributed to psychotherapy, which offically belongs
to the doctrines of homeopathy?

But we may return to the new heralds of suggestion. Liébeault's book on
the artificial sleep in 1866 became the starting point of the new great
movement. Yet at first it remained unnoticed. It is claimed that for a
long time only one copy was sold. But he continued to make his hypnotic
experiments on the poor population of Nancy and they finally attracted
the attention of some of the leading medical men there. Bernheim became
convinced and Dumont, the physiologist Beaunis joined the movement, and
in the eighties we find Nancy the center of hypnotic interest to which
medical men from everywhere made their pilgrimage. This latter phase was
paralleled by Charcot's studies in Paris, who brought hypnotism into
nearest neighborhood with hysteria. And also the later development of
the Paris school by Richer, and especially the brilliant work of Janet,
kept hysteria in the foreground of the therapeutic interest. Liébeault's
experiment had brought the psychology of suggestion entirely into the
center of this whole circle of phenomena and this view controlled the
development of the last few decades, which was essentially an
elaboration of the special treatment of diseases. Forel in Switzerland,
Moll and Vogt in Germany, Wetterstrand in Sweden became the chief
exponents of therapy by hypnotism. Others, like Dubois, in Switzerland,
emphasized more the suggestive treatment through persuasion. In England
at first Carpenter, later Hack-Tuke gave serious attention to hypnotism,
in Russia Bechterew, and in the last few years the literature on therapy
by suggestion became developed in practically all countries. In America
Beard, Hammond, and others belong to the older school; Osgood, Prince,
Peterson, Putnam, Sidis, and others to the most recent years. At the
same time, under the leadership of Kraepelin, Ziehen, Sommer, and
others, the methods of the psychological laboratory, especially the
reaction and association methods, were made useful for the purposes of
psychopathology.

But interest in suggestion does not represent to-day the last step of
psychotherapy. The latest movement, which is entirely in its beginning,
the development of which no one can foresee, but which promises wide
perspectives, is connected with the name of Freud in Vienna. The
entirely new turn of psychotherapy is given by the fact that his aim is
not to overcome a symptom by suggestion but to make it disappear by
removing the ultimate mental cause. He found that large groups of mental
disturbances result from a psychical trauma, a disagreeable idea which,
inhibited in the mind, becomes the source of mischief and produces
phobias and obsessions and hysterical motions. The cure of the symptoms
demands the recognition of this first mental accident, which may lie
back for years and which may no longer be in the memory of the patient.
As soon as this earlier experience is brought to consciousness again, it
needs only a natural discharge and a normal expression and the symptoms
which it brought about will disappear. Thus the cure itself needs no
hypnotism and no persuasion or suggestion but the reawakening of
forgotten situations, and only in the service of this effort hypnotism
may be used to reënforce the memory. Yet this represents only the first
period of Freud's activity, in which he collaborated with Breuer, a
phase which is represented by their book on hysteria, in 1895. But there
followed a further development which is still more essential. The
hysterical disturbance may indeed have started with such an accidental
traumatic impression but that does not explain why just this impression
had such a strong effect. Other impressions of equal strength and
emotional vividness may have passed without leaving any damaging result.
And therefore there must be some prior cause in the subject which makes
just this particular impression so injurious; and here is the point of
Freud's fundamental discovery, which for the layman appears on the
surface to have little probability but which has proved of greatest
consequence for clinical work. It was found that only those situations
become injurious and become starting points for hysterical symptoms
which touch on repressed and artificially inhibited ideas of the sexual
sphere.

Entirely new perspectives have been opened by these studies. Above all,
now for the first time there is in sight a psychotherapy which not only
aims to remove symptoms but which really uproots the disease itself.
That earlier method of bringing the trauma to consciousness and making
it discharge, the so-called cathartic method, removes only the
particular group of disturbances but the patient remains a hysteric, and
if ever new accidents should happen which would touch again those inmost
repressed ideas, new hysterical symptoms would develop. But if we can go
back to that starting point, if we can discover those first suppressions
of desired gratifications which often most indirectly are related to the
sexual sphere, and if we can liberate the mind from those primary
strangulated affections, then the patient is really cured. Freud himself
practically abstained from the help which hypnotism can give for the
reawakening of forgotten experiences, while some of his pupils still
prefer this short way to the forgotten memories. His way is, on the
whole, to let the imagination bring up any chance material of associated
ideas and then to study their connections and follow the hints they
give. He calls it the psychoanalytic method. Others prefer the methods
of association tests, again others tap the lower layers by automatic
writing, but the chief problem remains always to discover those
repressed desires and to understand through them the injurious effects
of accidental experiences. The whole field of hysteria, and perhaps
still more that of the anxiety neurosis, has come into new perspective
through this pioneer work which men like Bleuler, Jung, and Stekel have
developed in various directions.

Thus in recent decades the thorough work of scientific physicians has
developed a psychotherapy of considerable extent and of indubitable
usefulness, far removed from the simultaneous efforts of the churches
and of the popular mental healing cures. A number of eminent men in all
countries have tested the methods and have published the results. But
the curious side of it is that all this is essentially a movement of
leaders while the masses of the profession hesitate to follow. It is a
set of officers without an army. Every large city has one or another
specialist who applies suggestive therapy, one or another nerve
specialist who hypnotizes, but the average physician moves on without
any serious effort to utilize psychotherapy. It is as if the
prescription of the modern chemical drugs were confined to some leading
scholars in the country, while the thousands abstained from it in their
office work and in their family practice. In reality psychotherapy ought
to be used by every physician, as it fits perfectly the needs of the
whole suffering community. Its almost exceptional use in the hands of a
few scholarly leaders deprives it of its true importance. It is the
village doctor who needs psychotherapy much more than he needs the knife
and the electric current.

Why does the medical profession on the whole show this shyness in the
face of such surprising results? In other fields they do not show any
reluctance in taking up the newer developments of method. Even the
Roentgen ray apparatus has quickly won its way, and psychotherapy is
less expensive. To be sure, the most important reason is probably one
which is most honorable. The physicians do not like to touch a tool
which has been misused so badly. Psychotherapy has come too much into
the neighborhood of superstition and humbug. Where miracles are
performed, the man of science prefers to leave the field. The less one
knows about those groups of problems, the less one is able to see the
sharp demarcation line between true scientific studies, for instance, in
hypnotism, and the pseudo-scientific fancies of psychical research.
Experiments in suggestibility are then easily mixed with experiments in
telepathy, and those go over by gradual degrees to clairvoyance and
premonitory apparitions, and from there the way is not far to the
reappearance of the dead and the routine performances of the spiritists.
It seems to many as if there is no point where they have a reason to
stop. If they begin with such abnormal phenomena at all, it seems as if
they are necessarily carried over to all the mysteries of supernatural
energies. Even the competition with Christian Science, and other mental
healers whose judgment is not hampered by any previous study of
medicine, might seem rather unattractive to the serious physician.

