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

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

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

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

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

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

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

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

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

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

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

Also the next man is familiar to all of us.

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

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

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

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

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

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

Authors run easily into such states. Here is another.

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

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

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

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

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

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

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

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



XI

THE BODILY SYMPTOMS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



PART III

THE PLACE OF PSYCHOTHERAPY



XII

PSYCHOTHERAPY AND THE CHURCH

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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