Psychotherapy. James Joseph Walsh
to be pessimistic must be taken out of the sick room, and there must be only cheerful faces and cheery people around him. Hence the modern trained nurse, and especially the picked nurse, who does not allow herself to be disturbed, who is not fussy, who is not forcibly cheerful but quietly placid and confident and cheery, means much for the patient's recovery. Relatives are almost sure to exert strong unfavorable suggestions, though time was when the devoted wife or mother might be depended upon to cover up all her personal feelings and give the best possible service for the mental uplift of the patient. When she can thus conceal her own solicitude, a near relative may be the best possible auxiliary in psychotherapeutics.
Natural Relief.—The fourth step in the application of psychotherapeutics is that all the natural modes for the relief of symptoms, the making of patients comfortable in body as well as in mind, must be employed. In acute rheumatism, for instance, a number of small pillows must be at the disposition of the patient so that his limbs can be fixed in those positions in which there is the least discomfort. Every physician should frequently read Hilton's classical volume on "Rest and Pain" because of its unpretentious significance for psychotherapy, as well as its enduring value in the treatment of painful conditions. Just as soon as a patient finds that simple procedures relieve his pain and add to his comfort, his fear of the seriousness of his ailment is lessened, and he begins to get bettor. Cold water in fevers, cold fresh air in pneumonia, all the natural modes of treating disease, thus become active factors in the application of psychotherapy. When fevers were treated by the administration of hot drinks the effect upon the patient's mind must have been quite serious. Freedom to use cold water, just as one wants it and whenever it is craved for, is of itself an excellent suggestion.
Neuroses in Organic Disease.—Fifth, psychotherapy, by suggestion, may alleviate or even completely eradicate neurotic symptoms that develop in connection with organic diseases. Such neurotic symptoms may prove even more bothersome to the patient than the symptoms due to his underlying affection, and may, by interfering with nutrition, hamper recovery. The appetite of a patient who is worrying about a chronic disease will be disturbed, and, as a consequence of insufficient food, constipation and a whole train of attendant evils may ensue. Headache, sleeplessness, worry at slight irritation and exaggerated complaints from slight pain may all be due to this worry and not to the underlying disease. All these, the result of over-solicitude, are attributed by the patient to his chronic ailment. They can be relieved by simple measures after he is saved from his own worry. Until the patient is made to rouse himself and look hopefully at the situation, eating more, getting out more, and relaxing his mind from its constant attention to himself, he cannot get better.
Application of Principles.—It should be pointed out to the patient that there is a constant tendency to exaggerate the significance of disease. This is true in acute as well as in chronic disease, but in acute diseases the necessity for removing unfavorable influences directly is not so urgent, since usually the presence of the physician, with his simple declaration of the meaning of symptoms, is sufficient to neutralize the effect of previous exaggerations.
Secondly, the action of unfavorable suggestions due to imperfect knowledge (everything unknown is magnified, as Cicero said), or to previous medical opinions which the case does not justify, must be stopped. The natural dread which comes to all men in the presence of symptoms of disease must be as far as possible removed.
Thirdly, the favorable elements in the case should be emphasized. This needs to be thoroughly done in order to secure the patient's co-operation, even though the serious possibilities of his ailment may be pointed out to his friends. These friends, however, must be persons who can be absolutely depended on not to reveal by word, or, what is much more important, by their looks or actions, the possible worse prognosis of the case.
Unfortunately, people expect a doctor to tell them the worst, rather than the best. Many physicians seem to have formed the habit of representing the condition of patients as grave as possible, in order, apparently, that they may have more credit when the patient recovers. Not a little of the tendency of ills to hang on in neurotic persons is due to this habit. Over-cautiousness leads some physicians to reveal a case in its worst aspect, lest, by any chance, something unexpected should happen, and the friends of the patient might think that the physician was incompetent because he had not anticipated it. Some of the serious accidents of disease are quite beyond anticipation; but they occur only rarely. For the sake of safeguarding the possible reflection on the physician because of them, it is quite unjustifiable to make bad prognosis habitually, for this acts deterrently on the vital resistance and delays recovery.
Symptoms of Organic Disease .—It is usually considered that psychotherapy is beneficial only in nervous cases; yet we know that all sorts of affections with tissue changes in the skin, in the circulation, and very probably also in the internal organs, may be produced in hysterical affections—ailments dependent on loss of control over the vaso-motor nervous system. Just as ills can be produced, so they may also be cured. As a matter of fact, analysis of the statistics of disease cured by mental influence, shows that it has been more strikingly manifest in organic than in so-called nervous or functional diseases. Neurotic patients often make extremely unsuitable subjects for the exercise of mental influence, because their very nervousness is a manifestation of lack of power properly to control the mind. Cures by mental influence have oftenest been reported in non-neurotic patients. As Dr. Hack Tuke pointed out in "The Influence of the Mind on the Body" as long ago as 1884, it is in such cases as rheumatism, gout and dropsy that benefit was most frequently reported by mental means.
Tuberculosis, certain digestive and intestinal ailments that evidently are associated with tissue changes, have in recent years come particularly into this category of ailments affected by psychotherapy. Dr. Hack Tuke's declaration, made nearly thirty years ago, seems conservative even at the present day: "The only inference which we are justified in drawing from the statistics of the affections cured by mental means is that the beneficial influence of psychotherapeutics is by no means confined to nervous disorders." Many physicians are likely to hold that when cures take place the so-called organic diseases were not actual, but were only supposed to exist because of certain obscure symptoms that apparently could not otherwise be explained. But many of the cases have had external symptoms, striking and unmistakable. To assume that physicians of experience and authority were in error in diagnosing them is simply to beg the question. It is more probable that mental influence acted curatively even over tissue changes as it so often does, directly under our observation, in the production of such changes in the skin.
Tissue Changes From Nerves .—Until one recalls how many physical changes may be brought about by mental influences or emotional disturbances, it is not always clear just how mental influence can affect disease favorably or unfavorably. Prof. Forel, of Zurich, in his "Hygiene der Nerven und des Geistes im Gesunden und Kranken Zusande," Zurich, 1905, English translation 1907, brings together into a single paragraph most of these physical and physiological influences of the mind upon the central nervous system:
Through the brain and spinal cord, thoughts can lead to a paralysing or stimulation of the sympathetic ganglion nodes, and consequently to blushing or blanching of certain peripheral parts. Through disturbance of this mechanism, many nervous disorders arise, such as chilblains, sweats, bleeding of the nose, chills and congestions, various disturbances of the reproductive organs, and, if it lasts long enough, nutritional disturbances in the part of the body supplied by the blood vessels affected. In the same way there are peripheral ganglionic mechanisms which superintend glandular secretion, the action of the intestinal muscles, etc. These likewise can be influenced through the brain by ideas and emotions. Thus we can explain how constipation and a vast number of other disturbances of digestion and of menstruation can be produced through the brain, without having their cause in the place in which they appear. It is for the same reason that such disturbances can be cured by hypnotic suggestion.
Health and the Central Nervous System .—Nature has so constituted and ordered the human economy that its health depends to a great extent on conditions in the central nervous system. We discuss elsewhere the return of vitalism in physiology—that is, the reassertion of a principle of life behind the chemical and physical forces of the human organism regulating it, supplying energy, occasionally enabling it to transcend the