IN MY EXPERIENCE, genuine rest cures are seldom indicated; what most patients want is a “work cure”. Surely the genuine case of nervous exhaustion is a much rarer phenomenon than is commonly supposed; the really over-worked, over-tired nervous system, incapable of sustained attention or mental effort. What we do encounter, with deplorable frequency, is the case of perverted attention; attention that is introspective and dominated by the fixed idea of the seriousness of the patient’s state of health. One cannot direct the conversation into any other channel but the consideration of her tremors, palpitations, and flushings, or the tape-like quality of his stools, or the general incapacity of his “vital processes?” Consequently, these patients develop, more or less logically, a type of asthenia in conformity with their own ideas.

What happens if you give them the orthodox rest-cure? Just the opportunity to go more fully than ever into their own ailments.

The line of treatment must be very different – and very definite. Having initiated this by suggestions made at the first interview, the patients require to be employed mentally and physically, and not to be given a breathing space for their own thoughts. But their management is not easy, and every case is different. With intelligent patients it is more necessary than ever to accord them a patient hearing of their own story, and to cultivate a good memory for its details, in order to be able to beat them at their own game, if need be. The following case illustrates my meaning.

An active, intelligent, talkative little woman

The patient was an active, intelligent, talkative little woman, nearing the climacteric. She had consulted me a few years before as to her heart. I then assured her that she had no real angina, but was suffering from some dyspepsia, and I strongly urged more exercise, which was deficient. She suffered from the misfortune of having no children and an indulgent affectionate, and over-sympathetic husband.

After a time, not carrying out my advice, she obtained a further opinion to the effect that she was suffering from angina pectoris. Whether she rightly understood or not I cannot say; at any rate she was sent to bed for a month for perfect rest. That finished her, as it were. For all practical purposes she never really got up again.

When I saw her, she could not raise herself in bed; she was dyspeptic and thin, consequent upon insufficient food; her muscles were thin and flabby, and there was a host of other symptoms of the usual kaleidoscopic kind. She was very depressed, always on the verge of tears, and frankly admitted that she had no outlook in life. Yet she was devoted to “the best of husbands,” in comfortable circumstances, hosts of friends, numerous (former) activities and a complete freedom from any worry she could name.

Yet I felt there was behind it something more. I then learned that she had lost her only child – a boy aged 10 – from acute appendicitis, under rather tragic circumstances, some seven years before. The symptoms dated definitely from then, and had gradually increased. The point was that she avoided all mention of this grief, for her husband’s sake and for a proof to herself of her own self-control. It became with her of the nature of a submerged idea which dominated her conscious life.

Against her desires I insisted on removal to a nursing home, telling her (1) that her heart was sound, (2) that her asthenia, though real enough, was due solely to flabby muscles and would vanish under massage, and

(3) that her pessimism would under the special routine, melt away like mists before the sun.

My principal reliance was placed on:

(a) skilled massage and progressive exercises, which produced their certain effect on the muscles, and

(b) a specially selected nurse, who had instructions to talk freely about her bereavement whenever possible.

Floods of tears were the first result, naturally; but a series of reasoned conversations on the full prospects which life still held for her had the desired effect. The nurse’s principal duty was to engage her in games and puzzles, (for which she had declared herself for ever incapable), and before long to take her out shopping. She had promised to stay a month, but I told her that it would be extended if she did not get well. She got well, and has remained well. After an interval, her husband came to report progress. He told me that his wife was a different being again, and had resumed most of her former activities.

The backbone of psychotherapy

The case is typical of many, but through out its treatment the systematic implantation of suggestion was carried out. The method of what may be termed “reasoned and graduated conversations” was employed; this is the backbone of psychotherapy, and is a powerful factor in permanent recovery. It means a visit of an hour, perhaps, instead of the conventional five minutes, filled up by an enquiry as to the bowels or a promise to alter a prescription, coupled, may be, with a cheery assurance that “you are decidedly better this morning.” This is not enough, for it is too crude for the intelligence of most people; the same idea must be instilled more gradually and subtly, and left to develop itself by the aid of the patient’s own reasoning power and intelligence.

I conclude by quoting a passage from Walsh, at the end of his chapter on the General Principles of Psychotherapy:

“Psychotherapy represents one of the important elements in therapeutics, and we must learn to use it in a way suitable to our patients. We have to learn to use our drugs in accordance with the nature and physical make-up of the patient. We have to find out by experience just how to use hydrotherapy for each individual. Varying current of electricity and varying forms of electrical action are needed for different individuals. Just in the same way, our psychotherapy must be dosed out according to the special need of each individual, the form of the affection and the particular kind of mind that is to be dealt with.”