Psychotherapy

by Hugo Münsterberg

Other methods work on the same basis. Prominent among them is the psychotherapeutic effect of a formal assurance. The psychotherapist assures the patient that he will sleep the next night or that the pain will disappear or that he will be able to walk with such firmness that the counter-idea is undermined. It depends on the type of patient whether such suggestions of belief work better when it is assured with an air of condescension, spoken with an authority which simply ignores every possible contradiction, or with an air of sympathy and hope. Experience shows that it is favorable to connect such assurance with the entrance of a definite signal. "You will sleep to-night when the clock strikes ten," "The pain will disappear when you enter the door of your house," or perhaps, "Read this letter three times quietly in a low voice, and at the end of the third reading your fear will suddenly stop." Psychological insight will further decide whether it is wiser in the particular case to assure the patient of the resulting effect or rather of the power to bring about the effect. With some people, it works better to insist that the result will happen, with others to promise that they themselves can secure it; in the one case they feel themselves as passive instruments, in the other as real actors. To some hysterics, it is better to say: "You will walk," to others, "You can walk."

This belief in the future entrance of a change frequently demands an artificial reënforcement. There belongs first the application of external factors which awaken in the background of the mind the supporting idea that something has been changed in the whole situation or that some helpful influence has made the improvement possible. Medicines of colored and flavored water, applications of electric instruments without currents, in extreme cases even the claptrap of a sham operation with a slight cut in the skin, may touch those brain cells which words alone cannot reach with sufficient energy and may thus secure the desired psychophysical effect. The patient who by merely mental inhibition has lost his voice for weeks may get it back as soon as the physician has looked into his larynx with a mirror and has held an electrode without battery connection on the throat. Another way of helping by make-believe methods is to give the impression that a decided improvement is noticeable. The uneducated patient believes it easily when the physician at his very entrance into the office expresses his surprise about the external symptoms of a change for the better, perhaps seen in the color of the skin or the shading of the iris in the eye and reaffirmed by some pseudotests of the muscle reflexes. All that is not very edifying and the decent physician, who justly feels somewhat dragged down to the level of the quack in applying such means frequently, will abstain from them wherever possible. He knows that in the long run, even the psychasthenics are best treated with frankness and sincerity and he will therefore only in exceptional cases resort to such short-cut treatment by making believe. Yet that it is sometimes almost the only way to help the patient cannot be denied.

A neater way to secure the sufferer's belief in the possibility of a cure is by securing the desired effect at least once through little devices. As soon as it is once reached, the patient knows that it can be reached and this knowledge works as a suggestion. The hysteric who cannot speak when he thinks of his words, or who cannot walk when he thinks of his legs, may by the skillful physician be brought to a few words or steps before he himself is aware of it by completely turning his attention to something else and producing the stimulus toward the movement in a reflex-like way. Still more successful is the effort to resolve the inhibited action into its component parts and to show to the patient who cannot perform the action as a whole that he can go through the parts of it after all. As soon as he has passed through a few times, a new tactual-visual image of the whole complex is secured for his consciousness and this image works then as a new cue for the entire voluntary action, overcoming the associated counter-idea.

Another excellent way to overpower a troublesome idea or impulse or emotion is to reënforce the opposite idea by breaking open the paths for its motor expression. The effort to hold the counter-idea before consciousness may be unsuccessful so long as it is only an idea which tries in vain to produce any motor effect; but if the action itself has been repeatedly gone through, the idea will find it easier to settle and it becomes vivid in proportion to the openness of the channels of motor discharge. This holds true even for emotional states. A certain word perhaps picked up by the psychasthenic in a particular experience may produce whenever it is seen a shock and a depressing emotion. If we ask the patient to go artificially through the movements which express joy and hilarity, make him intentionally grin and open wide the eyes and expand the arms and inhale deeply, and after training this movement complex of joyful expression, speak the dreaded word at the height of the movement a new feeling combination clusters about the sound and may overcome the antagonism. Sometimes you will give to the desirable idea sufficient strength by mere repetition, sometimes you force the attention better by unusual accentuation, connecting the suggestion with a kind of shock. From here it is only one step to the suggestion in the form of a sharp order which breaks down the resistance just by its suddenness and loudness, supported perhaps by a quick arm movement which gives a cue for imitative reflexes. In the case of a youngster even a slap may add to the nervous shock; also a sudden clapping of the hands may favor effectiveness of the suggestive order.

