With less diagnostic elegance we sometimes reach the same end by taking careful records of pulse and breathing and involuntary movements during an apparently harmless conversation. The instruments at the disposal of the psychologist are those familiar to every psychological laboratory: the pneumograph, which registers the movements of respiration; the sphygmograph, which writes the pulsation of the artery in the wrist; the automatograph, or other instruments, which register the slight unintentional movements of the arm. If the examiner is skillful, he will not fail to discover the changes in breathing and pulse and reaction as soon as the painful groups of ideas are approached. More of theoretic interest and too cumbersome for practical diagnosis is the unfailing galvanic reaction from the skin in which the glands change their activity and their resistance to the galvanic current under the influence of hidden emotions. Yet all these methods, with exception of the last, are essentially useful only if the starting experience is still accessible to the memory of the patient. He may be unaware that it had anything to do with his nervous symptoms but he recognizes the experience still as soon as his attention is directed towards it. The psychologically more interesting but probably more exceptional situation is the one in which it is not only forgotten but cannot be recognized when it is brought to consciousness. The shortest way to get hold of such past impressions is the hypnotic one. The hypnotic state sharpens the memory and experiences of early childhood or apparently insignificant experiences of later life may be brought back when they would have been inaccessible to any intentional effort of the attention. Even still more surprising is the success if the association is left to a dreamy play of ideas suggested perhaps by gazing into a crystal ball or by a meaningless talking. Perhaps the patient lies with closed eyes on the couch while the physician holds his hand. A few words are given to him as a starting point and then he is thoughtlessly to pronounce whatever comes to his mind, not only unfinished sentences but loose phrases, single words, apparently without meaning and slowly ideas arise which betray the original intrusion. At last memories and lost emotions come again to the surface, and the watchful psychotherapist may discover the complex, which is then to be removed by discharge or by side-tracking. This is the so-called psychoanalytic method.
Finally the psychotherapist may go still one step further. After all it often seems inexplainable that just this or that emotional experience made such a deep and lasting impression while a thousand other experiences passed by without leaving any mischievous after-effect. It seems that indeed the conditions are still more complicated. That emotional disturbance operated dangerously perhaps only because it itself appealed to a suppressed desire and this seems to hold true especially for suppressed emotions of the sexual sphere. The desire for gratification in normal or abnormal channels was perhaps attached by the mind to some group of objects. It was completely suppressed but it left an abnormal tension in the central system. If now a chance experience touches on this group of ideas, there results an explosive reaction; and movements, convulsions, spasms, obsessions, and fears set in which get their particular character not through the secondary intrusion but from the primary desire. To discharge that intrusion leads therefore only to the elimination of those symptoms which resulted from it, but the primary disturbance goes on and any new chance intrusion will produce new explosions. The psychotherapist should therefore go deeper and relieve the mind from those primary desires which may belong to early youth and which are entirely forgotten. Even the method of automatic writing may here sometimes lead to an unveiling of those deepest layers of suppressed desires. In the same way a careful, subtle analysis of dreams may support the search for the hidden source of interference.
We have spoken of the technical methods of the psychotherapist. It would be short-sighted to ignore the great manifoldness of secondary methods which he shares with the ordinary intercourse between man and man, the methods which the teacher uses in the schoolroom, which the parents use in the nursery, which the neighbor uses with his neighbor, methods which build up the mind, methods which train the mind, methods which reënforce good habits and suppress unwholesome ones, methods which stimulate sound emotions and inhibit a quarrelsome temper, methods which indeed are not less important in the psychiatric clinic and in the hospital than in our daily life, and which certainly have central importance in that borderland region which is the particular working field of the psychotherapist.
