Psychotherapy Part 84

Men sometimes seem to persuade themselves that it is a brave thing thus to face death. The shadowy terrors of what may come after death are too little realized to deter a man from his act when compared with the real disgrace that he is so familiar with and that he has often witnessed in actual life. It is the man, as a rule, who has most condemned others when something has gone wrong, who has found no sympathy in his heart for the slips of his fellows, who discovers no courage in himself when he has to face disgrace. He does not realize that for most men there are so many extenuations of any evil that a man may do, that the large-minded man is ready to forgive and eventually to forget almost anything that happens. "To know all is to forgive all," and the more we know of men the readier we are to forgive them. Little men do not forgive and cannot forget the failings of their fellows and they think that everyone else looks upon men's failings in the same way. It is only the small, narrow man who contemplates suicide as a refuge from disgrace, and the fact that he can complacently plan the abandonment of others not only to the disgrace which he himself is not ready to face, but to all the suffering consequent upon it, is the best proof of his littleness of soul. The utter pusillanimity of suicide is the best mental antidote for the temptation to it.

Besides, the thought that deterred Hamlet may well be urged:

There's the rub; For in that sleep of death what dreams may come.

When we have shuffled off this mortal coil, Must give us pause; . . . who would fardels bear, To grunt and sweat under a weary life; Cut that the dread of something after death.-- The undiscovered country, from whose bourn No traveller returns.--puzzles the will; And makes us rather bear those ills we have.

Than fly to others we know not of?

It is sometimes said that this is the argument of a coward, but such cowardice is as reasonable as the dread of touching a wire that may be carrying a high charge of electricity. Besides it is only such an argument that will properly suit the man who, in his cowardice, is ready to let others bear the brunt of his disgrace, flying from it himself. [Footnote 57]

[Footnote 57: Is life worth living? How old this argument as to suicide is can perhaps best be appreciated from the fact that it is discussed very suggestively in a papyrus of the Middle Kingdom the date of which is probably not later than 2500 B. C, which is now in the Berlin Museum and is recognized to be the most ancient text of its kind that has been preserved in the Nile Valley. I have referred to this in the initial historical chapter. I think that I have more than once turned men's thoughts from the serious contemplation of suicide--always a dangerous thing--by discussing with them this fact that men have at all times in the world's history argued just the same way on these subjects. Men prefer not to resemble the dead ones, and a motive is all that is needed. ]

There has sometimes been an erroneous tendency to confuse suicide and heroism, but Chesterton, in "Orthodoxy," [Footnote 58]

has well expressed the difference:

[Footnote 58: "Orthodoxy" by Gilbert K. Chesterton, New York, John Lane Co., 1909. http://www.gutenberg.org/ebooks/130]

{723}

A soldier surrounded by enemies, if he is to cut his way out, needs to combine a strong desire for living with a strange carelessness about dying. He must not merely cling to life, for then he will be a coward, and will not escape. He must not merely wait for death, for then he will be a suicide, and will not escape. He must seek his life in a spirit of furious indifference to it; he must desire life like water and yet drink death like wine. No philosopher, I fancy, has ever expressed this romantic riddle with adequate lucidity, and I certainly have not done so. But Christianity has done more: it has marked the limits of it in the awful graves of the suicide and the hero, showing the distance between him who dies for a great cause and him who dies for the sake of dying. And it has held up ever since above the European lances the banner of the mystery of chivalry: the Christian courage, which is a disdain of death; not the Chinese courage, which is a disdain of life.

