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General Principles Of Psychotherapy

In formal, deliberate psychotherapeutics the first and most important
principle is the treatment of the individual patient, and not of his
disease. It is much more important to know the kind of an individual
who has pneumonia, as a rule, than to be able to tell the amount of
pulmonary involvement. If heart, kidneys or lungs are affected when
the disease declares itself, the outlook is extremely unfavorable.
Similar conditions are true of the patient's mind. If he is of the
worrying kind, the outlook is serious. If, on the contrary, he faces
it bravely, and without after-thought except that of responding to
medical treatment, he will probably get well.

Pneumonia is only one example of the part the individual plays in
therapeutics. In the popular mind it is supposed that for each disease
there is a definite remedy, and that when the physician gives that
remedy the patient gets well. This idea of specific remedies has come
to the people from the physician, but only the quack now pretends to
cure disease, the physician helps the patient to overcome the
affection from which he is suffering.

No Incurable Patients.--There are many incurable diseases, but there
are no patients to whom a doctor should say with truth, "I can do
nothing for you." We may be unable to do anything for the underlying
disease. That may be absolutely incurable. In spite of this, there are
practically always symptoms for which the patient can be afforded so
much relief that he feels better than before. This is the most
important attitude of mind for the physician who would use
psychotherapy. He can always do something. Prof. Richet said not long
since, "Physicians can seldom cure, but they can nearly always relieve
and they can always console," and it is the physician's duty to lift
up and console the mind as well as to heal the body.

Unfavorable Suggestions.--Patients often have many opinions and
conclusions with regard to their ailments which are not confided to
their medical attendants, and which constitute the basis of many
annoying symptoms. They have mental convictions with regard to the
incurableness of their ailments, the supposed progressive character of
the disease, and the development of symptoms which will still further
annoy them, that are often more serious and harder to bear than the
symptoms from which they are actually suffering. Unless the physician
has their complete confidence, these patients may suffer much in
silence, though the revelation of their state of mind would
often be sufficient to afford a good measure of relief, and the
correction of false notions would do nearly all the rest.
Psychotherapy confers its benefits mainly by securing the most
complete rapport between the mind of patient and physician. Good
advice is often more important than any medicine. The correction of
wrong notions will do more to relieve the patient, and make whatever
symptoms he has bearable, than most of the anodyne drugs. The
stimulation of hope means more than almost anything else in arousing
the latent forces of nature and predisposing to recovery. The removal
of unfavorable suggestions is but little less efficient.

Study of the Individual.--The great differences in the relations
between physicians and their patients is well recognized. To some
physicians a patient will present only conventional symptoms, while a
follow practitioner will discover the elements of an interesting case.
Above all, the painstaking physician, interested in psychology, will
find mental and other personal manifestations in his patient that
distinctly modify the course of the disease. We must know all that is
possible about the patient's attitude of mind toward his malady, and
all the ideas that he has acquired with regard to it, either from
previous relations with physicians or from what he may have read or
heard from others. The removal of many false notions that are thus
working harm will reward the medical practitioner who gets at his
patient's ideas. The old rule in therapeutics is non nocere--to be
sure to do no harm. The special rule in psychotherapy is to be sure to
remove all the ideas that are doing harm to the patient and making his
symptoms mean more to him than they really signify.

Neutralizing Contrary Suggestion.--In the application of
psychotherapy, then, the first principle is the neutralization of
unfavorable mental influence. In our day men have such a smattering of
knowledge about disease, especially about the worst forms of it, that
they are likely to be in a frame of mind with regard to many
affections that is quite unfavorable. Many patients think disease and
not health. Disease means discomfort, and consequent loss of vital
energy and disturbance of the resistive vitality that would enable the
patient to throw off the affection. Sometimes the physician does not
realize what a large part unfavorable suggestions are playing in the
affection. Sometimes patients conceal their state of mind lest the
doctor should confirm their worst fears. The preliminary to all
successful treatment is to remove unfavorable suggestion.