Further not a few have the impression that such suggestive treatment
directly demands from them that they also begin to humbug their patients
or to throw out suggestions which they themselves do not believe, in
short, that they be brought down to the level of the miracle performer.
Yet, however much all that speaks in favor of the conscientious instinct
in the physician, it is ultimately based upon a misinterpretation. The
line between real science and its counterfeit is here as everywhere a
distinct one, and the true man of science ought not to hesitate in doing
his duty from fear that he might not be discriminated from the
charlatan. A well-conducted psychotherapeutic treatment as a scientific
physician ought to carry it out, is entirely different in meaning and
appearance, from the first step of diagnosis to the last treatment of
after-effects, from every unscientific faith cure. It is also in no way
necessary that the psychotherapist ever leave the path of complete
sincerity. There is no reason at all for promising that the patient will
be entirely cured if the physician believes that a real cure through
suggestion is impossible. The more the true physicians undertake
psychotherapeutic work, the more it will carry with it that dignity
which is now too often lost by the predominance of those who treat
without diagnosis and cure by mere appeal to superstition.

All that does not mean that other motives do not hold the physician
back. Not seldom he is afraid of unfavorable consequences. He does not
feel sure that, for instance, a deep hypnosis is without dangerous
results or that he will be able to produce it in the technically correct
way. But all these objections mean nothing but insufficient acquaintance
with the facts. Of course every technique needs its period of
preparation for the task, but it is now sufficiently demonstrated that
hypnotism carried through in a scientific spirit will never have any
injurious consequences. The morphine injection and the Roentgen rays are
by far more dangerous. Those who think that for hypnotizing especially
inborn power is needed stand, of course, outside of a serious
discussion. They do not even know the elements of the modern theories.
Every physician has in himself the necessary means for a
psychotherapeutic treatment in every form.

More scientific insight belongs to the argument that most of these
psychotherapeutic schemes are essentially for treatment of symptoms. We
have acknowledged that throughout. The possibility of a relapse or of a
new obsession is thus to a high degree open, and that is certainly a
discouraging feature. Yet we have seen sufficiently that as soon as the
symptoms are removed, there is no lack of means, also by psychotherapy,
to prevent the recurrence. Moreover, to remove the present symptoms is
in any case a great gain and in many cases a decisive gain. And whatever
can be secured by such methods is of such a character that hardly any
other method could have been substituted. It can be said with certainty
that hundreds of thousands leave the offices of their doctors every year
without relief where relief could be secured by psychotherapeutic means.

To be sure, one reply of the physicians is not infrequent and carries
some weight. Psychotherapeutic methods demand much time and patience and
skill. To relieve a cocainist of his desire by mere suggestion may
demand an assiduity which the average physician simply cannot afford;
and nothing requires more time than a real use of Freud's psychoanalytic
method. Hours and hours of conversation about the most trivial
occurrences have to be spent to relieve the repressed ideas and to give
them a chance for a free ascension. It cannot be denied that most of the
really illuminating work in all these fields has been done by scholars
who combine a strong theoretical interest with their effort to cure the
patients, and who therefore examine and treat the individual case
primarily from the wish to get new insight into the laws of nature. The
average physician whose time is his income may be the less willing to
enter into such time-devouring schemes, as the patients too easily may
think that the physician did not do much for them when he simply was
sitting down and gossiping with them.

Yet after all, behind all of it stands one motive which has held back
the development of psychotherapy in the medical profession more than
anything else. The physician feels instinctively that a real success can
be reached in every one of these fields, only if he possesses a
reasonable amount of knowledge of psychology. He feels that wherever he
touches the patient's body, examines his lungs or his heart or his
reflexes, that a large background of anatomical knowledge and of general
pathology gives meaning to every single observation. But in the field of
mental abnormities, in the whole world of ideas and emotions and
volitions, he simply lacks that background. Everything seems to him
without reference to real knowledge. He feels as amateurish as if he
were to operate on the abdomen without knowing its anatomy. He is
instinctively aware that even the simplest mental life represents a
bewildering complexity and that to stimulate ideas or feelings or to
suppress emotions, to inhibit volitions, must demand always a most
subtle disentanglement of the most widely different components. He
abstains from approaching that ground at all rather than to blunder by
his ignorance of psychology. And after all, he is right. But is he right
in allowing that ignorance? Can the medical profession afford to send
into the world every year thousands of young doctors who are unable to
use some of the most effective tools of modern medicine, and tools which
do not belong to the specialist but just to the average practitioner,
simply because they have not learned any psychology?

Indeed the times seem ripe for a systematic introduction of
psychological studies into every regular medical course. It is not a
question of mental research in the psychological laboratory where
advanced work is carried on, but a solid foundation in empirical
psychology can be demanded of everyone. He ought to have as much
psychology as he has physiology. Moreover the psychological study ought
not to be confined to the normal mental life. Again we do not speak of
psychiatry. What is needed is abnormal psychology, entirely independent
of the therapeutic interests of the alienist. The mental variations
within the limits of normal life and the borderland cases ought to be
studied there as well as the complete derangements. The ideal demand
would be that the future physician should spend at least a year of his
undergraduate time on empirical psychology, especially on experimental
and physiological psychology. He would take perhaps half a year's
lecture course on the whole field of psychology as covered in the
English language by the well-known text-books of James, Wundt,
Titchener, Judd, Royce, Calkins, Angell, Baldwin, Kuelpe, Ebbinghaus,
Thorndike, Stout, Ziehen, Ladd, and so on. In the second half-year the
course ought to be either advanced psychology entering into the more
complex phenomena or a practical training course in elementary
laboratory psychology as indicated for instance by Titchener's
"Experimental Psychology. A Manual of Laboratory Practice." If the
undergraduate can possibly afford the time in his college course, he
ought to add courses which either lead him towards the philosophical
problems of psychology or towards the comparative aspect of psychology.
If he can find time for a year of post-graduate work between college and
medical school, he could hardly spend it more profitably than by a year
of research in a well-conducted psychological laboratory to become
really acquainted with an independent analysis of mental states. On the
other hand in the medical school, room must be found for a course in
abnormal psychology, which of course presupposes a thorough knowledge of
normal psychology and, if possible, follows the courses on nervous
diseases and precedes the course on psychiatry.

For the average future physician, it would be wiser to omit even the
psychiatry studies than those in abnormal psychology. The latter ought
to lead him far enough to discriminate early between a mere
neurasthenia, for instance, and a beginning of insanity. As soon as the
discrimination is perfected and insanity is found, he has to give the
case out of his care anyhow and hand it over to the specialist and to
the asylum. The knowledge of psychiatric treatment is, therefore, not
essential for the average practitioner. But no one can relieve him from
the responsibility for those borderland cases, for the hysterias and
psychasthenias and neurasthenias, and he can never master them without
normal and abnormal psychology. Moreover it must not be forgotten that
mental factors may enter into every disease. The psychology of pain, for
instance, and of comfort feeling, the psychology of hunger and thirst,
of nausea and dizziness, the psychology of the sexual feelings, the
psychology of hope and fear, of confidence and discouragement, of
laziness and energy, of sincerity and cunningness play their rôle in
almost every sick room. And if the physician haughtily declares that he
does not care for the methods of suggestion, it might justly be asked
whether he can be a physician at all if he does not apply some
suggestions; yes, if his very entrance into the sick room does not
suggest relief and improvement from the start. The introduction of a
serious study of psychology is the most immediate need of the medical
curriculum. Instructorships in abnormal psychology must be created in
every medical school; institutes for psychotherapy should soon follow.
But in all this, there is nowhere to appear any artificial antithesis
between mind and body, any more than between organic and functional
diseases; we have discussed all that with full detail. Only the
physician who has a thorough psychological preparation can fulfill the
manifold demands which modern life must raise; he alone is prepared to
coöperate with the other factors of the community in the development of
a sound and healthful nation, to work towards the hygiene of the nervous
system and of the mental life; and to correct the injuries which the
perversities of our civilization inflict.

