Psychotherapy

by Hugo Münsterberg

Nearest to the psychophysical processes stands the bodily symptom of insomnia. There is no doubt possible that the work of the psychotherapist can be very beneficial in producing sleep by suggestion. That autosuggestions for sleep play an important rôle is popularly accepted. Next to the most immediate means such as lying down, or cutting off sense stimuli, or trying not to think, or avoiding movements, certainly the most well known factor is the expectation of sleep with the belief that sleep will come. This belief may be reënforced to strong autosuggestion which may then overcome other factors that hinder sleep. For instance, I have repeatedly received letters from strangers containing expressions of gratitude with news which under other circumstances would at least not flatter an author. They wrote to me that immediately after reading one or another essay of mine on hypnotism, they fell into deep sleep. Yet as they were always patients who had suffered from insomnia, I was pleased with this unintended effect of my writings. But in most cases a real cure demands heterosuggestion.

There is room for any variety of effects; often they enter immediately. The other day I gave sleep suggestion to a young woman who had overworked herself in literary production. For months she had not slept more than three or four hours a night and even that only after taking narcotics. I intentionally did not allow her to come into a hypnotic sleep but kept her fully awake, increasing her suggestibility while her eyes were wide open. I suggested to her to take a walk, then to eat her dinner, and after that to go to bed at once. She went to bed at seven o'clock and slept without waking until ten o'clock the next morning, and after fifteen hours' sleep she was like a different being. A regular eight hour sleep is sometimes secured, even where no immediate direction has been given for it. On the other hand, I cannot deny that I have sometimes been entirely unsuccessful in securing better sleep by the first three hypnotic treatments. When the first three treatments were unsuccessful, I always gave it up on account of lack of time. Yet the experience of others shows that in such cases, often after a long continued hypnotic treatment insomnia yields to suggestion. One of the great factors which work against the mental treatment is the habit of so many sufferers of relying on their sleeping powders which, to be sure, remain effective only by increasing the dose and thus finally by making them dangerous. Every chemical narcotic has in itself suggestive power and strengthens the belief of the sleep-seeker that he cannot find rest without his dose. To overcome the monopoly of the opiates is one of the most important functions of psychotherapy.

It is not surprising that the relations of psychotherapy to sleep show such a great variety. The factors which coöperate in normal sleep are many and the disturbance can have very different character. We had to speak of the psychophysics of sleep when we discussed the theoretical relation of sleep to hypnotism and insisted that it is misleading to consider hypnosis simply as partial sleep. We claimed a fundamental difference between the selective inhibition in hypnotism and the general reduction of functions in sleep. To understand sleep, we have to recognize it as one of the fundamental instincts, comparable with the instinct for food or for sexual satisfaction. Every one of such instincts has a circular character. Mental processes, subcortical processes, and physical effects are involved in such a way that each reënforces the others. The physical effect of the sleep instinct, comparable with the pepsin secretion in the food instinct, or with the hyperæmia of the sexual organs in the sexual instinct, is a change in the cortex by which the sensory and motor brain centers are put out of action. What kind of a change that is, is quite indifferent. It may be a chemical one but more probably it is a circulatory one. Let us say it is a contraction of blood-vessels which by the resulting anæmia makes the sensory centers unfit for perception and the motor centers unfit for action. In this way the brain becomes protected by sleep against the demands of the surroundings. The mental reactions are eliminated and the central nervous substance has an opportunity to build itself up. This protective physical activity is now evidently itself controlled by a subcortical center, just as secretion and sexual hyperæmia are controlled. This center probably lies in the medulla oblongata.

Some theorists, to be sure, are inclined to think that the fatigued brain cells enter directly through their exhaustion into the protective sleep state. But that simplifies the situation too much. It is quite true, as these theorists claim, that monotonous stimulation of the senses produces sleep. But it is evident that the sleep occurs even then not only in the particular overtired brain cells. A monotonous stimulation of the acoustical center raises the threshold of perception for all the senses and brings sleep to the whole brain. This control of the whole apparatus is thus surely regulated by one definite center. But this lower center, which controls the anæmia of the cortex, is itself directly dependent again upon a mental condition, the mental experience of fatigue. The fatigue sensation, which is possibly the result of toxic processes, works on that lower sleep center, just as the appetizing impression or the sensual images work on the centers of the other two instincts. On the other hand this protective blood-vessel contraction creates again as in the other cases a characteristic organic sensation, the sensation of rest which arises when the threshold of perception and activity is raised. The world begins to appear dim and far away, no impulse for action excites us. This organic feeling of rest associates itself with the fatigue feeling. The fatigue sensation, the subcortical sleep center, the contraction of the vessels in the cortex, and finally the rest sensation form together the complete circle. The difficulty which arises in this case lies only in the fact that the cortex gone to sleep annihilates also, of course, the fatigue sensation and the rest sensation. For that reason the real circle can appear only in the preparatory stages of sleep. As soon as sleep itself sets in, the circle is broken. The circle character of every instinct must lead the physical effect upward to a higher and higher degree. Not to become excessive, the physical effect must be checked somehow. In all other spheres, it finds its end in satisfaction, for instance, by eating or by the sexual act. In sleep the circular process ends automatically by its own effect as soon as complete sleep is reached. Its causes, the fatigue and the rest feeling, are stopped, as soon as the effect, the anæmia, is secured.

