Boris Sidis Archives Menu Table of Contents Chapter II
A Symposium by Frederic H. Gerrish... James J.
Putnam... E.W. Taylor... Boris Sidis... George A. Waterman... John E.
Donley... Ernest Jones... Tom A. Williams...
Boston: Badger, 1908
THE PSYCHOLOGICAL PRINCIPLES AND FIELD OF PSYCHOTHERAPY
BY MORTON PRINCE, M. D.
Professor Emeritus, Tufts College Medical School
SO much that is pseudo-scientific or mere platitude, so many misstatements have been set forth in the lay and medical press both by those who are the advocates of psychotherapy and by those who are its critics; many erroneous ideas abound regarding both the nature of the disturbances of the mind and body which we to allay and the modes by which we endeavor to do it, that it is not to be wondered at that the facts of observation have been mistrusted and the methods of therapeutics have met with cynical criticism.
If we are to judge the soundness of the theory on which this mode of treatment is based, the field of its usefulness, its limitations, and the methods of its application, it is absolutely necessary that we should begin any discussion of psychotherapy, in a symposium of this kind, with an understanding of its underlying principles. There are certain facts of observation with which we begin.
1. It will be agreed that common experience has that certain unhealthy habitual states of mind are apt to be accompanied by various derangements of the functions of the body. By “unhealthy” I would designate those which tend to misadapt a person to his environment, and among these habits or states of mind I would classify depressive or disruptive emotions and feelings; apprehensions, and fear of disease or of the consequences of business or social acts; fixed beliefs in fictitious disease; illogical doubts, scruples, and anxieties; habits of thought such as constant introspection, self-consciousness, the concentration of the attention on the physiological functions of the body, the expectation of ill consequences following any course of conduct, and so on. I need not go into details, for that such conditions of mind are accompanied by derangements of the bodily functions is a fact of common knowledge which is confirmed by the experience of laymen as well as physicians and psychologists. Furthermore, in certain persons the modes of mental activity I have described if frequently repeated tend to become habits or habitual reactions to the environment that are not easily discarded. Often the mental states when persistent and intense become disabilities in themselves, constituting veritable psychoses, such as the anxiety psychosis, phobias of various kinds, morbid shyness and self-consciousness, association psychoses, etc. It is not to be affirmed that these unhealthy mental states of mind, even when they become habitual psychoses, are accompanied in every individual by disturbance of bodily functions, but the tendency is such in persons of a certain temperament and so-called nervous organization.
2. It is also a fact of observation which is too well admitted to be mistrusted that, when healthy mental states are substituted for unhealthy ones of the character I have described, the functional derangements of the body tend to disappear.
The two classes of facts just enumerated become comprehensible when we remember that physiological and clinical observations have shown that temporary or passing mental states when accompanied by strong feeling tones often alter in a marked degree the various visceral functions. To mention but a few of these effects: The increase of the heart's action; the increase of the blood pressure; the variations of the vasomotor system; the increased muscular energy and feeling of well-being; the pouring out of the appetite juice and saliva (Pavlow), etc., through the influence of ideas associated with sthenic pleasurable emotions—all these have been attested by the observations of the physiologist and of the clinician. Per contra, the suppression of salivary and gastric secretions; the inhibition of peristalsis and segmentation; the contraction and dilatation of the blood vessels; the increased functions of the sweat glands; the alteration in the rhythm and rapidity of the respiration and heart’s action; the inhibition of many functions (gastro-intestinal); the decrease of muscular energy; the awakening of the sense and symptoms of fatigue; these and many such phenomena have been shown by carefully recorded tests to accompany the temporary excitation of ideas that are associated with depressing and painful emotions. That the persistence of such mental states should be accompanied by persistent disturbance of function is not to be wondered at.
3. A third class of facts must, I think, also be accepted as proven; namely, that emotional shocks are apt in certain persons to leave persisting after-effects manifested by disturbances of function of the nervous system. We need not inquire at this moment into the exact nature of these disturbances or give them a name. It is generally agreed that they are of the character which is called functional and owe their evolution to the principles which I will presently describe. In their most obtrusive form they are observed as the traumatic neuroses (psychoses).
4. A fourth class of facts is of importance for psychotherapeutics, viz.: In all persons to a certain extent and in some persons to a large extent suggested ideas tend to work themselves out to fulfilment. In certain diseased states (hysteria) and in certain artificial states (hypnosis) this tendency reaches a maximum and, consequently, by suggestion, intentionally given to persons in such conditions, disturbances of function can be produced artificially and removed again. Likewise ideas originating in the mind of the person himself may induce the same phenomena (auto-suggestion). Thus the physiological side functional paralysis, contractures, anaesthesias, spasms, etc.; and on the mental side amnesias, hallucinations, sleep, trains of ideas and feeling, etc., can be artificially produced and afterwards modified and removed. In this statement I am not including the basic condition, whatever it may be, that gives rise to the increased suggestibility, but to the phenomena resulting from suggestion. How far that condition comes within the influence of suggestion is another question to which I will later return. The phenomena of suggestion have been determined by experiment over and over again, while the history of medicine testifies to the occurrence of such phenomena under accidental conditions. Indeed a distinguished neurologist (Babinski) has recently advanced the thesis, though as I believe erroneously, that all hysteria is nothing but a group of suggested symptoms.
We cannot be too cautious in generalizing from limited facts of this kind which are observed under special conditions, but the basic principle is of great importance and one that obviously can be made use of in psychotherapeutics. To what extent it can be used is another question that can only be determined by experience.
After this general statement of certain fundamental facts of observation I would call attention to certain principles, if not laws, which observation has shown govern the functioning of the nervous system.