In all that he will not avoid the comradeship of the clergyman. He will,
of course, not forget the fundamental difference of attitude between
them, he will not forget that the minister seeks for the meaning and
values of inner life while he, the physician, has to consider that same
inner life from a causal point of view and thus has to work with it as
with natural material for the normal functioning of the organism. But
the interrelation between them can be intimate in spite of the
difference of their standpoints. The minister, to be sure, ought not to
consider health as such as the greatest good, but he will not forget
that a wholesome devotion to ideals cannot be carried through when the
attention is absorbed by the sufferings of the body and the mental
powers are debilitated. Only in a sound mind the full ideal meanings of
life can be realized. The minister must therefore seek the health of his
congregation not because health is the ideal of life but because the
true ideals cannot be appreciated by the mental cripple. On the other
hand, the physician from his standpoint should in no way feel it his
duty to play the amateur minister and to put emphasis on the spiritual
uplifting of his patients. But he knows well that not a few of the
suggestive influences which are needed for the relief from disease are
most effective when an emotional emphasis can be given to the
suggestions and that this emphasis is for large numbers most powerfully
supplied by the religious emotion. Thus the minister will be a very
important assistant to him and the church will most successfully do for
many patients what for other patients perhaps travel or music or the
theatre, sport or social life, may do.

Just in the relation to the church, the physician will need subtlest
discrimination, and he will not forget that while even a strong
religious emotion may be without damage for a normal man, it may well be
injurious to the unstable brain. But if the physician uses tact and
wisdom, he will be surprised to find how often the religious stimulation
can indeed be helpful for his purposes and the division of labor
demands that this be supplied not by himself but by the minister. He
will advise the consulting sufferer to seek the influence of a godly man
who awakens in him upbuilding wholesome emotions and volitions. The
minister may in this way very well become the assistant of the
physician. But whether this coöperation is looked on from the one or
from the other point of view, in every case it needs absolute clearness.
Nothing is gained and too much is lost if the two functions are
carelessly mixed together. It is never the task of the minister to heal
a mind and never the task of a physician to uplift a mind. One moves in
the purposive sphere, the other in the causal sphere. Their friendship
can seriously endure only as long as they remain conscious of the fact
that they have two entirely different functions in the service of
mankind.




XIV

PSYCHOTHERAPY AND THE COMMUNITY


Both the physician and the patient find their place in the community the
life interests of which are superior to the interests of the individual.
It is an unavoidable question how far from the higher point of view of
the social mind the psychotherapeutic efforts should be encouraged or
suppressed. Are there any conditions which suggest suspicion of or
direct opposition to such curative work?

Of course society has to be sure that no possible misuse and damage are
to result from such practice. Fears in that direction have been uttered
repeatedly, but from very different standpoints. One which is perhaps
most often heard in popular circles results from an entire
misunderstanding and deserves hardly any discussion after our detailed
study of the processes involved. It is claimed that suggestive power,
especially in the form of hypnotization, may be secretly misused to make
anyone without his knowledge and against his will a passive instrument
of the hypnotist's intent. Often this is coupled with telepathic
fancies. The hypnotist is believed to have mystic power to bring any
person in a distant region under his mental control and thus to be able
to carry out any sinister plans by the help of his innocent victim. All
hypnotizing therefore ought to be interdicted by the state. The
presuppositions of such a view are, as we know now, entirely absurd. We
know that hypnotism is not based on any special power of the hypnotizer;
there is no magnetic fluid in the sense of the old mesmerism. The
imagination of the hypnotized person is the only hypnotizing agency.
Thus no one can be hypnotized without his knowledge or against his will.
The story of telepathic mysteries which is often brought before the
public is probably always the outcome of a diseased brain. It is indeed
a frequent symptom in paranoia and other insanities that the patient who
feels abnormal organic sensations and abnormal unaccountable impulses
interprets them as influences of a distant enemy. Whole pamphlets have
been written with elaboration of such insane misinterpretations and
requests to legislatures have been made in that spirit, but the
physician recognizes easily throughout the whole argumentation the
well-known phenomena of the mental disease.

To be sure, while no one can be hypnotized against his will, many a
person is liable to accept suggestions from others and thus to carry out
the wishes of others almost without knowing and certainly without
willing that the other mind interfere with the interplay of the own
motives. But if we were to strike out all suggestive influences from
social life, we should give up social life itself. Suggestion is given
wherever men come in contact; in itself it is neither good nor bad. The
good resolution and the bad one can be suggested, the good example and
the bad can be effective; both encouragement of the noble and imitation
of the evil may work with the same mental technique. Certainly there are
some persons who have a stronger influence than others on the
imagination of those with whom they come in contact; their expression
awakens confidence, their voice and their words reach deeper layers of
the mind, their calmness and firmness overwhelm more easily the
antagonistic ideas. But the chief difference lies after all in the
different degrees of suggestibility among those who receive such
impressions. The easily suggestible person cannot be protected by any
interdict; he may catch suggestions everywhere, any advertisement in the
newspaper and any display in the shop-window may overrun his own
intentions. What he needs is training in firmness. The application of
reënforced suggestion or even of hypnotism in the doctor's office is
even for him no possible source of danger.

On a higher level are objections which come from serious quarters and
which are not without sympathy with true science. In recent times this
opposition has repeatedly found eloquent expression. It is an objection
from the standpoint of morality, belonging therefore entirely to the
purposive view of the mind, but we have now reached a point where it is
our duty to do justice to this purposive view too. As long as we
discussed the problem entirely from the standpoint of the physician, no
other view of mental life except the causal one could be in question. As
soon as we look at it from the standpoint of the community, it becomes
our duty to bring the causal and the purposive view into harmony, and it
would be narrow and short-sighted simply to draw the practical
consequences of a naturalistic view of the mind without inquiring
whether or not serious interests in the purposive sphere are injured. If
there is moral criticism against suggestive therapy, it is the duty of
the community to consider it. This opposition argues as follows:
Hypnotic influence brings the patient under the will control of the
hypnotizer and thus destroys his own freedom. Whatever the patient may
reach in the altered states is reached without his own effort, while he
is the passive receiver of the other man's will. His achievement has
therefore no moral value, and if he is really cured of his drunkenness
or of his perverse habits, of his misuse of cocaine or of his criminal
tendencies, he has lost the right to be counted a moral agent. It would
be better if there were more suffering in the world than that the
existence of the moral will should be undermined.

