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CHAPTER XVII

GENERAL PSYCHOTHERAPEUTIC METHODS

            THE overcoming of the exaggerated pathological state of the impulse of self-preservation and of the unduly developed fear instinct with all the accompanying associations is the object of a rational Psychotherapy. This is done by studying closely the patient’s history, the development of the case from early childhood, by learning the various fears that have grown up, and have become formed round the nucleus of personality. Everything in the patient’s life should be studied closely, sympathetically, without condemnation and blame. The patient's views of life should be well looked into, and the defects and mal-adjustments put in such a light that the patient should realize where the faults and shortcomings lie. The matter may be put before him in an indirect way of research, but the patient himself is to assimilate the material, laid before him; he is to work the matter into the spirit of his personal life. Our help should rather be that of the guide, should be indirect, and should only be open when the patient realizes the importance of our aid, and asks for it himself. Of course, there are cases where it is requisite to put the findings before the patient directly, fairly, and squarely. This is a matter of the physician’s judgment, and no cut and dried rule can be laid down in such cases.

            We must help the patient straighten out his warped personality. The exaggerated pathological state of the impulse of self-preservation should be moderated, the fears should be eased, controlled gradually, and completely annulled. The patient should not be left to himself, he should not be abandoned to the chance influence of other people while under treatment. He should feel that he has the physician with him, that in case of need he has a man on whom he can absolutely rely for help, a man who understands him, who is always willing to help him, and deliver him from all scares and fears.

            Light cases of psychoneurosis or of somatopsychosis may be treated in the office for a few minutes or for half an hour twice or three times a week. In severe cases, however, the patient should be constantly under the physician’s care until he is delivered from the worries of his fears and from the obsessions of his pathological impulse of self-preservation. The work of reconstruction must be not only persistent and systematic, but must also be carried on incessantly and unremittingly.

            Mental anabolism, the construction of personality, is the object of therapeutic work in psychopathic maladies. The psychopathic malady being essentially a disease of personality in various stages and degrees, the cure is the gradual modification of the pathological state of the affected mental systems, conscious and subconscious. The subconscious systems predominate in the total aspect of the psychopathic symptom complex. That is why it is requisite to go into the subconscious workings of the mind and to inform oneself of the early experiences of the patient's as well as to observe closely the patient’s habits, dispositions, character, mental and moral, his views of life, his actions, and be specially informed of the environment under which the disease had its origin, or of the psychogenesis of the affection, and of the further conditions under which the malady kept on growing and developing. The present environment under which the patient lives, the mode of activity and occupation, the duties and the responsibility of life, and the various relations, family, social, economical, political, religious, and ethical, should all be taken into consideration and closely considered in the treatment of the case. In short, the patient’s mental life should be subject to a thorough searching study, the case should be looked at from all standpoints.

            The physical condition should not, however, be neglected, because quite often, as it is in some psychopathic cases, the physical symptoms form nuclei round which the psychopathic affections and manifestations become organized in clusters of symptoms. This is especially the case with psychosomatic patients. The physician should, therefore, devote time to that side of the patient’s life. The cardiac, the circulatory, digestive, and urinary systems should be examined and attended to.

            The Method of Metathesis and of Emotional Antagonism is often consciously or unconsciously employed by psychopathic patients. When a fear becomes annoying, troublesome, and uncontrollable the patient calls up some other fear replacing the present fear which has occupied the field of attention. This forms a relief to the patient. This process often helps in the spreading of the psychopathic state to other mental systems. Temporarily, however, there is some relief. Many a patient who has learned the value of this method employs it as a subterfuge to escape the terrors of facing his fear systems. The study of the fear systems, the discussion of the various aspects of the fears in their origin and development helps both to face the fears, and at the same time brings about a transference of emotional fear agitation. This helps to moderate the fears by bringing about mutual antagonistic reactions. One fear may be skilfully played towards the neutralization of others. The patient, however, should be unaware of it. The neutralization of pathological systems by antagonistic fear systems is important, but the method is dangerous and should only be employed after careful consideration of each step so as to get effects of interference and inhibition and not effects of increase and superposition of morbid emotion. Each case should be treated on its own individual merits. There are no cut and dried rules in Psychotherapy. The work with this method requires a good deal of tact, foresight, and insight into the personal character of each patient. What may be effective with one patient may turn out a failure with another.

            The synthesis of dissociated systems and the transformation of the patient’s personality should be brought about by a slow and gradual process of system modification. New experience, new knowledge and activity, mental and moral, should be cultivated. The new material acquired and assimilated into the patient’s personal life, as well as the new ways of thinking and acting help in the modification of the various systems which form the nucleus of the psychopathic state. The modification, although performed gradually, may in the long run amount to a complete metamorphosis of the patient’s states, and thus bring about a complete synthesis and transformation of the morbid mental and emotional systems, both conscious and sub-conscious. The enlargement of the patient’s mental horizon and activity is indispensable to a permanent cure. This, however, from the very nature of the work, must be effected slowly and gradually.