1. COMPLEX FORMATION
It is a law that associated ideas, feelings, emotions, sensations, movements, visceral functions of whatever kind, tend, after constant repetition or when accompanied by strong emotion and feeling tones, and under other conditions, to become linked together into a system or group in such fashion that the stimulation of one element in the group stimulates the activity of the rest of the group. Such a group is conveniently called a complex, and as such I shall hereafter refer to it. This tendency to linking of functions obtains whether the mental and physiological processes when linked form a complex which subserves the wellbeing of the organism and adapts the individual to his environment, or whether they form one which does not subserve the wellbeing of the individual, but misadapts him to his environment. In the former case the complex is called normal, in the latter abnormal. This is only another aspect of the well-accepted principle that pathological processes are normal processes functioning under altered conditions. Both are the expression of one and the same mechanism.
The linking of function may be almost entirely of ideas, as is expressed by the well-known psychological law of “association of ideas.” Its pathological manifestations we see in so-called fixed ideas or obsessions. We see it also exemplified within normal limits in so-called moods, when certain large systems of ideas accompanied by strong emotion tones occupy the mental field to the exclusion of other systems which find it difficult to take possession of the field of consciousness. When such moods are developed and intensified to an extreme degree we have veritable pathological alterations of personality and even, it may be, multiple personality. But in moods besides association we meet with another principle in an exaggerated form, namely, dissociation. Of this I will presently speak.
The linking again may be of physiological process as exemplified by synergesis of muscular movements. This is seen in the linked combination of muscles us in writing, piano playing, skilled use of tools, and implements of games (golf, tennis, etc.). Even the simpler movements of a finger, hand, or arm require the coaptative synergesis of several muscles. These synergetic movements are admittedly the result of education through repetition, although undoubtedly the compound cerebro-spinal reflexes so beautifully studied and brought to light by Sherrington are made use of.
The possibility of organizing physiological processes into memories by artificial means and linking them psychological processes is shown very neatly by the extremely important experiments of Pavlow and his co-workers on the reflex stimulation of saliva in do The facts which I wish here to recite are thus described by Pavlow:
“In the course of our experiments it appeared that the phenomena of adaptation which we saw in salivary glands under physiological conditions, such, for instance, as the introduction of the stimulating substances into the buccal cavity, reappeared in exactly the same manner under the influence of psychological conditions -that is to say, when we merely drew the animal’s attention to the substances in question. Thus, when we pretended to throw pebbles into the dog’s mouth, or to cast in sand, or to pour in something disagreeable, or, finally, when we offered it this or that kind of food, a secretion either immediately appeared or it did not appear, in accordance with the properties of the substance which we had previously seen to regulate the quantity and nature of the juice when physiologically excited to flow. If we pretended to throw in sand, a watery saliva escaped from the mucous glands; if food, a slimy saliva, and if the food were dry—for example, dry bread—a large quantity of saliva flowed out, even when it excited no special interest on the part of the dog. When, on the other hand, a moist food was presented―for example, flesh,—much less saliva appeared than in the previous case, however eagerly the dog may have desired the food. This latter effect is particularly obvious in the case of the parotid gland.”1
More than this the psychical excitation may be part of a wider complex; everything that is in any way psychologically associated with an object which physiologically excites the saliva reflex may also produce it,—the plate which customarily contains the food, the furniture upon which it stands, the person who brings it, even the sound of the voice and sound of the steps of this person.2
“Any ocular stimulus, any desired sound, any odor that might be selected, and the stimulation of any part of the skin, either by mechanical means or by the application of heat or cold, have in our hands never failed to stimulate the salivary glands, although they were all of them at one time supposed to be inefficient for such a purpose. This was accomplished by applying these stimuli simultaneously with the action of the salivary glands, this action having been evolved by the giving of certain kinds of food or by forcing certain substances into the dog’s mouth.”3
It is obvious that reflex excitation thus having been accomplished by the education of the nerve centers to a previously indifferent stimulus the reproduction of the process through this stimulus is in principle an act of physiological memory.4
In man as an example may be cited the vesical reflex which may similarly, as is well known, be educated to react to the sound of running water.
These pathbreaking demonstrations of Pavlow furnish the key to the mechanism of many neuroses and psychoses, for indeed the educated reactions of the gastric and salivary glands to ordinarily indifferent stimuli from the environment and to psychical states are in reality nothing but an artificially created psychoneurosis—a perversion of the normal reactions. Such artificial syndromes render comprehensible the mechanism of such neuroses as the well-known neurotic type of hay fever which belongs to the association neuroses.5
In this type the whole physiological group of functions composing the neurosis—lachrymation, congestion of the mucous membranes and erectile tissues, secretions, cough, dyspnoea, etc.,—are linked into an automatically working mechanism by repetition and excited by a stimulus from the environment, e.g., the sight of a rose (which may be artificial), dust, sunlight, etc. Psychical expectation (auto-suggestion) of course prepares and keeps alive the association. This neurosis, composed mostly of physical symptoms, strikingly illustrates the principle of an educated functional disease and typifies many forms of neuroses.
In other psycho-neuroses the syndrome may be made up partly of psychical elements and partly of physical processes. This is seen in psychasthenia, where, for instance, fears, anxieties, scruples, confusion of thought, etc., are associated with all sorts of disturbances of the body,—dizziness, palpitation, tremor, perspiration—the whole constituting a phobia or anxiety neurosis.
Now without pursuing these illustrations further, the point I would like to emphasize is that the whole process by which these functional syndromes are created is educational. The education may be unintentional, i.e., accidental, as in the hay fever neurosis and those resulting from continued auto-suggestion; or it may be intentional, as in Pavlow’s experiments on the digestive functions.