We see now how widely different starting points can lead to sleep and can understand from it how widely different disturbances can prevent sleep. Sleep must result when fatigue is coming, but sleep must also result when the elements of the rest feeling are produced, and as we saw that the components of the rest feeling were the sensations of decreased sensitiveness and decreased activity, sleep must result when either the sensations and associations are absent and actions are suppressed, or when monotonous sensations and automatic actions raise the threshold. Sleep must arise further if our will associates the mere idea of such rest, and finally physical or chemical means may produce a sleep bringing effect either on the lower center or on the blood-vessels and cells of the cortex. Correspondingly sleep may be prevented by disturbances in any one of these spheres. There may be no normal fatigue, there may be no fatigue sensation, there may be no rest feeling on account of perceptions, or on account of associations, or on account of impulses to action; there may be no normal response in the subcortical center, there may be no physical effect in the cortex on account of an existing hyperæmia or on account of an abnormal condition of the cells. The psychotherapeutic treatment must carefully analyze which element would be fit to supply the last link in the circular chain. Sometimes we need the suggestion of fatigue, sometimes the inhibition of ideas, sometimes the suppression of impulses, sometimes the suggestion of rest, and so on. A mere general suggestion of sleep is on the whole effective only in the cases of those persons in whom this idea in itself awakens those various components. Very often it is entirely ineffective in this general form. Sometimes it is possible to carry the hypnotic state itself directly over into sleep, but it seems more in the interest of the patient to separate those two states distinctly.

We are still confined to processes in the brain itself if we turn to headache. If it were only a question of inhibiting the pain by mental suggestion, the case would not be different from inhibiting the pain of a peripheral organ without attempting to cure the diseased organ itself. But in the case of headaches, it seems justified to claim that in certain varieties of this multifold symptom, not only the pain is suppressed but the disturbance itself is removed. Especially where the headache seems to result from hyperæmia, the trouble seems to be accessible to psychotherapeutics. On the other hand I have never seen any lasting effect on the so-called sick headache or migraine. While continuous headaches or headaches which occur daily yielded to my influence, sometimes completely, I was unable to prevent even by preparatory hypnotization any migraine which appears periodically, for instance, simultaneously with menstruation.

A few words only as to the general diseases and disturbances for which a very strong therapeutic effect has been claimed by masters of the craft like Wetterstrand, Moll, Dubois, and others. From my own experience I can affirm the often lasting effect in the disturbances of the functions of the digestive apparatus. The stomach and the intestines seem to a high degree under nervous influences which can be changed through hypnotic suggestion. If we consider what intimate connection exists between the functions of these organs and the normal emotions, it seems hardly surprising that mental factors can regulate their disturbances. Vomiting, diarrhea, and especially constipation, often yield to slight suggestions, even in a superficial hypnotic state. Here, too, I have seen repeatedly a complete regulation of a long-standing disturbance as an unintended by-product of hypnotic suggestion directed towards the cure of psychical troubles. Much value is claimed for hypnotic method in the treatment of anæmic conditions. It is said that anæmia improves after a few hypnotic treatments, the appetite becomes better, the cold hands and feet grow warmer, the headaches disappear, the capacity for work increases rapidly, and most surprising of all the leucorrhea ceases. As to heart disease, we ought to think in the first place of the disturbances of nervous innervation. I have seen repeatedly a remarkable decrease of nervous palpitation of the heart through direct mental influence, abstracting here from the secondary effect of suppressing mental excitement and fear. Where organic heart diseases are surely present, it seems that hypnotism can sometimes act beneficially if the heart trouble is accompanied by anæmia and general debility; of course a developed valvular disease cannot be removed. In the same way it seems that in Bright's disease, certain painful symptoms may be suppressed, but the kidneys certainly cannot be influenced. At least open to serious suspicion are the insistent claims that diabetes can be cured by suggestion. Dr. Quackenbos of New York, for instance, gives to some of his diabetes patients a hypnotic suggestion by the following words: "If your pancreas be crippled in its production of the natural ferment which is given off to blood and lymph and which conditions the normal condition of sugar in the body or restrains the output of sugar from the liver tissues, you will see that it forthwith pours into your blood or lymph the sufficient quantity of sugar oxidizing ferments." It certainly transcends our present understanding if we are to believe that a suggestion of this type will change the action of the pancreas. It is hardly worth while to enter into the still more extravagant claims from other sides like those for curing cancer and phthisis. On the other hand, in the light of all that we have discussed, there is no difficulty in understanding the easily observable influence in the regulation of menstruation, in the cure of contractions, local congestions, and incontinency of urine. I may mention finally the use of hypnotism for helping in a safe and quick confinement.

