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CHAPTER III

SIMPLE EXPLANATION AND RE-EDUCATION AS A THERAPEUTIC METHOD

BY E. W. TAYLOR, M.D.
Assistant Professor of Neurology, Harvard Medical School Chief of Service, Neurological Dept., Mass. Gen. Hospital

TWO difficulties are evident in the present aim to rationalize psychotherapeutic procedure. One is its supposed simplicity and the other its reputed complexity. A very considerable group of men in the medical profession apparently considers that nothing new has been discovered within the past few years relative to the treatment of disease by mental means. Another group is equally insistent that the whole subject constitutes a special branch of medicine and is quite beyond the practical reach of the general practitioner. Both of these positions are wrong. In the first place, it is apparent that the investigation of recent years has so far rationalized old methods that the physician now has in his hands a perfectly definite means of attack against many abnormal and distressing conditions. However widely psychotherapeutic measures have been practised from the earliest period of medicine, the time has now come when such measures may be used with a degree of scientific accuracy hitherto unattained, a precisely similar situation to that prevailing in all other departments of therapeutics. The means of treatment have always been at hand. The use to which those means are put constitutes advance. On the other hand, it is true that the final solution of the complex problems upon which we have now entered is no doubt far distant, and the pioneer work in this somewhat limitless field must be left to a special student. There is, however, no longer a question that sufficient facts have been established to render certain of these therapeutic measures available for the practitioner. Here again the situation is not different from that of other departments of medicine. The problem of immunity, for example, remains obscure, and in great measure unsolved, but the practical applications of this laborious work are already in a measure are already in a measure available.

It should in general be our aim to place this whole much discussed question of psychotherapeutics on precisely the same plane as other therapeutic problems. So far as facts are ascertained and capable of practical application, it is the manifest duty of practitioners to employ such facts for the benefit of their patients. So far as facts are still in doubt it is the natural work of special students of the subject to bring what order is possible out of the existing chaos. Our methods of procedure should be the same, so far as the character of the subject permits, our results should be subjected to the same strict scientific judgment, and our liberality toward this branch of therapeutics should be precisely similar to that toward any other which promises much for the future.

The object of this symposium, so for as I understand it, is for the time being to lay aside theoretical considerations and to bring to the attention of this society such facts and practical considerations as the time at our disposal and our individual experience permit. It is my purpose in what I shall have to say under the somewhat inadequate title selected to draw attention to the simplest and therefore most widely available method of psychotherapeutic procedure and to attempt to show how such a method may be made practically useful by the physician in a degree hitherto not always attained.

In discussing the general psychotherapeutic problem with physicians, the purely practical question of method is almost invariably raised. What the practitioner needs and rightly demands from those who claim any special knowledge of the subject are directions as to treatment of individual patients. The evident difficulty heretofore in treating even the simple neuroses has been the failure on the part of physicians to recognize clearly that such neuroses very frequently have a mental cause in the life of the individual precisely as a murmur over the heart area, for example, has a physical cause in the life of the individual. Our first object, as practitioners, is the determination so far as lies in our power of the exact cause of the condition we are called upon to treat. In other words, a diagnosis is demanded. This we make readily enough in the physical sphere or admit our incapacity to do so. In the mental sphere, we too often make no attempt, however apparent the cause might be after adequate investigation. The first point, therefore, I would make is that we must be as conscientious in one field of medicine as in another. We must search the mind of the individual for the source of his discomfort in appropriate cases in exactly the same spirit in which we search his body for the source of other discomforts. This certainly requires no special personal attributes on the part of the physician, and is surely available for practitioners of no special education in this field. The word “explanation” used in the title describes somewhat inadequately the actual procedure, which consists essentially in the following steps:

First. After eliminating or properly estimating physical causes the mental attitude of the patient toward his ailment should be carefully determined; in other words, a diagnosis should be made.

Second. This is best accomplished by allowing him to tell his complete story rather than by a primary process of interrogation on the part of the physician.

Third. Having determined the false point of view almost invariably revealed which has led up to the neurosis the attempt is made to explain why such a series of events as that disclosed would be likely to lead to this result.

Fourth. Having impressed the patient with the correctness of the physician's point of view the process of readjustment begins, or, to use the more popular but possibly too comprehensive term, his re-education.

Fifth. This is accomplished by pointing out in a painstaking way the correct way to mental health through a realization on the part of the patient of his previous misconceptions and through an accompanying effort toward the establishment of more rational mental adjustments.