In these facts which I have only incompletely collated we have the manifestations of a broad general principle governing nervous processes in. normal and abnormal life. It is the principle of pedagogy. Unless nervous processes could be artificially linked into coaptative synergetic systems adapted to a purpose, education in any field would be impossible. Intellectual acquisitions, from the repetition of the alphabet to a complete knowledge of a language or a science, and physiological acquisitions, from the use of a tool to the mastery of the piano or the vocal apparatus, not only would be unknown but would be unthinkable. The education of the mind and body depends upon the artificial synthesizing of functions into a complex adapted 'to an end or useful purpose. By the same principle functions may be synthesized by education into a complex which does not serves useful purpose but rather is harmful to the individual. When this is the case we call it abnormal or a psychoneurosis.
From this point of view how inadequate is the allegation which we often see stated that there is no such thing as a functional disease. What can be the conception of function which must be held by those who maintain such a theory is something that passes comprehension. A functional disease is a perversion of the normal processes brought about by some acute, intense experience or by repetition of an experience, i.e., by education. Theoretically it would follow that what can be done by education can be undone by the same method, and in practice we find this to be true. We shall presently see that there are often types of functional disease, but each is based on a perversion of the normal mechanism.
Another principle or tendency of the functioning of the nervous system has been firmly established by repeated experimentation and observation. Its importance for psychotherapy can hardly be exaggerated. It is this: All our experiences—anything that we have thought, seen, heard, or felt—tend to be conserved in such a way that they can be reproduced in a form approaching that of the original experience. Upon this memory depends. It is evident that we never could remember anything, that all experiences would be lost to consciousness, unless somehow and somewhere they were preserved, unless there was some physical arrangement for preserving them. In what form mental and other experiences are conserved we do not know, we can only theorize; but we must infer that some kind of residue or impression, chemical or physical, is left in the neurones in consequence of which they have a disposition to reproduce, when again stimulated, the original experience, whether an idea or physiological reaction. Hence these residues are called unconscious “residua” or “dispositions.” They have a hypothetical existence like the atoms and molecules of physics, but upon them the theory of memory is based. They may be likened to the impressions left in the wax cylinder or the magnetization of the wire of the phonograph by the spoken word. A complex of such residua is an “unconscious complex.”
But besides mental experiences all observation and experimentation show that pure physiological reactions associated with a given mental experience are conserved as a part of that association. The ideas, for example, belonging to a fright complex which originally were accompanied by palpitation of the heart, tremor, perspiration, muscular weakness, etc., when reproduced in memory are again accompanied by all these physiological reactions. So in Pavlow’s dogs the repeated experiences of a sensation of touch, accompanied with the physiological reactions of saliva, became a complex which was conserved and reproduced on subsequent occasions. The nervous system faithfully conserves and reproduces its experiences. Conservation is fundamental for education; for upon it the law of linking of complexes depends. It is obvious, for instance, that the education of coaptative synergesis of muscular movements for purposeful acts would be impossible unless by the act of experience something capable of reproduction were impressed upon the neurones. Now the more often an experience is repeated and the stronger its emotional tone, the more likely it is to be conserved. Thus we repeat a verse or a rule of grammar until we know it by heart; or we repeat a movement until it becomes automatic.
But without repetition the elements of an experience may become linked and conserved. We undergo an emotional experience accompanied by various bodily reactions, as in a railroad accident, or we experience an abhorrent idea, or one of apprehension, or repulsive desire—in each case the nervous organism remembers the experience and upon proper stimulus can reproduce it. The emotional tone seems to intensify the impression on the brain organization.
Further, on the principle just described of the linking together of experiences into complexes, or associated groups of ideas, feelings, and physiological reactions, it is evident that large unconscious complexes, representing experiences, may be conserved and afterward reproduced as a whole by stimulation of the neuron residua. Observation shows that this is exactly what happens; and when these complexes are of an unhealthy kind we call them obsessions, phobias, etc., which in reality are nothing but experiences faithfully conserved as residua and reproduced from time to time. They may also be called association psychoses or neuroses on the basis of their mechanism.
Now another fact which has been proved by experimentation and observation: A complex, i.e., the unconscious residua of a complex, may be almost photographically conserved notwithstanding that we may not be able to voluntarily reproduce it, i.e., recall the original experience. It may be preserved in the unconscious neurons and be made to reproduce itself by some special device. E.g., a childhood experience may be entirely forgotten, yet that it may be still preserved is shown by the fact that it can be recalled in even all its minute details in hypnosis, dreams, etc. When recalled in dreams it often takes on a distorted form and, freed from a true appreciation of its meaning, it awakens the liveliest and often terrifying emotions. This latter is a matter of considerable significance, for the same principle plays a part in hysterical crises.
Another fact of observation needs to be grasped in all its significance, for it underlies one practical method of psychotherapy. The failure to appreciate this has led to misunderstandings of the principle of hypnotic suggestion and indirectly to a denial that such suggestions are of therapeutic value, while at the same time it is admitted that waking suggestion is efficacious. The fact is this: It makes no difference in what state complexes are formed, whether in every day life, in sleep, trance, dissociated personality, subconscious states or hypnosis, they are or may be equally firmly organized and conserved, and they are conserved whether we can voluntarily recall the experiences or not. Whether they are to become organized depends upon the mode and conditions under which the impression is made upon the mind or nervous system, but once organized they are conserved and become a part of our personality. We cannot get rid of them unless they are effaced by the corroding action of time or disease. We are accustomed to think, of experiences belonging to such states as not belonging to ourselves. This is a mistake. All experiences, however, and wherever formed, if conserved, are a part of ourselves and belong to the storehouse of our knowledge, though we may or may not afterwards draw upon that storehouse in practical life. We know that dreams which are not even remembered may be not only conserved but may influence the personality during quite long periods of time for good or for ill. I have now a case under observation where an idea complex occurring in a dream persisted after waking as an obsession, and has continued as such to the present time, a period of twelve years.
