Psychotherapist

“ A well-conducted psychotherapeutic treatment as a scientific physician ought to carry it out, is entirely different in meaning and appearance, from the first step of diagnosis to the last treatment of after-effects, from every unscientific faith cure. It is also in no way necessary that the psychotherapist ever leave the path of complete sincerity. There is no reason at all for promising that the patient will be entirely cured if the physician believes that a real cure through suggestion is impossible. ”

“ Even if psychotherapy could not do more in the treatment of bodily diseases than to secure a joyful obedience to the strict demands of the physician, it would yet have to be accredited with an extremely important service.
In a parallel line comes the effective aid by the stimulation of hope and the suppression of fear, by suggestion of a feeling of encouragement and the inhibition of the emotions of worry. This is a field where even the average physician is most easily inclined to play the amateur psychotherapist. ”

“ 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. ”

“ The psychologically trained physician has no difficulty in height [Pg 223] ening 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. ”

“ Yet the different tendency is easily recognized, if we turn only, for instance, from the mere sympathy and encouragement to the method of reasoning with the patient about the origin of his special complaint. Just now the medical profession moves along this line a great deal. Of course no well-trained psychotherapist will make the blunder of arguing with the insane. To dispute by argument with the paranoiac and to try to convince him would not be only without success, but easily irritating. ”

“ Among our patients we see many so-called immoral tendencies, therefore the thought involuntarily forces itself upon the psychotherapist as to how things would go if all these desires were to be gratified. ”

“ Of course, the patient does not accept the explanation at once. He feels sure that he is not accessible to suggestion and that he has least of all a tendency to autosuggestions, but the skillful psychotherapist will find somewhere an opening for the entering wedge. He may develop to the patient the modern theories of the origin of neurotic disturbances, all with entire sincerity and yet all shaped in a way which gives to the special case an especially harmless appearance. He may even enter into experimental proof that the patient is really accessible to autosuggestions. ”

“ We have discussed the psychological tools with which the psychotherapist has to work but we have not spoken as yet of psychotherapy itself. All that we have studied has been by way of preparation; and yet the right preparation is almost the most important factor for the right kind of work. ”

“ The depression of the neurasthenic must not be treated like the depression of the melancholic, the [Pg 181] obsession of the psychasthenic must not be mixed with the fixed ideas of a paranoiac, the hysteric inability to walk must not be confused with an injury of the motor nerves; in short, each symptom has to be treated as part of a complete situation. The efforts of the psychotherapist will move over as large a part of the disease as possible and cover, perhaps, the causes of the disturbance as far as they are of psychical origin. ”

“ This is an influence which is most easily misunderstood and which has most often become the starting point for misleading theories. Before we enter into the study of the practical effects of suggestion and the psychotherapeutic results, we must examine this tool in the hand of the psychotherapist from a purely psychological viewpoint. The patient may perhaps sometimes profit from suggestion the more, the less he understands about its nature, but the physician will always secure the better results, the more clearly he apprehends the working of this subtle tool. ”

“ The whole spacially extended mass of the pathogenic material is thus drawn through a narrow fissure and reaches consciousness as if disjointed into fragments or strips, and it is the task of the psychotherapist to recompense it into the conjectured organization. ”

“ Above all, as the psychotherapist sees at once, it will occupy her mind, keep down anxiety and lessen pain in many natural ways, besides encouraging concentration of attention on muscular effort instead of on painful sensation. ”

“ Psychotherapy is sharply to be separated from psychiatry, the treatment of mental diseases. Of course to a certain degree, mental illness too, is open to mental treatment; but certainly many diseases of the mind lie entirely beyond the reach of psychotherapy, and on the other hand psychotherapy may be applied also to diseases which are not mental at all. That which binds all psychotherapeutic efforts together into unity is the method of treatment. The psychotherapist must always somehow set levers of the mind in motion and work through them towards the removal of the sufferer's ailment ”

“ And in all cases emotional reaction may set in with anxieties, and bodily symptoms such as palpitation of the heart may result, whenever an effort is made to disregard the nervous fear. There is perhaps no group of patients which so much deserves the [Pg 173] most careful efforts of the psychotherapist. Still more than the hysterics they suffer from the fate of seeing their ills counted as not real. For them everybody has the good advice that they ought to overcome their fancies; and yet they feel their life ruined with their endless fight against the overpowering enemy. ”

“ It is to be understood that such a complication of relations may be the source of manifold feelings for the physician, especially for the psychotherapist. The personal interest of the physician is greater, his authority is less. ”

“ In the service of our ideals we may thus transform the world into a mechanism: out of our [Pg 398] freedom we desire to conceive ourselves as necessary products. Whenever we aim to produce changes in the world, we must calculate the effects through the means of this causal construction, but we never have a right to forget that this calculation itself is therefore only a tool and that our reality, in which our duties and our real aims lie, is itself outside of this construction. The psychotherapist wants to produce effects inasmuch as he wants to cure disease. ”

“ But after a long experience, I have my doubts as to whether a man was ever cured in such a way by hypnotism of serious disturbances and of those anomalous actions which the critics want to see overcome by the patient's own moral efforts. On the contrary, every suggestion has to rely on the efforts and struggles of the patient himself and all that the psychotherapists can give him is help in his own moral fight. His own will is presupposition for being hypnotized and for realizing the suggestion. ”

