Translated by Maria Marshall, PhD, RP
Fundamentals of Medical Psychology: Psychodiagnostics and Psychotherapy in Everyday Practice (1925)
Dr. med. Heinz Fendel, Specialist of Internal Medicine and Nervous Disorders
Hoechst, Frankfurt on the Main River, Germany
Publisher: Urban & Schwarzenberg
Berlin Friedrichstrasse 106 B / Vienna I Mahlerstrasse 4
Chapter 20: Logotherapy
The main medium of every psychotherapy is the spoken word. It is therefore obvious that the verbal message, aside from its activating principles, can be by itself a method. As Dubois emphasized when he stated: “the only weapon of the doctor—when one leaves aside the power of suggestion or hypnosis–is clear understanding, a gift, to communicate facts to the patient clearly, and free from false assumptions.” It is notable that such healing influence on the soul that can be transmitted merely through word based on reason (Logos), requires certain characteristics of the patient and the doctor: It comes into play in the case of certain patients, who have a refined psyche and experience structure. It requires from the doctor the highest mastery of verbal capacity, style, and content, to express such welled up realities. Constating the initially unrecognized complaints, doubts and objections of the patient, exploring deeper to bring out the correcting counter arguments based on their own presenting observations and declarations, that leads to an appreciation of the absurdum of the illogical conception of illness, is the great art, that confronts us in Dubois’ work. To whomever this process “seems really primitive” (Heyer), must not yet have fully appreciated the finest possibilities of psychological healing. Certainly, just like in the case of other forms of psychotherapy, the formal, suggestive, affective, and irrational elements are also at work, however, from simply a methodological point of view, it is an art to be able to utilize this tool.
As much as the content of the logotherapeutic intervention matters, it is also important and difficult to arrive to what is right and to avoid what is wrong. As a principle, the rule not to harm, ranks higher than the bid to use. Kretchmer says: “Whoever has not hurt their patients psychologically is already a good psychotherapist.” Who among us doctors can boast with such “never?”
Specifically, doctors have the duty not to reveal an unfavorable diagnosis, when that has no vital significance to the patient, further, to avoid any communications with the patient that can lead to overexaggerated and erroneous conclusions. How often these rules are disrespected! Especially those who are charged with the care and healing of accident victims. There, through quite unbelievable and construed connections between the harm and subjective difficulties, the dynamics of accident neurosis is brought into motion. For sick notes, literally, and therapeutic measures are much more convenient and “gratifying,” than the clarification of the real (psychogenic) nature of suffering. Since the latter often requires great self-denial. Whoever is only interested in their name and in their practice can never become a true psychotherapist.
Psychotherapeutic activity stands in strict opposition to the anti-psychotherapeutic “goal-directed neglectfulness” (Bruns). To the point that one could speak directly of a “methodical neglect-therapy.” As Dubois explains: “In a case of aphonia that lasted already for six months, I intentionally engaged in a negative suggestion procedure, because I did not only simply ignore the aphonia, but I did not concern myself about it at all. The patient had a host of neurotic disturbances: sleeplessness, diarrhea, pain in the legs. During the first visit, she complained with a toneless voice: ‘Doctor, I can still not talk!’ I still said nothing in response and instead started to ask her about all her other symptoms. I wanted her to forget about her suffering from the aphasia. This went so well that after two days, she started to talk with a loud voice.”
In other cases, and now we arrive to the actual theme of this chapter, it is absolutely necessary to take a detailed look at the patient’s complaints in order to empathize with their condition and even the most subtle aspects of it, whilst, nevertheless, steadfast holding on to the psychological nature of their disturbance. Only from this base one can build the required trust in the words of the doctor.
The methodical principle of restoring sanity comes with clarification. We shall say to the patient: “You are wrong about yourself. Your consideration and judgement are based on false premises. Let’s establish what is clear,” which Dubois put into these words:
“The human machine is so complicated that each and every day we could constate a disturbance somewhere. In can be a gastric disturbance, an undefined pain, heart palpitations, a fleeting neuralgia. But out of full trust in our good health, we forgo this trivia. The hypochondriac, however, paves the path to illness, just from the mere thought.”
What is the best advice so that hypochondriac thoughts do not materialize? Humor (good cheer) and confidence have been proven by science to lead to healthy patterns that support wellbeing and break the chain of harmful patterns. Away with self-tormenting ruminations. These ruminations themselves become the cause.
Pascal’s words: “Man is just a pipe, weakest in nature, but a thinking pipe,” can have two layers: It is possible for us to remedy our weaknesses through knowledge, prudence, and care. However, it is also possible for us through hyper-reflection and through hypochondriacal brooding to exaggerate shortcomings and disturbances to such extent that they arise from nothing. It is an advantage to these latter types of people who have a tendency for such rumination to be thinking beings.