If a complex, then, of ideas, which make up points of view, attitudes of mind, beliefs, hopes, and aspirations, is once firmly formed and organized in hypnosis, it remains as a part of our personality.
Further, experimentation and clinical observation have conclusively proven that a complex of ideas formed in hypnosis, whether remembered when the personality is awake or not, can affect, modify, or determine the ideas, beliefs, feelings, emotions, etc., of the individual. The elements of the hypnotic complex enter the stream of thought of every-day life and modify it. Whether it will do so or not depends on various conditions. How it does so is another question which we cannot enter into here. That it may do so is a fact which can be proven as often as we wish to try the experiment. If this is so when there is complete amnesia after waking from hypnosis it can be understood how much more easily it may be the case when, as happens in nine tenths of such procedures, hypnosis is little more than a state of relaxation and abstraction and is not followed by amnesia, but, on the contrary, the whole hypnotic experience, all the ideas of the complex which were therein formed are remembered by the subject. When it is remembered that in hypnosis there is increased suggestibility, and that there may be induced a dissociation of all ideas which clash with and antagonize the suggested ideas, thereby allowing a new synthesis to be formed, we can see what a powerful influence can be exercised on the personality by this procedure.
The next principle to which I would call your attention is one to which I have already referred above, namely dissociation. It is a general principle governing the normal psycho-nervous mechanism and therefore in a highly marked form only is pathological. A characteristic type is functional amnesia by which an epoch or a long period of time is blotted out of the memory. You will recall cases where following an emotional trauma the preceding hours or days or months are forgotten. The experiences of this time cannot be recalled as memories; but they are still preserved as brain residua, for they can be reproduced by artificial means through hypnosis and other methods. The amnesia for the hypnotic state and dreams after waking is also due to the same principle, as is also that following numerous other states which I cannot spare the time to mention here. What has happened in such conditions is a dissociation between the systems of brain residua which correspond to the psychological experiences. There is an inability to synthesize these systems into one personality and hence the amnesia.
Amnesia, of course, as a technical term, includes only ideas, but dissociated systems or complexes may include motor and sensory functions, and these we meet with as paralyses and anesthesias as observed in hysteria. That such dissociations are purely functional is shown by the fact that they can be produced by suggestion and removed (synthesis) by suggestion. When, as sometimes happens, a single symptom like paralysis and anesthesia cannot be removed by suggestion, if the whole dissociated system to which this symptom belongs is synthesized by suggestion the symptom, paralysis or anesthesia, disappears. Here again we have a fact important for psychotherapeutics,—the fact that we can produce dissociation and synthesis by suggestion,—for if, as experimental investigation has shown, the basis of certain psycho-pathological conditions like hysteria is dissociation, we have a means at our command which may be used for the resynthesizing of the personality, i.e., the restoration of the normal individual. It is important not to lose sight of the fact that dissociation is a function of the normal mechanism of the mind and nervous system, and is made use of in normal life for the adaptation of the individual to the constant and ceaseless changes of the environment. It is the enormous exaggeration and perversion of this dissociating mechanism that constitutes abnormality. A suggested idea simply stimulates and makes use of the normal mechanism, otherwise it can have no effect.
Among the normal phenomena of dissociation are to be reckoned temporary and some permanent forms of forgetfulness, the limitation of the field of consciousness in absent-mindedness, moods, anger, and other strong emotional states and sleep. Amongst the artificial and pathological conditions characterizing largely or chiefly the dissociations are hypnotic and hypnoidal states; suggested and hysterical amnesia, paralyses, contractures, anesthesiae, etc.; somnambulism, trance, psycholeptic attacks, etc.
Emotion, again, is a powerful factor in producing dissociation as well as the linking and conservation of complexes.
In the so-called neurasthenic state and hysteria, dissociation plays a very important part. All cases of hysteria and many of neurasthenia are, as I see the matter, cases of dissociated personality,6 but it would carry us too far from our main subject to discuss this aspect of the matter at this time.
Subconscious Ideas. There are certain important phenomena of dissociation and conservation that ought not to be omitted, considering the important part which they sometimes play, and the large amount of attention which they have received.
When the conserved residua of an unconscious complex are stimulated, this complex becomes a conscious memory of which we are aware, but sometimes something else happens—it becomes a conscious memory of which we are not aware. Ideas are awakened, but we are not aware of them. These are what are called subconscious, or better, co-conscious ideas, which means ideas dissociated from, split off from the main consciousness. This is an interpretation of certain phenomena belonging to abnormal psychology which would carry us too far afield to consider here; but the evidence is so strong that it is impossible to resist the conclusion. Now when this is the case such ideas often resemble dreams—fixed dreams. The ideas, like dreams freed from the control of the personal consciousness which has no appreciation of their existence or meaning, take on a distorted form, and when accompanied by emotions acquire all the characteristics of nightmares—subconscious nightmares they may be called. That they should produce psychological and mental disturbances is not to be wondered at. This is what is sometimes found in hysteria when they produce the so-called hysterical crises. To get rid of such subconscious nightmares must plainly be an object for psychotherapy. A simple type of the dissociated co-conscious idea is found in hysterical anesthesia. Here there is no absolute anesthesia. The lost tactile sensations are only split off from the personal consciousness and, although the patient is unaware of them, they are preserved as co-conscious perceptions or tactual ideas. To resynthesize these perceptions with the personal consciousness is to make the patient aware of them and remove the anesthesia.
