Psychic And Motor Re-Education
( Originally Published 1908 )
THERE is one aspect of psychotherapeutics which has received but a limited degree of attention, and yet when this phase of the problem is more clearly understood, we can hope for further advances along these lines. We refer to what may be termed the psychological mechanism of psychotherapeutics. Certain beneficial results can be produced by means of the various forms of suggestion, but how these results are produced offers at present a wide field for speculation. When we understand how suggestion from without can cure an hysterical paralysis which the hysteric is unable to control by suggestion from within (auto-suggestion), or how a fixed idea or a phobia can be eliminated from consciousness, we have advanced towards a final solution of the problem. To state that in hypnosis or in certain states of abstraction or distraction there arises a condition of hyper-suggestibility, is to leave a portion of the question unanswered.
On ultimate analysis it appears that psychotherapeutic procedures are either substitution, suppression, inhibition, elimination, analytical or educational. In certain morbid psychopathic or neuropathic states we attempt to substitute a healthier emotional complex for the existing diseased condition. In still others, inhibition or suppression is the proper line of treatment. Sometimes, when the symptoms are caused by the voluntary sup-pression of some emotion or emotional episode, a full confession on the part of the patient will relieve the mental tension. By analytical we mean an inquiry into the origin and nature of the mental or nervous state, by means of special technical methods, thus laying bare the essential mechanism of the particular disorder. This is especially difficult when we are dealing with dissociations of consciousness, such as psycho-epileptic attacks or re-current sub-conscious ideas, automatisms or motor states. With the exception of psychic re-education, all of the above subjects have been discussed more or less extensively, but these educational methods are so important that a more extended account of their principles seemed necessary.
In many cases the patient has become the victim of a faulty habit of thinking and has thus built up a series of abnormal associations. These abnormal tendencies have not only served to give the disease an indefinite continuance, but the unhealthy auto-suggestion has created artificial symptoms. Thus a vicious circle is continually being formed. It is just in these severe and chronic cases that another method of suggestive treatment is indicated, what is known as psychic re-education. Psychic re-education may be briefly defined as a system of mental gymnastics or rather a systematized method of applying suggestion, whatever particular method is used. Of course all psychotherapy is mental re-education, but the term is best limited to those methods which attempt the mental reconstruction of the patient.
Education forms certain habits and these habits become "set" in our nervous system. One of the peculiarities of the nervous system is that it is plastic in nature. This plasticity decreases with old age and therefore re-education is more difficult in the old than in the young, or in the chronic than in the more acute diseased conditions. Thus we see that the principles on which psychic and motor re-education are based, are physiological principles. We are dealing with the dynamics of living matter. Living matter, and this applies particularly to the substance of which the nervous system is composed, is distinctly plastic in character. It is thus able to store up stimuli and impressions in the same manner that the retina stores up colors and reproduces them as after images. The frequent repetition of stimuli makes a firmer impression on this plastic nerve substance and this summation of stimuli finally produces so firm an organization that it can be obliterated only with difficulty. Even a minimal stimulus if applied for a sufficiently prolonged period can leave its traces on the nervous system. In an analogous manner, constant suggestions, applied judiciously, at first simple in nature, but gradually increasing in complexity, can remold the plastic nervous system, whether in health or in disease. The repetition of bad movements, or constant auto-suggestion along unhealthy lines of thought, may at first seem foreign to the organ-ism, but by the constant repetition and summation of these stimuli, a habit becomes established, either of morbid consciousness or of abnormal motility. What at first was accomplished consciously and with effort, now becomes an automatic action. A person will develop a peculiar mannerism as an act of defense towards some external stimulus; for instance, he may twist his head in a peculiar manner to avoid contact with the roughened edge of a collar. At first this is a so-called reaction of defense, but by constant repetition this normal movement may degenerate into a pathological habit spasm. The individual has broken down the line of normal resistance in his nervous system: the movement has become thought-less, automatic. The treatment of such a condition consists in leading the individual back to his normal state by means of carefully co-ordinated muscular exercises and by an increasing, conscious inhibition of the abnormal muscular movements. It is a discipline in will power as well as in motor training. This is motor re-education, a form of psychotherapy which is also of great value in hysterical paralysis and in the inco-ordinated muscular movements of locomotor ataxia.