The feature of incidents in life that bring with them disgrace and punishment which needs to be insisted on for those to whom the thought of suicide comes, is that the sensation which the revelation of such acts causes is but a pa.s.sing phase of present-day publicity, and that after all it is not even a nine-days' wonder, but a two- or three-days' wonder, and then it is forgotten and replaced by something else. The facing of the condemnation for the moment may seem an extremely severe trial. The world's blame, however, is largely a bogey, a dread that is phantom-like and that disappears, or at least diminishes, to a great degree as soon as it is bravely faced. Besides, as practically every man who has been carrying around a guilty secret with him for years is free to confess, there is an immense sense of relief once the worst is known. At last the effort at concealment, the nervous tension, the fear of the moment of exposure are all past and a new set of thoughts can be allowed to come. Those may be unpleasant and yet they are not so bad as the dread of discovery that hung over the unfortunate. If a man can be braced up to meet exposure, usually he will find in a very few days that there are sources of consolation that make it much easier for him to live than he thought possible before.

Real Suffering a Tonic.--Probably the best remedy for a man or a woman who talks of suicide and seems to fear lest the temptation should overcome them is, if possible, to give them an opportunity to see some real suffering. I have on a number of occasions had the opportunity to note the effect on a discouraged man or woman of the sight of a cancer patient suffering severely, yet bearing the suffering patiently, wishing that the end might come, yet ready to wait until it shall come in the appointed order of nature. Suffering, like everything else, becomes much more bearable with inurement to it. The old have learned the lesson of not only not looking for pleasure in life, but of being quite satisfied with their lot if no pain comes to them, and they even grow to consider that they have not much right to murmur if their pain is not too severe. It is not among those who have to suffer severe pain that one finds suicides as a rule. It is true that young, strong, healthy persons who suddenly find that pain is to be their lot for a prolonged period may grow so discouraged and moody over it as to take their lives. The patients that I have seen suffering from incurable diseases have expressed no desire at all that their life should be shortened, except during the paroxysms of their pain, unless they feel that they are a serious burden on others when they may express the wish to be no more.

Euthanasia.--Every now and then there is a discussion in the newspapers {724} of the justifiableness of euthanasia, that is, the giving of a pleasant death to those who are known to be incurably ill and who are doomed to suffer pain for most of what is left of their existence. The question usually discussed is whether patients have the right to shorten their own existence and then, also, whether their physician might have the right or, even as some people say, the duty, to lessen human suffering by abbreviating existence for such incurable cases. The discussion has always seemed to me beside the realities of things, because physicians do not see many patients, I might almost say any patients, who really want to shorten their lives or would want to have them shortened. I have known many physicians die of cancer, but very seldom is it that one tries to shorten his own existence, or that even his best friend in the profession would consider that he was justified in doing this for him. This, it seems to me, should be the test of the problem. It is true that not infrequently, in the midst of their paroxysms of pain, patients wish they were dead, but there come intervals of surcease from discomfort to some degree at least that make life quite livable for a time again and even occasionally there is real happiness in these intervals, deep, human, natural happiness in heroic forbearance and example.

We can recall AEsop's fable of the old man who, gathering wood for the fire in the winter that he needed so much, finds the burden of his labor and the wood too much for him and calls loudly for death to come to him. Promptly Death makes his appearance and asks what the old man wants. "Oh! nothing," is the reply; "only I would like you to help me to carry this bundle of sticks." This is the att.i.tude of mind of practically all who have grown old in suffering. They have learned to bear with patience, and that patience gives even something of satisfaction. After all, it is not so often the pleasant things in life that we look back on and recall with most satisfaction as the difficulties and trials. Virgil said long ago, _"Forsan et hoc olim meminisse juvabit"_--perhaps at some future time we shall recall these, our trials and pains, with pleasure. It is the conquering of difficulty that means most for men and even the standing of pain is not without an aftermath, if not of pleasure, at least of broad human satisfaction. When we talk about euthanasia, then, it would be well to ask some of these old people whether they want it or not. Seldom will the answer be found to be that which is so often presumed, by those in good health and strength, to be inevitable under such conditions.