I pass over as a controversial matter the mechanism by which co-conscious ideas are dissociated from the main content of the personal consciousness, i.e., by which the person becomes no longer aware of them. Differing views are maintained. By some it is held that in disease, as in hysteria, the splitting of the mind is due to fatigue and emotional trauma; by others that it is due to the direct volitional repression, or the pushing out of consciousness of ideas which are unacceptable to the individual. But whichever mechanism is the correct one, whether dissociation is brought about by voluntarily repressing painful or unacceptable ideas or whether by an over-intense stimulus from an emotional trauma to which the individual is not adapted, or by fatigue, in any case the pathological dissociation is but an exaggeration or perversion of a normal dissociating mechanism. That it still remains functional is shown by the fact that a functional stimulus (suggestion) is capable of producing it and removing it. We have here a type of functional disease which is somewhat different in form from that which results from the educational process, although this may come later into play in evolving subsidiary symptoms. I hardly need point out that the secondary effects of dissociation—hysterical stigmata, etc.—are but the products of the normal functioning of the mutilated and dissociated fragments of the personality.
In the mechanism of normal psychic life, automatism plays a much larger part than is generally realized. This principle tends to the economy of effort. We see it in habit actions and absent-minded acts when our attention is directed to some other train of thought than that engaged in the actions. Even language symbols tend to become associated into set phrases and formulas, which tend to become automatic and labor-saving devices for the expression of thought. In expletives and explosive phrases which almost unconsciously give vent to our feelings we easily recognize these language automatisms. Less conspicuous as automatisms is the activity of complexes of ideas, however formed, which function more or less automatically as a group and determine the direction of our thought and its content. The association experiments have done much to bring to light this automatic activity of complexes, and we are under deep obligations to Freud, Bleuler, and Jung for having directed our attention to this principle and emphasized these particular facts. In pathological fixed ideas which rush into consciousness unbidden and undesired we can clearly see this automatic activity. So in establishing fixed habits of thought, in forming deeply rooted ideas and points of view, beliefs, etc., we form complexes which are capable of more or less autonomous action.
When psychological and physiological processes become dissociated, and thereby freed from the inhibitory control of the personal consciousness, automatism is observed in its most highly developed form. The split off groups of psychological or physiological elements acquire what may be called a hyper-excitability and are capable of extremely independent functioning. The manifestations may be in the form of subconscious ideas, hallucinations (sensory automatisms), tics, spasms, convulsions, contractures (motor automatisms), etc. Primarily such pathological phenomena depend upon dissociation of the nervous organism and the stimulus by some excitation from within or without of the nervous mechanism involved. With re-association and cessation of stimulus the automatisms logically cease. The aim of psychotherapy, therefore, must plainly be to re-associate the split up personality, and to form such healthy complexes of ideas as will not stimulate the undesired complexes, but by their automatic activity will contribute to the well-being of the individual and adapt him to his environment.
5. EMOTIONAL ENERGY
It is a fact of observation that intense sthenic emotions and feelings are accompanied by an increase of the vital functions while, per contra, certain depressive emotions and feelings are accompanied by a decrease of the vital functions. Further, it is generally recognized by psychologists that most, if not all, ideas have a feeling tone attached to them. Consequently if certain complexes of ideas which have intense sthenic feeling tones are brought into the personal consciousness there is awakened a state of energy, a feeling of wellbeing and capacity, and an invigoration of the whole organism. If, on the other hand, complexes of ideas which have depressive or distressing feeling tones are brought into the personal consciousness, the contrary effect is produced. Stating the same fact in another way, exalting emotions have an intense synthesizing effect while depressing emotions have a disintegrating effect. This last we see exemplified in emotional trauma (traumatic neuroses) where sometimes a complete dissociation or splitting of the personality occurs, being manifested by altered personality, anesthesia, paralysis, etc. Every one who has studied the hypnotic states must have observed these phenomena experimentally produced. With the inrushing of depressive memories or ideas whether originating autochthonously in the associations of the mind of the patient, or accidentally or intentionally suggested by the experimenter, there is suddenly developed a condition of fatigue, illbeing, and disintegration, followed after waking by a return or accentuation of all the neurasthenic symptoms. If on the other hand exalting ideas and memories are introduced and brought into the limelight of attention there is almost a magical reversal of the process. The patient feels strong and energetic, the neurasthenic symptoms disappear, and he exhibits a capacity for sustained effort. He becomes revitalized so to speak. This, I believe, is the secret of those changes of character and physical capacity which William James has so brilliantly illuminated in his essay on the “Energies of Men.” Complexes of ideas accompanied by strong feeling tones which have long lain fallow are brought out of their dormant abode and made to become a part of the working force of the mental factory.
In this principle, then, we see a mechanism which tends to the development of the neuroses and psychoses on the one hand, and to states of invigorating health on the other, according as whether disintegrating or synthesizing emotions and feelings are brought into the conscious field of the individual. In the hypnoidal state of Sidis and in hypnosis it is particularly easy to bring out of the dormant consciousness into this active central field memories and ideas which have been pushed aside or upon which the individual has lost his grip by reason of their having become dissociated by fatigue, friction with the environment, or by other disintegrating factors. It is thus easy to modify the personality at will by measures which make use of this principle. The transformation effected by the development of energy in this way is often most striking and is often commented upon by the patient. On the other hand, I have observed that when for any reason depressive memories and such idea-complexes enter and remain in the mind of the hypnotized subject, no matter what suggestions are given, the patient on waking becomes or remains correspondingly depressed and neurasthenic.