Favorable Suggestion.--The next thing is to set certain favorable
suggestions at work. It is possible always to do this. Even in certain
of the acute diseases favorable suggestion has its place, and for all
chronic cases this form of therapeutics is extremely important. The
very presence of the physician, especially if he is thoroughly in
control of himself, placid, imperturbed, evidently ready to use all
his powers without any excitement, is of itself the strongest kind of
favorable suggestion. From the very beginning of medical history the
presence of the physician has in most cases meant even more than his

Muensterberg, in his recent book on Psychotherapy, has emphasized this
in a way that deserves to be recalled:

There is one more feature of general treatment which seems almost a
matter of course, and yet which is perhaps the most difficult to
apply because it cannot simply be prescribed: the sympathy of
the psychotherapist. The feelings with which an operation is
performed or drugs given do not determine success, but when we build
up a mental life, the feelings are a decisive factor. To be sure, we
must not forget that we have to deal here with a causal and not with
a purposive point of view. Our sympathy is therefore not in question
in its moral value, but only as a cause of a desired effect. It is
therefore not really our sympathy which counts but the appearance of
sympathy, the impression which secures the belief of the patient
that sympathy for him exists. The physician who, although full of
real sympathy, does not understand how to express it and make it
felt will thus be less successful than his colleague who may at
heart remain entirely indifferent but has a skillful routine of
going through the symptoms of sympathy. The sympathetic vibration of
the voice and skillful words and suggestive movements may be all
that is needed, but without some power of awakening this feeling of
personal relation, almost of intimacy, the wisest psychotherapeutic
treatment may remain ineffective. That reaches its extreme in those
frequent cases in which social conditions have brought about an
emotional isolation of the patient and have filled him with an
instinctive longing to break his mental loneliness, or in the still
more frequent cases where the patient's psychical sufferings are
misunderstood or ridiculed as mere fancies, or misjudged as merely
imaginary evils. Again everything depends upon the experience and
tact of the physician. His sympathy may easily overdo the intention
and further reinforce the patient's feeling of misery, or make him
an hypochondriac. It ought to be sympathy with authority and
sympathy which always at the same time shows the way to discipline.
Under special conditions, it is even advisable to group patients
with similar diseases together, and to give them strength through
the natural mutual sympathy; yet this too can be in question only
where this community becomes a starting point for common action and
common effort, not for mere common depression. In this way a certain
psychical value may be acknowledged for the social classes of
tuberculosis as they have recently been instituted.

Favorable Environment--After the removal of unfavorable suggestion and
the implanting of favorable suggestion, the next point must be the
persistent occupation of the patient's mind with thoughts favorable to
his condition. A nurse who is inclined to be pessimistic must be taken
out of the sick room, and there must be only cheerful faces and cheery
people around him. Hence the modern trained nurse, and especially the
picked nurse, who does not allow herself to be disturbed, who is not
fussy, who is not forcibly cheerful but quietly placid and confident
and cheery, means much for the patient's recovery. Relatives are
almost sure to exert strong unfavorable suggestions, though time was
when the devoted wife or mother might be depended upon to cover up all
her personal feelings and give the best possible service for the
mental uplift of the patient. When she can thus conceal her own
solicitude, a near relative may be the best possible auxiliary in

Natural Relief.--The fourth step in the application of
psychotherapeutics is that all the natural modes for the relief of
symptoms, the making of patients comfortable in body as well as in
mind, must be employed. In acute rheumatism, for instance, a number of
small pillows must be at the disposition of the patient so that his
limbs can be fixed in those positions in which there is the least
discomfort. Every physician should frequently read Hilton's classical
volume on "Rest and Pain" because of its unpretentious significance
for psychotherapy, as well as its enduring value in the treatment of
painful conditions. Just as soon as a patient finds that simple
procedures relieve his pain and add to his comfort, his fear of the
seriousness of his ailment is lessened, and he begins to get
bettor. Cold water in fevers, cold fresh air in pneumonia, all the
natural modes of treating disease, thus become active factors in the
application of psychotherapy. When fevers were treated by the
administration of hot drinks the effect upon the patient's mind must
have been quite serious. Freedom to use cold water, just as one wants
it and whenever it is craved for, is of itself an excellent

