Psychotherapy

Paul Schilder, Schilder, Paul

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415210409
• eBook ISBN: 9781136327360
• Topic: Medicine
• Subtopic: Health Care Delivery

This is Volume XXVIII of thirty-eight in a collection on General Psychology. Originally published in 1938, this study developed from a conviction that psychotherapy is not an art but a technical procedure based upon scientific principles. It is a part of the science of psychology and psychopathology.

Chapter 1
Some General Principles

Patients come to the physician because they suffer. They may suffer from any type of bodily ailment, such as pain, weakness, tension, or nausea. However, their complaints may not pertain to the body, but to their thinking, their emotions, or their inability to work. The difficulty may be that they are unable to establish proper relations with their fellow human beings. They themselves feel quite all right, but the reactions of other people to them are such that they finally suffer. In milder degrees of adaptation difficulties, the individual may feel that his lack of success in life, from which he suffers, is due to his own failings and his emotional attitudes. He seeks to change these attitudes. No one can be successful always. Difficulties may occur in everyone's life, such as the loss of one's beloved. The outward circumstances of life, because of the general political and economic situation, may become unbearable and cause the individual to suffer. He may feel that his suffering is out of proportion to the actual difficulties in his situation, and will therefore ask for help in these problems of everyday life. Finally, the individual may be brought to the physician by someone else. He may believe himself quite healthy, but those around him suffer more or less through his actions and do not hold this opinion. They believe something is wrong with him in the mental sphere, and therefore they insist that he get help from a physician. To this group belong children with mental deficiency or behavior problems, criminals, psychopathic personalities, and mentally ill persons. Thus we have five roughly divided groups of individuals who are brought to the physician either because they themselves suffer or because they make others suffer, i.e., individuals with (1) a physical complaint, (2) a mental com plaint, (3) a complaint of lack of success, (4) complaints due to the ordinary difficulties of human life, and (5) complaints of others.

In the first group we find patients afflicted with the so-called organic diseases or organic deficiencies. A person who has lost a leg, for instance, needs a prosthesis, exercise, advice, and help for mental aQd physical adaptation. Many persons who complain about physical ailments are not what we would call organically ill. We have learned that every mental problem reflects itself in the physical sphere. It may take a form resembling an organic disease without being identical with it. There are at least some organic diseases that originate in the psychological sphere. In most of these cases the patients will complain, not about their psychic conflict, but about their physical ailment. In some cases the organic complaint, having originated in the psychic sphere, may be only occasionally corroborated by so-called physiological changes. The patient who complains about a physical ailment which is purely organic in character professes by the mere fact that he goes to the physician that he suffers and needs relief. He seeks not only help by physical agents but the aid of the physician as person to person.

In the second group of cases we find neurasthenics and patients with obsessional neurosis who complain about the disturbances in their psychic processes, such as a lack of concentration, or about their obsessions and compulsions as such. Depersonalization cases may complain about their lack of interest and their inability to feel. It is, however, rare that the complaints are restricted to the psychic sphere. Patients of this type almost invariably complain about physical signs like fatigue, constipation, tensions, and pain. Many of the cases with complaints about difficulties in their psychic life are organic cases. Obsessional symptoms in encephalitic cases are common, and as my own investigations have convinced me, careful examination, even with our present imperfect methods, will often reveal signs of an organic process or of an organic inferiority in ob sessional neurosis. The difficulties in concentration may be due to an arteriosclerotic process, or to a beginning general paresis. De personalization signs may be connected with a true depression, which, I believe, has at least strong organic components. Also the schizophrenic, who suffers from a disease which is organic in the same sense as a depression, might complain about the change in his mental activity.

The third and fourth groups of our patients have not always gone to the physician when they needed help. They previously went to the priest or minister, or they sought moral guidance. Many of the individuals of this type are not free from physical symptoms, especially at a time of stress. In some of these cases an organic disease may be a partial cause of the maladaptation.

In the last group we may expect to find a comparatively large number of individuals who are organically ill.

Even such a casual survey gives us the impression that most of the persons who suffer, suffer in body and soul. Furthermore, the border line between a psychic and a physical ailment would not appear to be very sharp.

Human beings are social beings. They have social contacts of various types. The child is at first dependent upon his mother and the persons who nurse him. Social contacts with other children are limited. When the child grows older he may develop contact with siblings and the other children in the neighborhood and school. Then contacts with teachers and other grownups are added. The grownup has relations to persons of both the same and the opposite sex. We may talk about friendship and love. He has social relations to his family, to the social group in which he moves, to his professional, racial, and political circles. He lives in a complicated system of social interrelations. These are rather obvious and trite observations. My own investigations have revealed that the social character of human experience goes even further. We build up the image of our own body only in relation to others. Even when we perceive and are interested in objects outside of ourselves, we are addressing ourselves to others. The lonely dreamer and the philosopher in se~lusion dream and philosophize before and for an unseen public.

The relations to other human beings may be roughly divided into two groups: the social relations in the narrower sense, and love relations.

