Psychotherapy is the use of psychic factors in the treatment of disease.

An essential element of psychotherapy is suggestion. Its successful practice is dependent on the nature of the disorder, the attitude of the patient, and the personality of the physician.

The psychoneuroses are most amenable to psychic treatment. The graver psychoses are much less readily influenced.

The patient must have full confidence in the physician and in his methods. "The nervous patient is on the path to recovery as soon as he has the conviction that he is going to be cured; he is cured on the day when he believes himself to be cured."1

It follows that the physician must be able to inspire respect and trust. According to Griesinger 2 he must have "a kind disposition, great patience, self-possession, particular freedom from prejudice, an understanding of human nature resulting from an abundant knowledge of the world, adroitness in conversation, and a special love of his calling."

As to the manner of employing suggestion the indications must be sought in the individual case. In some cases, the patient's faith being strong, a mere statement that the symptoms are quickly disappearing may be sufficient. In other cases "rational" suggestion with an explanation of the cause of the symptoms and of the best means of combating them is more effective. "There is a great difference in mentality between the man who is content with a statement, who allows himself to be under the influence of the personality of a healer, and the man who acquires confidence by the clear exposition of the reasons to believe." 3 In still other cases hypnotic suggestion affords good results.

The following practical advice, evidently borne of abundant experience, is given by Dercum:

"The physician should not be too aggressive with his suggestions, especially in the beginning. Indeed, his attitude should be that of accepting the illness and symptoms of the patient as a matter of course.

1 Paul Dubois. The Psychic Treatment of Nervous Disorders. English translation by Jelliffe and White. New York, 1905. P. 210.

2 Quoted by Kraepelin. Psychiatric. Seventh edition. Vol. I. 3 Paul Dnbois. hoc. cit., p. 227.

The mere institution of rest and the various physiological procedures, is a proof to the patient of the sincerity of the physician. It is only after the treatment has been established and has been under way for some time that the physician should begin a really serious psychotherapy. He should never be in a hurry to begin. The mistake may be beyond remedy, at least, so far as he, individually, is concerned. Time must be allowed for the patient to ' settle down,' i.e., to adapt herself to her new environment, her nurse and her physician. Very soon the luxuriousness and exquisite physical comfort of a properly instituted rest treatment makes its impression upon the patient. As the days go by, the physician and the patient gradually become better acquainted. The nurse, too, learns the little personal peculiarities of her patient, all of which she faithfully communicates to the physician. Very soon opportunities occur for more lengthy conversations, and the physician being now thoroughly en rapport with his patient and having fully gained her confidence, can venture to make free use of suggestion. Indirect suggestion, we will say, has been employed from the beginning, but direct suggestion, explanatory and logical in form, can now be employed with great effectiveness.

Sometimes the conversations with the patient reveal the way in which this or that special symptom arose, and this clue may be of value in its subsequent disposal; the physician may point out the inadequacy of the cause alleged and at the same time ' explain away ' the symptom." l

Special mention should be made of religious influences, which are of extraordinary efficacy in some cases. Cures produced by pilgrimages to shrines or by the practice of Christian Science are instances in point. Equally striking are the cures of habits of intemperance produced by religious conversion or, among good Catholics, by taking the pledge of total abstinence. In these, as in other measures of psychotherapy, the active principle is suggestion and therefore the existence of strong faith is a condition necessary for success.

In cases of mental deterioration the object of psychotherapy is re-education, not with the hope of bringing about recovery, but with that of training the subject to do some simple yet productive labor (basket weaving, mat making, chair caning, sewing, farm labor, etc.).

1 F. X. Dercum. Rest, Suggestion, and Other Therapeutic Measures in Nervous and Mental Diseases. Second edition. Philadelphia, 1917.

Delusional states are notoriously refractory to suggestion or reason. Yet in selected cases, in which the delusional system is, so to speak, of a parasitic nature, not essentially a function of a vicious mental organization, something may be accomplished when a favorable opportunity presents itself of demonstrating to the patient the incorrectness of his belief.

I shall quote from the published autobiography of a man who had suffered from a severe and prolonged manic-depressive psychosis from which he subquently recovered.1

This man had developed a complex system of delusions of persecution by detectives. Within the space of a fraction of a minute he succeeded in fully correcting all his false ideas when he found convincing proof that he whom he had regarded as his brother's double and a detective was indeed his true brother.