Neuroses in Organic Disease.--Fifth, psychotherapy, by suggestion, may
alleviate or even completely eradicate neurotic symptoms that develop
in connection with organic diseases. Such neurotic symptoms may prove
even more bothersome to the patient than the symptoms due to his
underlying affection, and may, by interfering with nutrition, hamper
recovery. The appetite of a patient who is worrying about a chronic
disease will be disturbed, and, as a consequence of insufficient food,
constipation and a whole train of attendant evils may ensue. Headache,
sleeplessness, worry at slight irritation and exaggerated complaints
from slight pain may all be due to this worry and not to the
underlying disease. All these, the result of over-solicitude, are
attributed by the patient to his chronic ailment. They can be relieved
by simple measures after he is saved from his own worry. Until the
patient is made to rouse himself and look hopefully at the situation,
eating more, getting out more, and relaxing his mind from its constant
attention to himself, he cannot get better.

Application of Principles.--It should be pointed out to the patient
that there is a constant tendency to exaggerate the significance of
disease. This is true in acute as well as in chronic disease, but in
acute diseases the necessity for removing unfavorable influences
directly is not so urgent, since usually the presence of the
physician, with his simple declaration of the meaning of symptoms, is
sufficient to neutralize the effect of previous exaggerations.

Secondly, the action of unfavorable suggestions due to imperfect
knowledge (everything unknown is magnified, as Cicero said), or to
previous medical opinions which the case does not justify, must be
stopped. The natural dread which comes to all men in the presence of
symptoms of disease must be as far as possible removed.

Thirdly, the favorable elements in the case should be emphasized. This
needs to be thoroughly done in order to secure the patient's
co-operation, even though the serious possibilities of his ailment may
be pointed out to his friends. These friends, however, must be persons
who can be absolutely depended on not to reveal by word, or, what is
much more important, by their looks or actions, the possible worse
prognosis of the case.

Unfortunately, people expect a doctor to tell them the worst, rather
than the best. Many physicians seem to have formed the habit of
representing the condition of patients as grave as possible, in order,
apparently, that they may have more credit when the patient recovers.
Not a little of the tendency of ills to hang on in neurotic persons is
due to this habit. Over-cautiousness leads some physicians to reveal a
case in its worst aspect, lest, by any chance, something unexpected
should happen, and the friends of the patient might think that the
physician was incompetent because he had not anticipated it. Some of
the serious accidents of disease are quite beyond anticipation; but
they occur only rarely. For the sake of safeguarding the possible
reflection on the physician because of them, it is quite unjustifiable
to make bad prognosis habitually, for this acts deterrently on
the vital resistance and delays recovery.

Symptoms of Organic Disease.--It is usually considered that
psychotherapy is beneficial only in nervous cases; yet we know that
all sorts of affections with tissue changes in the skin, in the
circulation, and very probably also in the internal organs, may be
produced in hysterical affections--ailments dependent on loss of
control over the vaso-motor nervous system. Just as ills can be
produced, so they may also be cured. As a matter of fact, analysis of
the statistics of disease cured by mental influence, shows that it has
been more strikingly manifest in organic than in so-called nervous or
functional diseases. Neurotic patients often make extremely unsuitable
subjects for the exercise of mental influence, because their very
nervousness is a manifestation of lack of power properly to control
the mind. Cures by mental influence have oftenest been reported in
non-neurotic patients. As Dr. Hack Tuke pointed out in "The Influence
of the Mind on the Body" as long ago as 1884, it is in such cases as
rheumatism, gout and dropsy that benefit was most frequently reported
by mental means.