            The Method of Disintegration is of import in Psychotherapy. The disintegration may be brought about by associating various aspects of the patient's systems or insistent ideas with disagreeable moods or with counteracting systems, or by a clear comprehension of the silliness, and lack of adaptation of the ideas and their ultimate harm to the patient, by a realization of the lack of rationality and meaning of the recurrent states. Again, the disintegration may be accomplished by convincing the patient that the interpretation he puts on the facts is quite erroneous, and that the meaning is altogether different from what he or she ascribes to the symptoms. What the patient thinks as meaning illness, sickness, mental or physical, is really either indifferent or actually the manifestation of something good and healthy. The evil may thus be turned to good account. This may be done directly or indirectly by various insinuations which often are even more impressive and lasting than direct explanations.

            I have shown in my “Psychology of Suggestion” that of the forms of suggestion, the direct and the indirect, the direct suggestion is specially adapted to the hypnotic condition, while the indirect is adapted to the waking state. It is possible to use both forms, the direct and indirect. This should be borne in mind when we are using the various methods in the waking state and more specially in the hypnoidal state, a state which we have described in our former works and which we shall describe further on in this volume.

            The Method of Disintegration by interpretation may be practiced, by putting a special construction on the experiences and the symptoms of the psychopathic patients. Some psychopathologists express it by saying that they find the “real meaning” of the symptoms. In other words, what they do is to find a meaning which is harmless and even useful to the patient in his adaptations instead of the harmful and morbid construction put by the patient. In most cases, as we have pointed out, the psychopathic symptom complex lacks meaning, it is simply a morbid series of manifestations due to some harmful events, associated with baneful experiences of early child life. This psychopathic symptom complex keeps on recurring, reproducing itself after the biological type of the recurrent moment consciousness, with no meaning except the ones that from time to time become accidentally associated with it. The patient may at one time give one construction and at another time may give a totally different meaning to the symptom complex. “The meaning” depends entirely on the patient’s mood and on the subsequent experiences that help to keep up the fundamental symptom-complex. The patient does no more understand the condition than the savage can explain the meaning of many of his bizarre and absurd rites. The only reason, or meaning is the very fact that the ancestors of the savage have practiced the same customs from time immemorial.

            If the physician learns to know the patient well and is able to give the morbid symptom complex a determination in a definite direction by supplying a good, healthy “meaning,” and is able to work it into the tissue of the patient’s personal life, a good deal of the battle is won. On the one hand it is requisite to associate the morbid manifestations with systems which are of little moment to the patient, so that he should underestimate the significance of the morbid manifestations; on the other hand the good manifestations should be associated with systems, charged with emotion of vital import in the patient’s personal life. In this way the active pathological systems become dissociated and disintegrated into their component parts, and finally disappear from consciousness and subconsciousness.

            This method of disintegration is by no means new. I have employed it for many years under various conditions and circumstances. The physician has to be careful in the use of this method not to associate the disintegrated portions of the mental systems with emotions or instincts which may indeed for some time give a different meaning to the morbid symptom complex and thus deflect the discharge of energy in different directions or even completely inhibit all morbid manifestations of energy, but may work incalculable mischief in other directions. Such, for instance, is the case of the physician who plays with the sex instinct, keeps on arousing the intensity of the sex instinct and thus deflecting the morbid activity of the psychopathic systems in other directions, sexual in character. In this case the remedy is worse than the disease. Such patients run the risk of being morbidly introspective in the direction of the sex instinct into which the physician deflected the activity of the psychopathic groups. I have seen many patients who have become wrecks under the treatment carried out by that harmful, sexual, introspective analysis. Treatment along such lines should be discouraged by every sincere, intelligent, and conscientious physician. Nothing can be more harmful to the sensitive and already damaged personality of the pyschopathic patient. Many a patient came to me ruined in mind and debauched in soul by the supposedly well-meaning, but extremely harmful sexual analysis. I, therefore, warn the physician who wishes to devote his time to the practice in Psychotherapy to avoid sexual analysis, to avoid the formation of artificial sexual associations which in the end become the bane of the patient’s life. The patient may as well be habituated to narcotics to still his troubles. Every conscientious and intelligent physician should be warned against the use of such detrimental and damaging treatment.

            We have pointed out in our works that “a dissociated system present in the subconscious when coming to the surface of the upper strata of consciousness becomes manifested with intense sensori-motor energy. Dissociation gives rise to greater dynamogenesis. This principle of dynamogenesis is important, and eases of so-called impulsive insanities and psychic epilepsy are really due to this cause, and are studied and treated on this principle with great success.

            “A system entering into the association with other systems is set into activity not only directly by its own appropriate stimuli, but also indirectly through the activities of the various systems associated with it. These associative interrelations bring about an equable and normal functioning activity, controlled and regulated by the whole mass of associated systems. The mass of associated systems forms the ‘reductives’ of each individual system. In dissociated systems the controlling influence of the ‘reductive mass’ is lost and the result is an over-activity, unchecked by any counteracting tendencies.

            “This relation of dissociation and dynamogenesis is closely related to periodicity of function with its concomitant manifestation of psychomotor activity characteristic of all passions and of periodically appearing instincts. Dissociated systems present impulsiveness, because of the lack of associated counteracting systems. The only way to diminish the overpowering impulsiveness with which the dissociated subconscious systems make an onset in their rush into the region of personal consciousness is to bring about an association, to work the dissociated systems into the tissue of the patient’s consciousness.

            “Physiologically it may be said, that a neuron aggregate, entering into association with other aggregates, and being called into activity from as many different directions as there are neuron aggregates in the associated cluster, has its neuron energy kept within the limits of the physiological level of the total energy of the neuron.