The evolution of many psychic conditions (fixed ideas, phobias, obsessions, hypochondriacal, neurasthenic and hysterical states) has frequently a closely related mechanism. Many of these are association neuroses or the results of habits of expectation and apprehension. We are really dealing with recurrent mental or nervous conditions. The mechanism may also work in an opposite direction. Constant repetition along normal lines of thinking or motor activity may react in a favorable manner on the nervous system, for the function makes the organ, just as much as the organ makes the function. Thus the training of the will is an important factor in psychic re-education, for the will is nothing but a selective action or reaction to certain ideas. By constant repetition, this selection can be directed into almost any channels.
This is the basis of psychic and motor re-education, and educational methods are so successful because the nervous system is a plastic and not a rigid tissue. We can educate ourselves to good habits of thinking, feeling, and doing as well as to bad. Thus we have seen the physiological principles of psychic and motor re-education and are now prepared to consider the more practical aspects of the question.
Psychic re-education is a combination of mental therapeutics and physiological hygiene. Educational treat-ment is complex, requires considerable time to carry out properly, and taxes all our patience and ingenuity, because of the individual variations of even similar diseases. It would exceed the scope of this chapter to consider all these points in detail, as they involve technicalities into which we cannot enter here. We must be careful, how-ever, to maintain a neutral attitude, for in some cases suggestion is necessary: in others, only educational methods are of value. A rational psychotherapy is an individual problem and must be modified according to the personality of the patient and the character of the disease. To treat all functional disorders blindly by the same methods spells failure.
A few details taken from actual cases will perhaps make these principles of psychic re-education clearer. It is in the chronic neurasthenic and hysterical states that these methods of mental gymnastics have been most successfully utilized. In many cases of neurasthenia, particularly those of long duration, rest, isolation and over-feeding during the prevalence of the more acute stage, have been used with little benefit. So long as such theories of auto-intoxication or of visceral ptosis were promulgated to explain the neurasthenic symptom-complex, and treat-ment was instituted along the lines suggested by these theories, just so long did therapeutics fail to accomplish the desired result — the cure of the patient. We do not mean to affirm that in certain acute exhaustive states of the nervous system rest is not beneficial, but we do claim that in those cases where the fatigue is not a real fatigue, but only a habit fatigue, we are very apt to create artificial symptoms. If we interpret neurasthenia as a disintegration of the personality, our efforts at cure must be directed along educational lines, to synthetize the dissociated states of consciousness. Of course appropriate methods of hygiene and direct suggestion will have to be combined with our educational procedures in order to suppress individual symptoms. The neurasthenic is the victim of an apprehension and an expectation which has reached the permanency of a fixed idea, and thus there arises an emotional complex, associated with feelings of anxiety and depression and not with those of health and well-being. Constant, morbid auto-suggestion has served to lend to these feelings an indefinite continuance and to make them worse. Here we have a habit neurosis, a constantly recurring mental state. Not only is the method of thinking at fault, but also the reaction to surroundings. The patient yields to every slight sensation of fatigue and to every fleeting pain. The object of the educational method in neurasthenia is to train the patient to healthier habits of thought and to substitute for the morbid emotional complex a feeling of pleasure and of energy in all the acts and reactions of everyday life. The process is naturally a slow one analogous to all educational methods, but "as use doth breed a habit in a man," so constant application can direct the mind into healthier channels. As an athlete is compelled to go through a certain method of training before his muscles become fit for the competitive contest, or the beginner in piano playing requires long practice to arrive at any degree of proficiency, so the faulty neurasthenic habit of thought requires a long course of mental gymnastics to transform it to a normal mode of activity. This is the secret of the psychic re-education of neurasthenia and, once this mental reconstruction of the patient is established, recovery follows as a natural consequence.
