“One could not express any better, or any more directly, what we never cease to maintain, however lacking in science it may seem at the first—namely, the real therapeutic action of kindness.
Liberated morally, and having regained consciousness of self, and freed in addition from his functional manifestations by the appropriate processes ... the patient is cured. He is cured from his actual attack. But his mental foundation, his psychological constitution, still remains in the same condition which permitted him under emotional influences to become a neurasthenic. The rôle of the physician is, therefore, not ended. He must still build up his patient’s life, still practise prophylaxis, and get the patient into a condition where his character will be established.”[36]
Rational Treatment. So far in this chapter we have been discussing what may be described as general methods of treatment, which do not necessarily involve any attempt to probe into distinctive individual symptoms and to discover the real fundamental cause or causes of the trouble. The measures so far considered are empirical rather than rational. But they are the only methods of treatment discussed in most of the text-books.
It is an axiom in medicine that correct diagnosis is the indispensable preliminary to the rational and intelligent treatment of disease. This fundamental principle is universally recognised in dealing with bodily affections; but it is the primary object of this book to insist that it is equally necessary to observe the same principle in the case of mental illness.
It may seem ironical to stress this elementary consideration, but it is notorious that accurate diagnosis is too often ignored in cases of incipient mental disturbance. It is idle to pretend that such a procedure is unnecessary, or to urge in extenuation of the failure to search for causes that many patients recover under the influence of nothing more than rest, quiet, and ample diet.
Many mild cases of illness, whether bodily or mental, may and do recover even if undiagnosed or untreated. But on the other hand many mild cases get worse; and it is the primary duty of the physician correctly to diagnose the nature of the trouble and to give a prognosis—to decide whether the illness is mild or severe. Some of the most serious cases of incipient mental trouble are those of patients who do not seem to be really ill, and are easily overlooked by a visiting physician. They are quiet and inoffensive and display no obvious signs of the insidious processes that are at work in them. But all the time they may be, and often are, brooding over some grievance or moral conflict, worrying about their feelings, misinterpreting them and gradually systematising these misunderstandings until they become set as definite delusions or hallucinations. If, acting on the belief that it is bad to talk about a patient’s worries, the physician leaves such a man alone, he is clearly neglecting his obvious duty. For the whole trouble may be due to some trivial misunderstanding which he could easily correct.
In the severer forms of mental disease, precise diagnosis is even more intimately related to treatment than in the case of bodily illness. For when a patient’s illness is recognised as some bodily affliction, such as pneumonia or appendicitis, certain general lines of treatment are laid down as soon as the appropriate label has been found for the complaint, though, in the case of the latter illness, there is added the further problem of whether or not surgical interference is indicated.
In cases of mental disturbance, however, the general lines of treatment cannot thus arbitrarily be determined merely by finding an appropriate label. It is true that as in the treatment of bodily disease, certain general principles must be observed, such as the provision of abundant and suitable food, and the protection of the patient from all disturbing influences. But the essence of the mentally afflicted patient’s trouble is some particular form of anxiety or worry which is individual and personal. The aim of the diagnosis, therefore, should be not merely to determine the appropriate generic label for the affliction, but rather to discover the particular circumstances which have given rise to the present state. The special object of the physician should be to remove or nullify the exciting cause of the disturbance; and in order to do this it is essential that he should discover the precise nature of the trouble. The diagnosis, therefore, must be of a different nature from that demanded in case of physical illness, where the condition may be adequately defined by some such generic term as “lobar pneumonia” or “acute appendicitis,” and its gravity estimated by the general condition and physique of the patient. In the case of mental trouble, the physician has to make an individual diagnosis, based not only upon an insight into the personality but also into the particular anxieties of each patient.
But even when it is recognised that exact diagnosis of the particular circumstances of each individual patient is essential, if the trouble is to be treated rationally and with insight, there still remain many difficult problems as to procedure.
Amongst those whom experience has convinced of the efficacy of psychological treatment for this class of case, there are indications of a divergence of opinion in the matter of procedure. Some believe that it is sufficient if the medical man has discovered the real cause of the trouble and explained it to the patient. Other workers look upon a preliminary psychical examination merely as a means of diagnosis, the unveiling of the hidden cause of the trouble; and consider that the treatment should be the laborious and often lengthy process of re-educating the patient, and so restoring to him the proper control of himself. It is of the utmost importance to emphasise the undoubted fact that those who maintain either of these views to the exclusion of the other are committing a grievous and dangerous error, for there is no sharp line of demarcation between the two procedures.