I have thus far briefly formulated the main psychological principles upon which psychotherapy rests. The point I wish to bring out into strong relief is that these principles or tendencies govern the normal functioning of the psycho-nervous system, and that it is the perversion of these tendencies which constitute functional disease; that is to say reactions which misadapt the individual to his environment and which result from normal functioning under conditions to which the individual is not adapted. Functional disease is therefore a process of perverted functioning. Conversely psychotherapy makes use of these same principles or tendencies to readapt the individual to his environment, to re-educate him to healthy reactions.
Psychotherapy simply makes use of the normal mechanism of the mind and body, of the physiological machinery to bring about a restitution of the disordered functions and restore the individual to health. Thus suggestion can only act by stimulating the physiological mechanism, it can only make use of machinery already provided; it cannot create anything anew, do anything that is not in accord with the laws of the nervous system. As a method psychotherapy is comparable in every way to what is now known as physiological therapeutics which has taken such an important place in modern treatment in internal medicine.
I fear my exposition has been too brief to enable these principles to be clearly grasped by those who have not systematically studied and observed the phenomena of abnormal psychology. The field of investigation is a wide one, and to thoroughly comprehend the meaning of the facts that are to be observed one must make himself familiar with them at first hand as one would expect to do in bacteriology if he would understand the principles of infectious disease and immunity.
The psychological principles I have attempted to elucidate may be summed up as: First, Complex formation; second, Conservatism; third, Dissociation; fourth, Automatism; fifth, Emotional Energy.
Each of these principles is made use of by psychotherapy in greater or less degree according to the conditions presented. If we are dealing with a simple psycho-neurosis of the neurasthenic type where the disturbance can be traced to the first class of facts I have mentioned,—i.e., to unhealthy ideas, self-examination, worry, erroneous beliefs in and apprehension of disease with the depressive emotional tones that go with such states, to habits of introspection and concentration of the mind on the functions of the body, etc., —the main principle to be made use of is the organization and substitution of healthy complexes in place of the unhealthy ones. This is not a simple procedure, but an art. It often requires all the skill which can be acquired from a knowledge of human nature, of life, the data of abnormal psychology, and, above all, from a recognition of the principles above formulated. The point of view, the attitude of mind, the beliefs, the habits of thought, must be modified by the introduction of new points of view, of data previously unknown to the patient and drawn from the wider experience of the physician; by instruction in the meaning of symptoms and in their organization and causes; by the suggestion of expectations that justly may be fulfilled; of ambitions that ought rightfully to be entertained; of duties to be assumed but too long neglected; of confidence and hope; and, above all, by the suggestion of the emotion and joy that go with success and a roseate vista of a new life. There is no fact of life that does not have more than one aspect, no conduct that does not have more than one interpretation, no judgment that does not have an alternative, no conduct that does not have more than one relation. Thus the old systems of ideas carrying with them apprehensions, anxieties, and depressive emotions are modified by being interwoven with new ones, and new systems of ideas or complexes are artfully created and substituted for the old. These systems should be such as will stimulate healthy reactions of the body in place of the unhealthy perverted reactions.
Finally the whole complex, by repetition, emphasis, and the stimulus of emotion, is firmly linked and organized until is becomes conserved as unconscious brain residua and a part of the individual’s personality. If thus conserved it will be reproduced whenever stimulated. To be effective ideas must be fixed, conserved, else they become the sport of every passing thought and feeling. But for this they must be accepted and to be accepted they must be the truth, as they should be on ethical and rationalistic grounds. Every person can bear the truth but it should be the whole truth and not half the truth or only one aspect of the truth or the truth that allows erroneous interpretations. All this therapeutic procedure of course means the education, or perhaps better, the re-education of the patient. It is the same process that in Pavlow’s dogs led to the secretion of gastric juice and saliva by educated reactions to the environment, and in hay fever neurotics to the creation of the coryza complex as a perverted reaction to mental and physical stimuli. Only the therapeutic process is the association through education of healthy ideas and stimuli that adapt the individual to his environment.
6. THE RELATIVE ADVANTAGES OF EDUCATION IN HYPNOSIS AND IN THE WAKING STATE
This is a much discussed question. One meets often with assertions rather than arguments which are made with a warmth and acrimony of feeling that betokens prejudice rather than a masterly knowledge of the subject. From the point of view of formation of complexes it must be evident, if the psychological principles which I have set forth are well grounded, that it matters little in what state these therapeutic systems of ideas are formed, whether in hypnosis or in the waking state. When once formed they become a part of our personality and take part in swelling, modifying, and directing the stream of mental life. This can readily be apprehended when it is remembered that in ninety per cent of cases so-called hypnosis is little more, as I have already said, than a condition of abstraction with relaxation in which suggestibility is heightened. On returning to the full waking state there is complete memory of the whole hypnotic episode, so that the suggested ideas are accurately remembered. As a matter of fact hypnosis is only necessary in a small minority of cases. In obstinate cases hypnosis has the advantage that, suggestibility being increased and antagonistic ideas being dissociated or inhibited, the new ideas are more readily accepted and the complexes more easily and firmly organized. Then, after waking, the patient who remembers the suggested complexes finds that his whole state of mind is modified.
