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Psychotherapy
by Hugo Muensterberg
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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 role 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 reenforcement 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 reenforced 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 reenforce 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 role 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 reenforced 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 reenforced 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 naive. 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 reenforced 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 reenforced 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 reenforced 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 reenforced 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 reenforced 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 fiance, 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 fiance. 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 kinaesthetic 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 cooeperation 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.

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