The method outlined above is the simplest possible psychotherapeutic procedure. As in more complex methods described by other writers in this symposium its essential feature is the analysis of the mental state. Its value lies in its simplicity and in its appeal to the reason through the medium of commonsense. We are justified in calling it a method because it works in practice, when mere unmethodical encouragement and reassurance fail. That such a method stripped as it is of all appeal to the mysterious or to any form of sensationalism is capable of wide and legitimate application is self-evident. It is also apparent that it must often prove unsuccessful in those cases in which the course of a developed neurosis is so deeply buried in the past life of the individual that it cannot be brought to the surface by this simplest and in one sense most superficial of the analytic methods.

It may with truth be said that no person is wholly free from false conceptions of his own mental and physical condition, and this naturally applies to those who consult physicians in the most varied fields of practice. It is an error to stigmatize such persons forthwith as abnormal or neurotic or neurasthenic or psychasthenic. Many of the common neuroses met with in practice represent nothing more than aberrations of normal nervous systems into temporary useless or detrimental channels. As a matter of fact, a large proportion of so-called nervous invalids are incapacitated through no inherent fault of their nervous systems as such, but rather through the use to which their nervous systems have been put by circumstances or training or false instruction or unwise and superficial medical advice.

Quite apart from any psychophysical speculation as to the relation between the mind and the body which is wholly unessential from a practical standpoint, the clear recognition of the predominant mental origin of the neuroses, whether or not they have accompanying physical manifestations is of the utmost importance and unquestionably constitutes the essential advance of recent years in their intelligent treatment. We have gained much, if, for example, we may authoritatively tell our patients that their apparently disordered nervous symptoms have reacted in a perfectly normal way to the circumstances in which they have been placed, and to the ideas to which they have been exposed, and that their difficulties have been due to the character of these ideas and circumstances rather than to the much feared inherent weakness of the nervous system itself. The function of the physician at once becomes apparent. He hears the story, he sees wherein the individual has failed, wherein he has dissipated his energies in side issues, or, in popular parlance, wasted his opportunities. Out of this he recognizes that a so-called neurosis has developed which it becomes his task to diagnosticate accurately, to explain in an understandable way the steps by which he has arrived at his diagnosis, and to readjust the patient’s mental attitude on the basis of this knowledge.

In order to avoid any possibility of confusion I have used the word “explanation” to describe this rational process. It requires little actual experience to demonstrate that in order to explain these matters effectively to our patients we must follow some definite method. Otherwise, as in other departments of endeavor, we shall simply confuse and not benefit. It is furthermore imperative, with all the present day talk in the popular press as well as in medical literature regarding treatment by mental means, that we adopt a definite, commonsense basis of procedure, free from all subtlety or demand for highly specialized training.

From the foregoing discussion I wish to emphasize the following points: First, the wide prevalence of neuroses based on ignorance rather than inherent or acquired weak nervous organization. Secondly, the vital importance of recognizing the normal character of the nervous systems in which these neuroses have developed. Thirdly, the possibility as a rational means of treatment of explaining to an intelligent patient the mechanism of the development of his symptoms, and finally the probability of a readjustment of his mental state based on this explanation with the disappearance of the neurosis. The analogy of the mental state of the child is useful in this connection. Explanation forms the chief means of increasing a child's mental stability. Fear of the dark, to take a commonplace example, is not met on the part of the wise parent by harsh criticism and summary dismissal of the subject, but rather by explanation suited to the child’s comprehension that the dark in reality has no terrors, and by a demonstration of the truth of this fact. Similar fears in adult life are manifestly treated with far less consideration; on the part of the patient there is a tendency toward concealment of special anxieties, on the part of the physician there is often a wholly unsympathetic attitude in which explanation plays no part. The position of the adult is, however, precisely analogous to that of the child. Neither is the victim of disease or, necessarily, possesses a damaged nervous system. Both are victims of insufficient knowledge and both demand sympathetic explanation in order that their false points of view may be corrected. Both are real and often extreme sufferers from conditions which are not self-limited, but which tend to progress and become more complex in their organization. Our attitude toward children has on the whole been correct; our error has been the failure to realize that wisdom does not necessarily come with the years.