How is this psychic re-education carried out in these severe functional nervous states? Without entering into technical details, we may say that the best plan is to attack the diseased condition from various standpoints, thus bringing a number of forces to bear upon the patient. In the nature of things, this is more effective than any single line of treatment. First we must be sincere with the patient and instruct him in the nature of the disease and its individual symptoms, and thus free his mind from any popular medical misconceptions and fallacies. Next, the individual symptoms themselves must be suppressed by various therapeutic agents and corrected from this explanatory point of view and a healthier emotional state must be substituted for the existing abnormal one. The reaction to surroundings should be modified by an insistence on a changed daily routine and finally over-feeding and isolation may be necessary. So we see that the educational method comprises not merely mental therapeutics, but every therapeutic agent must be utilized to effect the complete mental reconstruction of the patient. It is really a summation of stimuli, the individual forces of which should harmonize with the most recent developments in scientific medicine.
Psychic training has its analogue in the physical sphere, namely motor re-education. As in the functional neuroses, the psychotherapeutic action of educational methods acts like a real force in reconstructing the mental attitude of the patient, so the motor educational methods can harmonize muscular inco-ordination. It is a training in motility when this motility acts in an abnormal manner. Before we pass to this aspect of the question, however, a few words are necessary as to the mechanism of co-ordinated movements.
We have already had one example of the disharmony of muscular activity in the development of habit spasms. The movements of the body as a whole or in part are produced by the muscles which are attached to the bony skeleton. All muscular movement is produced by the contraction of individual muscular fibers. These movements are under the direct control of the nervous system. Muscles are seldom or never contracted individually: all muscular movements are actions of groups of muscles. When we will a muscular contraction, the intended movements is for a common physiological purpose, such as loco-motion, sitting down, climbing stairs, or the carrying of food to the mouth. A number of muscles must be thrown into activity in order to produce these complicated movements. In the healthy, adult human being only harmonious muscular movements take place. For the production of muscular activity, the nervous system acts either as a conducting apparatus, chiefly by means of the spinal cord, or a selective idea of a co-ordinated muscular movement takes place in the brain. This selective idea is known as "willing" a movement. All normal muscular activity is co-ordinated or directed towards a specific end. When the conducting apparatus in the spinal cord is at fault, for instance as in the disease known as locomotor ataxia, or when the idea of a muscular movement is lost or suppressed, as in hysterical paralysis, the machinery of co-ordinated movements may then be said to be out of gear. The execution of voluntary movements then becomes faulty, ill-balanced, awkward: it cannot be directed towards a definite end. Locomotion is entirely lost or is so disordered that it resembles the gait of a drunken man or of a normal person attempting to walk on the ice. Liquids cannot be carried to the mouth without spilling, while the finer movements of the fingers, as in writing, become impossible. The list might be indefinitely extended to comprise any variety of motor activity of which the human adult is capable. Vision is very important for normal muscular activity and this is why the blind walk awkwardly or letters are poorly formed when we attempt to write with the eyes closed.
The study of the normal and abnormal movements has recently received a strong impetus by the taking of instantaneous photographs and projecting these upon a screen, as in biograph pictures. The film of course can be stopped at any desired point and thus a complicated movement can be studied at leisure in any of its stages.
This method has been applied to the gait in locomotor ataxia, paralysis, habit spasms, and epileptic convulsions.
We have seen that co-ordinated muscular activity in normal individuals is adapted to specific, intended actions, and these actions are the result of education and practice. This is true of only voluntary movements which are under the control of the will. Involuntary muscular movements, such as breathing and the heart-beat, are innervated by the lower brain centers and therefore automatic in action. This is an admirable mechanism, as these activities are necessary for the preservation and continuance of life, and if under voluntary control would not only demand an amount of conscious thought in-compatible with any other activity of every-day life, but would also cease during sleep.