Tuberculosis, certain digestive and intestinal ailments that evidently
are associated with tissue changes, have in recent years come
particularly into this category of ailments affected by psychotherapy.
Dr. Hack Tuke's declaration, made nearly thirty years ago, seems
conservative even at the present day: "The only inference which we are
justified in drawing from the statistics of the affections cured by
mental means is that the beneficial influence of psychotherapeutics is
by no means confined to nervous disorders." Many physicians are likely
to hold that when cures take place the so-called organic diseases were
not actual, but were only supposed to exist because of certain
obscure symptoms that apparently could not otherwise be explained. But
many of the cases have had external symptoms, striking and
unmistakable. To assume that physicians of experience and authority
were in error in diagnosing them is simply to beg the question. It is
more probable that mental influence acted curatively even over tissue
changes as it so often does, directly under our observation, in the
production of such changes in the skin.

Tissue Changes From Nerves.--Until one recalls how many physical
changes may be brought about by mental influences or emotional
disturbances, it is not always clear just how mental influence can
affect disease favorably or unfavorably. Prof. Forel, of Zurich, in
his "Hygiene der Nerven und des Geistes im Gesunden und Kranken
Zusande," Zurich, 1905, English translation 1907, brings together into
a single paragraph most of these physical and physiological influences
of the mind upon the central nervous system:

Through the brain and spinal cord, thoughts can lead to a paralysing
or stimulation of the sympathetic ganglion nodes, and consequently
to blushing or blanching of certain peripheral parts. Through
disturbance of this mechanism, many nervous disorders arise, such as
chilblains, sweats, bleeding of the nose, chills and congestions,
various disturbances of the reproductive organs, and, if it lasts
long enough, nutritional disturbances in the part of the body
supplied by the blood vessels affected. In the same way there are
peripheral ganglionic mechanisms which superintend glandular
secretion, the action of the intestinal muscles, etc. These likewise
can be influenced through the brain by ideas and emotions. Thus we
can explain how constipation and a vast number of other disturbances
of digestion and of menstruation can be produced through the brain,
without having their cause in the place in which they appear.
It is for the same reason that such disturbances can be cured by
hypnotic suggestion.

Health and the Central Nervous System.--Nature has so constituted
and ordered the human economy that its health depends to a great
extent on conditions in the central nervous system. We discuss
elsewhere the return of vitalism in physiology--that is, the
reassertion of a principle of life behind the chemical and physical
forces of the human organism regulating it, supplying energy,
occasionally enabling it to transcend the ordinary laws of osmosis, or
the diffusion of gases. The main seat of this principle of life is in
the central nervous system and especially in the cerebral cortex. The
importance of this portion of the human anatomy can scarcely be
exaggerated. In his inaugural address to the Royal Medical Society,
[Footnote 23] delivered at Edinburgh in 1896, Prof. T. S. Clouston,
the distinguished English psychiatrist, has a passage on this subject
that deserves to be recalled:

[Footnote 23: British Medical Journal, January 18, 1896.]

I would desire this evening to lay down and to enforce a principle
that is, I think, not sufficiently, and often not at all, considered
in practical medicine and surgery. It is founded on a physiological
basis, and it is of the highest practical importance. The principle
is that the brain cortex, and especially the mental cortex, has such
a position in the economy that it has to be reckoned with more or
less as a factor for good or evil in all diseases of every organ, in
all operations and in all injuries. Physiologically, the cortex is
the great regulator of all functions, the ever active controller of
every organ and the ultimate court of appeal in every organic

Psychotherapy in Its Relation to Patient and Physician.--In spite of
the present-day fad for psychotherapy, I have no illusions with regard
to its popularity among patients, unless practiced with due regard to
individuals and with proper tact. Psychotherapy has been most
effective in the past when it was cloaked beneath the personality of
the physician; when it was felt that there was in him a power to do
good that must help the patient. This personal influence has to be
maintained if the patient's mind is to be influenced favorably. Very
few people are willing to think, and still less to welcome the
thought, that they themselves are either bringing about a continuance
of their symptoms or are hindering their own recovery. They are quick
to conclude that this would be a confession that their ills are
imaginary. "Imaginary" has no place in medicine. There are physical
ills and mental ills. Mental ills are just as real as physical ills.
There are no fancied ills. A person may be ailing because he persuades
himself that he is ailing, but in that case his mind is so affecting
his body that he is actually ailing physically, though the etiology of
the trouble is mental.