But even when amnesia follows after waking the result is the same. Then7 on examination we find, however complicated, that the suggested ideas and emotions weave themselves into the thoughts of the conscious individual and modify them; or the emotions, alone, may intrude themselves and determine the mood and the whole psychic content. To take an actual case, I suggest to B. C. A., in hypnosis, ideas of wellbeing, of recovery from her infirmity; I picture a future roseate with hope, stimulate her ambitions with suggestions of duties to be performed, deeds to be accomplished. With all this there goes an emotional tone of exaltation which takes the place of the depression and of the sense of failure previously present. This emotional tone gives increased energy to her organization, revitalizing, as it were, her pyscho-physiological processes. The whole I weave artfully and designedly into a complex. Whatever neurotic symptoms were previously present, I do not allow to enter this complex. Indeed, the complex is such that they are incompatible with it. The headache, nausea, and other bodily discomforts, pure functional disturbances in this instance, are dissociated and cease to torment. After “waking,” there is complete amnesia for the complex. Yet it is still organized, for it can be recovered again in hypnosis. It is simply dormant. But the emotional tone still persists after waking and invades the personal synthesis which takes on a correspondingly ecstatic tone. The aspect of her environment, her conception of her relation to the world, and her past, present, and future mental life have become colored, so to speak, by the new feeling, as if under a new light. But more than this, new syntheses have been formed with new tones. If we probe deep enough we find that many ideas of the dormant complex have, through association with the environment (point de repère), become interwoven with those of the previous personal consciousness and given all a new meaning. A moment ago [her view was that] she was an invalid, incapacitated, exiled from her social and family life, etc. What was there to look forward to? Now: What of that? She is infinitely better; what a tremendous gain; at such a rate of progress in a short time a new life will be open to her, etc.,—a radically new point of view. Now, too, she feels buoyant with health and energy, ready to start afresh on her crusade for health and life. Her neurotic symptoms have vanished. Such is the change that she gratefully speaks of it as the work of a wizard. But the mechanism of the transformation is simple enough. The exaltation, artificially suggested in hypnosis, persists, altering the trend of her ideas and giving new energy. The perceptions of her environment, cognition of herself, etc., have entered into new syntheses which the introduction of new ideas, new points of view have developed; thus the content of her ideas has taken a definite precise shape. Whence came these new ideas? They seem to her to have come miraculously, for she has forgotten the hypnotic complex. But forgetting an experience is not equivalent to its not having happened or to that experience not having been a part of our own psychic life. The hypnotic consciousness remains a part of one's self (as a psychological complex), however absolutely we have lost awareness of it. Its experiences become fixed though dormant, just as do the experiences of our personal conscious life. . . . The mechanism is the same.
The following letter from this patient, received by chance after these paragraphs were written, well expresses the psychological conditions following hypnotic suggestion.
“Something has happened to me—I have a new point of view. I don't know what has changed me so all at once, but it is as if scales had fallen from my eyes; I see things differently. That affair at L— was nothing to be ashamed of, Dr. Prince. I showed none of the common sense which I really possess; I regret it bitterly; but I was not myself and even as [it was] I did nothing to be ashamed of—quite the contrary, Indeed. . . . Anyway, for some reason—I don’t know why, but perhaps you do—I have regained my own self-respect and find to my amazement that I need never have lost it. You know what I was a year ago—,you know what I am now; not much to be proud of, perhaps, but I am the work of your hands and a great improvement on [my poor old self]. I owe you what is worth far more than life itself. . . namely, the desire to live. You have given me life and you have given me something to fill it with . . . I feel more like myself than for a long time. I am ‘my own man again’ so to say, and if you keep me and help me a little longer I shall be well.”
When dissociation exists it becomes self-evident that a restoration of the healthy organization can only be attained by a reassociation of the dissociated functions. It is obvious that subconscious ideas, when disturbing, need either to be so modified that they cease to function, i.e., to be subconscious and dissociated, or to be reintegrated with the personal consciousness, i.e., brought into the full light of conscious knowledge, and thereby realized in all their meaning, rearranged and modified; just as a dream becomes modified and loses its psychological meaning and its physiological effects after waking with a full awareness of its falsity. Disintegrated personality needs to be reassociated into a unified complete personality, with full possession of its faculties and functions, etc. There are many empirical ways of doing this, physical and psychological, but amongst the methods experience has shown that there are several psychological procedures which are rational and prove efficacious when physical and empirical methods fail. So-called psycho-analysis, suggestion in the waking state and abstraction, in so-called hypnoidal states and hypnosis, mental and physical hygiene, all have proved to be efficient in bringing about a reintegration of dissociated functions. But all these methods are only different forms of education.
The principle of dissociation and association is exemplified by the process of hypnotizing and awaking an individual. Hypnosis is dissociation; in awaking a person what we do is to re-synthesize the personality and to restore the normally functioning organism.
Finally I would point out that a prerequisite for such psychotherapeutic measures is a preliminary painstaking and exhaustive analysis of the symptoms, of the genesis of the psychosis, of the logical relation of the symptoms to each other and to mental and external causes, of the pathology of the symptoms and their significance; what are due to auto-suggestion, what to habit or education, what to fatigue, what to true organic disease—in short the complete meaning or philosophy of the disease must be determined. If, as is often the case, incidents in which the psychosis developed or which are the subconscious cause of repeated attacks are forgotten, the memories of these should be revived by one or the other of various technical methods of psycho-analysis. Only through a knowledge gained in this way in each individual case can a rational psychotherapy be undertaken. After such an analysis it is generally surprising to find that what at first seemed a mere chaos of unrelated symptoms will turn out to be governed by law and order.
