My VIews on the part played by sexuality in the aetiology of the neuroses 2 страница

In certain mental states described as ‘affects’, the part played by the body is so obvious and on so large a scale that some psychologists have even adopted the view that the essence of these affects consists only in their physical manifestations. It is a matter of common knowledge that extraordinary changes occur in the facial expression, in the circulation, in the excretions and in the state of tension of the voluntary muscles under the influence of fear, of rage, of mental pain and of sexual delight. What is less well known, though equally well established, is the occurrence of other physical results of the affects which cannot be counted as their expression. Persistent affective states of a distressing or ‘depressive’ nature (as they are called), such as sorrow, worry or grief, reduce the state of nourishment of the whole body, cause the hair to turn white, the fat to disappear and the walls of the blood-vessels to undergo morbid changes. On the other hand, under the influence of feelings of joy, of ‘happiness’, we find that the whole body blossoms out and shows signs of a renewal of youth. The major affects evidently have a large bearing on the capacity to resist infectious illness; a good example of this is to be seen in the medical observation that there is a far greater liability to contract such diseases as typhus and dysentery in defeated armies than in victorious ones. The affects, moreover, - this applies almost exclusively to depressive affects - are often sufficient in themselves to bring about both diseases of the nervous system accompanied by manifest anatomical changes and also diseases of other organs. In such cases it must be assumed that the patient already had a predisposition, though hitherto an inoperative one, to the disease in question.

States of illness that are already present can be very considerably influenced by violent affects. Such changes are usually for the worse; but there is no lack of instances in which a severe shock or a sudden bereavement brings about a peculiar alteration in the tone of the organism which may have a favourable influence on some well-established pathological condition or may even bring it to an end. Finally, there can be no doubt that the duration of life can be appreciably shortened by depressive affects and that a violent shock, or a deep humiliation or disgrace, may put a sudden end to life. Strange to say, this same result may be found to follow too from the unexpected impact of a great joy.

The affects in the narrower sense are, it is true, characterized by a quite special connection with somatic processes; but, strictly speaking, all mental states, including those that we usually regard as ‘processes of thought’, are to some degree ‘affective’, and not one of them is without its physical manifestations or is incapable of modifying somatic processes. Even when a person is engaged in quietly thinking in a string of ‘ideas’, there are a constant series of excitations, corresponding to the content of these ideas, which are discharged into the smooth or striated muscles. These excitations can be made apparent if they are appropriately reinforced, and certain striking and, indeed, ostensibly ‘supernatural’ phenomena can be explained by this means. Thus, what is known as ‘thought-reading’ [Gedanken erraten] may be explained by small, involuntary muscular movements carried out by the ‘medium’ in the course of an experiment - when, for instance, he has to make someone discover a hidden object. The whole phenomenon might more suitably be described as ‘thought-betraying’ [Gedanken verraten].

The processes of volition and attention are also capable of exercising a profound effect on somatic processes and of playing a large part in promoting or hindering physical illnesses. A famous English physician has reported that he can succeed in producing a great variety of sensations and pains in any part of his body to which he may choose to direct his attention, and the majority of people appear to behave similarly. It is in general true that in forming a judgement of pains (which are usually regarded as physical phenomena) we must bear in mind their unmistakable dependence upon mental determinants. Laymen, who like to sum up mental influences of this kind under the name of ‘imagination’, are inclined to have little respect for pains that are due to imagination as contrasted with those caused by injury, illness or inflammation. But this is clearly unjust. However pains may be caused - even by imagination - they themselves are no less real and no less violent on that account.

Just as pains are produced or increased by having attention paid to them, so, too, they disappear if attention is diverted from them. This experience can always be employed as a means of soothing children; adult soldiers do not feel the pain of a wound in the feverish heat of battle; martyrs are probably quite impervious to the pain of their tortures in the over-excitement of their religious feeling and in the concentration of all their thoughts upon the heavenly reward that awaits them. It is not so easy to produce evidence of the influence of volition on pathological somatic processes; but it is quite possible that a determination to recover or a will to die may have an effect on the outcome even of severe and precarious illnesses.

Our interest is most particularly engaged by the mental state of expectation, which puts in motion a number of mental forces that have the greatest influence on the onset and cure of physical diseases. Fearful expectation is certainly not without its effect on the result. It would be of importance to know with certainty whether it has as great a bearing as is supposed on falling ill; for instance, whether it is true that during an epidemic those who are afraid of contracting the illness are in the greatest danger. The contrary state of mind, in which expectation is coloured by hope and faith, is an effective force with which we have to reckon, strictly speaking, in all our attempts at treatment and cure. We could not otherwise account for the peculiar results which we find produced by medicaments and therapeutic procedures.

