Psychotherapy

by Hugo Münsterberg

Still stronger is the effect of personal contact. The psychophysiology of love indicates the most complex influence which contact sensations have on the whole nervous system and especially on the vasomotor apparatus of the body. Probably such vasomotor effect enters in, changing the blood circulation in the brain, when a personal contact between the transmitter and receiver of the suggestion is brought about. If the physician's hand rests quietly on the forehead of the patient who lies with closed eyes, or if he holds for a long while the hand of the patient, he may secure a nervous repose and submission which gives to the suggestions the most fertile soil. Needless to say that here again everything depends upon the accessories. An unsympathetic doctor may be entirely powerless where his neighbor has complete success. Neither a lifeless hand nor an agitating one will bring the desired repose, neither a cold nor a rough one. There must be strength and energy and even discipline, and yet sympathy in the pressure of the fingers. Again a psychologically different effect and yet one often to be preferred results from mild stroking movements, the stroke always to be repeated in the same direction, never up and down. The slow change in the position of the tactual sensations evidently produces a rather strong influence on the equilibrium of nervous impulses, and here again vasomotor reflexes seem to arise easily. Another variety of such bodily influences is given by artificial changes of the positions, for instance by bending the head of the subject backward while the eyes are closed. It may be that a certain lack of balance sets in in which the self-equilibrium is disturbed and an external influence can thus more easily get control of the psychophysical system. Again a certain monotony of speaking may easily add to the increase of the suggestibility.

Everyone knows that another most fruitful cause of this change is any mystic inspiration, any emotion in which the individual feels himself in contact with something higher or larger or stronger. Of course, the church can secure this effect easily, and here again the maximum will be reached if a bodily contact with the symbol of religious exaltation can be established. The patient who can touch the relics of the saints or bathe in the waters of Lourdes or at least feel on his forehead the hand of the minister, is wrought up to a state of suggestibility which makes suggestions easily effective. The objective value of religion again has nothing to do with it, as exactly the same effect can result from the most barbarous superstition. The amulets of a gypsy might secure the same resetting of the psychophysical system which the most sacred symbols awaken, and even many an educated person is unable to cross the threshold of a palmist or an astrologist, or to attend the performance of a spiritist, or to sit down with a purchasable trance medium without feeling an uncanny mental state which is objectively characterized by an increased suggestibility. But finally, the same effect sets in when the symbols of other emotional spheres are applied, perhaps for the patriotic soldier the flag of his country.

All the states of increased suggestibility which we have characterized so far still remain within the limit of normal wakefulness. We may turn now to the methods of the psychotherapist which produce in the interest of the suggestions an artificial state. However we have no right superficially to claim that the effectiveness of the suggestions is always greater in such unnatural states. On the contrary, we know that sometimes well applied suggestions work on wide-awake persons with increased suggestibility more strongly than on hypnotized subjects. Here even the instinct of the experienced physician may easily go astray, and it may need practical tests to find out which way will be the most accessible to the particular case. Often a certain rôle belongs even to natural sleep. It cannot be denied that some people can be influenced to some degree by words spoken to them during sleep. Most adults either wake up or show no signs of influence beyond effects on their dreams. But some absorb especially whispered words in such a way that their power becomes evident after the waking of the sleeper. Much more is this true of children. A suggestion to give up vicious habits, perhaps in the sexual sphere, or to speak fluently and no longer stammer may thus be beneficial. Yet the danger of this method is not small and extensive use of it is certainly not advisable. The more easily it can be carried into every bedchamber and can thus give to every mother and nurse the tools of a rather powerful therapy, the more a danger signal ought to be displayed. Interference with the natural sleep by outer influences creates abnormal conditions which cannot be removed at will. The chances are great that many unintended bad effects slip in and that not a few hysterias may be created by a method at the first glance so startling. Much less objectionable is it to make use of the effect of that period of half-sleep which precedes the natural sleep, and which is for many a period of increased suggestibility for autosuggestions. A resolution or the formulation of a belief which would be ineffective in a wide-awake state seems to get an accentuated effect on the mind, if it is repeatedly expressed in this transitional state. The psychasthenic who in such a half-dozing stage assures himself that he will no longer be afraid of going over a bridge or hearing a thunderstorm or will feel a disgust for whiskey or will have the energy for work, has a certain chance that such autosuggestions become reality the next morning. With many others there seems no effect to be obtained and not a few seem unable to catch the right moment. As soon as they begin to speak they become wide awake or fall asleep before they talk.