Physicians have all seen incurable cancer patients who were approaching their end inevitably and with the fatal termination not far off, have hours and days of alleviation of suffering and even of enjoyment that made up for the prolongation of life almost in the midst of constant agony. The distinguished New York surgeon who had the pleasure a few years ago of listening once more to his favorite singer and fairly seemed to get renewed life from the inspiration of her voice and who for days after had the pleasant consciousness of smooth running life in improvement so characteristic of convalescence, is a typical example of what may happen under such circ.u.mstances. I shall not soon forget Dr. Thomas Dunn English, the well-known author of "Sweet Alice, Ben Bolt," saying at an Alumni dinner of the University of Pennsylvania, that, like Bismarck, he used to think that all the joys of life's existence were in the first eighty years of life, but of late years he had found {725} that many of them were also in the second eighty years of life. He was at the time 83. He made the most joyous and happiest speech on that occasion. He was quite blind, was almost deaf, had been reported dying some months before, and had gone through prolonged suffering, yet he was by his cheeriness and whole-hearted gaiety on that occasion a joy and inspiration to all the younger men at the table.

Dread of Suicide.--There are patients who come to the physician worked up because they fear they may commit suicide. Every now and then the thought comes to them that some time or other they will perhaps throw themselves out of a window, or be tempted to drop in front of a pa.s.sing train, or over the side of a steamboat, or impulsively take poison. Some nervous people become quite disturbed by these thoughts.

Every physician is sure to have some patients who must be rea.s.sured, every now and then, that they are not likely to commit suicide. Their nervousness over the fear of this may serve to make them supremely miserable and it evidently becomes the doctor's duty to rea.s.sure them.

It is not difficult to do this, as a rule, provided the physician will be absolutely confident and unhesitating in his declaration that there is no danger that they will commit suicide, since it has almost never been known that patients who dread it very much and, above all, those who dread it so much that they take others into their confidence in the matter, take their own lives. The very fact that the thought produces so much horror and disturbance in them is the best proof that they will not impulsively do anything irretrievable in this way.

Prof. Dubois has discussed this subject in his usual thoroughly practical way and his words serve as an authoritative confirmation of what has been already said, though as a matter of fact the expressions and experience of nearly every nervous specialist thoroughly justify the position here a.s.sumed. Besides, it must be realized that this confident a.s.surance is the best possible prop that doubting patients can have with regard to the actions they dread, and by positive declarations the physician will accomplish more than in any other way.

There are patients who are subject to strange obsessions. They are afraid that they will throw themselves out of the door of a car, or climb over the parapet of a bridge. They are afraid that they will throw their relatives out of a window, or will wound somebody with a knife or a gun. There are some with a strong impulse to open their veins. But if there is a certain attraction in such things, it is really a phobia. It tends to make one shrink back and not to act.

Nothing quiets these patients like the frequently repeated statement that they will not do anything. It is necessary to show them the vast distance there is between the impulse toward suicide and murder and the phobia which, however distressing it may be, is a safeguard.

One must keep at this education of the mind with imperturbable persistence and use the most forceful and convincing arguments that one can think of to correct the judgment of his patient, in order to make the strings of moral feeling and reason vibrate in unison.

It is through lack of courage and perseverance that we err in the treatment of these psychoneuroses. We wait too long to distinguish the morbid ent.i.ties that bear on a certain etiology or a different prognosis. We do not see clearly enough the bond which unites these different affections.

It may seem to some physicians as though they would be a.s.suming too much responsibility in giving patients such positive a.s.surance that their dreads {726} will not be fulfilled, but as a matter of fact the experience of physicians is quite sufficient to justify the confident statements here suggested. It is true that occasionally a person who afterwards commits suicide talks the matter over and hints at the possibility of taking his own life. He does not, as a rule, speak of it with dread, however, but as one of the alluring solutions of his difficulties that he sees ahead of him. He is much more likely to write a letter to his physician telling him that all his arrangements are made and that by the time this letter reaches him he will be already dead. The prospective suicide is usually quite secretive about this purpose, not only to friends, lest he should be prevented from accomplishing it, but even with his physician, in whom he has had absolute confidence and to whom he has told practically everything else. The patients who fear the possibility of committing suicide, who tell how much they dread the horror of it, and who rush to consult the physician to help them against themselves, show by the very fact the unlikelihood of action on their part.