The most noticeable effects of this kind of expectation coloured by faith are to be found in the ‘miraculous’ cures which are brought about even to-day under our own eyes without the help of any medical skill. Miraculous cures properly so-called take place in the case of believers under the influence of adjuncts calculated to intensify religious feelings - that is to say, in places where a miracle-working image is worshipped, or where a holy or divine personage has revealed himself to men and has promised them relief from their sufferings in return for their worship, or where the relics of a saint are preserved as a treasure. Religious faith alone does not seem to find it easy to suppress illness by means of expectation; for as a rule other contrivances as well are brought into play in the case of miraculous cures. The times and seasons at which divine mercy is sought must be specially indicated; the patient must submit to physical toil, to the trials and sacrifices of a pilgrimage, before he can become worthy of this divine mercy.

It would be convenient, but quite wrong, simply to refuse all credence to these miraculous cures and to seek to explain the accounts of them as a combination of pious fraud and inaccurate observation. Though an explanation of this kind may often be justified, it is not enough to enable us to dismiss entirely the fact of miraculous cures. They do really occur and have occurred at every period of history. And they concern not merely illnesses of mental origin - those, that is, which are based on ‘imagination’ and are therefore likely to be especially affected by the circumstances of a pilgrimage - but also illnesses with an ‘organic’ basis which had previously resisted all the efforts of physicians.

There is no need, however, to bring forward anything other than mental forces in order to explain miraculous cures. Even under conditions such as these, nothing happens that can be considered as beyond our understanding. Everything proceeds naturally. Indeed, the power of religious faith is reinforced in these cases by a number of eminently human motive forces. The individual’s pious belief is intensified by the enthusiasm of the crowd of people in whose midst he makes his way as a rule to the sacred locality. All the mental impulses of an individual can be enormously magnified by group influence such as this. In cases in which someone proceeds to the holy place by himself, the reputation of the place and the respect in which it is held act as substitutes for the influence of the group, so that in fact the power of a group is once more in operation. And there is yet another way in which this influence makes itself felt. Since it is well known that divine mercy is always shown only to a few of the many who seek it, each of these is eager to be among the chosen few; the ambition that lies hidden in everyone comes to the help of pious faith. Where so many powerful forces converge, we need feel no surprise if the goal is sometimes really reached.

Even those who are without religious faith need not forgo miraculous cures. In their case reputation and group-influence act as a complete substitute for faith. There are always fashionable treatments and fashionable physicians, and these play an especially dominant part in high society, where the most powerful psychological motive forces are the endeavour to excel and to do what the ‘best’ people do. Fashionable treatments of this kind produce therapeutic results which are outside the scope of their actual power, and the same procedures effect far more in the hands of a fashionable doctor (who, for instance, may have become well-known as an attendant upon some prominent personality) than in those of another physician. Thus there are human as well as divine miracle-workers. Such men, however, who have reached eminence owing to the favour of fashion and of imitation, soon lose their power, as is to be expected from the nature of the forces which give it to them.

An intelligible dissatisfaction with the frequent inadequacy of the help afforded by medical skill, and perhaps, too, an internal rebellion against the duress of scientific thought, which reflects the remorselessness of nature, have in all periods (and in our own once more) imposed a strange condition on the therapeutic powers alike of persons and of procedures. The necessary faith only emerges if the practitioner is not a doctor, if he can boast of having no knowledge of the scientific basis of therapeutics, if the procedure has not been subjected to accurate testing but is recommended by some popular prejudice. Hence it is that we find a swarm of ‘nature cures’ and ‘nature healers’, who compete with physicians in the exercise of their profession and of whom we can at least say with some degree of certainty that they do far more harm than good. If this gives us grounds for blaming the patients’ faith, we must yet not be so ungrateful as to forget that the same force is constantly at work in support of our own medical efforts. The results of every procedure laid down by the physician and of every treatment that he undertakes are probably composed of two portions. And one of these, which is sometimes greater and sometimes less, but can never be completely disregarded, is determined by the patient’s mental attitude. The faith with which he meets the immediate effect of a medical procedure depends on the one hand on the amount of his own desire to be cured, and on the other hand on his confidence that he has taken the right steps in that direction - of his general respect, that is, for medical skill - and, further, on the power which he attributes to his doctor’s personality, and even on the purely human liking aroused in him by the doctor. There are some physicians who have a greater capacity than others for winning their patients’ confidence; a patient will often feel better the very moment the doctor enters his room.

