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 way as the savage is afraid[359] 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 changes 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[360] 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 rational 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 consciousness.[18] It is, therefore, the physician’s object to lift the patient out of this low form of mental activity to the higher types of rational, personal life in which the patient can rise above the perturbations of life, 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 in 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[361] 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 consciousness, 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 whit 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 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[362] 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. The 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.
[363]
The first and foremost characteristic of psychopathic states is the narrowing down of the patient’s life interests. He begins to lose interest in abstract 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 bec............