Think about it! Not the reality, not the absolute givens, what may be so serious, but the mental mediation of the absolutes is the greater source of suffering. One fears the hereditary, transmissible, or other sources of illness. Attempt to think about these things in a philosophical manner! What do we know about reality and its relation to us? We have found a couple of categorical formulas that should reveal to us something about the absolute. However, those who have reverence understand that we have not the slightest idea if we can really understand.
“Everything to which much consideration is given, becomes thinkable,” said Nietzsche. To them, everything becomes possible, because they think about it a lot. They judge too swiftly. Whoever makes him or herself the subject of gruesome self-criticism must come across insufficiency and limitation.
Look at it another way! Others can do much less to you than you to yourself. But they worry less, and they have fewer inhibitions.
They have already proved to themselves that they can cope well with real misfortune and adversity. You can conclude from this to your advantage that for you, only intellectual mediation is at the stake.
You will reply: “I do not think about the illness, I am not just imagining something, it is the illness that finds me too often, surprises me and ambushes me at every turn, without my slightest wish or defense against it; I only think and hope for my recovery and wellbeing.”
Alas, you are wrong. Even while you are ignoring the symptoms and try not to think about them, you fear them unconsciously. You may not believe the power of these unconscious thoughts that can overtake our entire ego and have a more direct connection to our bodily organs than those thoughts that we have conscious awareness of. As you are hoping for recovery, the thought of not being healthy is already there, and unconsciously you may be already doubting if you will be healthy.
Visualize your childhood. How effortlessly and naturally everything flew. As soon as you went to bed, you feel into deep sleep. You did not think at all about sleep when you went to bed. You would have been just as ready to remain awake. This is how children fall asleep automatically, without any wish or prohibition to do so. What do you do now? You think about sleep maybe during the day already and calculate the chances of not getting enough sleep. Surely, you do this at the time of going to bed. Sleep is important to you. You interpret it in terms of your health and ability to function. You overrate this function quite a lot. Each time you think about sleep, and long for it, and fear sleeplessness, you whisk it away. On the other hand: if you did not care so much about sleep and while lying sleeplessly in bed you could say to yourself: “I am resting, even if I am not asleep,” with a peaceful mind, calm images would arise—and you would fall asleep.
Or: Our you are in the grip of anxiety. But not the anxiety, but the anxiety from the anxiety, is what is causing the most anxiety and suffering.
So, you suffer, without intending to, without knowing, that it is almost entirely suffering because of your thoughts, anticipation, and worries. On the other hand, the fact that you suffer should be a ground for trust and for comfort. Because the fact of suffering, anxiety, need, and the feeling of insufficiency, are the proof that with sound thinking and critique you can overcome these phenomena. You know that in the case of serious mental disorders this is not the case, and these feelings are taken for granted.
For the time being, while you have direct encounter with such feelings as weakness, excitement, lack of restraint, you must know that you have the capacity to achieve your final goal. You will get there. In Nietzsche’s words, “Everything important happens anyway.” Do not mistakenly overestimate the disadvantages of such nervousness. Von Speyr has expressed it directly: “Only the neurasthenic achieves something.” Keep in mind that this nervosity is the sign of a high sensitivity that is also the prerequisite of achievements and enjoyment, that other people may not have access to.
All in all, you will have a calmer life and greater life enjoyment if you manage to master the challenging art of whenever possible to look away from yourself, reach out to your environment, nurture your relationship with yourself, value and compare yourself against you, spend less time in self-reflection and self-mirroring to others than to genuinely seek to live for others and to think of others.
Humanity lost paradise in the moment when human beings became concerned about themselves. They can regain it in the moment when they can re-dedicate themselves again to things and people in their environment with original naivety and with the joy of unlimited self-giving.
We must learn and re-learn to gaze upon the objective instead of the subjective. Since all sorts of difficulties stem from circumstantial thinking that are just the products of themselves. If one takes things as out there, without reference to us, without relevance to our need and plans, they lose their sting against us. One learns to identify tangential thinking.
Specifically, one gets fulfilled in fulfilling others, with the freedom to look into the eyes of the objectively given facts, and take them for what they are, instead of drawing personal connections that result in self-depreciating and judgmental thoughts that weight the soul down. So, let us beware of overvalued ideas, complexes, and all other forms of painful manifestations of mental mediation.
We do not need to act with suspicion. Always establish the objectivity of the facts first. Whether it is ambiguous telephone conversations or messages, not to let these right away alter one’s inner landscape. There is the possibility for a goal-directed evaluation of the content and managing of the experience.
Caveat! The proposed objective look at the experience is not for the sake of eventually disclosing an inherent self-interest as means to an end, but rather for a finer understanding of the invaluable asset of the acquisition of finer and more refined psychological knowledge, according to which unwanted and automatic, unconscious impulses are more likely to take advantage of disorganized thought processes.