No one ought to take such arguments lightly. The spirit which directs
them is needed more than anything else in our time of reaching out for
superficial goods. No one can insist too earnestly that life is worth
living only if it serves moral duties and moral freedom and is not
determined by pleasures and absence of pain only. Those who set forth
this argument are entirely willing to acknowledge the profound effect
which suggestive therapeutics may create. More than this, they have to
acknowledge it to gain a basis for their attack. Just because the
hypnotizer can entirely change the desires and passions, the habits and
perversities of the suffering victim, he seems to them a moral wrongdoer
who negates the principle of human freedom. A forcible book of recent
days calls the suggestive power of the psychotherapist "The Great
Psychological Crime." It says to the hypnotist: "By your own testimony,
you stand convicted of applying a process which deprives your subjects
of the inalienable right and power of individual self-control. In
proportion as you deprive him of the power of self-control, you deprive
him of that upon which his individual responsibility and moral status
depend. In proportion as you deprive him of the free control and
exercise of those powers of the soul upon which his individual
responsibility and moral status depend, you thereby rob him of those
powers upon which he must depend for the achievement of individual
immortality."

But this censure too is entirely mistaken, not because it urges the
purposive views against the causal but because it is in error as to the
facts. Such critics are fully under the influence of the startling
results which are reached; they do not take the trouble to examine the
long and difficult way which has had to be traversed with patience and
energy. It is quite true that if I hypnotize a man and suggest to him to
take up after awaking the book which lies on my table, he follows my
suggestion without conflict and in a certain sense without freedom. He
feels a simple impulse to go to the table and lift the book and, as no
stronger natural desire and no moral objection stand in the way, he
carries out that meaningless impulse and perhaps even invents a foolish
motive to explain to himself why he wanted to look at that book. But
after a long experience, I have my doubts as to whether a man was ever
cured in such a way by hypnotism of serious disturbances and of those
anomalous actions which the critics want to see overcome by the
patient's own moral efforts. On the contrary, every suggestion has to
rely on the efforts and struggles of the patient himself and all that
the psychotherapists can give him is help in his own moral fight. His
own will is presupposition for being hypnotized and for realizing the
suggestion. If again and again I hesitate to undertake new cases, it is
just because I have to see during the treatment too much of this daily
and hourly striving against overpowering impulses. The joy of removing
some obstacles from the way of the patients is too much overshadowed by
the deep pity and sympathy with their suffering and craving during the
whole period of successive treatments. To make a man fight where despair
is inevitable, and where the enemy is necessarily stronger than his own
powers, can certainly not be the moral demand. Morality postulates that
everyone find conditions in which he can be victorious if he puts his
strongest efforts to the task.

In our discussion of the mental symptoms I reported as an illustration
of the suggestive treatment of the drug passion the case of a
morphinist. To make clear this purposive side of the case as against the
causal one which alone interested the physician, I may add a few
features to the short report as a typical example. When that man left my
laboratory for the last time to go out to work and happiness, you might
well have believed from his joyful face that it had been an easy and
pleasant time in which hypnotic influence smoothly removed from him the
dangerous desire for morphine. In truth it was the result of four months
of the most noble and courageous suffering and struggling. He had been
for years a slave to his passion. To quote from his little
autobiography: "When I realized that I was addicted to morphine, I was
at first not at all worried as I did not then understand the real horror
of the thing, and did not then realize all the future suffering and
misery that is coming to anyone who is the user of opium or any of its
alkaloids. For the first few months, I found great relief after every
injection of morphine, but soon I could not get the same easy feeling
and could eat but very little and what sleep I got was in the daytime. I
finally went to the sanitarium of a doctor but it was simply a
money-making business for him; if he ever cured anyone, I never heard of
it. I then tried another one; it was the same kind of a place as the
former. When I first went to see the professor in the Harvard
Psychological Laboratory, I was using between thirty-two and
thirty-eight grains of morphine daily. He put me under his treatment
October 6th and that day cut me down by hypnotic treatment to nine
grains a day or three doses of three grains a day. I took my hypodermic
as directed, but on the following day I lay on the bed too exhausted to
get up even to get around the room, and I could not eat and only drank a
very little water. The desire for the drug was something terrible. But
in about four days I got used to the loss of so much morphine and stayed
on this amount for a week, seeing the professor every other day for
hypnotic treatment and then returning to my room where I spent
twenty-two hours of the twenty-four on the bed, but did not sleep more
than two or three hours a day. At the end of the week I was cut off by
hypnotic suggestion half a grain and this put me to fighting the desire
again. This lasted two or three days and then I began to feel better and
began to sleep a little more. But at the end of the week I was cut off
another half grain, and the whole fight would have to be begun over.
These reductions of the dose were made a week apart and sometimes only
two days. The worst time of all was a cut from four injections of a
fourth of a grain each to four of one eighth of a grain each, which was
about January 10th. At this time I had the worst two days of my life. I
tried whiskey, but it gave relief only for about half an hour and then
the desire was worse than ever."

In this way every few days I gave the poor fellow under hypnotic
influence the suggestion to reduce the dose of morphine in a prescribed
way, and with enormous effort he withstood his craving for more, in
spite of the fact that he had during all this winter a bottle with a
thousand tablets of morphine, prescribed by an unscrupulous physician,
in his writing desk. He was thus at every moment during the day and
night in full possession of the deadly poison with which he could have
fully satisfied his craving. It was a moral victory when he finally
reached the point at which he went for several weeks without any desire
for morphine and finally presented the remaining tablets to a hospital.
And yet there would not have been the least chance for his winning this
ethical victory without the outer help of the hypnotist. We do not
eliminate the moral will but we remove some unfair obstacles from its
path. We have no mystic power by which our will simply takes hold of the
other man's will, but we inhibit and suppress by influence on the
imagination those abnormal impulses which resist the sound desires. If
that were immoral, we should have to make up our minds that all
education and training were perverted with such immoral elements. Every
sound respect for authority which makes a child willing to accept the
advice and maxims of his elders is just such an influence. If it were
really a moral demand that the will be left to its own resources and
that no outside influence come to strengthen its power or remove its
hindrances or smooth its path, then we ought to let the children grow up
as nature created them and ought not to try to suppress from without by
discipline and training, by love and encouragement, the willful
impulses and the ugly habits. Even every good model for imitation is
such a suggestive influence from without and every solemn appeal to
loyalty and friendship, to patriotism and religion, increases the degree
of suggestibility. That is the glory of life that the suggestive power
may belong to moral values instead of mere pleasures, but it is not the
aim of life to remain untouched by suggestion. And he who by suggestion
helps the weak mind to overcome obstacles which the strong mind can
overthrow from its inborn resources works for the good of the individual
and of the community in the spirit of truest morality.