            “A dissociated neuron aggregate, on the contrary, is not affected by the activity of the aggregates; it is rarely called upon to function, and hence stores up a great amount of neuron energy. When now an appropriate stimulus liberates the accumulated energy, the activity is overwhelming and is very much like the eruption of an underground volcano, giving rise to temporary attacks, to ‘seizures’ by subconscious states of the whole field of the upper consciousness,—‘seizures’ which being really of the nature of post-hypnotic automatisms are generally mistaken for epilepsy, the attacks being regarded as epileptic manifestations, as ‘larval epilepsy,’ as ‘epileptic equivalents,’ as ‘psychic epilepsy.’ With the restoration of equilibrium of the neuron-aggregates, with the synthesis of the dissociated systems, a synthesis which can be brought about by different methods, the subconscious eruptions, attacks, or ‘seizures’ vanish never to return. This principle of synthesis of dissociated systems is clearly demonstrated in our researches.

            “In cases where a stably organized, pathological system is to be disintegrated by the artificial formation of counteracting systems, the principle of dynamogenesis by dissociation is of the highest consequence.”

            The Method of Integration or Synthesis is to be used on similar lines. The systems, requisite in the building up of the patient’s personality, should be approached at first in an indirect way. By all forms of impressions, conscious and subconscious, the right and healthy minded direction should be indicated to the patient. Normal regulations of life should be shown in such a way that the patient should think that he himself arrived at them voluntarily. He should see that the right course is the one for him to follow, and that strength, health, and energy are in that direction. He must see clearly for himself that the ways he followed before were not only erroneous, but resulted in sickness, weakness, physical and mental. He must realize that his old life is not only one of misery to his family, but also to himself; that the fault lies with himself rather than with others. The psychopathic patient must learn that his life is directed on wrong lines, that he has been leading a poor life, mean, short, and brutish; that he must build up a life on new lines,—on higher intellectual and moral levels. This mental up-building, this anabolic process, must be accomplished by all kinds of ways, by enlarging the patient’s views of life, his mental horizon through courses of actual studies, and more especially by force of intimate example and companionship. Giving books to the patients may be all right, but it does little good. What is needed is the personal touch, the intimate relationship, the example of a friendly life which the patient may follow of his own free decision.

            The next step is to have the patient act out his good resolutions and decisions, and get habituated to them. This will strengthen the new habits of life and adjustments, while it will weaken the old habits of behavior. This can only be effected when the patient is under personal care and guidance. The physician must live with the patient. Nothing will encourage so much the patient to try again as the personal interest he sees the physician takes in his efforts. Afterwards, the patient will learn to do for its own sake what was done for approbation.

            Perhaps it maybe well that the physician in treating psychopathic diseases should also take into consideration the fact that the patients are characterized by the tendency of formation of habits which are hard to break. The patients are apt to ask that the same thing be done again and again for the simple reason that it has been done several times before. In other words, psychopathic neurosis is characterized by automatism and routine. This tendency to recurrence is characteristic of all forms of primitive life as well as of mental activities which are on the decline,—it is the easiest way to go along. The making of effort is specially abhorrent to the patient, and in fact one may say that he is afraid of change in the same way as the savage is afraid of any novelty or of any change in custom. The tradition is holy, and in a double sense, because it has been handed down by former generations who are regarded as divine and superior, and because the new is strange and, therefore, may prove dangerous and of evil consequence. What has not been tried may prove harmful, pernicious, and even deadly. The old has been tried and approved by generations and the consequences are known, while the new may be in alliance with the evil powers. The same holds true in all cases obsessed by the impulse of self-preservation and the fear instinct. What the patients have tried several times and what has proved good and pleasant is insisted by the patient on being repeated, the new is not known and may be risky, dangerous. I have great difficulty in making changes in the life of advanced psychopathic cases, because of this fear of the new, neophobia. Once the change is made, and the patient becomes adapted to the new way, then the old way is shunned. In short, neophobia is an essential trait of psychopathic patients.

            The physician must take this trait of neophobia into account, and as the patient begins to improve, he must gradually and slowly wean the patient of this phobia, inherent in the very nature of the malady. The patient must learn to do new things, and not simply follow mechanically a regime, laid out by the physician or by the nurse. The life must be personal. The patient should be made to change many of his ways, and above all he should learn to follow reason rather than habit and routine. Everything, as much as possible, should be reasoned out, he should be able to give a rational account of his habits and actions. Whatever appears to be a matter of routine, irrational and unaccountable habit, simply a matter of recurrence, of repetition of action should be discarded, should be changed to actions and adaptations for which the patient could give a rational account. We must remember that the patient lives in the condition of recurrent mental states, that his mental activity, as I have pointed out, follows the laws of recurrence, characteristic of the type of recurrent moment consciousness. It is, therefore, the physician’s object to lift the patient out of this low form of mental activity to the higher types of rational, personal life in which the patient can rise above the perturbations of life, above the pettiness of existence with its worries and fears. This procedure is essential.