Objectivity should therefore aid to ward off the inner experiences that mentally take over to the detriment of mental and bodily functioning.
The art of objectivity –with respect to observing the ideas—is not realism or materialism, but rather a subjectivism; to the end that this subjectivism could lead to a richer and stronger development of the subject, after he or she had learned how to overcome hypochondriacal limitations and unrealistic connections.
In this regard, you can understand the doctor’s clarifications with respect to the entirely unnecessary, obsessional, and harmful conclusions of thinking. Dubois already illuminated the logical failures of nervousness! Think about what this means! The nervous person uses their mental powers to artistically make themselves sick!
They feel limited in their surroundings, in their families. This stems from a unique perception of reality, a wrong conclusion. The closest to them in fact, is who gives them motivation to work and a goal. This shows you the helplessness and the indifference that they fall into when they distance themselves from those close to them.
Their exhaustion and tension are the consequence of something conscious or unconscious mentally mediated feelings of displeasure, not an actual bodily exhaustion. Any young woman can confirm this who will feel fresh and poised to go for a walk after an entire night of dancing, while another feels miserable and tired after an uninspiring company the night before.
Their heart palpitations, as unexpected and as unbelievable, are directly related to their unconscious expectations. Why would these manifest exactly while lying down when the heart is required to make the least effort? Because in the absence of divertissement and other thought contents, these hypochondriacal ideas freely step in. Strong associations build up between going to bed, climbing the stairs, and chasing the tram, and the unconscious expectation of heart palpitations that are quite automatically enacted. If they had once experienced coming late in the theatre or the concert, climbed the stairs, rushed in, and stumbled unexpectedly into the middle of a captivating performance, the heart palpitations were not noticed then because the affective excitement left no space for attention to the heart.
Dubois explained the key to the reason of feeling unwell to a lady suffering from the strongest heartaches the following way: “I suppose you have paid a lot of attention to both circumstances, and as a rule, in your case, they occur together. But please, for once try to put an end to this fateful shortcut between cause and effect! As long as you are convinced that they will occur together and you expect to see heartaches show up at the end of your period, they will really occur. Ignore the observation, as logical as it may be, and hold on to the idea: I am young, strong and healthy. I do not suffer from heart problems, no organic reasons for heart disease can be found, and from a simple nervous suffering, it is impossible that I can die! Then the anxiety will disappear, your heart will stop beating wildly, and you will sleep like a child.”
Their sadness, upset, and their anxiety is not without a ground, since it is unleashed by earlier traumatic memories or thoughts which may reoccur as a result of the chemical state of their personality, but this is exactly the time when they should sit down with themselves and have a dialogue with themselves until this content is made indifferent, and they are over it, and the phase is ended. Digestive problems, even pains and vomiting—as long as there is no evidence of medical reasons—are not the best to treat with dieting. First of all because the unconscious anchoring of the symptoms of illness may persist without patient’s slightest awareness and lock the symptoms into a pattern. Second, because of the loss of energy can lead to physical illness.
The derivation and the propagation of such and similar unhelpful thought processes is the task of logotherapy to tackle. After understanding the symptom, and the individual situation of each patient, we appeal to their individual capacities to take an intellectual and moral stand. “There is something praiseworthy in each and every person: they may be intelligent, reasonable, or have a depth of feeling and heart. Even religious feelings can come handy to mentally uphold the sick” (Dubois).
The goal of therapy is to influence the disposition of the psyche. In this task, everything can be helpful that is at its disposal for comfort and healing that is a renewable daily resource: The art through which we can influence our mental wellbeing (Dasein) , that allows us to be mindful of the uplifting knowledge that we are members and partakers of a spiritual world, ever living, that no death can destroy, and able to overcome time and brokenness—this knowledge given to humanity through religion. Dejerines’ assertion according to which the religious person cannot become nervous or hysterical sure sounds very enthusiastic, and it contains a grain of truth because in it lies, in a sense, living psychotherapy. Eucken said: “In the struggle for a spiritual self-preservation that one is driven to religion.” Nietzsche adds: “Religion and religious significance brings sunshine to plagued human beings and makes their very sight to themselves bearable, refreshed, refined, and capable of making the most of their suffering to even sanctifying and just ends.”
The innate desire of every human being to believe in something more than the self, comes back with vengeance when it has been for a long time suppressed. It fills the resulting vacuum with artificial blockades, jams, absurdities, and pointlessness. In the case of those suffering from neurasthenia, this leads to a cacophony and discord. The so-called religious people live not only more satisfied and happier lives in their huts and in poverty, but they also live with less conflicts and carefree lives in the palaces of riches.
Therefore, “even those who do not regret the appearance of religious illusions in today’s cultural world, admit that they offer to those bound by them the strongest protection against the danger of neurosis, as long as they have strength.” (Freud in “Mass Psychology and Ego Analysis”).