It is often difficult to change the hour of taking the princ.i.p.al meal, but in special cases this can be done with decided advantage. I have seen such a change make all the difference between slow recuperation from bad colds, and have seen it of the greatest possible importance in tuberculosis. The very changing of the hour will sometimes suggestively react to make the patient eat more heartily than usual, the day is broken up better, the reaction against the morning discouragement comes earlier, and the patient's general condition improves. Many people rest better at night if their princ.i.p.al meal is taken at the middle of the day.

CHAPTER V

THE LEISURE HOURS.

Then comes the return from business. Here once more the ordinary method of getting on a crowded train, standing up to be pushed and jammed, to have all sorts of unpleasant things happen, to have the pessimism of one's nature stirred to its depths by the utter disregard for women, the heedless rush of men, the roughness of railroad employees, and the general lack of humanity that characterizes the evening rush from business in a large city, is eminently unsuitable as a preparation for dinner; while a calm walk of three to five miles is ideal. To walk home will probably take twenty minutes or half an hour longer, but not more than this--and it avoids the undesirable features of the usual method.

Gymnastics.--Occasionally one finds that men rush through the last hour of business in order to spend an hour in a gymnasium. Often this is quite undesirable. Exercise within doors, taken in a routine manner and merely for the sake of exercise, with no diversion of mind, is eminently unsuitable for the busy man. What he needs is air much more than exercise. Walking out of doors is the very best thing for him. If he walks at a rapid pace, swinging his arms a little freely and carrying a cane in one hand and perhaps a book in the other, because this exercises his fingers and keeps him from having any unpleasant congestion of the hands when they hang down, then the exercise is almost ideal. Owing to the novelty of it, and the interest that a new occupation arouses, great benefit will at first be derived from the gymnasium. Very often, too, the cold plunge after the exercise does more good than the exercise itself. The plunge is real fun, especially when taken with many others, but the exercise itself is likely to degenerate into the sorriest kind of a task. If the man who walks home will take a bath before dinner, the temperature of the water being made suitable to him and the reaction that comes to his particular nature, there is no need of anything else, and there is nothing better that he could do. The walk must be varied. The course must not always be through the same streets. Occasionally it {182} should even lead one to see some monument or new building, or to go out of the way with a friend, so that variety is introduced.

Work at Home.--There are men who in busy times take some of their work home with them. This is a mistake. And though it is the custom to tell the doctor that they cannot do otherwise, it is practically always a bit of self-deception. When the case is properly put before them, they realize, if they already have any neurotic symptoms, that to continue home work will be a serious risk. Most men who carry business home with them, easily get into the habit of pushing certain details away from them during the day with the idea that they will have more time for that in the evening. They do a certain amount of dawdling over their work. If they really resolved to finish work during business hours they could do it, and do it better than during the evening at home. Six hours of work is about all that a man ought to do with his intellect at high pressure. This should be pretty well divided into two periods of three hours each, with an interval of an hour to an hour and a half between. The nearer a man can come to this arrangement the better for him, and the better, also, for his affairs. If he has a.s.sumed obligations that require more of his time and attention than this, he is trying to do too much.

After-Dinner Hours.--The evening hours and their proper occupation are important for the business man, or for anyone who is much occupied during the day. The temptation to let the work of the day run over into the evening must be overcome at all costs, or it will prove serious for the health of most men. It is important as far as possible to get something completely different for men to do at night. Many men settle down to the reading of a newspaper or of a magazine or novel.

While this does very well under some circ.u.mstances, reading does not provide diversion whenever there is serious worry or solicitude over business matters. A man may think that he is occupying himself with the newspaper, but we all know very well that business cares intrude, that business troubles are often doubled by reading about others. The reading of novels does well for a while, but the serious-minded man tires of them and then, while they may occupy a couple of hours, they have exactly the same objection as the newspaper. A genuine diversion should give the physical basis of mind an opportunity literally to remake itself by storing up new energies.