4 Physicians have practised mental treatment from the beginning of time, and in early days to a far greater extent even than to-day. If by mental treatment we mean an endeavour to produce such mental states and conditions in the patient as will be the most propitious for his recovery, this kind of medical treatment is historically the oldest. Psychical treatment was almost the only sort at the disposal of the peoples of antiquity, and they invariably reinforced the effects of therapeutic potions and other therapeutic measures by intensive mental treatment. Such familiar procedures as the use of magical formulas and purificatory baths, or the elicitation of oracular dreams by sleeping in the temple precincts, can only have had a curative effect by psychical means. The physician’s personality acquired a reputation derived directly from divine power, since in its beginnings the art of healing lay in the hands of priests. So that then as now the physician’s personality was one of the chief instruments for bringing the patient into a state of mind favourable for his recovery.

Now, too, we begin to understand the ‘magic’ of words. Words are the most important media by which one man seeks to bring his influence to bear on another; words are a good method of producing mental changes in the person to whom they are addressed. So that there is no longer anything puzzling in the assertion that the magic of words can remove the symptoms of illness, and especially such as are themselves founded on mental states.

All the mental influences which have proved effective in curing illnesses have something incalculable about them. Affects, concentration of the will, distracting the attention, expectation coloured by faith - all of these forces, which occasionally remove an illness, sometimes fail to do so without there being anything in the character of the illness to account for the different result. What stands in the way of regularity in the therapeutic results achieved is evidently the autocratic nature of the personalities of the subjects, with their variety of mental differences. Since physicians came to realize clearly the important part played in recovery by the patient’s state of mind, the idea naturally occurred to them of no longer leaving it to the patient to decide how much mental compliance he should show but of deliberately imposing a propitious state of mind by suitable methods. It is from this attempt that modern mental treatment has taken its start.

5 Quite a number of different methods of treatment have thus arisen, some of them simple to arrive at and others which could only be reached on the basis of complex hypotheses. It is easy to see, for instance, that the physician, who can no longer command respect as a priest or as the possessor of secret knowledge, should use his personality in such a way as to gain his patient’s confidence and, to some degree, his affection. He himself may succeed in doing this with only a limited number of patients, whereas other patients, according to their inclinations and degree of education, will be attracted to other physicians. Such a distribution will serve a useful purpose; but if the right of a patient to make a free choice of his doctor were suspended, an important precondition for influencing him mentally would be abolished.

There are many very effective mental procedures which the physician is obliged to renounce. He either has not the power or has not the right to invoke them. This applies in particular to the provocation of strong affects - the most powerful of all the means by which the mind affects the body. The vicissitudes of life often cure illnesses through the experience of great joy, through the satisfaction of needs or the fulfilment of wishes. The physician, who is often impotent outside his profession, cannot compete along these lines. It might be more within his power to employ fear and fright for therapeutic ends; but, except in the case of children, he must have the gravest doubts about the use of such double-edged tools. On the other hand, the physician must rule out any relations with his patient that are bound up with tender feelings, owing to their implications in practical life. Thus from the first his power to bring about mental changes in his patients seems so restricted that mental treatment conducted on a deliberate plan would seem to offer no advantages over the earlier haphazard method.

The physician can seek to direct his patient’s volition and attention, and he has good grounds for doing so in the case of various pathological conditions. He may, for instance, persistently oblige a person who believes he is paralysed to carry out the movements of which he professes himself incapable; or he may refuse to fall in with the wishes of an anxious patient who insists on being examined for an illness from which he is quite certainly not suffering. In these instances the physician will be taking the right course, but such isolated cases would scarcely justify us in setting up mental treatment as a special therapeutic procedure. There exists, nevertheless, a queer and unforeseeable method which offers the physician a possibility of exercising a profound, even though transitory, influence on the mental life of his patients and of employing that influence for therapeutic purposes.