Much more justified than such ethical objections are the fears which
move entirely in the causal sphere. It must be acknowledged that a
method which has such powerful influence over the mind that it can
secure ideas and emotions and impulses which the own will of the patient
cannot produce, ought to be allowed only to those who are prepared for
its skillful use. To hypnotize or to perform any persistent
psychotherapeutic treatment may thus be dangerous, if it is done by the
unfit. We have discussed before the injuries which might result from the
administration of such powerful psychotherapeutic effects through the
best meaning minister, but we can extend this fear to anyone who has not
systematically studied medicine and to a certain degree normal and
abnormal psychology. The possibilities of overlooking symptoms which
ought to suggest an entirely different treatment, or of adjusting the
treatment badly to the special physical conditions, or of ignoring the
desirable physical supplement by drugs, or of creating unintentionally
by suggestion injurious effects, are always open when medical amateurs
undertake such work. Certainly there is no physician who is not liable
to make mistakes, and a physician who has never given any attention to
psychology and psychiatry would also be a rather poor agent of
psychotherapeutic methods, but the probability is that such a physician
would simply abstain by principle from all psychotherapeutic methods;
his mistake only begins if from his lack of acquaintance with the
subject he draws the conclusion that the method itself is undesirable.
That his real preparation ought to include psychological studies we have
pointed out before, and the time seems ripe for the community to urge
such a reform of the studies.

All that involves the conviction that even the experimental psychologist
as such is not prepared to enter into medical treatment; and a
"Psychological Clinic," managed by a psychologist who is not a doctor of
medicine, is certainly not better than a church clinic. I cannot even
acknowledge the right of psychologists to make hypnotic experiments
merely for the psychological experiment's sake. Nobody ought to be
brought into a hypnotic or otherwise abnormal state of mind if it is not
suggested by the interests of the subject himself. Science has the right
to make hypnotic experiments, or experiments with abnormal mental
states, only under the one condition that a physician has hypnotized the
subject in the interests of his health and that the patient has agreed
beforehand to allow in the presence of witnesses certain psychological
studies. Needless to say that any hypnotization for mere amusement and
as a parlor trick ought to be considered as criminal.

On some other objections which interest the community as such we had to
touch before, and there is no need of returning to them with any
fullness of argument. We spoke of the danger which the mental cures
carry with them when they are based on any particular creed, and
especially when they are tied up with a semi-religious arbitrary
metaphysics. What is gained if some nervous disorders are helped by
belief, if the belief itself devastates our intellectual culture and
brings the masses down again to a view of the world which has all the
earmarks of barbarism? That is indeed one of the central dangers of all
non-medical suggestive cures, that while any belief may cure through the
mere emotional power of the act of believing, the content of the belief
gains an undeserved appearance of truth. Any absurd superstition can
become accredited because its curative value may be equal to a truly
valuable suggestion. The intellectual life of the community would have
to suffer greatly if the way to be freed from bodily suffering had to be
the belief in the metaphysical doctrines of Mrs. Eddy's "Science and
Health." From a cultural viewpoint, too, suggestive therapeutics must
stand the higher, the more sharply it is separated from special
philosophical or religious doctrines. No theory of the world and of God
ought to gain authority over the mind from such an external motive as a
belief in its curative effects. Freest from such implications is
certainly the hypnotic method of the physician who does not need the
strong religious reënforcement of the suggestion because he reënforces
instead the suggestibility of the patient by slight influences on his
senses.

Even where sound religion without superstition and without
pseudophilosophy stands behind the therapeutic work, the community will
not give up the question whether the church does not necessarily neglect
by it the interests which are superior. The community becomes more and
more strongly aware that too many factors of our modern society urge the
church to undertake non-religious work. Social aid and charity work
ought to be filled with religious spirit, but to perform it is not
itself religion. Still more that is true of the healing of the sick.
Whether or not such expansion of church activity in different directions
saps the vital strength of religion itself is indeed a problem for the
whole community. The fear suggests itself that the spiritual achievement
may become hampered, that in the competition of the church with the
other agencies of social life the particular church task may be pushed
to the background, and that thus the church in imitating that which
others can do just as well or better loses the power to do that which
the church alone can do. The final outcome is therefore practically in
every way the same. From whatever starting point we may come, we are led
to the conviction that the physician alone is called to administer
psychotherapeutic work, but that he needs a thorough psychological
training besides his medical one.

But the interest of the community is not only a negative one. Society
does not only ask where psychical treatment can be dangerous, but asks
with not less right whether the scheme and the method might not be
fructified for other social ends besides the mere healing of the sick.
If psychotherapy demonstrates that for instance hypnotism makes possible
the reshaping of a pathological mind, it is a natural thought to use the
same power for remodeling perhaps the lazy or the intemperate, the
careless or the inattentive, the dishonest or the criminal mind. Both
educators and criminologists have indeed often raised such questions,
and social reformers have not seldom seen there wide perspectives for
social movements in future times.

There can be no doubt that the possibility of such remodeling activity
is given, but as far as education is concerned certainly grave
misgivings ought to be felt. When we spoke of the treatment of the sick,
we had always to emphasize that the suggestion cures symptoms but not
diseases. In the same way hypnotic suggestion might reënforce a single
trait but would not reform the personality of the child. Yes, the
artificial reënforcement of such special features would deprive
education of that which is the most essential, namely, the development
of the power to overcome difficulties by own energy. Wherever a
reasonable amount of own will force and attention can be expected to
overcome the antagonistic influence, there artificial hypnotic
influence ought to be avoided. Everything ought to be left in that case
to suggestions within normal limits, in the form of good example and
persuasions, authority and discipline, love and sympathy. That holds
true even for very slight abnormalities which seem still within the
limits where the own energies can bring about the cure. For instance, I
have steadily refused requests of students and others to use hypnotism
for the purpose of overcoming merely bad habits, such as the habit of
biting the nails. A child who finds some difficulty in sticking
seriously to his tasks might learn now this and now that under the
influence of hypnotic suggestions but he would remain entirely untrained
for mastering the next lesson. In the same way some naughty traits might
be artificially removed but the child would not gain anything towards
the much more important power of suppressing an ugly tendency by his own
effort. All that finds its limits where the inhibitions or obstacles in
the brain of the child are too strong possibly to be overcome by the own
good will, but in that case we already stand in the field of abnormal
mental life and then of course psychotherapy has its right. The
feeble-minded and the retarded child, the perverse child and the
emotionally unstable child, belong under the care of the physician, and
in such a case he ought not to hesitate to use the whole supply of
psychotherapeutic methods which are at his disposal.

Still more complex is the criminological problem. It sounds like an easy
remedy for the greatest social calamity, if it is proposed simply to
hypnotize the criminal and to supplant his antisocial will by a moral
one. And if the absurdity of such a proposal is recognized it seems to
many justified to demand such an intrusion at least in the case of the
born criminal, even if the occasional criminal cannot be reached. But
the conception of the born criminal is also only a label which is
superficially used for a great variety of minds. That men are born with
a brain which necessarily produces criminal actions is not indicated by
any facts. The varieties which nature really produces are brains which
are more liable than others to produce antisocial actions. We recognized
from the start that the abnormal mind never introduces any new elements
but is characterized only by a change of proportions. There is too much
or too little of a certain mental process and just for that reason there
must be a steady and continuous transition from the normal to the
entirely abnormal. Here again we have not a special class of brains
which are criminal; but we have an endless variety of brains with a
greater or smaller predisposition for antisocial outbreaks. The
variations which produce this criminal effect may lie in most different
directions.