            We can realize how pernicious those schemes are which physicians and many people in sanitariums lay out for the patients just to keep them busy for the time of their stay under special care. As soon as the patients leave, they are in the same predicament as before. The patients wish to have their lives conducted in the same mechanical, automatic routine. In this way they are really on the same low plane of mental life, on the plane of recurrent moment consciousness, a type which forms the pathological web and woof of the patient’s life. Unless the patient is lifted out of this low, mean, and animal form of conscious activity, he cannot be regarded as cured. Instead of having the patient’s life saturated and controlled by the recurrent automatisms of the fear instinct, he should learn to be controlled by the light of reason. “A free man is he,” says Spinoza “who lives under the guidance of reason, who is not led by fear.” Epicurus and the ancient Epicureans laid special stress on the necessity of getting rid of fear through reason, enlightenment, and education. Thus the great poet Lucretius:

            “The whole of life is a struggle in the dark. For even as children are flurried and dread all things in the thick darkness, thus we in the daylight fear things not a whit more to be dreaded than those which children shudder at in the dark and fancy future evils. This terror, therefore, and darkness of mind must be dispelled not by the rays of the sun and glittering shafts of day, but by a knowledge of the aspect and law of nature."

            As Carlyle tersely puts it; “The first duty of a man is still that of subduing Fear. We must get rid of Fear; we cannot act at all till then. A man's acts are slavish, not true but specious (we may add psychopathic); his very thoughts are false, he thinks too as a slave and coward, till he have got Fear under feet. . . Now and always, the completeness of his victory over Fear will determine how much of a man he is.”

            The patient complains of lack of confidence. This is a pathognomonic symptom of psychopathic states. At the same time there is confidence in the symptom complex which is often described by him with microscopic minuteness. The patient has no doubt about that. The patient is in search of someone who can overcome this symptom complex in a way which he specially approves. The patient matches the symptoms against the physician’s control. The physician is to be subdued by the authority of the diseased personality, by the ruling symptoms of the patient's life. Either the physician meets with opposition, and after some time, must give up the treatment of the case, or he is victimized by the patient's demands, and must comply with them. In the last case the patient may stick to the physician for some time. In both cases the patient is not really cured. It is only when the patient’s diseased self becomes subdued and falls under the physician’s control, it is only then that a cure is really possible.

            The first and foremost characteristic of psychopathic states is the narrowing down of the patient’s life interests. The patient begins to lose interest in general, abstract problems, then in that of his own profession or occupation, then he loses interest in the welfare of his party or his country, and finally, in his family, wife, and children. Even in the case of lovers the psychopathic patient seeks to utilize the person he loves for his own benefit, namely, his health. He loves the person as a wolf loves a lamb. The self becomes narrowed down to health, the key to his supposed spiritual life. This is clearly seen in the case of Christian scientists. Self-preservation and fear permeate the patient’s life.

            We notice that the patient's life activity, especially his mental life becomes narrowed down. His attention becomes circumscribed to a few subjects and objects. This is the limitation of the extent of attention. There is afterward a limitation of the temporal span of attention. The patient cannot keep his attention on any subject for any length of time. This span of attention becomes more and more limited with the growth and severity of the psychopathic malady. If the patient is educated and has had an interest in various subjects, the latter becomes more and more limited in scope. Finally the patient becomes reduced to the least amount of effort of the attention, and that only for a brief period of time. When the trouble reaches its climax, the patient loses all interest and capacity of reading and of studying. He cannot think, he becomes less and less original in his thought, he becomes even incapable of thinking. The patient's whole mind becomes limited to himself and to the symptoms of his disease.

            Along with it the fear instinct grows in power and inhibits all other activities. There is a limitation of the patient’s personal self. The personality becomes reduced to the lowest levels of mere existence and caring for his own selfish pains and small pleasures which are exaggerated and magnified to an extraordinary degree. In other words, the personal life of the patient becomes more and more limited as the pathological process goes on. It becomes harder and harder for the patient to take an active interest in life, to exercise his functions, his life interests as well as his life activities.

            It is clear that under such conditions the tendency of the patient is to rest and brood about himself, and keep indulging his limited interest which gets still more limited as the pathological process becomes more extensive and intensive. Under such conditions it is suicidal to indulge the patient and suggest to him a rest cure, a cure which lies along the line of the disease process, thus tending to intensify the symptom complex. What the patient needs is to change his environment, and be put under conditions in which his interests of life can be aroused, his life activities can be stimulated to functioning on the right lines, laid out by physicians who understand the patient’s condition.

            What we must remember in the treatment of psychopathic patients is the fact that we deal here with the aberrations of the impulse of self-preservation, the most powerful, the most fundamental and the least uncontrollable of animal impulses, and with the fear instinct which is the most primitive of all animal instincts. This morbid state of the impulse of self-preservation must be fully realized by the physician before any treatment is begun. The physician must also see and study closely the line on which the self-preservation impulse is tending, and to comprehend the associations along which the impulse takes its course in the history of the patient and in the symptom complex.

            What the physician must specially look after is the elusive feeling of self-pity which manifests itself under various garbs, and hides itself under all kinds of forms. As long as the patient is introspective and has the emotional side of self-pity present, so long is his condition psychopathic.

            The patient’s history should be inquired into very closely and while one reviews his history one may get a chance to point out to him indirectly the various psychopathic faults from which he suffers and which must be overcome and corrected. This has to be done by the method of indirect association or suggestion. This method is of the utmost importance in the treatment of psychopathic states. The method of direct association or suggestion should also be practiced both in waking and trance states, hypnotic and hypnoidal. The physician, however, will find that the method of indirect association or suggestion will have to be employed all through the course of the treatment. All the surroundings of the patient must be of such a character as to continually arouse indirectly thoughts, feelings, and emotions which should neutralize the patient’s feelings and emotions, and should control his fears and his abnormally developed impulse of self-preservation. He must learn self-control in the presence of other people, and finally even when other people are away; he must give up self-pity as ludicrous and degrading.