Incomparably more value belongs to the artificial sleep, the mesmeric state of earlier days, the hypnotism of our time. We have discussed its theory and recognized that an abnormally increased suggestibility is indeed its chief feature. We know hypnotism in most various degrees; the lowest can be reached practically by everyone, the highest by rather few. It is almost arbitrary to decide where those waking states with high tension of suggestibility end and the hypnotic states begin, and not less arbitrary to call the higher degrees only hypnotism and to designate the lower degrees as hypnoid states. If we do it, we certainly should acknowledge from the start that the hypnoid states are for therapeutic purposes not a bit less important than the full hypnotic states. Certainly the hypnoid states do not allow complex hallucinations and absurd post-hypnotic actions, but they offer excellent starting points for the removal of light obsessions and phobias and for the reënforcement of desirable impulses, volitions, and emotions. Many persons cannot under any circumstances be brought beyond such a hypnoid degree. The physician who has not theoretical experiments but practical success in view ought therefore never to trouble himself with the inquiry exactly which degree has been reached. This advice is given because nothing interferes with the progress of hypnotic influence so badly as the constant testing. It must naturally often lead to a point where the subject finds that he can very well still do what the hypnotizer told him not to do. If the doctor assures him that he can no longer move his arm and the patient is yet able to move it, the doctor secures the very superfluous knowledge that this special degree of suggestibility has not been reached, but the patient is sliding backward and the lower degree which actually had been reached will be less accessible later. The physician might rather resort to the opposite course and assure the patient, even after the first treatment which might have been a slight success, that he saw from definite symptoms that hypnosis had set in. That will greatly smooth the way for real hypnotic effects the next time.

The best method of hypnotizing is the one which relies essentially on the spoken word, awakening through speech the idea of the approach of sleep. If the hypnotizer assures the subject in monotonous words that a feeling of fatigue is setting in, that he is feeling a tiredness creeping over his shoulders and arms and legs, that his memories are fading away and that he is now hypnotized, for not a few all is done that is needed. The hypnotic state will come and will hold until the verbal suggestion takes it off again. Perhaps the hypnotizer says that he will count three and at three the subject is to open his eyes and feel perfectly comfortable. It is wise to tell the patient beforehand that he will not lose consciousness and that he will remember afterward whatever happens as many people believe that loss of memory belongs to the hypnotic state, and that they were not hypnotized if they can remember what happened. Such a skeptical after-attitude can seriously interfere with the success of the treatment.

Yet in most cases, it will be safer not to rely on words only but to supplement them by manipulations which all converge towards the effect of increasing the suggestibility and thus of overcoming the resistance to the suggestions introduced. It is well known that for this purpose it is advisable to begin the influence with some slight fatiguing stimulations. The effect is most easily reached when the patient fixates perhaps a shining button held over his eyes or listens to monotonous sounds. A particularly strong effect belongs again to very slight touch stimuli. If the subject with his eyes closed is touched perhaps by two pencils at various and unexpected points of the face and hands, a skillful playing on his tactual senses soon produces a half-dozing state of hypnoid character. In the same group belong those so-called passes which evidently have a reflex influence in the blood-vessel system. It is advisable to combine the various elements in such a way that at first physical stimuli upon eye or skin produce an over-suggestible state and that only as soon as this state is reached the verbal suggestion sets in, perhaps with the words, "I shall hypnotize you now." Under such conditions every subject may soon be brought to that degree of hypnotization which is accessible to him. Yet more than one treatment is usually necessary for the higher degrees. Much less importance for therapeutic purposes belongs to that hypnoid state which is reached without the idea of sleep where the subject comes with open eyes into a kind of fascination, produced perhaps by a sudden flash of light or by the firm eye of the hypnotizer. It is a state which can lead to a strong submission of will and which has its legal importance. Therapeutically it can hardly secure an effect which cannot better be secured through the real sleeplike hypnotism. Under certain conditions, chemical substances may well prepare for the hypnotic treatment, for instance bromides or alcohol. Others rely on the suggestive effect of flavored water. But all that is unwise. The confidence of the patient is the best preparation for the securing of the helpful degree of hypnotism.

Of course only a small part of the therapeutic usefulness is secured during the hypnotic state itself. A pain may be removed, sleep be secured, an idea be inhibited, a movement be reënforced in cases where non-hypnotic suggestions would have found insurmountable obstacles. During the hypnosis we may also open the storehouse of memory and bring to light the ideas which disturbed the equilibrium of the suffering mind. Further in those most complex hysteric cases of dissociated personality, new memory connections may be formed during the hypnosis by which a synthesis of the double or triple personalities into the old one may be secured. Yet the general effect which the physician has to hope for from hypnotic treatment is the post-hypnotic one. Not what happens during the hypnosis but what the suggestion will produce after hypnosis is essential to him. The fixed idea is to disappear forever, the paralyzed limb is under control, the desire for morphine and cocaine is gone for all future time, the perverse longing is annihilated, the old energy is to remain again for all time. It is the post-hypnotic after-effectiveness which gives to the hypnoid and to the hypnotic states their importance for the treatment of the most exasperating symptoms. To be sure, the treatment often must be a prolonged one. A man who for years has used thirty grains of morphine a day cannot be rid of the desire after two or three hypnotic sittings. In such a case the treatment may cover three or four months, if it is to be of lasting value and without any damage during the treatment.