The brain may be for instance inclined to overstrong impulses, so that
any desire rushes to action before the inhibiting counter-idea gets to
work. Or, on the other hand, the brain may have unusually weak
counter-ideas so that even a normal impulse does not find its normal
checking. The fact that selfish and thus antisocial desires awake in the
mind is not abnormal at all; only if they are not normally inhibited,
the disturbance sets in. Furthermore the associative apparatus of the
brain may work especially slowly; it may thus bring it about that the
counteracting ideas do not arise in time. Or the emotions of a person
may be unusually strong. Or there may be strong suggestibility, by which
a bad example or a strong temptation has especially easy access. Or
there may be negative suggestibility, by which a moral admonition stirs
up a vivid idea of the opposite. In short, there may be a large number
of factors, sometimes even in combination, each one of which increases
the chances that the individual may come in danger in the midst of
developed society. Yet no one of those factors involves just the
necessity of crime. The same kinds of brains might simply show stupidity
or credulity or inconsiderateness or brutality or stubbornness or
egotism, and might by each of those factors decrease their chances in
the community without directly running into conflict with the law. The
criminal is therefore never born as such. He is only born with a brain
which is in some directions inefficient and which thus, under certain
unfavorable conditions, will more easily come to criminal deeds than the
normal brain.

With the idea of a stereotyped born criminal there disappears also the
idea of a uniform treatment against criminal tendencies. That men are
different in their power of resistance or in their power of efficiency
or in their intellect or in their emotions, we have to accept as the
fundamental condition with which every society starts. It would be
absurd to remodel them artificially after a pattern. The result would be
without value anyhow, inasmuch as our appreciation is relative. No
character is perfect. The more the differences were reduced, the more we
should become sensitive even for the smaller variations. All that
society can do is, therefore, not to remodel the manifoldness of brains,
but to shape the conditions of life in such a way that the weak and
unstable brains also have a greater chance to live their lives without
conflicts with the community.

The situation is different as soon as the particular surroundings have
brought it about that such a brain with reduced powers has entered a
criminal career. The thought of crime now becomes a sort of obsession or
rather an autosuggestion. The way to this idea has become a path of
least resistance, and as soon as such an unfortunate situation has
settled itself, the chances are overwhelming that a criminal career has
been started. If such cases should come early to suggestive treatment
which really would close the channels of the antisocial autosuggestion,
much harm might be averted. Yet again the liability of the brain to
become antisocial would not have been removed, and thus not much would
be secured unless such a person after the treatment could be kept under
favorable conditions. With young boys who through unfortunate influence
have caught a tendency, for instance, to steal, and where the fault does
not yield to sympathetic reasoning and to punishment, an early hypnotic
treatment might certainly be tried. I myself have seen promising
results. But if the impulse has irresistible character in such a way
that the good will is powerless, we are again in the field of disease
and the point of view of the physician has to be substituted for that of
the criminologist.

Whether pedagogy and criminology are to make use of the services of
psychotherapy is thus certainly an open question. It would be
short-sighted to overlook the serious obstacles which stand in the way.
But while the social life outside of the circle of real disease may
better go on without direct interference by psychotherapeutic
influences, it is certainly the duty of the community to make the
underlying principles of psychotherapy useful for the sound development
of society. The artificial over-suggestions which are needed to overcome
the pathological disturbances of mental equilibrium may be left for the
cases of illness. But we saw that every mental symptom of disease was
only an exaggeration of abnormal variations which occurred within the
limit of health. To reduce these abnormalities means to secure a more
stable equilibrium and thus to avoid social damages, and at the same
time to prevent the growth of the abnormality to pathological
dimensions. To counteract these slighter variations, these abnormalities
which have not yet reached the degree of disease, will demand the same
principles of treatment, only in a weaker form. It is in a way not
psychical therapy but psychical hygiene. And this is no longer confined
to the physician but must be intrusted to all organs of the community.
And here more than in the case of disease, the causal point of view of
the physician ought to be brought into harmony with the purposive view
of the social reformer, of the educator and of the moralist.

The ideal of such mental hygiene is the complete equilibrium of all
mental energies together with their fullest possible development. To
work towards this end does not mean to aim towards the impossible and
undesirable end of making all men alike, but to give to all, in spite of
the differences which nature and society condition, the greatest
possible inner completeness and outer usefulness. The efforts in that
direction have to begin with the earliest infancy and are at no age to
be considered as finished; the whole school work and to a high degree
the professional work has to be subordinated to such endeavor. Society
has further to take care that those spheres of life which stand less
under systematic principles, such as the home life of the child and the
social life of the man, his family life and his public life, are
steadily under the pressure of influences which urge in the same
direction.

Harmonious development without one-sidedness, and yet with full justice
to the individual talents and equipments, should be secured. That means
from the start an effort to secure balance between general education and
particular development. The latter has to strengthen those powers by
which the boy or girl by special natural fitness promises to be
especially efficient and happy. It has to be supplemented later by a
wise and deliberate choice of such a vocation as brings these
particular abilities most strongly to a focus. Yet this alone would mean
a one-sidedness in which the equilibrium would be lost. More important,
it would leave undeveloped that power which the youth especially needs
to acquire by serious education, the power to master what does not
appeal to the personal likings and interests. An equilibrium is secured
only if at the same time full emphasis is given to the learning and
training in all which is the common ground of our social existence. From
the multiplication table to the highest cultural studies in college, the
youth is to be adjusted to the material of our civilization without any
concession to the emasculating desire to adjust civilization simply to
the particular youth. He has to learn learning and not only to play with
knowledge, he has to learn to force his attention in adjustment to those
factors of civilization which are foreign to his personal tendencies and
perhaps unsympathetic. Free election of life's work and unyielding
mental discipline in the service of the common demands should thus
steadily coöperate. The one without the other creates a lack of mental
balance which is the most favorable condition for a pathological
disturbance.

The mere learning is of course on both sides only a fraction of what the
community has to develop in the youth. Mental hygiene begins with
physiological hygiene. The nourishment of the child, the care for the
child's sense organs, the recesses and the rest from fatigue, and
especially the undisturbed sleep are essential conditions. The
interferences with sufficient sleep are to a high degree responsible
for the later disturbances of the mental life. It must not be forgotten
that the decomposition of the brain molecules can never be restituted by
anything but rest, and ultimately by sleep. Physical exercise is
certainly not such restitution. In the best case it brings a certain
rest to some brain centers by engaging other brain parts. The child
needs sleep and fresh air and healthful food more than anything else, if
his mind is active. The careful examination of the sense organs and of
the unhindered breathing through the nose is most important. Even a
slight defect in hearing may become the cause of an under-development of
attention.

More important than mere physical hygiene is the demand that a sound
character and a sound temperament are also to be built up, at the side
of a sound interest. Here again everything depends upon a wise balance
between the development of that which is given by nature to the
particular individual and the reënforcement of that which society
demands and which belongs therefore to the common equipment. The
emotional stability and emotional enlargement of the mind is perhaps
most neglected in our educational schemes. On the one side it demands a
systematic discipline of the emotions, on the other a healthy
stimulation of emotions. Here is the place where imagination in play and
later in art come in. The biological value of play always lies in the
training for the functions of later life, and especially for the
emotional functions. The play of our children is too little adjusted to
this task. For this reason it leaves too many unprepared for the world
of art and for the emotional experiences of real life. Both lack of
emotional discipline and narrow one-sidedness of emotions interfere with
the harmonious development. Destructive emotions like terror ought to be
kept away and not needlessly brought near by uncanny stories and mystic
superstitions. It is the healthy love and sympathy of the home which
contributes most strongly to the normal development of emotions. Again
in the field of will, we want the strong, spontaneous, independent will
which is not frightened by discomfort and not discouraged by obstacles,
and yet we want the will which is not stubborn and selfish but which
subordinates itself to the larger will of the social group and to the
eternal will of the norm. There is no balance where independence and
subordination do not supplement each other. A wide education not only
trains for both but also secures habits which work as autosuggestions in
both directions.

