Psychotherapy

by Hugo Münsterberg

Both psychodiagnostic and psychotherapeutic studies must be devoted to cases in which the mind itself is abnormal, further to cases in which the normal minds registers the abnormalities in other parts of the body, and finally to cases in which the normal mind influences abnormal processes in the body. These latter two cases have to be subdivided into those where the bodily disturbance still lies in the brain parts and those where it lies outside of the brain. But the situation becomes still more complex by the mutual relations of those various processes. The impulse to take morphine injections may have reached the character of a mental obsession and thus represent an abnormality of the mind, but yielding to it produces at the same time disturbances in the whole body which thus become again external sources for abnormal experiences in otherwise normal layers of the mind.

Of course the interest of the psychologist as such remains always related to the psychological factor, but the relation of the psychological factor itself to the total disturbance may be of most different character. If I diagnose or treat the fixed idea of a psychasthenic, the psychological factor itself represents the disturbance. On the other hand, if I study the pain sensations of a patient who suffers from a disease of the spinal cord, then the sensations themselves, the only psychological factor in the case, are only indications of a disease which belongs to an entirely different physical region; the mind itself is normal. Or, on the other hand, if I try to educate a sufferer from locomotor ataxia to develop his walking by building up in his mind new motor ideas to regulate his coördinated movements, the mind again is entirely normal but the physician needs his psychology on account of the influence which the mind has on the bodily system. Again, we must insist that psychomedicine covers this whole ground. Wherever a psychical factor enters into the calculations of the physician either by reason of its own abnormality or by its relation as effect or as cause to a diseased part of the body in the brain or without, there we have a psychomedical task, and as far as it is therapeutic, we have psychotherapy.

The psychodiagnostic research lies outside of the compass of our book, but we cannot emphasize sufficiently the great importance which belongs to that work. Moreover, just in the field of psychodiagnostics, the methods of the modern experimental psychological laboratory are most promising and successful. Let us not forget that we deal with such psychological factors even when we test the functions of eye and ear and skin and nose by examining the sensations and perceptions. The oculist who analyzes the color sensations of a patient and the aurist who finds defects in the hearing of the musical scale and discovers that certain pitches cannot be discriminated, is certainly dealing, for diagnostic purposes, with the material that the psychological laboratory has sifted and studied. Even that sensation symptom which enters into so many diseases, the sensation of pain, belongs certainly within the compass of the psychologist and it is only to be regretted that the systematic study of the pain sensations, mostly for evident practical reasons, has been much neglected in the psychological laboratory.

The psychologists have been at work all the more eagerly in the fields of association and memory, attention and emotion, habit and volition, distraction and fatigue. Here subtle methods have been elaborated, methods which surely common sense cannot supply, and which showed differences of mental behavior with the exactitude with which the microscope reveals the hidden differences of form. If physicians are slow in accepting the help which the psychological laboratory can furnish, it may be in good harmony with the desirable conservative policy in medicine, but finally the time must come when this instinctive resistance against new methods will be overcome. The recent attachment of psychological laboratories to certain leading psychiatric clinics is a most promising symptom. Yet the diagnostic studies with the means of the psychological laboratory cannot be confined to the cases of mental disease. The mild abnormalities of the mind, and especially the nervous disturbances which exist outside the field of insanity, demand this support of psychology much more. And even the normal personality will be more safely protected from disease and from social dangers for its mental constitution if the resources of experimental psychology are employed. The more we know of the psychological constitution of the individual, the more we can foresee the development which is to be hoped for or feared and which may be encouraged or retarded.

The psychologist may determine, for instance, the degree of attention with its resistance against distracting stimuli, the power of memory under various conditions and on various material, the mental excitability and power of discrimination, the quickness and correctness of perception, the chains of associations, the rapidity of the associative process for various groups, the types of reaction, the forming of habits and their persistence, the conditions of fatigue and of exhaustion, the emotional expressions and the emotional stability, the time needed for recreation and the resistance against drugs, the degree of suggestibility and the power of inhibition: and every result in any of these lines may contribute to the diagnosis and prognosis of cases. The chronoscope here measures the reaction times and association times in thousandths of a second; the kymograph, by the help of the sphygmograph, writes the record of the pulse and its changes in emotional states, while the pneumograph records the variations of breathing, and the plethysmograph shows the changes in the filling of blood vessels in the limbs which is immediately related to the blood supply of the brain. Here belongs also the ergograph, which gives the exact record of muscular work with all the influences of will and attention and fatigue, the automatograph which writes the involuntary movements, especially also the galvanoscope which may register the influence of ideas and emotions on the glands of the skin, and thus lead to an analysis of repressed mental states, and hundreds of other instruments which are used in the psychological laboratory.