            The extreme selfishness and the uniqueness with which the psychopathic patients regard their own condition should be eradicated from their mind. It must be impressed on them that their case is quite common and that there is nothing exceptional about them. It must be made clear to them that the whole trouble is a matter of mal-adjustment, that they have developed inordinately the impulse of self-preservation and the fear instinct until their mental life has become morbid and twisted. The whole personality has to be readjusted. It is the special tendency of psychopathic patients to regard themselves as unique, privileged above all other patients, they are a kind of geniuses among the afflicted, possibly on account of the special endowments possessed by them, gifts of quite exceptional and mysterious a character. “Have you ever met with a case like mine?” is the stereotyped phrase of the psychopathic patient. As long as the patient entertains that conception of nobility the impulse of self must still be regarded as morbid.

            He must be made to understand clearly that there is no aristocracy in disease, and that there is no nobility of the specially elect in the world of morbid affections any more than there is in the domain of physical maladies.

            The egocentric character of the psychopathic patient puts him in the position of the savage who takes an animistic, a personal view of the world and of the objects that surround him. The forces are regarded as dealing specially with man and his fate, often conspiring against man. Magic is the remedy by which he tries to defend himself and even to control the inimical or friendly natural forces or objects, animate and inanimate, with which he comes in contact. This same attitude, animistic and personal, of the primitive man is present in the psychopathic patient. The patient is afraid that something fearful may happen to him. Against such accidents he takes measures often of a defensive character which differ but little from the magic of the savage and the barbarian. The whole of nature has the patient as its centre and may crush him. That is why these patients are the victims of all kinds of fakes, schemes, panaceas of the wildest type, unscrupulous patent medicines, absurd regimes, mental and religious, whose silliness and absurdity are patent to the unprejudiced observer. The mental state of the psychopathic patient is that of the savage with his anthropomorphic view of nature, with his fears based on the impulse of self-preservation. The psychopathic patient is in a state of credulity with its faith in magic.

            The emotional side of the impulse of self-preservation and of the fear instinct should always be kept in mind by the physician who undertakes the treatment of psychopathic cases. The physician must remember that the emotions in such cases are essentially of the instinctive type, that they therefore lie beyond the ken of the patient’s immediate control and action of the personal will. The physician should not therefore be impatient, but while protecting the invalid against the fears that assail the latter, he should gradually and slowly undermine the violence of the impulse of self-preservation and the anxiety of the fear instinct.¹

            We have pointed out that under the fear instinct are comprehended all concomitant sensory processes, glandular, intestinal, respiratory, and motor reactions to external and internal stimulations, as well as sensory, perceptual, and ideational processes. All these processes enter as elements into the emotions, and especially into that psycho-biological reaction known as the fear instinct. The emotional and instinctive, psycho-physiological processes, may be looked at from a three-fold standpoint, from the afferent, central, and efferent. Some psychologists emphasize the central and others, especially of recent date, are apt to over-emphasize the efferent and afferent aspects of emotion in general and of instinct in particular. As a matter of fact all the three aspects enter indissolubly into emotion and instinct wherever the two are in any way associated. In the treatment of the fear instinct which underlies all psychoneurotic and psychosomatic cases one must bring about the modification of that instinct with its fundamental impulse of self-preservation.

            In utilizing the principle of metathesis and modification which we have pointed out in our previous chapters of this work, one must take into consideration the various aspects of the self-impulse and fear instinct, afferent, efferent, and central. All the elements must be affected in order to obtain satisfactory results. Some psychologists claim that the sensory and central elements are unmodifiable, and that only the efferent, motor elements can be modified in the emotions and impulses. This claim is not justifiable by facts. My clinical facts and cases go to show that such a claim is untenable. All the elements entering into an emotion are modifiable, and are being modified in the course of ontogenetic  development of the individual as well as the phylogenetic evolution of varieties, species, and genera. The sensory elements and mental states, going to make up the afferent states of the emotions, keep on changing, and so do the central elements and states, the qualitative feeling and ideational aspects into which the afferent and efferent elements enter as constituent components. All that we can possibly claim is that sensory elements are more modifiable than central, and that the motor are more modifiable than the sensory elements. Even this statement is subject to restriction. It is not that the sensory elements and central states are less modifiable than the efferent, motor elements and states, but that the latter are more modifiable, because they are more accessible to external and internal influences.

            From the standpoint of the amount of modifiability we may say that the central element and states are even more modifiable than all the other elements, since they form the psycho-physiological products of all the afferent, incoming stimulations, both purely sensory and kinaesthetic processes. In other words, inasmuch as the central elements form the product of the afferent and efferent processes from the sensory incoming stimulations from the motor processes and glandular reactions, the central elements and states may be regarded as being more modifiable than all the other elements. It is not because motor elements are intrinsically more modifiable than sensory and affective elements, but because movements are directly accessible to our control than are peripheral sensory, central, and emotional processes in general. It is not that the afferent and central emotional elements are not modifiable per se, as some would have it, but because the efferent or motor elements are easier to modify. I quote from a work of mine written by me some fifteen years ago. Since the generalization is of import, both from a theoretical and practical therapeutic as well as an educational standpoint, and since some have misapprehended it by overstatement, I take the liberty of quoting at some length:

            “Ideo-motor life is more subject to changes from slight stimulations than sensory life: motor elements enter readily into new combinations. From a biological standpoint one can see the importance of the greater ease of modifiability displayed by sensori-motor elements, since in the adaptation of the organism to its environment it is these elements that are mainly employed in reaction to stimuli of the external world. From the standpoint of adaptation, a slightly appreciable difference of sensory experience may give a widely different and highly complex motor reaction.