But all this harmonious development of intellect and temperament and
character has to go on when the school days are over and just here
begins the duty of the community as a whole. The special functions of
the teachers have to be taken up by the public institutions. The whole
social life must shape itself in such a way that everyone finds the best
possible chances to perfect this harmonious growth. In the field of the
intellect, the community must take care that thoroughness of training
and accuracy of information is rigidly demanded and not thrust out by
an easy-going superficiality. The expert ought to replace the amateur in
every field. Every society which allows successes to superficiality
diminishes its chances for mental health. Yet while thoroughness demands
concentration in one direction, society must with the same earnestness
insist on well-rounded general education and continuity of general
interests through life. Literature and the libraries, the newspapers and
the magazines play there a foremost rôle, and again the mental health of
the community has to pay the penalty if its newspapers work against
general culture. In the emotional field art and music, fiction and the
theater on the one side, the church on the other side, remain the great
schools for a development of sound emotions. Where literature becomes
trivial, where the stage becomes degraded, and where the church becomes
utilitarian and uninspiring, great powers for possible good in emotional
education are lost. But with this enrichment of feelings the
disciplinary influence too has to go through the whole social life.
Where art is sensational and the church hysterical,--in short, where the
community stirs up overstrong feelings,--the wholesome balance is lost
again. In a similar way the public demands should throughout stimulate
the energy and ambitions and initiative of the man, and yet should keep
his desires and impulses in control.

Few factors are more influential in all these directions than the
administration of law. Sound sober lawmaking and fair judgment in court
secure to the community a feeling of safety which gives stability to
emotions and feelings. The disorganization which results from arbitrary
laws, from habitual violation of laws, from corruption and injustice
works like a poison on the psychophysical system. A similar unbalancing
influence emanates from overstrong contrasts of poverty and comfort. A
poverty which discourages and leaves no chances and a wealth which
annihilates the energies and effaces the consciousness of moral
equality, create alike pernicious conditions for mental balance.

Unlimited furthermore are the influences which depend upon the sexual
ideas of the society. It is the sphere in which it may be most difficult
to indicate the way towards a development without dangers. There is no
doubt the arbitrary suppression of the sexual instinct must be
acknowledged as the source of nervous injury while indulgence may lead
to disease and misery. But in any case frivolous habits and easy divorce
contribute much to the unbalanced life which ruins the unstable
individual. Not less difficult and not less connected with the mental
hygiene is the alcohol problem. For normal adult men mild doses have
through their power to relieve the inhibitions undeniable value for the
sound development of the community. Its intemperate use or its use by
young people and by pathological persons is one of the gravest dangers.
Whether intemperance ought to be fought by prohibition or rather by an
education to temperance is a difficult question in which the
enthusiastic women and ministers, backed by the well justified fears of
psychiatrists, will hardly be on the same side as the sober judgment of
scientists, unprejudiced physicians, and historians. In any case the
saloon and its humiliating indecency must disappear and every temptation
to intemperance should be removed. Above all, from early childhood the
self-control has to be strengthened, the child has to learn from the
beginning to know the limits to the gratification of his desires and to
abstain from reckless over-indulgence. With such a training later on
even the temptations of alcoholic beverages would lose their danger. Not
less injurious than the strong drinks are the cards. All gambling from
the child's play to the stock exchange is ruinous for the psychophysical
equilibrium. The same is true of any overuse of coffee and tea and
tobacco, and as a matter of course still more the habitual use of the
drugs like the popular headache powders and sleeping medicines. The life
at home and in public ought to be manifold and expansive but ought to
avoid over-excitement and over-anxiety. A good conscience, a congenial
home, and a serious purpose are after all the safest conditions for a
healthy mind, and the community works in preventive psychotherapy
wherever it facilitates the securing of these three factors.

For that end society may take over directly from the workshop of the
psychotherapist quite a number of almost technical methods. Suggestion
is one of them. The means of suggestion through education and art,
through the church and through public opinion, through example and
tradition, and even through fashion and prejudices, are millionfold,
but not less numerous are the channels for antisocial and antihygienic
suggestions. No one can measure the injury done to the psychophysical
balance of the weaker brains, for instance, by the sensational court
gossip and reports of murder trials in the newspapers for the masses.
But while the influence of suggestion is on the whole familiar to public
opinion, the community is much less aware of another factor which we
found important in the hands of the psychotherapist. We recognized that
mental disturbances were often the result of suppressed emotion and
repressed wishes. For the cure the psychotherapist has to aim toward the
cathartic result. The suppressed ideas had to be brought to
consciousness again and then to be discharged through vivid expression.
Society ought to learn from it that few factors are more disturbing for
the mental balance than feelings and emotions which do not come to a
normal expression. It is no chance that in countries of mixed Protestant
and Catholic civilization, the number of suicides is larger in
Protestant regions than in the Catholic ones where the confessional
relieves the suppressed emotions of the masses. This is also the most
destructive effect of social and legal injustice; emotions are
strangulated and then begin to work mischief. The community should take
care early that secret feelings are avoided, that the child is cured
from all sullenness which stores up the emotion instead of discharging
it. Certainly all education and social life demands inhibition and also
the child has to learn not to give expression to every passing feeling.
To find there the sound middle way is again the real hygienic ideal. Too
much in our social life and especially in the sphere of sexuality forces
on the individual a hypocrisy and secrecy which is among the most
powerful conditions of later mental instability.

Of course the background of a hygienic life of the community remains the
philosophy of life which gives unity to the scattered energies and
consequently steadiness to the individual through all his hazards of
fate. It might seem doubtful whether society could get the prescription
for such a steady view of the world also from the workshop of the
psychotherapist. To the superficial observer the opposite might seem
evident, as every word of our psychotherapeutic study indicated that
that is a view of life which makes man's inner experience simply an
effect of foregoing causes. All life becomes a psychophysical mechanism
and from that point of view man's thinking and acting become the
necessary outcome of the foregoing conditions. Nothing seems more unfit
to give a deeper meaning to life and a higher value. And yet if there
was one thought which controlled our discussion from the beginning, it
was certainly the conviction that this causal view itself is only an
instrument in the service of idealistic endeavors; the reality of man's
life is the reality of will and freedom directed towards ideals. One of
these ideals is the reconstruction of the world in the thought forms of
causality. In the service of our ideals we may thus transform the world
into a mechanism: out of our freedom we desire to conceive ourselves as
necessary products. Whenever we aim to produce changes in the world, we
must calculate the effects through the means of this causal
construction, but we never have a right to forget that this calculation
itself is therefore only a tool and that our reality, in which our
duties and our real aims lie, is itself outside of this construction.
The psychotherapist wants to produce effects inasmuch as he wants to
cure disease. He is therefore obliged to adjust his work as such
entirely to the causal aspect of man, as soon as he wants to seek the
means by which he can reach the end. But even the fact that he decides
in favor of those ends, that he aims towards their realization, binds
him to a world of purposes, and therefore, he, too, with his whole
psychophysical work, stands with both feet in a reality of will which is
controlled not by causes but by purposes, not by natural laws but by
ideals.