6 It has long been known, though it has only been established beyond all doubt during the last few decades, that it is possible, by certain gentle means, to put people into a quite peculiar mental state very similar to sleep and on that account described as ‘hypnosis’. The various means by which hypnosis can be brought about have at first sight little in common. It is possible to hypnotize someone by getting him to stare fixedly at a bright object for some minutes, or by holding a watch to his ear for a similar length of time, or by repeatedly passing the open hands, at a short distance away, over his face and limbs. But the same result can be brought about by describing the onset of the state of hypnosis and its characteristics quietly and firmly to the subject - that is, by ‘talking him into’ hypnosis. The two procedures may also be combined. We may make the subject sit down, hold a finger in front of his eyes, tell him to gaze at it fixedly and then say to him: ‘You’re feeling tired. Your eyes are closing; you can’t hold them open. Your limbs are heavy; you can’t move them any more. You’re falling asleep---' and so on. It will be observed that all the procedures have in common a fixing of the attention; in those first mentioned the attention is fatigued by slight and monotonous sensory stimuli. It is not yet satisfactorily explained, however, how it comes about that mere talking produces exactly the same state as the other procedures. Experienced hypnotists assert that by these means a definite hypnotic change can be brought about in some eighty per cent of subjects. There is no way of telling beforehand, however, which subjects are hypnotizable and which are not. Illness is far from being one of the necessary preconditions of hypnosis: normal people are said to be particularly easy to hypnotize, while some neurotics can only be hypnotized with great difficulty and the insane are completely resistant. The hypnotic state exhibits a great variety of gradations. In its lightest degree the hypnotic subject is aware only of something like a slight insensibility, while the most extreme degree, which is marked by special peculiarities, is known as ‘somnambulism’, on account of its resemblance to the natural phenomenon of sleep-walking. But hypnosis is in no sense a sleep like our nocturnal sleep or like the sleep produced by drugs. Changes occur in it and mental functions are retained during it which are absent in normal sleep.

Some of the phenomena of hypnosis (for instance, alterations in muscular activity) possess a merely scientific interest. But the most significant indication of hypnosis, and the most important one from our point of view, lies in the hypnotic subject’s attitude to his hypnotist. While the subject behaves to the rest of the external world as though he were asleep, that is, as though all his senses were diverted from it, he is awake in his relation to the person who hypnotized him; he hears and sees him alone, and him he understands and answers. This phenomenon, which is described as rapport in the case of hypnosis, finds a parallel in the way in which some people sleep - for instance, a mother who is nursing her baby. It is so striking that it may well lead us to an understanding of the relation between the hypnotic subject and the hypnotist.

But the fact that the subject’s universe is, so to say, confined to the hypnotist is not the whole story. There is the further fact of the former’s docility in relation to the latter: he becomes obedient and credulous - in the case of deep hypnosis, to an almost unlimited extent. And the manner in which this obedience and credulity are carried out reveals a characteristic of the hypnotic state, namely that in the hypnotized subject the influence of the mind over the body is extraordinarily increased. If the hypnotist says ‘You can’t move your arm’, the arm drops motionless; the subject obviously tries with all his strength but is unable to move it. If the hypnotist says: ‘Your arm’s moving of its own accord, you can’t stop it’, the arm moves and the subject is seen making vain efforts to keep it still. The idea which the hypnotist has given to the subject by his words has produced in him precisely the mental-physical behaviour corresponding to the idea’s content. This implies on the one hand obedience but on the other an increase in the physical influence of an idea. Words have once more regained their magic.

The same thing happens in the domain of sense perceptions. The hypnotist says: ‘You see a snake; you’re smelling a rose; you’re listening to the loveliest music’, and the hypnotic subject sees, smells and hears what is required of him by the idea that he has been given. How do we know that the subject really has these perceptions? It might be thought that he is only pretending to have them. But after all we have no reason for doubts on the point; for he behaves exactly as though he had them, he expresses all the appropriate emotions, and in some circumstances he can even describe his imaginary perceptions and experiences after the hypnosis is at an end. We then perceive that he has been seeing and hearing just as we see and hear in dreams - he has been ‘hallucinating’. He was evidently so credulous in relation to the hypnotist that he was convinced that there must be a snake to be seen when the hypnotist told him so; and this conviction had such a strong effect on his body that he really saw the snake - a thing which, incidentally, can sometimes happen even to people who have not been hypnotized.

It may be remarked, by the way, that, outside hypnosis and in real life, credulity such as the subject has in relation to his hypnotist is shown only by a child towards his beloved parents, and that an attitude of similar subjection on the part of one person towards another has only one parallel, though a complete one - namely in certain love-relationships where there is extreme devotion. A combination of exclusive attachment and credulous obedience is in general among the characteristics of love.