Yet it would be misleading to think only of complex apparatus when experimental psychology is in question. An experiment is given whenever the observation is made under conditions which are artificially introduced for the purpose of the observation. Thus there is no need of the physical instrument. If I bring a spoonful of soup to my mouth at dinner and I become interested in the combination of warmth sensation and touch sensation and taste sensation and smell sensation, then I have performed an experiment if I take one more spoonful of soup just for the purpose of the observation. The physician too may carry out important psychological experiments, without needing the outfit of a real laboratory. Association experiments, for instance, promise to become of steadily growing importance. To make them serviceable to the problems of his office, nothing but a subtle psychological understanding is needed, inasmuch as any routine work schematically applied to every case alike would be utterly useless. Give your man perhaps a hundred words and let him speak the very first word which comes to his mind when he hears the given ones. You call rose, and he may say red or flower or lily or thorn; you call frog and he may answer pond or turtle or green or jump, and if you choose your hundred words with psychological insight, his hundred answers will allow a full view of his mental make-up. This is an experiment which does not require any instruments at all but a man's subtle analysis of the replies. That is not seldom sufficient to secure the diagnosis of complex mental variations. The method yields still more if the time for such a reply is measured, but there again not the costly chronoscope of the laboratory is indispensable; a simple stop watch which gives the fifths of a second would be fully sufficient for all practical purposes. From such simple facts of the mental inventory the association experiments may lead to complex questions which slowly may disentangle the confused ideas, for instance, of a dementia præcox, and thus lead to subtle differential diagnosis.

The psychological laboratory alone can also elaborate the methods of studying, for instance, the feeble-minded with all the individual variations. New and ever new methods have been tried; the memory was tested by reading and repeating figures or letters, or colored papers were shown or cardboards of different forms or nonsense syllables, and the powers of remembering were studied. Or the accuracy of arm movements was examined, or the quickness of understanding associated words, or the success in planning a complex movement like throwing a ball at a target, or the tapping of a key in the rhythm of a metronome, or the discrimination and recognition of the pieces in the game of dominoes and many another scheme. The laboratory has to analyze the conditions for such methods and the psychologist has to prepare the means for the use of the physician, just as the chemist has to prepare the sleeping powders. In a similar way the laboratory may furnish means to analyze the mental disturbances by a comparison with the experimental results of artificial influences, for instance, of over-fatigue or half-sleep, of drugs or alcohol, of poisons and emotional excitements. The psychological resolving of the mental symptoms may of course, in the same way, furnish the diagnosis where the mental variation is only a distant effect of a bodily ailment. The changes in the emotions, for instance, may lead to the recognition of a heart disease; lack of attention may be a hint of the overgrowth of the adenoids; irritability or apathy or delirious character of the mental behavior may indicate whether uræmic acid is in the system or an infectious disease: anæmia and undernutrition may be diagnosed and the psychology of fever demands too a much closer analysis with the means of the psychological laboratory than it has received so far.

We have not spoken as yet about those psychological methods which themselves introduce abnormal mental states like hypnotism, and which also not seldom are only means for diagnostic purposes. The hypnotic state may bring to memory forgotten experiences of which the physiological effects may have lasted in the brain and which may have brought injury to the psychophysical system. Hypnotic inquiry can thus lead to the recognition of the first causes in many hysterical states and where hypnotism is not the best adjusted tool, a certain dreamlike staring may be more effective. We have to return to much of that later in full detail because just for instance in hysteria, the clear recognition of the sources and of the character of the disease may at the same time prove to be in itself the right starting point for curative treatment.

We have spoken so far only about the relations of psychology and medicine from the point of view of diagnosis; the relations from the point of view of therapy will make up the second part of this book. We shall describe the methods and the results, the possibilities and the limitations with manifold detail. That is the chief topic of this volume. All that is needed to prepare for this principal problem is on the one side a preparatory clearing up of some fundamental conceptions, especially of those two which have played the chief rôle in the whole discussion, namely the subconscious and suggestion. And on the other side, we may consider at first some fundamental discriminations which steadily influence the inquiries and controversies in the field. I think of the difference between normal and abnormal mental states, between psychical and physical facts in psychotherapy, between functional and organic diseases, and to return to our starting point, between mental and moral influences.

Every curative effort presupposes that the normal state of health has been lost and that a diseased state has set in. Yet the mental analysis suggests still less than the bodily inquiry, just where the normal functioning is really lost. It would be easy to draw a demarcation line if the pathology of the mind introduced any mental features which are unknown in our normal existence, but the opposite is true. No mental disease introduces elements which do not occur in the sphere of health. A degenerated brain cell looks differently under the microscope from a normal one, but the ideas of a paranoiac, the emotion of a maniac, the volition of a hysteric, the memory idea of a paralytic is each in its own structure not different from such elements in any one of us. The total change lies thus only in the proportion; there is too much or too little of it. The pathological mental life is like a caricature of a face—each feature is contained, as in the ordinary portrait, but the proportion is distorted, there is too much or too little of chin or of nose. But who can indicate exactly the point where the distortion of the features constitutes a caricature? Every grotesque change in the relations ruins the healthy state: what makes us sure that the harmony of health is spoiled?