INDEX


Abnormal, 75

Abstinence, 281

Action, 34, 101, 276

Adenoids, 189

Adjustment, 102

Æsthetic, 63

Alcohol, 198

Alcoholism, 278

Alternation, 154, 174

Anæmia, 310

Anæsthesia, 174, 301

Analysis, 21

Antagonistic, 24

Anxiety, 272

Appeal, 93

Applied Psychology, 60

Appreciation, 10

Art, 87

Association, 29, 32, 42

Association Experiment, 72, 233, 359

Associationism, 44

Astrology, 350

Assurance, 215

Assyria, 322

Ataxia, 179

Atoms, 27

Attention, 46, 95, 99, 113, 200, 244

Attitudes, 13

Authority, 222

Automatic, 144, 237

Autosuggestion, 122, 172, 219, 255, 266

Awareness, 133, 149


Beauty, 197

Belief, 100, 329

Blood-vessels, 302

Blushing, 262

Braidism, 353

Brain, 29, 34, 67, 139


Cancer, 178

Cathartic, 233, 358

Causality, 14, 32, 57

Cell, 44, 81, 89

China, 321

Church, 319

Christianity, 324

Christian Science, 7, 55, 317, 327, 343, 344

Chronoscope, 71

Circulation, 79

Clairvoyant, 128

Clearness, 103

Cocainism, 283

Coconscious, 156

Communication, 22

Community, 370

Company, 197

Comparative Anatomy, 38

Complex, 232, 249, 270

Confidence, 221, 230

Conscience, 219

Consciousness, 11, 125, 130, 134

Contact, 223

Cortex, 47

Cretinism, 168

Crime, 112

Criminology, 383


Dementia, 168

Depression, 178, 267, 314

Description, 19

Diabetes, 311

Diagnosis, 66, 184, 241

Digestive, 177, 309

Dilettanteism, 2

Discharge, 49, 90, 218, 232, 252, 396

Discipline, 202

Disposition, 138, 143

Dissociation, 135, 152

Dream, 114

Drugs, 163, 334


Education, 389

Effort, 289

Efficiency, 194

Egyptians, 323

Electrobiology, 353

Emmanuel Church, 326, 328, 331, 341

Emotion, 88, 123, 235, 259, 314, 392

Encouragement, 206

Energy, 276, 288

Epidemic, 193

Epilepsy, 80, 207

Equilibrium, 160

Ergograph, 71

Ethics, 16

Ethnology, 329

Examination, 186

Exhaustion, 196

Experimental Psychology, 5, 61

Explanation, 19, 28, 41


Faith, 6, 335

Fascination, 116, 230

Fear, 172, 259, 263

Feeble-minded, 72, 295

Feelings, 23

Freedom, 51, 146

Functional Diseases, 81, 343


Galvanoscope, 71

Genetic Psychology, 39

Gospels, 324

Greeks, 323, 350


Half-sleep, 226

Hallucination, 246

Hastiness, 200

Headache, 309

Hearing, 300

Heart Disease, 310

Heterosuggestion, 122

History, 16

Hygiene, 389

Hypnoid, 116, 227

Hypnotism, 74, 85, 109, 122, 227, 243, 350

Hysteria, 122, 174, 269, 356


Idealism, 2, 33, 397

Illness, 67

Imagination, 111

Impulse, 89

Improvement, 299

Indecision, 290

Indians, 321

Inherited, 171

Inhibition, 86, 95, 113, 295, 305, 315

Insanity, 165, 256

Insomnia, 303, 312

Instinct, 305

Intemperance, 281

Intensity, 194

Interruption, 191


Japan, 322

Jews, 322


Kymograph, 71

Knowledge, 11


Lawyer, 87

Learning, 390


Magnetism, 351

Make-believe, 216

Memory, 138

Mesmerism, 128, 253

Minister, 57, 207, 332, 340, 367

Monotony, 203

Moral, 65, 84

Morality, 372

Morphinism, 283, 376

Motor Process, 46, 97, 218

Movement Sensation, 24

Mystic, 224, 315


Naturalism, 4

Negativism, 220

Nervousness, 193

Neurasthenia, 169, 246, 290, 292

Neuron, 164

Nutrition, 79, 312


Obedience, 201

Object, 13, 18

Obsession, 246

Opposite Idea, 97

Oppression, 272

Organic Diseases, 81, 343

Organism, 23


Pain, 69, 167, 298, 309, 313, 342

Parallelism, 33, 37, 40

Passes, 117

Pathology, 36

Pauses, 190

Pedagogy, 63

Perception, 20, 34, 133

Personality, 11, 25, 154

Persuasion, 214

Perversity, 176

Phobia, 94

Physical, 18

Physician, 57, 347

Physicotherapy, 1

Pneumograph, 71, 235

Poet, 59

Posthypnotic, 120, 231

Postulate, 41

Prayer, 207

Prohibition, 198

Protestantism, 325

Psychasthenia, 172, 264, 277

Psychiatry, 70

Psychical, 18

Psychoanalytic, 236, 272

Psychological Laboratory, 5, 36, 60, 72, 356

Psychology, 5, 8, 25, 39, 364

Pulse, 235, 294

Purposes, 11, 17

Purposive, 13, 33, 65, 145, 338


Reactions, 50, 143

Realism, 2

Reality, 15

Reasoning, 212

Recklessness, 201

Recuperation, 191

Relapse, 281

Relativity, 195

Religion, 84, 207, 329, 341

Reparable, 165

Reservoir, 209

Resistance, 105

Rest, 191

Retardation, 169, 202

Revival, 337


Savages, 320

Secrets, 185

Self, 24, 131

Self-consciousness, 136

Sensation, 22, 28

Sense Organ, 300

Shamanism, 320

Sidetracking, 236, 249, 271

Sleep, 112, 177, 226, 303, 307

Somnambulism, 114, 153, 352

Sphygmograph, 71, 235

Stammering, 175, 274

Stomach, 309

Subconscious, 125, 161

Subcortical, 143, 306

Subject, 13

Suggestibility, 88, 107, 221

Suggestion, 85, 100, 213, 273, 395

Superficiality, 200

Supervision, 279

Surroundings, 189

Sympathy, 205

Symptoms, 80, 186


Temperance, 198

Tones, 44

Toxic, 167


Unity, 52, 135


Vacation, 197

Vividness, 50


Will, 11, 31

Witness, 107

Worry, 259


Yogi, 350



+----------------------------------------------------+
|Transcriber's note:                                 |
|                                                    |
|Inconsistencies in hyphenation reflect the original |
| text.                                              |
+----------------------------------------------------+