Still we are not at the end of the psychotherapeutic methods and we may turn to a fascinating group of curative efforts which has especially come to the foreground in recent years. We mentioned before that mischief cannot seldom be traced back to earlier experiences with a strong unpleasurable feeling. In certain cases, the subject remembers such particular experiences as the beginning of his discomfort; in others, especially those of hysteric character, the starting point may have long been forgotten, and yet that early impression evidently left traces in the brain which produce disturbances in conscious life. The psychotherapist nowadays calls these groups of traces "complexes." We recognized clearly that there is no reason to refer such forgotten remainders of the past to any subconscious mind; they are physical after-effects which keep their influence over the equilibrium of the psychophysical system. Now modern psychotherapy finds that the entire disturbances which arise from such emotional disagreeable experiences, forgotten or not forgotten, can often be removed by psychical means. Two ways in particular seem open. As soon as the idea is fully brought back to consciousness again, the patient must be made to express the primary emotion with full intensity. Subtle analysis has repeatedly shown that many of the gravest hysteric symptoms result from such a suppression of emotions at the beginning and disappear as soon as the primary experience comes to its right motor discharge and gains its normal outlet in action. The whole irritation becomes eliminated, the emotion is relieved from suppression and the source of the cortical uproar is removed forever.

Practically still more important seems the other case which refers alike to hysterics and psychasthenics and which is applicable for the forgotten experience not less than for the well-remembered ones. This second way demands that the psychotherapist bring this primary experience strongly to consciousness and then by a new training link it with new and more desirable associations and reactions. The disturbing idea is thus not to be discharged but to be sidetracked so that in future it leads to harmless results. The new setting works towards an entirely new equilibrium. What was a starting point for abnormal fears now becomes an indifferent object of interest and all its evil consequences are cut off. It may be acknowledged that the full elaboration of these methods still belongs to the future. Both methods, the discharging, or the so-called cathartic one, and the side-tracking method evidently demand the discovery of the starting point in the service of the therapy and here again several methods are at the disposal of the psychologist.

A promising way to this end is the inexhaustible association test which we mentioned when we discussed the contributions of the psychological laboratory to the medical diagnosis. A series of short words are spoken to the patient and, as soon as he hears one, he is to pronounce as quickly as possible the first word which comes to his mind. If we use fifty words, we should be able to learn something as to the inner states of the man and as to the working of his mind, if we analyze carefully his particular choices. But two further conditions ought to be fulfilled. The time of the association ought to be measured. Of course there will be wide differences. A word which is often in a certain connection will quickly bring the habitual association. Abstract words will call forth their associations more slowly than concrete words, familiar words more rapidly than unfamiliar words. To measure such association time with fullest accuracy, as it is necessary for the purpose of scientific investigations, delicate electrical instruments are needed that indicate thousandths parts of a second. For the purpose of the practical physician such accuracy would be superfluous. His examination will be perfectly successful if it is carefully done with a stop-watch which shows the fifth part of a second, like those which are used at races. He speaks a word, presses at the same time the button of the watch, and presses the stopper when he sees the lips of the patient moving. He is thus able to examine not only the involuntary choice of association but also the time of every associative process. But a second condition ought also to be fulfilled. After some indifferent words, others ought to be mixed into the series which touch in a tentative way on various spheres corresponding to the possible suspicions. The groups to which the hidden thoughts of psychasthenics, for instance, belong are not many. As soon as our series of words strikes such a group, the reaction of the mind may be discriminated. The effect may be a general perturbation resulting either in an unusual delay of the fitting association or in an effort to cover the sore spot by an unfitting association. Sometimes the dangerous association may rush forward even with unusual rapidity but, as soon as it is uttered, it gives a shock to the mental system, brings the whole associative process into disorder, and the result is that the next following associations are abnormally delayed. The skilled psychologist will quickly take such a change as a cue for the selection of the later words in his series. Of course, he will at first return to neutral words, but as soon as he has found a danger spot, he will approach it from various sides, perhaps in every fourth or fifth word, and may then find out which particular experiences are disquieting the patient. Words like women or money or career or family or disease are often sufficient to get the first inkling of a mental story.