            “Psychomotor processes form the most important and largest portion of mental life. With the exception of man, all the representatives of the animal kingdom, from the lowest to the highest forms, represent but different stages in the evolution of sensori-motor life. The great majority of mankind still leads a life closely allied to animal sensori-motor states. Even in the highest, and most developed forms of mental activity, motor ideas and representations are by far the most predominant. Without motor elements, ideational life is arrested. It is these sensori-motor and ideo-motor elements that constitute the ‘stream, the flow, the current’ of our thoughts. Motor elements enter freely into combinations with all other elements of mental life. This freedom in forming new combinations and associations makes the suggestion of motor ideas and representations highly effective.

            “Throughout the scale of animal life from the lowest to the highest forms, intelligence is intimately related to the degree of development of the muscular system and the delicacy of its motor adjustment. Among the lower forms of life, the Cephalopods are well equipped with powerful muscular arms capable of executing a great variety of vigorous movements. Now the Cephalopods also possess a more highly developed nervous system with a higher grade of mental functions than the rest of the Mollusca. The great activity of ants and bees is notorious and their instinctive psychic life is the richest among the Arthropoda. Note the great variety of motor adjustments of the beaver and also the intelligence that goes along with it. Birds possessed of a high degree of activity and motor adaptability are also the most intelligent of their kind, such for instance as the crow and the different species of talking birds. Notice the activity and great agility of the fox and also the unusual cunning for which he is so celebrated. The suppleness of the dog, his quick reactions to stimulations, the resources of his motor adjustments, and the great extent of his modifiability under changing conditions, are all well known, and along with them goes a high degree of psychosis. Of all the Mammals, the Quadrumana are the most active, the most imitative and full of mimicry, and with the exception of man they are also the most intelligent. When we come to man we cannot help admiring the high complexity and extreme delicacy of his motor adjustments. Most marvellous, however, is the human hand, that divine organ which gives shape and form to works of art, to all the outward, visible manifestations of civilization. The great artists and thinkers of antiquity held the human hand in great reverence. One of the great Greek philosophers did not even hesitate to declare that man’s superiority over the brute was due to his hand. Finally, in the wonderfully delicate motor adjustments of speech we find clearly illustrated the intimate relation between motor and psychic activities.

            “Experiments prove the same truth of the predominance of motor ideas and representations in our mental life. If a series of syllables or numbers is given to memorize after one reading, five out of ten can be remembered, though with some difficulty; but if the syllables or numbers are written down at the same time, though not looked at during the writing, a far greater percentage, such as six or seven syllables, can be remembered. If the motor elements in a train of ideas are suppressed, the order of the series becomes confused, and even destroyed, showing that the motor ideas are important links in trains of association of ideas.

            “Biologically regarded, voluntary activity—will is the organism’s power of adjustment to the conditions of the external environment. In its last psychological analysis, voluntary activity, or will, consists of representations of various modes of adaptations—that is, of motor memories, of highly complex systems of kinaesthetic representations, constituting the active subject of the highly developed personality. If this be realized, then the vital importance of motor memories cannot be too highly overrated. Motor memories are at the very heart of personality. We are what we can accomplish. Extreme variability and adaptability are the main characteristic traits of intelligence, will, personality, with their motor memories as their central nuclei.

            “The readiness of psychomotor elements and groups to enter into ever new combinations gives rise to the formation of a great wealth of associations which help to make the labile psychomotor groups and systems stable and easy of recall. In fact it may be said that the ease of recall is proportionate to the mass of associated kinaesthetic memories. If under the action of adverse conditions associations are dropped or lost, many more still remain to recall the affected system, some of the functional bonds of which have become loosened. The great wealth of associations formed by motor memories brings about their ease of recall, also their recurrence in consciousness even under unfavorable conditions of dissociation. The great modifiability and variability of systems of motor memories requisite in the adaptation of the organism to the varying condition of its environment make the ever greater instability of motor memories an imperative necessity in the struggle for existence. Forming the predominant elements, both as to intensity and mass, of the most complex, relatively stable, though ceaselessly shifting groups and systems constituting the highly developed organization of the personal self, the motor elements, presentative and representative, are also the first to become involved in the process of dissociation. In the various forms of nervous and mental diseases, under different conditions of intoxication and auto-intoxication, in the traumas caused by shock, physical or psychic, the delicate movements of adjustments are the first to become affected, dissociations of systems of motor representations are first to occur with their concomitant motor derangements.

