It would be rash to deny that up to a certain point this convention is susceptible of defence. But, carried too far, it is productive of disastrous results. Moreover, it is impossible for a doctor to treat many varieties even of physical disease without becoming to a great extent the confidant not only of the patient but often of his family. And there is no doubt that the present unwritten law that the doctor should confine himself to the patient’s physical ills is often judiciously disobeyed by very many successful practitioners. Yet it must be recognised that the convention exists, and like all social usages is extremely tenacious.
The chief medical objection, which we shall now consider, is usually expressed in some such form as the assertion that “it makes the patient worse to talk about his worries” and that one should rather “try to make him forget them.” Let us examine these statements, both of which contain a certain amount of truth, but if applied without qualification to serious cases of incipient mental disorder can by their respective negative and positive tendencies do an incalculable amount of harm. They are often the result of applying experience acquired by the successful reassuring of a certain type of “malade imaginaire,” to the consideration of far more complicated cases in which such easy and straightforward treatment is impossible. A man, let us say, visits a doctor and confesses to him his fear that he is suffering from some organic disease. The physician after a careful examination proves to the patient by objective means that there is nothing the matter with him; the sufferer is reassured and returns to his daily business and in due course forgets about this worry or ceases to be troubled by the memory of it. Here the diagnosis, treatment, and cure may be uncomplicated and “on the surface.” But even here it should be emphasised that in one sense, far from “making the patient worse” to talk about his trouble, the talking about it was the sine quâ non of cure; otherwise the doctor would never have known of the fear. In another sense, however, talking about the trouble did make the sufferer worse—but for a short time only, during a confession of his apprehensions, or perhaps even for a few days, if more than one visit to the consulting room were necessary before the doctor’s verdict could be obtained.
But not all visits to the doctor end so briefly or so easily as this. The patient’s trouble, on examination, may prove to be organic and of long standing. Does the doctor consider then that it is his duty to emulate the Christian Scientist or to “make the patient forget it?” On the contrary, he does not flinch from the employment of the most searching methods of investigation, lengthy and often painful treatment, and, if it seems necessary in the patient’s interest, he will carry out or arrange for operative interference which may be difficult, expensive, by no means free from danger, and is quite likely to “make the patient worse,” perhaps for a considerable time, before its beneficial results appear.
It is therefore idle to argue that on the one hand psychological methods of treating mental disorder are unnecessary because some patients get better without their application; while, on the other, they are dangerous because they may make a patient worse. The same remarks could be applied to most of the successful operative methods of present-day medicine. All of them are fraught with grave potentiality for harm if applied by unskilled persons.
The degree to which the doctor is medically justified in probing the patient’s intimacies is obviously dependent upon the individual case. Not all patients require such drastic incisions; a fact which has been clearly shown in the special military hospitals. An intelligent man of strong will, whose social relations have hitherto been normal and happy, might be temporarily “bowled over” by the emotional stress of the campaign, but after a few inquiries into the causes of his mental anguish and a few explanations, he is often set on his feet again.
We must not forget, however, the other side of the picture. There are many patients, who, far from being made worse by the confidential recital and discussion of their mental troubles to a suitable person, experience great relief as a result of this unburdening. Men in the military hospitals have expressed this over and over again, in such phrases as, “I have been bursting to tell this to someone who would understand,” or, “I have seen many doctors since I left the front, but you are the first who has asked me anything about my mind.” Frequently the troubles prove to be caused by their ignorance of the great individual differences in minds, so that the appearance in them of a new but by no means pathological mental phenomenon frightens them unduly. We have already referred to cases of this kind in Chapter I.[44] Another frequent cause of the most intense and continuous mental anguish is the exaggerated self-reproach which the patients attach to some real, but in the judgment of others, comparatively trivial defect or delinquency in themselves. To borrow an expressive phrase, the neurasthenic has “lost his table of values.” It is in such cases that a talk with a tactful, sympathetic, broad-minded physician may produce the happiest results.
To assume that one can make the patient forget such worries as these without first discovering what they are, is obviously fatuity at its grossest. Moreover, as we have seen, it is quite insufficient merely to discover that the patient is “suffering from hallucinations” or delusions and then to tell him to dismiss them from his mind. To suppose that, without understanding the nature of and the specific reasons for the development of a particular hallucination, one can “make the patient forget” his interpretation of a real experience which has appealed to him night and day for weeks, or banish a delusion which is gradually becoming systematised and rationalised—i.e., intimately interwoven into the tissues of the whole of his experience—is an assumption which has no foundation in fact.
The point cannot be too much emphasised that many of these patients are quite sane, if conduct be regarded as the criterion of sanity; but they are growing afraid of the appearance of these abnormal phenomena, and take them for signs of incipient—or, more usually perhaps, of established—insanity. Hence follows the important corollary that while treatment by isolation has obvious advantages in certain cases, in the particular group of patients which we are now discussing it is often dangerous, for the reasons already emphasised in the last chapter. The presence of such mental phenomena is usually confided to the physician only after great hesitation, and such worrying experiences are common in cases of insomnia and other disorders, which, though troublesome, do not appear to be grave. It is therefore possible that isolation may have serious effects in many cases in which its net result seems merely to be that the patient is no better.
It is granted then that in some instances (by no means all), the patient may be temporarily pained by the dragging into daylight of the causes of his worry, but it is usually a case of reculer pour mieux sauter. This procedure is often inevitable in the medical treatment of many disorders which have become complicated to any considerable extent.
We pass now to a difficult task; the consideration of the moral objections to the procedure of psychological analysis. The difficulty obviously lies in the circumstance that, while in the discussion of the other objections one could continually point to facts upon which at least, the great majority of civilised people are in cordial agreement, such unanimity is not so complete upon moral questions. Some of the varieties of the moral objection, however, are not based on such disputable grounds. For example, there is the argument that it is bad for the patient that he should have his inmost mental life dissected and analysed in the thoroughgoing way which we have described, since it is important for the preservation of his self-regard that, as far as possible, he should consider himself “master of his soul.” With the latter sentiment no reasonable person would quarrel. And where it is possible (as it often is) for a slight mental tangle to be straightened out without an extensive and lengthy inquisition, we hold that it is urgent in the patient’s interest that his privacy shall be respected. It should be pointed out, however, that since this procedure is equally in the interests of the honest physician—for it will save him time and trouble—it is likely to be adopted wherever possible. In the special military hospitals, for instance, it was often found unnecessary, in mild cases, to press the inquiry very far; the patient “learning his lesson” successfully at an early stage of the proceedings.