"I dared not ask for ink, so I wrote with a lead pencil. Another fellow patient in whom I had confidence, at my request, addressed the envelope; but he was not in the secret of its contents. This was an added precaution, for I thought the Secret Service men might have found out that I had a detective of my own and would confiscate any letters addressed by him or me. The next morning, my ' detective ' (a fellow patient who had the privilege of going and coming unattended) mailed the letter. That letter I still have, and 1 treasure it as any innocent man condemned to death would treasure a pardon or reprieve. It should convince the reader that sometimes an insane man can think and write clearly. An exact copy of this - the most important letter I ever expect to be called upon to write - is here appended:

August 29, 1902. "Dear George:

On last Wednesday morning a person who claimed to be George M. Beers of New Haven, Ct., clerk in the Director's Office of the Sheffield Scientific School and a brother of mine, called to see me.

"Perhaps what he said was true, but after the events of the last two years I find myself inclined to doubt the truth of everything that is told me. He said that he would come and see me again sometime next week, and I am sending you this letter in order that you may bring it with you as a passport, provided you are the one who was here on Wednesday.

1C. W. Beers. A Mind that Found Itself. 1908. New York Longmans, Green and Co.

"If you did not call as stated please say nothing about this letter to anyone, and when your double arrives, I'll tell him what I think of him. Would send other messages, but while things seem as they do at present it is impossible. Have had some one else address envelope for fear letter might be held up on the way.

Yours, Clifford, W. B.

"Though I felt reasonably confident that this message would reach my brother, I was by no means certain. I was sure, however, that, should he receive it, under no circumstances would he turn it over to any one hostile to myself. When I wrote the words: ' Dear George,' my feeling was much like that of a child who sends a letter to Santa Claus after his faith in the existence of Santa Claus has been shaken. Like the skeptical child, I felt there was nothing to lose, but everything to gain.

"The thought that I might soon get in touch with my old world did not excite me. I had not much faith anyway that I was to reestablish former relations, and what little faith I had was almost dissipated on the morning of August 30, 1902, when a short message, written on a slip of paper, reached me by the hand of an attendant. It informed me that my brother would call that afternoon. I thought it a lie. I felt that any brother of mine would have taken the pains to send a letter in reply to the first I had written him in over two years. The thought that there had not been time for him to do so and that this message must have arrived by telephone did not then occur to me. What I believed was that my own letter had been confiscated. I asked one of the doctors to swear on his honor that it really was my own brother who was coming to see me. He did so swear, and this may have diminished my first doubt somewhat, but not much, for abnormal suspicion robbed all men in my sight of whatever honor they may have had.

"The thirtieth of the month was what might be called a perfect June day in August. In the afternoon, as usual, the patients were taken out of doors, I among them. I wandered about the lawn, and cast frequent and expectant glances toward the gate, through which I believed my anticipated visitor would soon pass. In less than an hour he appeared. I first caught sight of him about three hundred feet away, and, impelled more by curiosity than hope, I advanced to meet him. ' I wonder what the lie will be this time,' was the gist of my thoughts.

"The person approaching me was indeed the counterpart of my brother as I remembered him. Yet he was no more my brother than he had been at any time during the preceding two years. He was still a detective. Suen he was when I shook his hand. As soon as that ceremony was over he drew forth a leather pocket-book. I instantly recognized it as one I myself had carried for several years prior to the time I was taken ill in 1900. It was from this that he took my recent letter.

" ' Here's my passport,' said he.

" ' It's a good thing you brought it,' said I coolly, as I glanced at it and again shook his hand - this time the hand of my own brother.

" ' Don't you want to read it? ' he asked.

" ' There is no need of that,' was my reply. ' I am convinced . . . '

" This was the culminating moment of my gradual readjustment. ... In a word, my mind had found itself."

The subject of psychotherapy is of too great a magnitude to be given full discussion here. The general lines of procedure have already been indicated. A special consideration of psychotherapy in application to the psychoneuroses will be found in the chapter devoted to these conditions in Part II, of this Manual. For fuller guidance in practical psychotherapy the student is referred to the work of Dubois.1

A special system of psychotherapy has developed in recent years out of the labors of Freud and his pupils. A presentation of this system will be found in the chapter on Psychoanalysis.