The Physician and Suicide.--By mental influence, then, the physician may lessen the tendency to suicide in the individual and in the community. To do this is to save suffering and to help in the solution of one of the most serious social problems in modern times. It can only be accomplished by a sympathetic att.i.tude towards the whole subject and a tactful understanding of each individual case. Every effort in the matter, however, is well worth while, for there is no more hideous blot on our modern civilization than the startling increase of suicide. It is particularly important to bring about improvement in this regard among young suicides, and fortunately it is here that the influence of the physician for good is likely to be most felt. The saving of life is the n.o.blest part of the mission of the physician and nowhere, perhaps, can this be accomplished more successfully than with regard to some of these patients whom a rash resolution, due to a momentary fit of depression and a sense of suffering exaggerated out of all proportion to their actual pain, is hurrying out of life.

CHAPTER IV

GRIEF

Grieving would seem at first glance to be one of the conditions for which the physician, especially if the etymology of the name of his profession be taken strictly, should not be called upon to minister, nor his remedies be expected to relieve. Grief is usually supposed to be due to moral ills and, therefore, at most to come under the care of the alienist, with the feeling that even he can accomplish very little for what is an affective rather than a true mental disorder. There is no doubt at all, however, that grieving, especially in the excess that shows it to be pathological, is always a.s.sociated with certain physical and mental conditions for which the physician can accomplish much. Indeed more often than not the physical condition of the grief-stricken person is a prominent factor in the production of the state of feeling which causes grief to be exaggerated, while, on the other hand, this state of mind {727} itself reacts upon the physical being so as to make it more sluggish in all its functions, and as a consequence a vicious circle of cause and effect is formed affecting unfavorably both the mental and physical conditions. It is when patients are run down in health that grief becomes extremely difficult or apparently impossible to bear and grief itself still further brings about a deterioration of health that makes the mind's reactionary power against its gloomy feelings still weaker than they were.

Viewed in this way, grief is an ailment that should properly come to the physician for treatment and with regard to which that important principle is eminently true that the physician cannot always cure, but he can nearly always relieve, and he can always console his patients.

On the one hand, an improvement in the general health always make grief easier to bear because it increases the resistive vitality of both mind and body. On the other, any diversion of mind that lifts the burden of grief even to some degree, releases new stimuli and physical powers for the restoration of bodily function to the normal and this brings about an immediate lessening of the depressive condition. In a word, for the vicious circle of unfavorable influences ever pushing the victim farther into depression, a virtuous circle, in the Latin sense of the word virtue, meaning courage, favoring strength, must be formed, that brings about an immediate improvement in the patient's mental and physical well-being. This is not a pretty bit of theory but is the result of the experience of every physician who has ever taken seriously the problems of caring for the grief-stricken.

Natural and Pathological Grief.--It is, of course, not easy to distinguish between grief that may be called morbid in the sense of a melancholy, that is, more than natural--a true mental disease--and that which represents only an affective state accompanied by depression from which there will be complete reaction. A mother loses a favorite, it may be an only son, and is plunged into grief. For days, even weeks, she refuses to take any interest in life, she thinks moodily about the awful affliction that has come to her and how blank the future is, and she cannot be aroused to attend either to her own affairs or to the duties of life around her. Such a grief is, in many cases, not more than the normal depression incident to such a loss. If after months, however, the mother still continues to refuse to take interest in life and the things around her, especially if, besides, she now talks of having been visited with this punishment because of some unpardonable sin in her own life, or because the Deity has been offended beyond all hope of propitiation, then the case verges over into one of true melancholy in which the mental depression is not merely a symptom of a pa.s.sing condition, but partakes of the nature of a mental disease, or is the consequence of a profound neurotic condition.