But in addition to all this, we have the great help which psychotherapy may bring indirectly in the treatment of physical diseases. I said, for instance, that I do not believe in a real help by mere suggestion in cases of diabetes. But no one ought to underestimate the value which may result for the treatment from a suggestion of a well-adapted diet. The patient who feels a craving for bread and potatoes and perhaps sweets, and is too weak to resist it, is indeed brought into safety if suggestion liberates him from such desires. The same holds true for every other diet and for any medical régime of life which does not harmonize with the natural instincts of the patient. For not a few sufferers, reënforcement of the interdict against coffee and tea or alcohol and tobacco is more important than any medicine. Hypnotic suggestion can easily create dislike of the prohibited material and can build up new desires and inclinations. In the same way it is indirectly most important to stir up, for instance, the sensations and feelings of appetite and thus to make normal nutrition possible. Also in cases of anæmia or tuberculosis, such indirect assistance can produce some beneficial consequences.

The same holds true of the power of the psychotherapist to secure sleep. The fight against insomnia which we discussed referred only to that sleeplessness which is itself an expression of the disease. But as a matter of course, the loss of sleep can accompany most different diseases, as an almost accidental result. To secure sleep means then not to treat the symptoms of the disease but a by-product; and yet every physician knows how much is gained if the lost energies are restituted by a sound sleep. And finally we have the indirect help towards the cure by the suggestive removal of pain. We have no right to say that it is a pure advantage for the treatment of the disease if the pain is centrally inhibited. Pain surely has its great biological significance and is in itself to a certain degree helpful towards the cure, inasmuch as it indicates clearly the seat and character of the trouble and warns against the misuse of the damaged organ which needs rest and protection. To annihilate pain may mean to remove the warning signal and thus to increase the chance for an injury. If we had no pain, our body would be much more rapidly destroyed in the struggle for existence. But that does not contradict the other fact that pain is exhausting and that the fight against the pain decreases the resistance of the organism. As soon as the disease is well recognized through the medium of pain and the correct treatment is inaugurated, not only the subjective comfort of the patient but the objective interest of his cure makes a removal of pain most desirable. While it would be absurd to say that hypnotism can cure tuberculosis or cancer, it is fully justifiable to say that hypnotic treatment in tuberculosis or cancer is to a high degree beneficial, inasmuch as it can secure sleep, appetite, and freedom from pain, three factors which indirectly help to fight the disease. The elimination of pain may sometimes also play its rôle in slight operations where other methods of narcosis seem for any reason undesirable, and very frequently hypnotic suggestion has been used for this purpose at childbirth.

The same importance which belongs to the removal of bodily pain in the treatment of a peripheral disease may be given to its mental counterpart, to the worry, excitement, and emotional shock. They all stand in the way of a real success in any cure. Even the chances of a dangerous operation are entirely different for the patient who goes to it with free mind and a happy mood, with full confidence in its success, from those of a patient who has worked himself into a state of fear and anxiety. Here again the depression and the excitement are not in question as symptoms of a disease, as they were when we discussed the phobias and despondencies of the neurasthenic and of the hysteric. They are merely normal side-effects of the bodily disease, accentuated perhaps by a suggestible temperament. To eliminate all these emotions means to change most helpfully the whole atmosphere of the sick-room and to deprive invalidism of its saddest feature. This negative factor corresponds of course most directly to the positive feature of building up new hope and joyful expectation. He who creates confidence makes convalescence rapid and strengthens the power to overcome disease.