Examples may make this clearer. A patient consults a physician in a highly disturbed nervous state popularly known as neurasthenic. The analysis of the entire situation reveals the fact that this patient considers that he has lost his memory. He has arrived at this conclusion because he finds that he is no longer able to read attentively and remember what he has read. From this as a starting point he argues, legitimately enough from his knowledge, as follows: I cannot remember what I have read; my memory must therefore be weakened; memory is a fundamental quality of the normal mind; my mind therefore must be failing, and forthwith one of the commonest and most distressing and incapacitating phobias is developed, namely, the imminent fear of insanity. In such a commonplace instance as this it is clear that the patient’s mind has worked out a rational conclusion from false premises, the original false premise being that because he could not remember what he read, therefore his mind was failing. It is easy to set such a person right by the simple explanation that his original difficulty arose from lack of concentration, a common human weakness, and that out of such lack of concentration the mental alienation which he feared is extremely unlikely to develop. This rational point of view is on the whole easy to impress, and its result on the developed neurosis with its various accompanying manifestations of sleeplessness, anxiety, incapacity for work, loss of appetite, and all the other phenomena of a disturbed mental state, forthwith becomes apparent. The essence of the benefit in such a case is to be attributed purely to a reasonable explanation of a series of events which the patient has himself been unable to estimate properly.

A further example illustrative of the point of view I am attempting to impress is the mental condition ordinarily associated with insomnia. There is a deeply rooted feeling in the popular mind that sleep is an absolute essential to continued mental health and conversely that deprivation of sleep is a direct sign of both physical and mental breakdown. Assuming this statement to be correct the ordinary person finds himself in a state of extreme anxiety when for any reason his sleep is interfered with. The result of this anxiety very naturally is such a fixation of the attention upon his physical and mental condition that sleep for this very reason becomes increasingly difficult. Thus, the ordinary vicious circle is formed. I have in mind a patient, a middle-aged man of active business interests, who was so strongly impressed with the idea that without sleep he must necessarily go to pieces, that his life was becoming a burden to himself and to his friends. Reasoning from his premises, he assumed that inasmuch as sleep was essential to continued health and he was certainly not having a normal amount of sleep, he could not continue well. The treatment of this situation stated in barest outline was in the first place to explain that he had a wrong conception of the significance of sleep, that complete physical and mental rest without sleep would suffice to restore him for the work of the succeeding day, and finally that could he compose himself to such complete physical and mental rest, sleep would naturally follow. This, as a matter of fact, is what actually happened. The cause of the sleeplessness in this instance was essentially the mental state induced by the fear that he would not sleep. A more striking instance is that of a man from the Provinces, also of middle age, who for some six years had been unable to sleep and had developed various so-called neurotic symptoms as he supposed in consequence of this sleeplessness. The origin of his difficulty he definitely attributed to a single occasion when he had more or less voluntarily remained awake practically all night in anticipation of a very early morning journey. From this simple and commonplace event, the habit of sleeplessness apparently was formed, and from that time to this it has been kept alive evidently by the anxiety which has developed in consequence of his conception of the necessity of sleep, precisely similar to the case just cited. Here also it was not difficult, after three or four interviews in which explanation alone was used, to show the patient wherein his knowledge had been deficient regarding various physiological processes connected with sleep and to make clear to him the pernicious part his faulty mental attitude had played in the development of his neurosis. The patient was easily relieved of his difficulty, at least until he left Boston to return home. I have not heard from him since.

It would be easy to multiply cases of this sort, illustrative of the part which incorrect deductions play in the development of most varied neurotic conditions. The foregoing instances, however, may suffice to illustrate in simplest form the principle underlying this method of psychotherapeutic procedure.

The possibilities and limitations of the method I have attempted to outline may be summarized but not detailed in so brief a communication as this. Its possibilities are that it may be used by any intelligent physician who realizes its importance; the personality of the physician about which we still continue to hear plays a small part in its success. It requires no special training, psychological or otherwise, beyond that which every educated physician might easily acquire. It is not limited to the treatment of so-called “nervous” cases. It should, for example, be applied antecedent to surgical operations, particularly on the pelvic organs of women. It is a commonsense method of approach to many of the minor ills and some of the major disorders to which all persons are exposed. It does not demand hypnotic procedure, or the use of suggestion as that word is ordinarily employed. Its essential basis is an appeal to reason and herein naturally lies its wide applicability. Its limitations are no less apparent. It will naturally fail in the psychoses, in hysterical states associated with fundamental disorders of personality, and in obsessional conditions of a high degree of fixity, matters to which no doubt others taking part in this discussion will refer.