It must not be forgotten that there is always the danger that exaggerated grief, as it seems for the moment to be, may be only the first symptom of a true melancholic condition. Only too often friends and physicians have been deceived by this. Some of the sad cases of self-destruction and a few cases of homicide and suicide have followed a condition that seemed to be only abnormal grief for the loss of a relative.

Etiology.--The cause of exaggerated, prolonged grief is, in a considerable proportion of the cases, a melancholic tendency, that is, a failure on the {728} part of the mind to react against depression.

The weakness of mind that predisposes to this may be inherent or acquired. Sometimes no special loss is needed to produce melancholia in susceptible individuals, while occasionally it is precipitated by some misfortune, inasmuch as this is a mental disease, very little can be done directly, and yet the patient can be helped and diversion of mind may bring a good measure of relief. More often, however, the reason for persistent grieving is that before the disturbing loss came into the life of the individual there had been a serious deterioration in health. This was due to the conditions preceding the unfortunate event. Wives sometimes have worn themselves out physically and mentally while nursing husbands, or mothers their children, and this has produced a lack of physical force which prevents them from reacting with healthy mentality against the subsequent shock of loss.

Prophylaxis..--For the melancholic tendency prophylaxis cannot be special, but must be general. We cannot prevent people from suffering serious losses, but we can foresee the possibility of a loss proving very depressing, and can, therefore, try to keep the individual in reasonably good physical condition. If this is done the subsequent depression will be much less than it otherwise would be. Very often there is little or no recognition of the fact that there is a definite tendency in some patients to too great an inclination toward melancholic thoughts, and it is not until an exaggerated manifestation of it comes that the danger is realized. It is not easy to make patients realize the dangers, but where the physician talks with a.s.surance and points out definite things to do in order to prevent serious developments, patients, or at least their friends, can be made to appreciate the dangers.

The best demonstration that I know of the value of work as a remedy for grief is my experience with members of religious orders. For them, as a rule, there is no interruption in life no matter what the loss may be. Their work goes on the day after the funeral just as before.

This is the most precious possible arrangement, time and occupation of mind are the two factors that will dull the edge of grief and while humanly we may resent the consolation that is thus brought by such conventional things as the pa.s.sage of time and humdrum occupations, they represent nature's resources. Above all, patients must be given something to do and if that something concerns other suffering human beings, there is every reason to expect relief.

Treatment.--The most important element in the treatment of grief cases is to prevent physical running down as far as possible and to build up the physical condition. Depression that comes to patients who have lost considerable weight, even though it may show some of the signs of melancholia, is always hopeful. Where patients are twenty or thirty pounds under weight the recovery of weight up to the normal condition will often mean the relief of their depressed condition. The one hope lies in this physical improvement. Mental treatment by diversion of mind must, of course, be practiced. This does not mean getting the patients interested once more in trivial things, but to be successful it means arousing the deeper feelings of their nature. Above all, the solace of tears will often save depressed and grieving persons from themselves. An interest in the sufferings of other people that awaken their sympathy will do the most to end exaggerated grieving over their own loss. The self-centeredness of their grief is the princ.i.p.al reason for its exaggeration. {729} It is because of overestimation of their own importance and of the importance of their loss that these people suffer severely.

_Motives of Consolation_.--The main resource of the physician who would employ psychotherapy for the treatment of those who are grieving beyond the limit of what is normal, is to supply motives by which they can understand the real significance of their loss. Very often, especially in young folks, there is no proper estimation of values in life and no recognition of the fact that human life was evidently not meant for happiness since that comes to but few, while suffering and partings are inevitable. They come to all, and apparently will always continue to do so. It is the young or, at least, those under middle age, who are most likely to be affected by exaggerated depression over losses and disappointments. Older folks have grown more accustomed to such incidents. These patients must be made to see how many motives there are to take their grief philosophically and while permitting themselves the luxury of sorrow, not to let this interfere either with their physical condition or their mental state to such a degree as to prevent them from taking the proper interest in their duties in life.