_Amus.e.m.e.nts_.--The fact of the matter is that a man must have, if possible, some other serious interest in life besides his business. He must have a hobby. We have discussed this in the chapter on Diversion of Mind and refer to it here only to indicate the importance of knowing something about a man's recreation as well as his work. It is not a casual occupation but a real interest that he should have. This need not necessarily be a useful employment and, indeed, it may be absolutely useless provided it is absorbing. Card playing is an excellent diversion for many people. When joined with gambling, new worries and feverish excitement usually make it harmful for neurotic persons. Chess is hard work, but of a different kind from that of the day and, therefore, often makes an excellent recreation. Any games are good. Bowling, for instance, is excellent, and billiards, if a man has an interest in it, is a fine sport for evening hours. It has the added advantage of physical exercise. A man does not sit down during billiards, crowding his {183} already well-distended abdominal viscera, but walks around and gives his viscera a better chance for their work and aids rather than r.e.t.a.r.ds peristalsis.

_Encroachment on Sleep_.--There is just one defect about some of the more absorbing recreations--they keep a man up too late. Whenever a so-called recreation takes up such time that a man has less than eight full hours in bed, then a mistake, almost sure to be serious sooner or later, is being made. When the physician tries to limit a man's recreation by suggesting an earlier hour for retirement, he may be told that his patient must have some time for diversion and recreation. But the physician must insist that no form of recreation is as good as sleep, and any other form must be limited in order that sleep may be obtained. A man may easily regulate his affairs so that he shall have eight hours of sleep, and it is only negligence of such regulation that gives him the idea that recreation cannot be obtained except after eleven o'clock at night. Little suppers after the theater are often fine diversions, but whenever they interfere with sleep they must not be allowed except at long intervals. Other diversions that keep a man out of bed after midnight are sure not to do good in the long run, though an occasional lapse in this matter may prove a stimulant rather than a depressant. It is custom that must be regulated; an occasional variant from it is rather good than otherwise.

Leisure of the Working Woman.--A woman's occupation, unlike a man's, holds out little future for her. Her occupation does not arouse her ambition. Daily work is a monotonous grind that must be endured for the sake of the wages that it brings. For a time this serves to occupy attention. After some years, when the prospects of matrimony grow less, and further advance is out of the question, women often need to have some special interest that will grip them. The working woman may then need to be tempted to some occupation of mind, especially with the companionship of others, that will give her renewed interests in life. Clubs, charities in which they are active, friends, serious intellectual interests, must all be appealed to, in different cases, in order to secure diversion. Women must have something to look forward to each week. They must know on Monday that before the following Sunday there is going to be a theater party, a lecture, a visit to friends, something to break the deadliness of weekly routine, which is antic.i.p.ated with pleasure and then pleasantly remembered.

This may seem to be only a slight matter, but it is of importance in many cases.

Feminine Occupations.--The occupations of women who stay at home are even more important than those of women who go out to work. In our time the root of much nervousness, as it is called, neurotic symptoms of various kinds and of many symptoms apparently quite distant from real nervousness, is really a lack of occupation. Many women who live in apartment hotels have almost nothing with which to occupy their minds. They are not obliged to get up in the morning if they do not want to, or, at least, any excuse, however slight, serves to keep them in bed. Very often there are either no children or the mother has nothing to do with her children early in the morning. After the age of three, they go off to kindergarten; later on they go to school.

Breakfast is sent up, there may be a nap of an hour or two after the meal, and often a magazine is glanced over lying in bed, and perhaps it will be twelve o'clock before madame gets up. Anyone in a position to do this, and who allows the habit to grow, is sure to be profoundly {184} miserable. Without any real occupation of mind, the mind occupies itself with the body and emphasizes every sensation, evokes new pains and aches, and the consequence is likely to be a highly neurotic state.

Such women have nothing serious to think about in the afternoon. At best it is a luncheon engagement with a friend, or attendance at the matinee, or a lecture, or a meeting of a club. For a while, and for a certain few, these things are satisfying, but after they have been indulged in for a time, they pall so completely on most people as to leave them almost helplessly at the mercy of their feelings. These persons may have some favorite charities that occupy part of their time. They may have other interests, but most of these interests are quite amateurish. They create no obligations; they arouse no sense of duty; they are abandoned at a moment for anything else that turns up, and consequently they lack that absorbing power that a real interest gives. It is quite impossible that these people should be either happy or healthy. These ladies of leisure sometimes have fads for physical exercise that keep them from becoming absolutely sluggish, but except in a few cases, these fads pall after a time, and in a few years women of the leisure cla.s.ses are generally without any interest that will save them from themselves. The root of many a case of nervousness that wanders from physician to physician and then from quack to quack, and from charlatan of one kind to charlatan of another kind, that takes up now this remedy and now that, and advertises each new method of healing--mental, hypnotic, mechanical--is due to nothing more serious than lack of proper occupation of mind.