Often it is wise to give the suggestion, not from without but to prescribe it in the form of autosuggestions. For instance, advise the patient not only to have the good will and intention of suppressing a certain fixed idea or by producing a certain inhibited impulse but to speak to himself in an audible voice, every morning and every evening, saying that he will overcome it now. Here, too, the autosuggestion may become effective by the frequency of the repetition or by the urgency of the expression or by the accompanying motor reactions. As a matter of course any associations which reënforce the idea may be used for assistance. Especially near-lying is the appeal to the man's conscience, but just such associations which touch the idea of the own personality and its deepest layers of feelings are always risky. They may touch and stir up old memories which interfere with success or they may awaken a feeling of contrast between duty and fulfillment which may disturb the whole equilibrium. If the physician knows that the good-will of the patient is insufficient to overcome the pathological disturbance, he ought not to make him feel ashamed or guilty, and that not only for moral reasons but also for strictly psychotherapeutic reasons.

In certain easily recognizable cases, it is essential to give the suggestion with avoidance of any emphasis, only as a hint, passing as if the suggestion almost slipped from the tongue of the doctor without his real intention. The hysteric who is resisting the suggestion which is intentionally given to her is sometimes surprisingly trapped by a half-hidden suggestion, perhaps not spoken to the patient herself at all but spoken in a low voice to a colleague in the room. Sometimes we have to trick those who suffer by "negativism," that is by an obstinacy which exaggerates that of the ordinary stubborn man. In such cases the suggestion not to perform an action works best if we want the action performed. There is hardly an end to the list of such methods for bringing beliefs and attitudes with suggestive power to the mind of the sufferer. Definitely to describe the conditions under which the one or the other form ought to be applied would be no wiser than to tell a statesman what steps are to be taken in every possible diplomatic situation. The instinctive selection of the right means among the many possible ones characterizes both the true statesman and the true doctor.

So far we have spoken only about the character of the suggestion, presupposing that the receiver remains in his natural state. This presupposition is certainly often entirely correct, but as far as it is correct, the results of the suggestion vary greatly with the different individuals. On the whole, we might say that such suggestions given to the subject in his normal state are effective only when the subject is by nature a suggestible being. In considering the psychology of suggestion, we recognized at once that the degree of natural suggestibility varies excessively. The non-suggestible mind is only to a slight degree influenced by any of these proposed forms of suggestion as long as the suggestibility itself is not heightened. To be sure, the question whether the person is suggestible by nature or not cannot be settled simply by his own impression. Many of the most suggestible persons believe firmly that they are superior to any suggestive influence.

To bring suggestions to greater effectiveness and to exert their influence practically upon every possible subject, we have thus not only to give suggestions or to advise autosuggestion but in both cases we have to secure, especially for the naturally less suggestible patients, a somewhat heightened suggestibility. Yet no one can overlook that some of the methods which we described have in themselves the tendency to reënforce the mental suggestibility. Those methods of emphasis and order, of assurance and make-believe, of practical training and of awakening counter-ideas, of persuasion and even of reasoning, wherever they are in a high degree successful probably always gain a certain part of their success by the increased suggestibility which the whole situation brings with it.

This reënforcement of the psychophysical readiness for suggestions results indeed quite directly both from expectation of the unknown and of the half-way mysterious, and from the confidence in the doctor. Of course it can work very differently. The expectation can upset the nervous system and produce unrest instead of suggestibility and, instead of confidence, the patient may feel that discouraging diffidence which settles easily upon those who have tried one fashionable physician after another. But where there is real confidence, based perhaps on the fame of the doctor and on the reports of his powerful achievements, there the conditions for effective suggestions are greatly strengthened. Still better is it if this confidence in the man is combined with a sincere hope for recovery. To lie down on a lounge on which hundreds have been cured fascinates the imagination sufficiently to give to every suggestion a much better chance to overcome the counter-idea. The expectation that something wonderful will happen can even produce an almost hypnoid state. The effect will be the greater, the less the barriers of systematic knowledge hinder the entrance of suggested ideas. The uneducated will on the whole offer less resistance to suggestions, just as superstitions find the freest play in the minds of the untrained. It is not by chance that the earlier epidemics of pathological suggestibility have on the whole disappeared with the better popular education. In a similar way work fatigue and exhaustion. The resistance has grown weaker, the suggested idea goes automatically into activity.

Skillful artificial means can still surpass the effect of these natural conditions. Here belongs everything which accentuates the authority and dignity of the originator of the suggestion. The psychologically trained physician has no difficulty in heightening the effect by simple surprises, if he cares for such tricks. If the patient for whom a mental treatment is recognized as necessary shows himself too skeptical to submit to the powers of the psychotherapist, such captivation of his belief can easily be secured. Let the man perhaps fixate a penny on the table with his right eye, while the left is closed and you show him that you can make another penny suddenly disappear when you move it a certain distance to the right and appear again when you move it still further. As the man has never heard of the blind spot in the retina, he accredits you with a special power. Many similar psychological illusions can well be used to prepare the mind for unsuspected healing powers.