The ethical motives that may be urged to keep people from grieving over-much are many, but there is sometimes the feeling in the physician's mind that it is scarcely his business to emphasize them in any way. It is supposed that to the clergyman must be committed the task of consoling people for losses in life. This has always seemed to me a serious mistake. As physicians we know how much the mind influences the body and since it is our duty to care for the body, we must, above all and first of all, care for the mind as far as we can.

_Mens sana in corpore sano_ is a very old motto and is usually taken only in the sense that to have a healthy mind one must have a healthy body. In its Latin form, however, it might very well also be taken to mean that to have a healthy body one must have a healthy mind. Since grief has an untoward influence on the body, physicians are bound to learn what to do for it in any and every possible way and to exercise every faculty they have for its relief. This is all the more true because in recent years many persons have no regular religious attendant who would come to offer them consolation or to whom they would go in their trouble. It is not at all with the idea of infringing on the rights of the clergy or invading his territory that I would insist not only on the right of the medical man, but even his duty, to afford consolation to the mind as well as relief for the body.

_The Family Physician_.--In older times the family physician was a friend of the family to whom people turned in all troubles where he might possibly be of aid, with just as much confidence and as promptly as they did to their religious attendant. Unfortunately, in the progress of medicine, though still more because of the social vicissitudes that have taken place in recent years, this relationship of the family physician has been largely diminished, but that const.i.tutes only one more reason why every physician, to whose attention the grief of a patient for any loss is presented as a cause of ill-health, should know all the means and be ready to employ them for the amelioration of the condition. As a matter of fact, there is often a feeling on the part of patients that it is more or less the business of the clergyman to afford consolation and that the performance of his duty in this matter is somewhat conventional, not {730} as if he performed it less thoroughly because of this, but as if the feeling of the routine practice detracted from its effectiveness.

Some of the motives for consolation advanced by the clergyman, then, lose in significance, in some persons' minds at least, because of this feeling, while motives presented by the physician rather gain in weight because of the impression that he is a thoroughly practical man, deeply interested in life's problems from a common-sense standpoint, and who knows the motives for consolation because he has realized that losses are inevitable, suffering unavoidable, and grief sure to come, though somehow we must learn to bear up bravely under life as we find it.

Physicians have always done this in the past, but in more recent years either they have lost the habit, or have considered it unworthy of their profession, or else, perhaps, only too often they themselves have had no motives to offer that might seem sources of consolation for those in suffering and especially those who are grieved for the loss of friends. If life were a mere chance, if there were not an evident purpose in it, if, as Lord Kelvin insisted, science did not demonstrate (not "suggest" but "demonstrate" is the word he used) the existence of a Creator and a Providence, Who, while caring for the huge concerns of the universe, can just as well employ Himself with the little details of human life, then there would be some reason for physicians thinking that their science kept them from seeking consolation from the ordinary motives. Even if they occupy an advanced agnostic position, however, they may still find sources of consolation that, if not so effective as those attached to the old beliefs, at least will provide something for the forlorn to take hold of, that will mitigate their grief and sense of loss and make the present and the future look not all too blank.

Few men have been so thoroughly agnostic as Prof. Huxley, yet on the death of his wife he found that some of the thoughts of the old beliefs might prove a source of consolation. Huxley had loved his wife very dearly and their separation by death meant very much. The epitaph that he wrote for her sums up his doubts yet plucks out of them something to console, expressed in old Scriptural language:

And if there be no meeting past the grave.

If all is darkness, silence, yet 'tis rest.

Be not afraid, ye waiting hearts that weep.

For G.o.d still giveth His beloved sleep; And if an endless sleep He wills, so best.