The Ambition to Have Nothing to Do.--It seems to be the ambition of everyone to reach a place in life so that he can give up work and do nothing. Men and women often envy those whose material situation is such that they are not compelled to work. It is from the leisure cla.s.ses, however, that our neurotic invalids are mainly recruited. The symptoms these people give will sometimes make one wonder whether they may not be suffering from some serious ailment, but just as soon as the details of their daily occupation are gone into, the real cause for their complaints can be readily seen. Nothing will do them any lasting good until they get interested enough in life to be distracted from themselves. Such men and women are invalids by profession. They are profoundly to be pitied, for they are much more the victims of present-day social conditions than of any special fault of their own.

They go from one health resort to another seeking relief and now and again finding it, not because of any special effect of the remedies that they take, but just in proportion to the amount of diversion and occupation of mind they are able to secure in their wanderings. After a time they relapse, then, the old cures having lost novelty, the physician who succeeds in occupying their minds does them good; his brother physician, who does not, fails; but anyone else, however absurd his quackery, who can in any way catch their attention, will benefit them at least for the time being.

Business Anxieties.--The physician should know all that concerns such sources of excitement, worry and anxiety, as are suggested by the words speculation, investment, going on bonds and securities, especially when the person bonded gets into trouble. Fortunately most of these latter sources of worry have been eliminated by the bonding companies of recent years. Details {185} of this kind were given to the old family physician as a matter of course. With the going out of the family physician there has often been no one to replace him in hearing such stories, and it has been harder for some to bear the consequences in solitude. The very telling of many cares lessens the burden of them. The warnings of a medical friend may be more effective in keeping a man from serious loss than those of financial friends.

Everyone realizes that the physician's advice is quite unselfish and that what he objects to, even more than the danger and loss of money, is worry and anxiety which may lead to loss of health.

For ordinary therapeutic purposes, the physician may be content to know only the physical signs and symptoms of his patient's affection.

For psychotherapeutics, he must, if he would be successful, know every possible source of worry and annoyance and, as nearly as may be ascertained, every slight phase of physical fatigue that may be a disturbing factor in his patient's life. It is surprising how many things the physician will find to correct when he carefully goes over all the actions of the day and ascertains all the possible sources of worry and anxiety his patient may have. It may happen that in many cases he will be unable immediately to remove these sources of worry.

But there is relief in telling them, and then, even when they cannot be completely eradicated, they can often be modified. Every improvement of this kind, however slight, is a fountain of favorable suggestion which makes the patient look on the brighter side of life.

From every amelioration, however trivial, there is a reaction on the feelings that gives more and more confidence.

{186}

SECTION IV

_GENERAL PSYCHOTHERAPEUTICS_

CHAPTER I

GENERAL PRINCIPLES OF PSYCHOTHERAPY

In formal, deliberate psychotherapeutics the first and most important principle is the treatment of the individual patient, and not of his disease. It is much more important to know the kind of an individual who has pneumonia, as a rule, than to be able to tell the amount of pulmonary involvement. If heart, kidneys or lungs are affected when the disease declares itself, the outlook is extremely unfavorable.

Similar conditions are true of the patient's mind. If he is of the worrying kind, the outlook is serious. If, on the contrary, he faces it bravely, and without after-thought except that of responding to medical treatment, he will probably get well.

Pneumonia is only one example of the part the individual plays in therapeutics. In the popular mind it is supposed that for each disease there is a definite remedy, and that when the physician gives that remedy the patient gets well. This idea of specific remedies has come to the people from the physician, but only the quack now pretends to cure disease, the physician helps the patient to overcome the affection from which he is suffering.