            “The instability of motor memories and of psycho-motor elements in general may be brought into relation with the fact of the early affection of muscular and kinaesthetic sensibilities, and with the predominance of sensori-motor over purely sensory symptoms so frequently occurring in the course of nervous diseases. With this may be correlated the significant fact referred to by Mosso, that ‘all substances which slowly destroy the organism must produce phenomena analogous to those of curari, since the motor nerves, according to our researches, have less vitality than the sensory.’ It would be more correct to substitute for ‘motor’ the term ‘sensori-motor,’ because muscular and kinaesthetic sensibilities are also involved in the same process of degeneration. It may also be observed in passing, that cellular kinoplasm with the ‘kinocentrum,’ the centro-some and its archoplasmic structures, possibly the most primitive motor organoids of the cell, similarly manifest a high degree of variability and instability.

            “Motor memories may be regarded as the labile elements of consciousness; they become easily and frequently dissociated and dropped into the subconscious, but for that very reason they are also very easily reproduced or regenerated. In this respect motor memories follow the general biological law of organic regeneration: Organs that are easily and frequently lost in the struggle for existence are also easily regenerated, as for instance, the legs and claws of Crustacea or the tentacles of the starfish and octopus. Dissociated systems of motor memories often become regenerated and under pathological conditions when synthesis is impossible they may even recur with great insistence, giving rise to the most uncontrollable types of insistent ideas and impulses and to various forms of so-called “psychic epilepsy,’ especially of the motor type, closely mimicking typical, organic epilepsy. Dissociated, subconscious systems, like rudimentary aborted organs, are very persistent and often very injurious to the organism. The recurrence of the subconsciously submerged dissociated systems has its parallel in the biological phenomena of reversion, or atavism. The development, growth, and recurrent persistence of a subconscious dissociated system is like a malignant sarcomatous neoplasm the cells of which present a reversion to the embryonic type. . . .

            “This fact, that the psychomotor elements, motor ideas and representations, enter more easily into combinations and form extensive associative systems, makes them easier of recall, and hence apparently more persistent in memory. From an educational standpoint, one realizes the importance of this fact of persistent recurrence and great ease of recall of motor memories. Children learn and remember things best, not by abstract notions, not by looking at objects and hearing of things, but by acting out whatever is taught them. Not only is the interest increased on that account and knowledge made more vital and better assimilated, but the content acquired is also far better retained and more easily remembered; it emerges with greater ease and is at the child’s command at any time, because of the nature of the interwoven motor memories. In the training of the mentally defective, the best method followed is that of motor instruction; the best way of teaching the mentally defective is to have the ideas acted out and from the actions get at the meaning, even if it be only automatically, of what is requisite to be learned. As a matter of fact, even the perfectly normal and well balanced mind gets at the meaning of things by handling them, by having the attributes of the object and the processes of the work to be learned acted out. Acting forms the greater part of man’s life. . . .

            “For therapeutic purposes it is certainly of importance to have the suggestion (influence, modification) as stable as possible. To effect this, the best way is to utilize this fact of persistence of sensori-motor and ideo-motor elements, of the greater ease of recall characteristic of kinaesthetic sensations and ideas. . . . Motor and kinaesthetic sensations and memories make suggestions durable.

            “It is, of course, preferable that the associated motor memories should not be of a passive, but of an active character. To guide and move the patient's limb, for instance, is not as good as when he carries out the acts of his own accord. In other words, active kinaesthetic associations are most potent. Along with other methods, use of kinaesthetic associations is of the greatest value in the process of formation and also of disintegration of a stably organized system.”

            This comes down to the practical principle of influencing the patient’s personality through an actual change of his mode of life. The tendency in the treatment is to make the patient work on right lines, not to have him work at his regular occupation, or to lay out for him some artificial trade, as it is done in some places, the patient being made to do definite tasks at certain specified times and in a definite, automatic way. Nothing can be more calculated to keep up the psychopathic condition of recurrent, mental life. The patient should be in the open air, he should be active, but his activity should be voluntary, spontaneous. The activity should not only strengthen him, it should help his mental condition, disintegrating the systems of fixed ideas and recurrent mental states. In some cases where the mind was paralyzed by the mental state or when his mental processes were so warped as to make the patient think in one direction, the thoughts should be directed on normal lines. The patient should be made interested in various mental processes and logical activities, in studies and in all kinds of subjects in which the intelligence becomes strengthened and the mind can think on sound lines, while at the same time getting information that gradually helps indirectly to disintegrate the pathological mental systems.

            Sometimes it is well to set the patient to do exhausting work so as to counteract the exhausting overactivity of the fear instinct and worry. In some cases I have achieved marvellous results when I suddenly switched patients from the so-called Weir-Mitchell treatment and other medical forms of treatment to a life full of activity and labor in the open, no plays and no games, but real labor of the severest type. These were cases who have complained of cardiac affections, counted their pulse, and fainted away at the least provocation. I was with them all the time, took an active interest in their labors and their progress, and utilized every opportunity to overcome their fear and psychopathic worries.

            We must, however, be careful and watch the patient closely, lest he overdoes and becomes so overfatigued as to be incapable of any work. In such cases the fear instinct returns with redoubled fury. It is then hard for the physician to control the course of the disease. The patient loses courage, may lose trust in the physician and all confidence in himself. The physician should have a personal, close watch over the patient’s work and not let it to the mercies of a nurse or an attendant. The patient should be in touch with the physician most of the time. In case of any set-back the physician should be on the spot to remedy the mischief. Not until the patient gains more or less confidence in himself is it wise to leave him to himself. This is one of the reasons why it is so hard, if not hopeless, to treat psychopathic patients in the office. The physician gives them the treatment and does not see them until the rest of the day, and sometimes not before several days later. Meanwhile, the patient falls a victim to his own fixed ideas and fear as well as to the influences, coming from all kinds of extraneous sources. Above all, it is impossible to regulate his life and see that the directions are carried out, that no evil influence get hold of the patient when he is at his lowest and needs the help of a strong hand. Unremittent vigilance is the price of the cure.

