Psychotherapy

by Hugo Münsterberg

The patient is a school-teacher in the Middle West, a nervous, thin-looking woman of about twenty-five. Her only complaint is a persistent idea that she may at any time get a child. She has had this idea "as long as she can remember," according to her first expression. She never had any intimate acquaintance with any man, she was never engaged, she hated bitterly every thought of immorality, she knows and has assured herself by much reading that it is entirely impossible that she might get a child without sexual contact. Yet this thought recurs to her all the time, even when she is talking with other people. It embarrasses her in school, in spite of her teaching only girls in a private institution. This thought keeps her away from company and the effect of its embarrassing occurrence depresses her, but she is sure that the thought itself does not include any emotion. It is a mere thinking of it with a full consciousness that it is absurd, and yet she cannot suppress it.

I began at once to try to find the origin of her queer obsession. After some efforts to pierce into her memories, we came to an experience of her youth. When she was about thirteen years of age, a young girl whom she had admired much for her beauty, living in the neighborhood of her parents, suddenly got a child which died after a few days. At that time no thought of immorality seems to have entered into that news. It was evidently mere sadness about the quick death of the child which gave to the experience its emotional tone. She was at that time completely naïve. She received an intense shock in the thought that an unmarried girl may suddenly get a child which would then quickly die. She cannot tell whether the thought that she herself would get a child had ever entered her mind before this occurrence in her neighborhood, nor can she say that it occurred immediately or very soon after it. She now knows only that she has always had that thought, but whether that means more than ten years, she does not know.

I considered it a justifiable hypothesis that this strong emotional experience early in life had become the starting point for that secondary absurd thought. I considered that primary experience as cause for a deep physiological brain excitement which had irradiated towards the ideas of her personality. It had stirred up there associations which kept their psychological character while the primary disturbance had long lost its psychical accompaniment. It worked its mischief in a physiological sphere but was probably still the starting point for the persistent obsession. My aim was to remove this cause. It would have brought little improvement simply to suppress the freak idea as long as that physiological source was active. On the other hand I should not have the means to stop the physiological after-effects of that real experience: I had to sidetrack it and to secure thus a reduction. I decided therefore to work on the basis of that hypothesis, to accept that physiological complex as existing, but to switch it off by linking it with appropriate associations, thus setting it right in the whole system of her thoughts.

For that purpose I brought her into a hypnoid state, bending her head backwards and speaking to her with slow voice until I saw that a slight drowsy state was reached. In this state I asked her to think back as vividly as she could of that experience of her youth, to fancy herself meeting that pretty girl, her neighbor, once more. She is to imagine that she speaks with her. Now I make her talk with me and she assures me that she sees the scene distinctly. She believes she sees the girl on the street. I ask her to tell the girl how indignant she feels over her behavior; she is to tell her that she understands now all which she did not understand in her childhood, that she knows now that she must have lived an immoral life; that she must have had a friend and that a pure girl like herself could never under any circumstances come into such a situation, that no pure girl could suddenly have a child. She is to express to the other girl her deepest disapproval of such conduct and her own feeling of happiness that anything like that could never happen to her. In accordance with my demands, she worked herself entirely into the scene: without using audible voice, she internally spoke with great vividness to her neighbor. When I awoke her from her drowsy state, she was quite exhausted from the excitement. I repeated that scene with her four times. She assured me that she felt it every time more dramatically. The power of the obsession weakened from the first day. After the fourth time, it had disappeared. The subcortical complex had evidently found its normal channels of discharge.

In discussing this method of side-tracking the complex, we mentioned that in other cases the result is reached by bringing the memory of that first experience to a vivid motor discharge, without substituting any other ideas. For that purpose no direct personal influence is necessary. Treatment might just as well be performed "by correspondence," provided that the right starting point is discovered and that right suggestions are given. As an illustration, I may choose a case which shows at least the maximum distance treatment by mail, from Boston to Seattle. This particular case presented no difficulty in getting hold of the starting point as my correspondent, whom I have never seen, himself at once pointed to the original source of his obsessing idea.