“ For the next patient, the opposite may be wiser. The belief that his brain is ill may have induced him to give up effort of the will instead of helping along by steady self-suggestion. He will be helped more if he understands that his mind is working wrongly. But the full truth is that both mind and body are in disorder; the function of the disturbed brain cells accompanies the ineffective will, and to reënforce the will means to bring into equilibrium again the disturbed brain cells. For the psychotherapist the temptation of giving the attention to the mental symptoms only is strong. ”

“ But for us as psychotherapists all those factors have no moral value but only a therapeutic one, and thus stand in line with any other influence that may help, even though from a purposive point of view it stands on a much lower level. A mere mental distraction by enjoyment and play and sport, an æsthetic influence through art, a mere stimulus to automatic imitation, an enforced mental rest, an involuntary discharge of suppressed ideas, and many similar schemes and even tricks of the mental physician belong with the same right to psychotherapy. ”

“ But at all costs let us be sure that we live full lives. I heard lately of a man who was so constantly assailed by sexual cravings, and so convinced that in him they were abnormally strong, that he went to consult a psychotherapist. ”

“ Psychosis is the most serious and incapacitating degree of mental illness. Emotional problems with symptoms of anxiety or depression, or both together, are called affective disorders. People who have affective disorders make up the majority of clients seen by most psychotherapists; these clients are not out of touch with reality. The problems that they have—though painful and sometimes obstacles to normal living—are essentially different from the difficulties that patients with psychoses have. ”

“ Behavioral psychotherapy is best known for focusing on symptoms as its main target, rather than viewing symptoms as signs of underlying problems. Like most generalities, this one has its exceptions; some behavioral psychotherapists are very much concerned with understanding the underlying causes of an individual's difficulties. Nevertheless, behavioral therapies do tend to aim for concrete, specific, and prompt relief of symptoms. They frequently are effective, and they are based on techniques that have been tested extensively. ”

“ You doctors, all of you, constantly practice psychotherapy, even when you do not know it, or do not intend it, but it has one disadvantage, you leave entirely to the patient the psychic factor of your influence. ”

“ I do not think it at all impossible that with the proper changes in the procedure it will be possible to disregard this contraindication, and thus claim a psychotherapy for the psychoses.
3. The age of the patient also plays a part in the selection for the psychoanalytic treatment. Persons near or over the age of fifty lack, on the one hand, the plasticity of the psychic processes upon which the therapy depends—old people are no longer educable—and on the other hand, the material which has to be elaborated, and the duration of the treatment is immensely increased. ”

“ It will happen that men who are not trained in diagnosis will occasionally try to use psychotherapeutic means when what is needed is the knife, the actual cautery, a good purge, some strong drug, or other efficient remedy whose value has been demonstrated and which any trained physician can use. It will also happen that men who lack tact will occasionally disturb patients' minds still further by what they say to them in a mistaken attempt at psychotherapy, and will sometimes suggest other symptoms and make sufferers worse by their clumsy attempts to remove symptoms that are already present. ”

“ There are many ways and means of psychotherapy. All methods are good which produce the aim of the therapy. Our usual consolation, "You will soon be well again," with which we are so generous to our patients, corresponds to one of the psychotherapeutic methods, only that on gaining a profounder insight into the neuroses we are not forced to limit ourselves to this consolation alone. We have developed the technique of hypnotic suggestion, of psychotherapy through diversion, through practice, and through the evocation of serviceable affects. ”

“ Every large city has one or another specialist who applies suggestive therapy, one or another nerve specialist who hypnotizes, but the average physician moves on without any serious effort to utilize psychotherapy. It is as if the prescription of the modern chemical drugs were confined to some leading scholars in the country, while the thousands abstained from it in their office work and in their family practice. In reality psychotherapy ought to be used by every physician, as it fits perfectly the needs of the whole suffering community. ”

“ To be sure, we do not yet know everything that we need for the understanding of our patients' unconsciousness. It is therefore clear that any progress in our knowledge means additional strength for our therapy. As long as we did not understand anything we did not accomplish anything; and the more we shall learn to understand the more we shall accomplish. In the beginning, the psychoanalytic treatment was inexorable and inexhaustible. The patient had to tell everything himself, and the activity of the physician consisted in constantly urging him to continue. Today things look brighter. ”

“ Likewise I am informed that this or that colleague has made appointments with a patient for psychic treatment, whereas I am certain that he does not know the technique of such a treatment. He must, therefore, expect that the patient will bring him her secrets, or he seeks salvation in some kind of a confession or confidence. I should not wonder if the patient thus treated would rather be harmed than benefited. The mental instrument is really not at all easy to play. ”

“ If he were to use psychotherapy consciously and were to receive a professional fee for it he would feel that he was being paid for a value that the patient had not received. A highly respected colleague once privately criticised a paper of mine (read before the Association of American Physicians) on the importance of psychotherapy. "What you said is true," he remarked; "we all use psychotherapy but we are a little ashamed of it; and it is better not to talk about it." Even he did not realize that every psychotherapy is also a physical therapy. ”