The newly born infant cannot perform any co-ordinate muscular movements It is unable to walk, can carry objects to the mouth only in an awkward manner, and even harmonious movements of the eyeball are absent, so that when a young child hears any unusual noise, it turns its entire head in the direction of the sound. Thus we see how even in the normal human being, the co-ordination of ordinary muscular movements has to be learned, in fact is educational. This is even more true of skilled actions. It is a training of the nervous system, and an action like learning to walk, performed at first with difficulty, finally becomes purely automatic. It is unnecessary for normal adults to think how to walk: they can perform other actions while walking and there is no need to observe the movements of the limbs. In the child, on the contrary, learning to walk is a distinctly conscious process, slowly and awkwardly performed. Distract this child from these conscious activities, or if he ceases to observe his limbs for a moment, he falls. When an adult is acquiring a skilled movement, like piano playing, skating, or bicycle riding, a new type of muscular co-ordination is needed. The beginner in skating or in bicycle riding resembles the child that is learning to walk. It is a conscious process and a visual perception of all the movements is necessary. By practice, a less and less conscious effort is needed, and finally it becomes entirely automatic. Thus again we see how the learning of co-ordinated muscular activity, whether the ordinary movements in the child or the skilled movements in the adult, has a purely physiological basis, depending upon the plasticity of the nerve substance. Now certain diseases of the nervous system are associated with this awkward muscular activity known as ataxia, which is in a way a reversion to the motor disharmony of the child. In learning any skilled movements (and all muscular co-ordination is in the highest sense skilled), we are all incoordinate or ataxic at first. Constant repetition, however, makes the movements less and less awkward, until finally they are executed with a minimum of effort and with absolute accuracy. This is the principle of motor re-education, the treatment of the various types of muscular inco-ordination by systematic and graduated exercises.
These methods of treatment by motor re-education are particularly applicable to such organic nervous dis-eases as locomotor ataxia and the ataxies of childhood, to such functional disorders as the various tics or habit spasms and to certain hysterical disturbances. In tabes (locomotor ataxia) there is a degeneration of certain portions of the spinal cord. One of the most prominent symptoms of this degeneration, in fact the symptom from which the disease derives its name, is muscular inco-ordination or ataxia. This effects the arms and legs, more particularly the latter, depending, of course, upon the portion of the spinal cord that is diseased. When the arms are involved, the finer skilled movements of the fingers and hands become impossible. If the legs are affected, locomotion is extremely difficult and ill-balanced. In the educational treatment of tabes, we do not influence the degenerated portions of the spinal cord, but we merely train other parts of the nervous system to take on those activities which the diseased spinal cord is incapable of carrying out. The plan of treatment is dependent upon the results of the neurological examination, but the motor exercises are carefully graduated, extremely simple in character at first and gradually increasing in complexity. Fatigue must be especially avoided. After a course of treatment, it is surprising to see the stumbling, ill-balanced ataxic walking with perfect confidence and steadiness.
In some forms of hysteria, the patient suffers from a peculiar group of symptoms. He is perfectly able to move the legs when lying down, there is no sign of muscular weakness or paralysis, but all attempts at walking are unsuccessful. Here is a purely functional disorder and not an absolute loss of nerve tissue as in tabes. The patient has lost or suppressed the mental images of the co-ordinated movements necessary for locomotion. His nervous system or tissue is intact; the most careful examination will fail to reveal any organic lesion of the brain or spinal cord. The object of the educational treatment is to substitute a new system of the mental images of loco-motion by carefully graduated exercises. Here we are dealing with motor plus psychic re-education, as the therapeutic action of confidence is a strong factor in these cases and this confidence increases in power as the normal motor activities become established.
The various tics or habit spasms are infinite in variety, as these pathological muscular movements may result from any of the normal muscular activities of which the body is capable. As indicated previously, these may result from reactions of defense or may arise almost spontaneously in a neuropathic individual. In all these cases, therefore, the mental or nervous condition of the patient must be made the subject of a careful analysis. The educational treatment of tics is a systematized motor and volitional discipline. Its object is not only a training of the affected muscles to perform their normal functions, but also an inhibition of abnormal muscular movements. All these can be accomplished by appropriate exercises.