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General Principles Of Psychotherapy

( Originally Published 1908 )

THE chief object of this volume is to present to the reader an epitome of one of the most important tendencies in modem medicine namely, the treatment of certain functional nervous disorders by means of suggestion. Technically, this is known as psychotherapy. As a great deal on the subject had been scattered through the chapters of this book, it seemed desirable to unify the various statements and to present a short account of the general principles of psychotherapy. While psychotherapy is by no means a new method of treatment, but has been employed by physicians in one form or another from the earliest dawn of medicine, yet its scientific and rational application has been the work of only recent years. Formerly much empiricism prevailed in this field, at least so long as psychology was looked upon as one of the occult sciences and a branch of a more or less unpractical metaphysics. But with the advent of physiological psychology, of sound experiment instead of hazy generalizations, with the modem advances in the study of hysteria and the various aspects of the dissociations of consciousness, it was soon perceived that a rational psychic treatment was indicated in purely psychic disorders. Therefore all the diagnostic criteria of modem neurology and psychiatry were brought to bear upon the study of functional nervous disorders, and the result has been not only new and sound conceptions, but rational psychologic indications for treatment.

In order to free the reader's mind from any a priori misconceptions, it will be well to state in the beginning, that while psychotherapy in some form or another is the rational treatment for functional nervous disorders, yet it is not indicated in all, neither are all functional dis-orders amenable to psychotherapy. It is rather in the severe cases which do not yield to ordinary physical methods and in certain types of pure dissociations of consciousness that psychotherapeutic treatment is indicated. We cannot reiterate too frequently that a thorough neurological, psychiatric, or general medical examination is absolutely necessary before the institution of any form of psychic treatment, not only to rule out any organic disease or distinctly organic complications of a seemingly pure functional disorder, but also to obtain an intelligent comprehension of the case. Only in this way can grave errors be averted and the patient saved much unnecessary loss of time if other lines of treatment are indicated. For instance, in one case of a middle-aged man, there was a complaint of some vague gastric disorder in association with ill-defined neurasthenic symptoms. A chemical examination of the stomach contents revealed a beginning cancer of the stomach. Immediate operation was advised, and while it is yet too early to ascertain a definite outcome, yet the chances of cure are much greater than if the patient's valuable time had been wasted by a wholly ineffectual psychic treatment. Another case will show an exactly opposite state of affairs. The patient was a young man who for ; years had been treated for an organic disease of the stomach, by means of drugs and special diet. He did not improve, however, and finally a careful neurological examination revealed that the symptoms referable to the stomach were not only functional in nature, but that these symptoms were only a portion of a severe functional nervous disease. In fact the patient was a sufferer from hysteria. Careful psychic treatment directed towards hysteria brought about a disappearance of the gastric symptoms and finally a cure. The above' are merely two cases out of many that could be cited.

Pyschotherapeutic methods vary, the object of some is purely therapeutic, of others distinctly analytical, to penetrate into the origin of certain disturbances and lay bare the essential emotional complex. Suggestions may be given in the waking, half-waking, or hypnotic state; psychic or motor re-education may be necessary in dis-eases of long duration, where habits of thought or of activity have become distinctly abnormal. Isolation is indicated in certain hysterical states, while persuasion or a rational, sincere explanation will often appeal to the more intelligent class of patients. Ignoring and purposeful neglect are sometimes of value in the hysteria of children. The principle of reserve energy 1 has opened up new vistas in psychotherapy. To all of these, of course, treatment by physical agents is frequently necessary rest, baths, electricity, massage, diet, drugs. Nor must we forget one factor of the highest importance, the individuality of the physician.

It would exceed the scope and purpose of this book to discuss the above methods in detail, as most of these are not only far too technical to admit of intelligent comprehension by the lay reader, but all presuppose a thorough medical examination. A rational psychotherapy can only be developed on the basis of a rational psychopathology.

The nature and value of hypnosis have already been discussed. In many cases, however, hypnosis is unnecessary; in fact, it is only used when other lines of treat-ment fail. Frequently in the psychoneuroses, a rational explanation and analysis of the patient's condition will go far toward relieving many distressing symptoms, especially if the patient, as is too frequently the case, has been the victim of some popular medical misconception or superstition. Recently the application of these pyschotherapeutic conversations in the management and treatment of certain paranoic states, or in limited types of delusion formation, has attracted considerable notice. Of course, for a sound, psychotherapeutic treatment, the psychogenesis of these states must be carefully analyzed, and this presupposes a knowledge of mental diseases that is not possessed by any of the pseudo-scientific cults of mental healing. For the principles of psychic re-education, the reader is referred to two papers by Prince and Coriat. The results in this series were most gratifying considering that the cases were of years' duration and had resisted all other methods of treatment. Here were treated and cured convulsive attacks of purely functional origin, the peculiar types of nocturnal paralysis, nocturnal enuresis, psychasthenic states, and functional gastric disorders. Of course, in some of these cases psychic treatment was combined with physiological hygiene, but the general principles of treatment were carried along the line of the correction of faulty habits of thought, instruction of the patient into the nature of his disease, and the suppression of individual symptoms by various suggestive measures.

Motor re-education has been of value in the various tics and habit spasms of adult life and childhood. These conditions are sometimes mistaken for chorea, but are really functional motor disturbances, in many cases the result of a faulty motor education. Isolation methods have been of great value, particularly in hysteria or neurasthenia, and recently Dubois of Berne has written a popular book on the purely psychic treatment of certain psychoneuroses.'

A question of great importance now arises what particular form of psychic treatment shall be used ? To this we reply that the method of treatment is absolutely dependent on the results of the medical examination, particularly, the origin and nature of the particular nervous disease. Also, it is frequently the case, that even in purely functional disorders, medical treatment is necessary in combination with psychotherapy, and sometimes, in a functional disorder, physical therapy alone is indicated. The outline of the treatment, like the diagnosis of the condition, should be in the hands of a competent physician.

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