            Among psychopathic patients may be found some who are really overworked, and who, in addition to their psychopathic state, actually suffer from overfatigue. In such cases one has to be careful not to set them hard tasks and bring about a still worse condition of fatigue. Such patients need rest, though not the Weir-Mitchell’s rest or the rest and seclusion advocated by Dejerine and other French neurologists. The seclusion method is not only detrimental to the patients, but it is also a matter of extreme cruelty, it savors of the prison and solitary confinement. The seclusion treatment should by all means be avoided in psychopathic cases.

            Active employment has been of late overworked. Many people who are not medical and know nothing of the complexity of psychopathic cases have undertaken the treatment of psychopathic patients by means of athletic exercises and other rough games. Nothing is further from the actual needs of such patients. In many cases such treatment is doing positive harm. It is, therefore, to be greatly regretted that even the medical man seems to be under this delusion of athletics as a remedy, and sends patients to such establishments where incalculable mischief is done. In some cases the patient comes to such places of his own accord, having heard that many others are sent there by reputable physicians, or because some notorious men have visited the place and have given it a good advertisement. There are cases that suffer from some cardiac trouble; such rough treatment is apt to cause damage often of a dangerous character. Even in cases where the physician examines the patient for cardiac affection before the patient goes to such athletic places, there is still the danger of overworking the patient who should be handled with care and given enough to do without drawing on his exhausted store of energy.

            There are psychopathic patients who suffer from cerebral fatigue. In such cases we need to give just enough work and occupation for the over-coming of the neurosis, and for the normal functioning of the body and mind. We must, however, be careful not to over work such patients. I have seen many a patient who came to me under treatment after he had gone through a strenuous athletic or occupational treatment. I have found such patients in deplorable condition. We must remember that cerebral fatigue may often be associated with psychoneurosis or with psychosomatic disturbances. When cerebral fatigue is present, we must be extremely careful with our regime of physical activities, exercises, and occupations. Without appealing to clinical experience and psycho-therapeutic practice experimental physiology warns us against such a course of reckless and inconsiderate treatment. I quote from Mosso on the subject:

            “Cerebral fatigue diminishes the force of the muscles, and with the ergograph we measure this phenomenon with exactitude. The need of rest after intense brain work arises then from the fact that the nervous centers are exhausted and the muscles weakened. The feeling of discomfort and the prostration which characterize intellectual fatigue are due to the fact that the brain, which is already exhausted, has to send stronger stimuli to the muscles in order to make them contract. The exhaustion is twofold: central and peripheral. This explains why after brain fatigue one feels one’s energy exhausted by the slightest movement, and why every obstacle which we have to overcome seems to have grown more serious. In these circumstances violent exercises should be avoided, because they are injurious: fencing, gymnastics, or any muscular effort whatever aggravates the conditions of the organism.

            “It is, therefore, a physiological error to interrupt lessons to make children do gymnastics in the hope that this may diminish brain fatigue. To restore the forces of the organism when exhausted by intellectual labor there is no remedy other than immobility and letting one’s thoughts wander. When we force the nervous system to muscular after cerebral effort, we find the muscles less fit for work; and we add to the cerebral fatigue another fatigue which, as we shall see later, is of the same nature and is equally harmful to the nervous system. The best way to rest is to sit still and ‘think of nothing,’ and to let children play about and amuse themselves in the open air.”

            In the case of psychopathic patients it is not desirable that they should sit still all the time, any more than it is desirable that children in school should all the time sit still. It is requisite that periods of activity should alternate with periods of repose. There are cases where I have to graduate the periods of work and regulate carefully the periods of repose. Each case, of course, should be treated individually on its own merits. Cases complicated with fear fatigue must be handled with care, and special conditions should be arranged for periods of work.

            For this purpose of inducing repose hypnoidization, or the induction of the hypnoidal state, is specially calculated to help in the treatment of psychopathic maladies. From a psychognostic standpoint the hypnoidal state is of great value, and it is of no less value from a psychotherapeutic standpoint.

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¹ Although I lay stress on the instinctive aspect of the fear emotion, I do not agree with those who lay down the law that all instincts have an emotional side to them, who go even to the extent of claiming that the emotion is the characteristic trait of instinct in general. I cannot agree to such an extreme statement, simply because the facts do not warrant it. There are instincts with no emotions and there are emotions with no instinctive side to them. The instincts of the Crustacea or of the Annelidae are hardly of an emotional character; it is questionable, if the instincts and the biological tropisms of lower life have anything emotional about them, and it is not certain if in the case of Mammalia or even in the case of the human infant just born the instincts present are in any way emotional. The early primitive instincts, ontogentic and phylogenetic, in all likelihood lack that emotional character which is probably a characteristic only of the high types of psycho-physiological organization. We may, however, grant that in the case of the psychopathic patient the instincts are charged with emotional energy, since the emotional element is a predominant factor in such neuroses and psychoses. We have shown in our works that the manifestation of such instinctive energy, as subconscious and inhibited, is eruptive in character, giving rise to attacks often of a violent nature.

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