When we come to deal with the more profound psychoneurotic states, those of the severer hysterias, a somewhat different therapeutic procedure is usually required. Here we have to do with dissociations, often of a profound type, with paralysis, anesthesia, alterations of personality and subconscious ideas of which the patient is unaware, or unconscious automatisms freed from the inhibitions of a fully synthesized personality. For psychotherapy reassociation of the dissociated functions is the essential principle, although again the formation of new healthy complexes is necessary to maintain the association. Our ingenuity is often taxed to the utmost in devising methods to reintegrate the psycho-physiological personality. Various technical devices can be made use of. I cannot go into this here, as I am only dealing with principles. Suffice it to say that sometimes reintegration can be formed in a special state of hypnosis; sometimes by suggestion in hypnosis or to the waking personality; sometimes by recalling to the full light of the waking consciousness the subconscious ideas or “dreams”; sometimes by recalling them to the full light of the hypnotic consciousness, etc. By doing this the subconscious “dream” or fixed idea—generally a memory of some emotional incident—becomes fully recognized as to its meaning and character, and thereby interwoven with the logical processes of waking thought; in other words, synthesized into a new, healthy complex. We see the same principle when, on waking from a nightmare, not only the dream but the realization that it was a dream comes into the full light of consciousness. With this realization the terrors and all the bodily disturbances cease.
I have pointed out that one theory of the mechanism by which ideas become dissociated is that of voluntary repression; the individual pushes out of his consciousness ideas which are painful and unacceptable. Consequently it is held by those who adopt this theory that those dissociated ideas must be resynthesized with the personality, i.e., brought to the full light of awareness—to effect a complete and permanent cure, and that the mere act of making the patient aware of them effects the cure. To accomplish this a special form of psychoanalysis (Freud’s) has been devised, not only to discover the dissociated ideas, but to synthesize them.
That this method is often useful and efficacious will be admitted, but its mode of working, as I interpret it, is not that which those who employ it suppose. Like other methods too, it is not always successful nor is it the only effective one.
Thus it is often not difficult by suggestion, with or without hypnosis, along the lines I have described, to effect a cure although the patient never becomes aware of the troubling ideas. More than this, it is worth while insisting that if psycho-analysis merely synthesizes the repressed ideas theoretically it is not the logical method to be employed. The assumed mechanism would require something more. The repressed ideas are pushed into the subconscious because they are in conflict with other wishes and feelings of the individual; the latter rebels against and will not tolerate them. Now if nothing more were done than to bring them back into the consciousness of the individual he still would not tolerate them and would push them out again. Theoretically, therefore, the method would be useless. But in fact the patient does, we will say, tolerate the ideas that before were unbearable; the conflict ceases. Empirically the method works. Why? The reason is simple: the complex of ideas has been changed by the technique of psycho-analysis and by the very act of bringing to the light of consciousness the repressed ideas—an elaborate process. We do more than this: we give the patient an insight into the meaning of his trouble; we let him see new points of view; we introduce new ideas and feelings into his complexes; in short, re-educate him. It is impossible to practice psycho-analysis without doing this; hence, it is nothing more than a special form of the educational treatment and has the same therapeutic value.
When the hysterical manifestations are due to the functioning of dissociated subconscious ideas it is not always necessary, as some writers insist, to recall those ideas to the personal waking consciousness. It is enough to break up the subconscious complex or to suggest antagonistic ideas, or to resynthesize the ideas, in the manner already described, into a healthy complex which gives a true appreciation of the facts which they represent. This can be done in hypnosis. After waking, though amnesia for the previous subconscious ideas may persist, the symptoms disappear, for those harmful subconscious ideas which caused the trouble have ceased to exist.
Some hysterical attacks are what have been aptly called by Boris Sidis recurrent mental and psychomotor states; that is, dissociations of the personality and the reproduction of systems of ideas which originally were an emotional mental accident that the patient once upon a time experienced. These experiences have been conserved as brain residua and come to life again from time to time as attacks. If a rearrangement of these conserved experiences, by education along the lines already laid down, can be brought about, a disappearance of the attacks may be expected.
Hysterical attacks that are due to auto-suggestion can be removed, as a rule, by simple suggestion. Automatisms, like contractures, tics, spasms, convulsions and crises, tend to cease with the restoration of the fully synthesized personality if the dissociating apprehensions and emotions have been removed and healthy complexes have been substituted therefor.
Whatever technical methods are employed, it will be found that they are all based on the psychological principles which have been above discussed.
It is needless to insist that a preliminary psycho-analysis is, as always in psychotherapy, a prerequisite procedure.
8. PSYCHASTHENIA AND OBSESSIONS
In so-called psychasthenia we are dealing with a somewhat different pathological condition from hysteria. Here we have recurrent mental states in the from of obsessions, represented by doubts, scruples, anxieties, phobias, impulsions, etc. The obsessional ideas are preserved as brain residua. When stimulated, instead of becoming subconscious, they enter the consciousness of the principal personality. The obsessional ideas occur in the form of attacks of which psycho-analysis will not only show the origin and meaning but that the attack in each instance is excited by association with some related thought which has flashed into the mind or other stimulus from the environment. Apprehension and expectation, acting as auto-suggestion, play in my experience a predisposing part in the mechanism. The pathology is too complex to go into here, but the same psychological principles underlie the psychotherapy, viz., psycho-analysis and education, the latter having for an end the substitution of healthy complexes for those organized systems of associated ideas which have become conserved as residua in the unconscious and which reproduce themselves as automatisms over and over again.
_______________1 The work of the Digestive Glands (English Translation), p. 152.
2 J. P. Pavlow: Psychische Erregung der Speicheldrüsen, Ergebnisse der Physiologie, 1904, I Abteil, p. 182.
3 Huxley Lecture, Br. Med. Jour., Oct. 6, 1906.
4 Prince: The Unconscious, Journal of Abnormal Psychology, Oct.-Nov., 1908.5 Morton Prince: Association Neuroses, Journal of Nervous and Mental Disease, May, 1891.
6 Morton Prince: Hysteria from the Point of View of Dissociated Personality, Journal of Abnormal Psychology, October, 1906.7 Cf. The Unconscious, Journal of Abnormal Psychology, April-May, 1909.
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