CONTROL OF THE NEUROTIC¹

        The first thing in the examination and treatment of neurosis is the elimination of any physical trouble. It is only after such an elimination that one should resort to psychotherapeutic treatment.

        In psychopathic or neurotic diseases one should take into consideration the fact that the patients are characterized by the tendency of formation of habits which are hard to break. The patients are apt to ask that the same thing be done again and again for the simple reason that it has been done several times before. In other words, psychopathic neurosis is characterized by automatism and routine.  This tendency to recurrence is characteristic of all forms of primitive life as well as of mental activities which are on the decline,―it is the easiest way to get along.

        Effort is abhorrent to the patient. He is afraid of change in the same ways as the savage is afraid of any novelty or of any change in custom. Tradition is holy, and in a double sense, because it has been handed down by former generations, regarded as divine and superior, and because the new is strange and, therefore, may prove dangerous and of evil consequence. What has not been tried may prove harmful, pernicious, and even deadly. The old has been tried and approved by generations and the consequences are known, while the new may be in alliance with evil powers. This holds true in all cases obsessed by the impulse of self-preservation and the fear instinct. What the patients have tried several times and what has proved good and pleasant is demanded by the patient to be repeated; the new is not known and may be risky, dangerous. I have great difficulty in making in the life of advanced psychopathic cases, because of the fear of the new, neophobia. Once the change is made, and the patient becomes adapted to the new way, then the old way is shunned. In short, neophobia is an essential trait of psychopathic patients.

        The physician must take this trait of neophobia into account, and as the patient begins to improve, he must gradually and slowly wean the patient of this phobia, inherent in the very nature of the malady. The patient must learn to do new things, and not simply follow mechanically a régime, laid out by the physician.

        The patient's life must become personal. The patient should be made to change many of his ways, and above all he should learn to follow reason, rather than habit and routine. Everything, as much as possible, should be reasoned out,―he should be able to give a ration account of his habits and actions. Whatever appears to be a matter of routine, irrational and unaccountable habit, simply a matter of recurrence, of repetition of action, should be discarded, should be changed to actions and adaptations for which the patient could give a rational account.

        We must remember that the patient lives in the condition of recurrent mental states, that his mental activity, as I have pointed out, follows the laws of recurrence, characteristic of the type of recurrent moment conscious². It is, therefore, the physician's object to lift the patient out of this low form of mental activity to higher types of rational, personal life in which the patient can rise above the pettiness of existence with its worries and fears. This procedure is essential.

        We can realize how pernicious are those schemes which physicians and many people and sanitariums lay out for the patients just to keep them busy for the time of their stay under special care. As soon as the patients leave, they are in the same predicament as before. The patients wish to have their lives conducted in the same mechanical, automatic routine. In this way they are really on the same low plane of mental life, on the plane of recurrent moment conscious, a type which forms the pathological web and woof of the patient's life.

        Unless the patient is lifted out of this low, mean, and animal form of conscious activity, he cannot be regarded as cured. Instead of having the patient's life saturated and controlled by the recurrent automatisms of the fear instinct, he should learn to be controlled by the light of reason. "A free man is he," says Spinoza, "who lives under the guidance of reason, who is not led by fear." Epicurus and the ancient Epicureans laid special stress on the necessity of getting rid of fear through reason, enlightenment, and education. Thus the great poet Lucretius:

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

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

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

        The first and foremost characteristic of psychopathic states is the narrowing down of the patient's life interests. He beings to lose interest in abstracts problems, then in that of his own profession or occupation, then he loses interest in the welfare of his party or his country, and finally, in his family, wife and, children. Even in the case of love, the psychopathic patient seeks to utilize the person he loves for his own, neurotic benefit, namely, his neurotic comfort and health. He loves the person as a glutton likes his meal, or as a drunkard his liquor. The self becomes narrowed down to health, the key to his supposed spiritual life. Self-preservation and fear permeate the patient's life.

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

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

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

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

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

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

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

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

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

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1. The discussion here is necessarily brief. The reader is referred for details to my "The Causation and Treatment of Psychopathic Diseases," Ch. XVII, General Psychotherapeutic Methods.
2.  See Sidis, "The Foundations," Part II, Moment-Conscious.

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