It is the duty of the physician to get at these mental causes of
physical ills and remove them by persuasion, by reassurance, by
changing the mental attitude, by making people understand just how
mind influences body, but this must be done tactfully. From the
beginning of time we have written our prescriptions in such a way that
ninety-nine out of one hundred patients have not been able to
understand them. It has often been said that we should change this
method of prescription writing, and write directions for the
compounding of our medicines in plain vernacular. Besides the many
scientific reasons against this, it is better for patients not
to know exactly the details of their treatment. Physicians, because of
their real or supposed knowledge, are usually the worst patients. If,
when a physician is ill, a drug is administered in which he has lost
confidence, he will really oppose its action by contrary suggestion,
and perhaps neutralize it. Confidence added to the action of the drug
itself, makes it much more potent and much more direct. Hence the
suggestive value of a prescription the ingredients of which are
unknown. Every physician knows of patients who have declared that a
drug has been tried on them without avail, when it has only been used
in such small quantities as to be quite nugatory in its effect. Such
use was enough to prejudice them against it so that when given in
physiological doses it failed to work properly.

Opium given to a trusting patient, in gradually reduced doses until
practically there is nothing but the flavor of the drug in the
compound that he takes, will continue to have its effect. But to a
patient prejudiced against the drug, even large doses of opium will
prove unavailing, because the lack of confidence disturbs the mind,
directs attention to whatever discomfort may be present, emphasizes
the ill and prevents sleep by preoccupying the mind with the thought
that neither the drug nor the dose can accomplish its purpose. In a
word, medicine plus mental influence is extremely valuable. Medicine
minus mental influence is valuable but sometimes ineffective.
Medicine, with mental influence opposed to it, is often without effect
because of the strong power the mind has over bodily functions.

Most people would rather be cured by some supposedly wonderful
discovery, which presumedly made it clear that they had been suffering
from a severe and quite unusual ailment, than by ordinary simple
methods. The recent growth of interest in psychotherapy and psychology
has, however, somewhat prepared people to accept mental influence as
an important factor in therapeutics. The direct and frank use of
psychotherapy will be of benefit to these people. But in most cases
mental influence will have to be exerted in such a way as to conceal
from patients that it is their own energy we want to tap to help them
cure themselves. This would be for them quite an unsatisfactory method
of being cured. In practically all cases such a combination of methods
is needed that the place of mental influence is not over-emphasized.
As a rule, mental influence must not be used alone. Its place is that
of an adjunct, a precious auxiliary, to other methods of treatment.

Psychotherapy represents one of the important elements in
therapeutics, and we must learn to use it in a way suitable to our
patients. We have to learn to use our drugs in accordance with the
nature and physical make-up of the patient. We have to find out by
experience just how to use hydrotherapy for each individual. Varying
currents of electricity and varying forms of electrical action are
needed for different individuals. Just in the same way, our
psychotherapy must be dosed out according to the special need of each
individual, the form of the affection and the particular kind of mind
that is to be dealt with. To learn the place of mental influence in
healing, so that we shall not be attributing to other therapeutic
factors what is really due to the mind, will be a great advance in
therapeutics. This is the mistake that we have been making in the

In brief, the applications of the general principles of psychotherapy
include all means, apart from the physical, of influencing
patients. Drugs will always have a large place in rational therapy.
Many physical remedial measures, hydrotherapy, electrotherapy,
climatotherapy and others, must be important adjuncts. To these is now
added psychotherapy. It has been used before, as have most of the
other forms of therapy, but in our day we are trying to systematize
therapeutic modes so as to secure the greatest possible information
with regard to their exact application. This is what must be done with
regard to psychotherapy also. Just now its importance is being
exaggerated by ardent advocates. In every department of therapy this
has always been done by enthusiasts. The business of the practicing
physician must be to select what is best, and above all what is sure
and harmless, from the many suggestions offered, so as to build up a
practical body of applied truth.

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