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

medicines.



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

psychotherapeutics.





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

suggestion.





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

disturbance.





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

past.



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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