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THE MENTAL SYMPTOMS[Contents]
We have discussed both the psychological theory and the practical work of psychotherapy in a systematic order without any reference to personal chance experience. After studying the fundamental principles, we have sketched the whole field of disturbances in which psychotherapeutic influence might be possible and all the methods available. It seems natural that our next step should be an illustrating of such work by a number of typical cases. Here it seems advisable to leave the track of an objective system and to turn to the record of personal observation. As this is not a handbook for the physician, dealing with the special forms of disease, we emphasized before that we avoid even any attempt in such a direction because it would have to introduce not only the questions of diagnosis, but above all the highly important questions of treatment by physical agencies. We saw that for us nothing else can be desirable, but to show the way in which the various symptoms which suggest mental treatment occur, and how they yield to the psychical methods. We had also agreed beforehand that for a first survey we might separate the mental from the bodily symptoms and group the mental ones with reference to the predominance of ideational, emotional, and volitional factors. And finally it may be said that we abstain from everything which is exceptional or even unusual, and confine ourselves to the routine observations with which the psychotherapist comes in contact every day and the simplest country physician surely every week.
Thus I turn from systematic objectivity to my unsystematic reminiscences of many years. Of course, they abound with eccentric abnormities and startling phenomena. As I have devoted myself to psychotherapeutics, always and only from scientific interest, as a part of my laboratory studies and therefore have refused to spend any time on cases which offered no special psychological interest to me, the striking and sensational cases have prevailed in my practice even to an unusual degree. Yet they are unessential for our purposes here, the more as their interest lies mostly in the complex structure of the mental state while the curative features are in the background. Our purpose of demonstrating practical cases as they occur in every village, and as they ought to be understood and treated by every doctor, thus rules out just those experiences which would be prominent in a theoretical study of abnormal psychology. We want to select only simple commonplace cases. Only those who have not learned to see are unaware that such cases are everywhere about them.
As a matter of course, I also leave out everything which refers to insanity, that is, every mental disturbance which lies essentially outside of the domain of psychotherapy. The helpful influence which psychical factors can exert in the asylums for the insane is, as we emphasized, entirely secondary. The psychotherapeutic methods in the narrower sense of the word are in the present state of our knowledge ineffective in the insane asylum. I should also be unable to speak of laboratory experience with insanity, as I insist on sanitarium treatment in every such case. The question of how to differentiate the diagnosis of insanity from that of the other mental abnormities is not our question at this moment. I select the few illustrations which seem to me desirable for the purpose of making more concrete our abstract discussion of methods, essentially from the class of neurasthenics, psychasthenics, hysterics, and so on.
In all these reports, I shall confine the account to the few points which are to illustrate the psychical factors, thus abstaining entirely from the further details which any medical history of the cases would demand and from all results of further examination and other particulars. As a matter of course, I exclude the possibility of identifying the patient. I may start with a typical case of obsessing ideas of simplest character and with simple routine treatment illustrating the emphasis on antagonistic ideas.
A man of mature age, well educated, well built and in every respect in good health, without nervous history and without other nervous symptoms, suffered vehemently by the persistent recurrence of a visual image which entirely absorbed his attention. He knew exactly the development of his trouble. A woman acquaintance of his had committed suicide by poisoning herself. He knew her slightly and the emotion of personal loss played hardly any rôle in the case. But he had met her at a gay dinner a short time before her death. The news of the suicide came to him when he was overtired from work. The idea of the contrast between seeing his friend partaking of the dinner and imagining her drinking the poison gave him a strong shock. There was hardly any grief mixed in. He remembers that he shivered at the thought of the contrast, and in that moment the visual image of the woman raising a glass of poison to her mouth flashed into his mind and thus became almost a part of the shock. From that time on, the memory image of this scene returned more and more frequently. At first it associated itself with any chance mentioning of death or suicide and to a very slight degree with the idea of a meal. More and more any element of a meal and of social life, the word soup or meat, the word gown or dance, brought up at once the picture of the woman, which had in the meantime lost every element of personal relation. Any sad thought of her ending had faded away. It remained merely a troublesome impression. The man fought against it by trying to suppress the idea but the more he fought against it, the more insistently it rushed forward through new and ever new association paths. Any advertisement in the newspaper referring to food, anything in a shop window referring to ladies' dresses, any household utensils related to a meal, and especially the meals themselves, forced the visual image into the centre and captured the attention to such a degree that a confusing distraction from the real surroundings resulted. The struggle against the idea became more and more exasperating, made life a torture, almost suggested despair, even faint thoughts of suicide, and especially a growing fear that it was a symptom of the beginning of insanity.