The social relation can be one of equality. The one individual is interested in having the other exist as an equal to himself. It is a relation of give~and~take. It can be one of superiority and inferiority. The individual still remains interested in the existence of the other person, but he does consider himself superior or inferior to the other person and does not wish to have this relation reversed. The give-and-take relation may still be present, but the giving may express either the superior or the inferior attitude. Usually, the superior person will maintain his superiority by giving. The relation between parent and child is one of the relations in which superiority is inherent in the situation. The same is true for the situation between teacher and pupil. The relation between employer and employee almost always belongs in the same category.

This relation may be one of aggression and submission. The aggressor may even have a tendency to a partial or total destruction of the other person, but he is still desirous that there be a sufficient number of counterplayers present who can be subdued. The subdued person might be gratified in his submissive role. We usually believe that a severe degree of destructiveness in the relationship between two persons also involves libidinous attitudes. We then speak about sadomasochism.

If a state of equality is attained, it cannot be a lasting one-it cannot be maintained. It is more or less of an ideal around which social relations move. At best it can be but a point of passage in a dynamic relation.

In all social relations the existence of the other is not only physically necessary but meets the inner psychic demands. Destructive impulses against the other, although present, are a phase in a social process in which interest in the existence and mental and physical integrity of the other plays a leading part. However, the seriousness of destructive tendencies should not be underrated.

Biologically and psychologically, the love relationship between two human beings is different from other social relations. In the love relation one individual professes his basic incompleteness and wants completion by the person of the other sex. A system of activities is co-ordinated to the erotic relations between two persons. In the basic love relation between man and woman there is no difference in the activities between the two sexes. There is merely- a difference in the phases of activity. Whereas the man is more active in the first phase of the love relation in general and of intercourse in particular, the woman is more active in the second phase of both. The dynamic equality between the two sexes may be changed into a relation of superiority and inferiority, aggression and submission (sadism and masochism).

In social and sexual relations human beings offer gifts to each other. These may be objects, or service, or erotic gratification. The actual satisfaction of physical needs, regardless of how they serve the maintenance of the body or sexual satisfaction, is but a small part of our life. We do not live only in the narrow presence of actual sensual experience. The range of our activities extends far beyond the horizon of immediate perception, in space as well as in time. We need not only actual gratifications but promises of future gratifica tions as well. This future gratification also transgresses the space of the immediate present. Humanity has elaborated a sign system for such gratifications. Such a sign system enriches our world in an al most immeasurable way. In this sign system, language and words play the most important part, but the system is in no way limited to the spoken and written word. I shall point to the function of money in social life.

Sentences and words may thus become signs for any type of gratification in social and erotic relations. When a sign is actually functioning, the value diffuses from the object into the sign, and the endearing word of the lover becomes a value in itself, irrespective of the fact that it promises the pleasures of intercourse.

The tool at psychotherapy is language as a sign system. The physician who treats a patient by physical methods introduces substances into the patient which change his body function directly. The surgeon actually cuts the human body. The physician plays the part of a physical agent in a more or less direct way. So do massage and physiotherapy in general. The psychotherapist has no immediate access to the body of the patient and to his gratifications. The influence he has on the patient is merely due to the words he speaks. What is the power behind those words? Two persons who speak to each other are in a social relation which in the widest sense of the word includes the erotic.

On the basis of the previous remarks about social relations we conclude that the following relations between the physician and the patient are possible. We speak here primarily about the psychotherapist, but since patients go to the physician because they suffer, it is obvious that the psychotherapeutic relation is inherent in every relation between physician and patient.

(a) Physician and patient are fellow human beings. There is no fundamental difference between them. The physician merely has more knowledge in a field of experience in which the patient happens not to be so well versed. In compensation for the advice, the patient gives money to the physician as he would give it to anyone else who serves him. Relations between physician and patient are mostly not of this type.

(b) The patient wants to go to an outstanding physician. The mere fact that the patient chooses the physician gives to the latter the superiority in their relation. The patient, especially when he comes with psychic problems, wants to find a leader in the physician. Human beings need a leader whom they admire and who takes a part of their responsibilities. In one type of leadership the leader is merely expected to have superior insight. If the patient expects such leadership, the relation between the two will be a relation of superiority and inferiority, and in their discussion common sense and reason will prevail.

(c) Since the discussion between patient and physician circles around the moral problems of life, it will sooner or later become apparent that purely from the point of view of reason, the physician is not greatly superior to the patient after all. Sooner or later the patient will have to add faith to his relation to the physician if he wants to get a sufficient amount of consolation out of this relation. The physician himself will eventually be compelled to demand faith from his patient, unless he discharges the patient in disgust as some practitioners do when they see that the patient cannot avail himself of the physician's advice. We may suppose that this elementary faith (not based upon reason) very often enters the psychotherapeutic relation without the knowledge of either patient or physician. The method of persuasion as developed by Dubois is, as we shall later see, far from being a method based upon common sense. When faith enters the relation, the superior~inferior relation between physician and patient is obviously still more emphasized, but seemingly a new element has been added. The relation becomes similar to that between the adult and the child, or better and more specifically, the relation is more like the one between parent and child. In such a parent~child relationship, sexual elements are almost invariably present in addition to the social elements. Furthermore, a sign (word) coming from the parent has a much greater value.