9 Some further points may be mentioned in connection with the state of hypnosis. The words spoken by the hypnotist which have the magical results that I have described are known as a ‘suggestion’ and it has become customary to apply the term as well where there is merely an intention to produce a similar effect. Not only do the hypnotic subject’s movements and feelings obey suggestions, but all his other mental activities; and he does not as a rule take any action on his own initiative. Hypnotic obedience can be employed in making a number of highly remarkable experiments, which afford a deep insight into the workings of the mind and produce in the observer an ineradicable conviction of the unsuspected power of the mind over the body. Just as a hypnotized subject can be obliged to see what is not there, so he can be forbidden to see what is there and is seeking to impress itself on his senses - some particular person, for instance. (This is known as a ‘negative hallucination’.) The person in question then finds it impossible to attract the subject’s attention by any kind of stimulation; he is treated as though he were ‘thin air’. Again, a suggestion may be made to the subject to carry out some action a certain length of time after waking from hypnosis (‘post-hypnotic suggestion’); the subject keeps to the allotted time and performs the suggested action in the middle of his waking state without being able to give any reason for it. If he is asked why he has done what he has, he will either refer to an obscure impulse which he was unable to resist, or he will invent some half-satisfactory excuse without remembering the real explanation - namely the suggestion he has been given.

The state of hypnosis is brought to an end without any difficulty by the hypnotist’s authority asserted in the words: ‘Wake up!’ After the deepest hypnosis there is no recollection of anything that has been experienced during it under the hypnotist’s influence. That portion of the subject’s mental life remains cut off, as it were, from the rest. Other subjects retain a dream-like memory, and yet others remember everything but report that they have been under an irresistible mental compulsion.

0 The scientific gain brought to physicians and psychologists by a knowledge of the facts of hypnotism can scarcely be exaggerated. But in order to gauge the practical importance of the new discoveries we must put a physician in place of the hypnotist and a patient in place of the hypnotic subject. Hypnosis would then seem pre-ordained to fulfil all the physician’s requirements, in so far as he seeks to act towards the patient as a ‘mind-doctor’. Hypnosis endows the physician with an authority such as was probably never possessed by the priest or the miracle man, since it concentrates the subject’s whole interest upon the figure of the physician; it does away with the autocratic power of the patient’s mind which, as we have seen, interferes so capriciously with the influence of the mind over the body; it automatically produces an increase of the mind’s control over the body, such as is normally to be observed only as an effect of the most powerful emotions; and, owing to the possibility of arranging that the instructions given to the patient during hypnosis shall only become manifest subsequently, in his normal state - owing, that is, to post-hypnotic suggestion -, hypnosis enables the physician to use the great power he wields during hypnosis in order to bring about changes in the patient in his waking condition. A simple pattern of procedure would thus seem to emerge for the purposes of mental treatment: the physician puts the patient into a state of hypnosis, he suggests to him (according to the particular circumstances) that he is not ill and that after waking he will not be aware of his symptoms. The physician then wakes the patient up and may feel confident that the suggestion has done its duty against the illness. And if a single application of this procedure were not sufficient, it could be repeated as many times as necessary.

There is only one consideration that might discourage the physician and the patient from making use of such a promising therapeutic method: the possibility that the advantages of hypnotism might be balanced by some damage - if, for instance, it left behind it a permanent disorder or weakness in the subject’s mind. But enough experience has already been gained to set aside such doubts: single hypnotic treatments are completely harmless and even if they are frequently repeated they are on the whole without bad effects. Only one point is to be noticed: if circumstances demand a persistent use of hypnotism, the patient falls into a habit of hypnosis and dependence on the physician which cannot be among the purposes of the therapeutic procedure.

Thus hypnotic treatment really implies a great extension of medical power and consequently an advance in therapy. Every sufferer may be advised to entrust himself to it, so long as it is carried out by an experienced and trustworthy physician. Hypnosis should, however, be used in a manner different from what is usual to-day. As a rule this method of treatment is only embarked upon after every other method has failed and when the patient is already despondent and dejected. He has then to leave his own doctor, who cannot or does not employ hypnotism, and turn to a strange doctor, who as a rule does not or cannot employ anything else. Both practices are disadvantageous to the patient. The family doctor should himself be familiar with hypnotic procedure and he should make use of it from the first, as soon as he judges the illness and the patient appropriate for it. Wherever hypnotism can be employed it should be on a par with other therapeutic procedures and should not be regarded as a last resort or even as a descent from science to quackery. But hypnotism can be employed not only in all nervous conditions and in disorders due to the ‘imagination’, as well as for breaking morbid habits (such as alcoholism, morphine addiction, or sexual aberrations), but also in many organic diseases, even of an inflammatory nature, in which, though the underlying disorder persists, there is a prospect of relieving the symptoms (such as pains or impediments to movement) which are troubling the patient. The selection of cases for hypnotic treatment must depend entirely on the judgement of the physician.

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