The patient who lived with his family in Seattle wrote to me the following: "——I shall undertake to describe in a few words a condition which the writer has fought against for about eight years and which has subjected him to untold mental anguish.——I was backward in a social way but altogether happy. After working in a bank about a year, was discovered one evening by the cashier smoking a cigar in the basement, was unable to look him in the face at the time. Went home that night and thought very little about it, but on the following morning during the regular course of business, I stepped up to him to ask some question, and as usual, unconsciously looked him in the face. His glance was questioning and suspicious, and that was the beginning of a life of anguish for me. At first I could not look him in the eyes, then when looking at some other person, I happened to think of it and so on, until in two or three days it was impossible to look at anyone who came to my window. The cashier did everything he could for me. No use: I quit my position, lost most of my friends, had to leave a happy home and came to Seattle to work for an old school friend. In the first year, owing to new environments, I managed to conceal my mental condition to a certain degree. All of a sudden, I was again plunged into the depths of black despair. It took me about two years to (partially) forget it, when the same thing occurred again, and I lost my grip. The last time about eighteen months ago was almost more than I could stand. These three or four instances I speak of were cases of extreme despondency, but my usual mental condition is extremely unhappy. If occasions arise where I have to sit and talk to anyone for ten minutes, controlling myself is such an effort that it leaves me with a case of the blues.... I shall come and see you as the relief would give me a new lease on life."

This letter was written on the twenty-third of January, 1908. I replied to him at once that he certainly ought not to come from the Pacific to the Atlantic, but that I wanted him to write to me much more about that first occurrence. As he was evidently right in considering that episode as the starting point of his troublesome associations, I supposed that these associated ideas had not yet become independent but were still the effect of that first "complex." Therefore I wanted to bring that to complete discharge. Accordingly I wrote him to think himself once more into that happening of years ago, to pass through it with all the power of his imagination, to describe it to me then in as full a statement as possible and to express in the letter also his conviction that there was no reason to avoid the eyes of his superior, that he might have looked straight into his face. As soon as he got my reply, he wrote to me on the sixth of February a description of that first episode, filling nineteen pages, telling me all about his relations to those various men and every minute detail was brought clearly to consciousness again. I did not add anything further, but the expected occurred. On the eighteenth of February, he writes to me: "In the last week or ten days, the writer has noted a decided improvement regarding mental condition. The result is a new interest in life. If you can spare the time, would like to have you write me a few lines. Gratefully yours." At the end of the month he writes: "Received your letter about half an hour ago. Hasten to assure you with a great deal of pleasure that I am feeling much better. Since sending you the letter regarding the first case, I have noticed day by day an improvement." On the eighth of March: "Since writing you last I have noticed a gradual improvement. It has given me wonderful encouragement." On the tenth of March: "Just a line to say that I am still improving." On the twelfth of April: "I desire to say that since the taking up of treatment with you, life has had a far different appearance to me than it has had for the last ten years." On the twenty-first of April: "Since my first letter to you, there has been such an improvement that I have accepted a position which carries with it much responsibility."

This case leads over to the large group in which the obsessing idea involves the relation to a particular person. I find in such cases autosuggestion more liberating than heterosuggestion if the development has not gone too far. Of course autosuggestion can never take hypnotic character, but makes use with profit of the transition state before normal sleep. The type of these cases which are everywhere about us may be indicated by the following letter.

The writer is a young woman of twenty-four, whom I did not know personally. She wrote to me as follows: "I am a writer by profession and during the last year and a half have been connected with a leading magazine. In my work, I was constantly associated with one man, the managing editor. This man exerted a very peculiar influence over me. With everyone else connected with the magazine, I was my natural self and at ease, but the minute this man came into the room, I became an entirely different person, timid, nervous, and awkward, always placing myself and my work in a bad light. But under this man's influence, I did a great deal of literary work, my own and his too. I felt that he willed me to do it. The effect of this influence was that I suffered constantly from deep fits of depression almost amounting to melancholia. This lasted until last fall, when I felt that I should lose my mind if I stayed under his influence any longer. So I resigned my position and broke away. Then I felt like a person who, having a drug to stimulate him to do a certain amount of work, has that drug suddenly taken away, and without it I am unable to write at all...." I wrote to the young lady that she could cure herself without hypnotism and without my personal participation. I urged her simply to speak to herself early in the morning and especially in the evening before going to sleep, and to say to herself that the man had never helped her at her work, but that she did it entirely of her own power, and that he had never had any influence on it, and that she can write splendidly since she has left the place, and much better than before. A few months later, she came to Cambridge and thanked me for the complete success which the auto-suggestive treatment had secured. She was completely herself again and was fully successful in filling a literary position in which she had to write the editorials, the book reviews, the dramatic criticisms, and the social news. As a matter of course, such treatment had removed only the symptom. The over-suggestible constitution had not been and could not be changed. Thus it was not surprising that in the meantime, while her full literary strength had come back, she had developed some entirely different symptoms of bodily character which I had to remove by hypnotism.

As soon as the obsessing idea of the influence of another person takes still a stronger hold and develops systems, the suspicion of insanity always lies near; especially when hallucinations are superadded, the probability is great that we then have to do with the delusions of a paranoiac, and thus no case for psychotherapeutic treatment. Yet it is always wise to keep a psychasthenic interpretation in view as long as the insanity is not evident. I may mention such an extreme case.