(d) From this relation to the complete surrender of the patient to the physician is only a short step. The physician does not only become a father, but he also becomes a father endowed with magic powers. The sexual element entering into this relation will be more or less primitive. Since the physician is so far superior in this relation, reasoning obviously becomes unnecessary, and the physician has to direct the faith of his patient. He may become a mystical leader, or he may use the more definite technique of suggestion and hypnosis. When the faith of the patient in such a relation is blind, the physician him self is no less blind. He is called to take over a leadership by reason or faith; and according to the whole situation, he cannot know where he should lead the patient. The physician ultimately will become dis contented with his role as a fellow adviser who does not know what to advise, and as a rational or mystical leader who does not know where to lead.

The modern approach to psychotherapeutic problems stresses the necessity of gaining insight into the patient's personality and conflicts. In this respect, Janet, Freud, Jung, and Adler are of the same opinion. A full social relation to other human beings is only possible on the basis of a general good will and the acknowledgment that they are fellow human beings. In order to respect them, we must know them; or in other words, we must acknowledge them as specific and distinct personalities. Psychotherapy, therefore, has the task of not only establishing the relation between the physician and the patient, but of finding out methods by which better understand ing can be had of the problems of the patient. Only then is a full relation between the patient and his physician possible. There is the underlying conviction that suffering due to psychic reasons is dependent on conflicts which the individual is not only unable to solve, but is not even aware of. The psychotherapeutic process therefore must reveal the personality and the conflicts not only to the physician but also to the patient himself. The approach by reason and faith is much less dependent upon theoretical assumptions than this type of psychotherapy, which Fritz Wittels has called "unveiling." The problems of this psychotherapy are:

(a) What method is there to uncover the conflict underlying the neurosis? (b) How can we bring the patient to understand his con flicts? (c) How can one bring the patient actually to use his insight?

(a) The method employed is necessarily based on uncovering new material. This new material can be obtained by a discussion directed by the underlying assumptions of the physician, as in individual psychology. By a more or less direct questioning, the facts of the life of the patient have to be elicited and grouped into an order which gives them a new meaning. The search for details which could lead to such a rearrangement will indicate the method of interpretation of dreams, of the mistakes in everyday life, and of seemingly unrelated events of life. Such an approach is basic for Adler's individual psychology and for Adolf Meyer's psychobiology. Psychoanalysis uses the method of so-called "free association." This method is based upon the assumption that when the individual is relieved from the necessity of logical thinking and reports everything going through his mind he will necessarily, under the pressure of emotions which tend to expression, bring forward basic material. Mistakes of everyday life, and dreams in which a partial liberation from the fetters of logic and repression is already achieved, will be particularly valuable material in this respect. This method assumes that the so-called logical and conscious thinking hinders important parts of psychic life from expression. This method therefore tends to a liberation of deeper layers of psychic life and emphatically stresses the emotional character of these deeper layers. This methodological principle is common to the classical psychoanalysis in the Freudian sense as well as to the Jungian type of analytic procedure.

(b) If one considers the process of insight preponderantly from the logical side, no special problems arise concerning the insight of the patient. The results of the physician's investigation merely have to be communicated to the patient. Those who use psychoanalytic procedures believe that insight is only possible in connection with emotional re-enactment of previous conflicts. If hypnosis is used for the recovery of forgotten material, the re-enactment becomes more or less a matter of course. Whereas psychoanalysis stresses the emotional re-enactment with the physician as the central figure, Jungian analysis stresses the emotional experiences in connection with emotional ex...

Table of contents

• Cover
• Title
• Copyright
• Contents
• PREFACE TO THE FIRST EDITION
• PREFACE TO THE REVISED EDITION
• 1 SOME GENERAL PRINCIPLES
• 2 THE PSYCHOLOGY OF ORGANIC SYMPTOMATOLOGY
• 3 THE SYMPTOMATOLOGY OF MENTAL SUFFERING
• 4 SOMATIC HEALTH AS AN EXPERIENCE
• 5 PSYCHIC HEALTH AS AN EXPERIENCE
• 6 TECHNICAL TOOLS OF PSYCHOTHERAPY
• 7 THE RELATION BETWEEN PHYSICIAN AND PATIENT
• 8 THE PSYCHOTHERAPEUTIC SYSTEMS
• 9 GROUP PSYCHOTHERAPY
• 10 THE TREATMENT OF SPECIFIC TYPES OF NEUROSES AND PSYCHOPATHIES
• 11 PSYCHOANALYSIS AND PSYCHOTHERAPY OF THE PSYCHOSES AND THE PSYCHOLOGY OF SHOCK TREATMENT
• BIBLIOGRAPHY
• INDEX