No Incurable Patients.--There are many incurable diseases, but there are no patients to whom a doctor should say with truth, "I can do nothing for you." We may be unable to do anything for the underlying disease. That may be absolutely incurable. In spite of this, there are practically always symptoms for which the patient can be afforded so much relief that he feels better than before. This is the most important att.i.tude of mind for the physician who would use psychotherapy. He can always do something. Prof. Richet said not long since, "Physicians can seldom cure, but they can nearly always relieve and they can always console," and it is the physician's duty to lift up and console the mind as well as to heal the body.

Unfavorable Suggestions.--Patients often have many opinions and conclusions with regard to their ailments which are not confided to their medical attendants, and which const.i.tute the basis of many annoying symptoms. They have mental convictions with regard to the incurableness of their ailments, the supposed progressive character of the disease, and the development of symptoms which will still further annoy them, that are often more serious and harder to bear than the symptoms from which they are actually suffering. Unless the physician has their complete confidence, these patients may suffer much in silence, though the revelation of their state of mind would {187} often be sufficient to afford a good measure of relief, and the correction of false notions would do nearly all the rest.

Psychotherapy confers its benefits mainly by securing the most complete _rapport_ between the mind of patient and physician. Good advice is often more important than any medicine. The correction of wrong notions will do more to relieve the patient, and make whatever symptoms he has bearable, than most of the anodyne drugs. The stimulation of hope means more than almost anything else in arousing the latent forces of nature and predisposing to recovery. The removal of unfavorable suggestions is but little less efficient.

_Study of the Individual_.--The great differences in the relations between physicians and their patients is well recognized. To some physicians a patient will present only conventional symptoms, while a follow pract.i.tioner will discover the elements of an interesting case.

Above all, the painstaking physician, interested in psychology, will find mental and other personal manifestations in his patient that distinctly modify the course of the disease. We must know all that is possible about the patient's att.i.tude of mind toward his malady, and all the ideas that he has acquired with regard to it, either from previous relations with physicians or from what he may have read or heard from others. The removal of many false notions that are thus working harm will reward the medical pract.i.tioner who gets at his patient's ideas. The old rule in therapeutics is _non nocere_--to be sure to do no harm. The special rule in psychotherapy is to be sure to remove all the ideas that are doing harm to the patient and making his symptoms mean more to him than they really signify.

_Neutralizing Contrary Suggestion_.--In the application of psychotherapy, then, the first principle is the neutralization of unfavorable mental influence. In our day men have such a smattering of knowledge about disease, especially about the worst forms of it, that they are likely to be in a frame of mind with regard to many affections that is quite unfavorable. Many patients think disease and not health. Disease means discomfort, and consequent loss of vital energy and disturbance of the resistive vitality that would enable the patient to throw off the affection. Sometimes the physician does not realize what a large part unfavorable suggestions are playing in the affection. Sometimes patients conceal their state of mind lest the doctor should confirm their worst fears. The preliminary to all successful treatment is to remove unfavorable suggestion.

Favorable Suggestion.--The next thing is to set certain favorable suggestions at work. It is possible always to do this. Even in certain of the acute diseases favorable suggestion has its place, and for all chronic cases this form of therapeutics is extremely important. The very presence of the physician, especially if he is thoroughly in control of himself, placid, imperturbed, evidently ready to use all his powers without any excitement, is of itself the strongest kind of favorable suggestion. From the very beginning of medical history the presence of the physician has in most cases meant even more than his medicines.

Munsterberg, in his recent book on Psychotherapy, has emphasized this in a way that deserves to be recalled:

There is one more feature of general treatment which seems almost a matter of course, and yet which is perhaps the most difficult to apply because it cannot {188} simply be prescribed: the sympathy of the psychotherapist. The feelings with which an operation is performed or drugs given do not determine success, but when we build up a mental life, the feelings are a decisive factor. To be sure, we must not forget that we have to deal here with a causal and not with a purposive point of view. Our sympathy is therefore not in question in its moral value, but only as a cause of a desired effect. It is therefore not really our sympathy which counts but the appearance of sympathy, the impression which secures the belief of the patient that sympathy for him exists. The physician who, although full of real sympathy, does not understand how to express it and make it felt will thus be less successful than his colleague who may at heart remain entirely indifferent but has a skillful routine of going through the symptoms of sympathy. The sympathetic vibration of the voice and skillful words and suggestive movements may be all that is needed, but without some power of awakening this feeling of personal relation, almost of intimacy, the wisest psychotherapeutic treatment may remain ineffective. That reaches its extreme in those frequent cases in which social conditions have brought about an emotional isolation of the patient and have filled him with an instinctive longing to break his mental loneliness, or in the still more frequent cases where the patient's psychical sufferings are misunderstood or ridiculed as mere fancies, or misjudged as merely imaginary evils. Again everything depends upon the experience and tact of the physician. His sympathy may easily overdo the intention and further reinforce the patient's feeling of misery, or make him an hypochondriac. It ought to be sympathy with authority and sympathy which always at the same time shows the way to discipline.

Under special conditions, it is even advisable to group patients with similar diseases together, and to give them strength through the natural mutual sympathy; yet this too can be in question only where this community becomes a starting point for common action and common effort, not for mere common depression. In this way a certain psychical value may be acknowledged for the social cla.s.ses of tuberculosis as they have recently been inst.i.tuted.

Favorable Environment--After the removal of unfavorable suggestion and the implanting of favorable suggestion, the next point must be the persistent occupation of the patient's mind with thoughts favorable to his condition. A nurse who is inclined to be pessimistic must be taken out of the sick room, and there must be only cheerful faces and cheery people around him. Hence the modern trained nurse, and especially the picked nurse, who does not allow herself to be disturbed, who is not fussy, who is not forcibly cheerful but quietly placid and confident and cheery, means much for the patient's recovery. Relatives are almost sure to exert strong unfavorable suggestions, though time was when the devoted wife or mother might be depended upon to cover up all her personal feelings and give the best possible service for the mental uplift of the patient. When she can thus conceal her own solicitude, a near relative may be the best possible auxiliary in psychotherapeutics.

Natural Relief.--The fourth step in the application of psychotherapeutics is that all the natural modes for the relief of symptoms, the making of patients comfortable in body as well as in mind, must be employed. In acute rheumatism, for instance, a number of small pillows must be at the disposition of the patient so that his limbs can be fixed in those positions in which there is the least discomfort. Every physician should frequently read Hilton's cla.s.sical volume on "Rest and Pain" because of its unpretentious significance for psychotherapy, as well as its enduring value in the treatment of painful conditions. Just as soon as a patient finds that simple procedures relieve his pain and add to his comfort, his fear of the seriousness of his ailment is lessened, {189} and he begins to get bettor. Cold water in fevers, cold fresh air in pneumonia, all the natural modes of treating disease, thus become active factors in the application of psychotherapy. When fevers were treated by the administration of hot drinks the effect upon the patient's mind must have been quite serious. Freedom to use cold water, just as one wants it and whenever it is craved for, is of itself an excellent suggestion.

Neuroses in Organic Disease.--Fifth, psychotherapy, by suggestion, may alleviate or even completely eradicate neurotic symptoms that develop in connection with organic diseases. Such neurotic symptoms may prove even more bothersome to the patient than the symptoms due to his underlying affection, and may, by interfering with nutrition, hamper recovery. The appet.i.te of a patient who is worrying about a chronic disease will be disturbed, and, as a consequence of insufficient food, constipation and a whole train of attendant evils may ensue. Headache, sleeplessness, worry at slight irritation and exaggerated complaints from slight pain may all be due to this worry and not to the underlying disease. All these, the result of over-solicitude, are attributed by the patient to his chronic ailment. They can be relieved by simple measures after he is saved from his own worry. Until the patient is made to rouse himself and look hopefully at the situation, eating more, getting out more, and relaxing his mind from its constant attention to himself, he cannot get better.

Application of Principles.--It should be pointed out to the patient that there is a constant tendency to exaggerate the significance of disease. This is true in acute as well as in chronic disease, but in acute diseases the necessity for removing unfavorable influences directly is not so urgent, since usually the presence of the physician, with his simple declaration of the meaning of symptoms, is sufficient to neutralize the effect of previous exaggerations.