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Points of View

WHAT MAKES THE PATIENT BETTER?AINSLIE MEARES

M.D., B.Agr.Sc. Melb., D.P.M.OF MELBOURNE, AUSTRALIA

I AM very often perplexed because I cannot find anysatisfactory reason why the patient has got better. Whena patient does not get better, it is easy enough for me toassume that my skill as a psychiatrist is wanting. Butwhat of the patient who genuinely recovers from his ner-vous or psychosomatic illness after two or three visits,when he has not been given any direct suggestions ofimprovement, and he has no real insight into themechanisms which produced his illness? Conversationwith colleagues leads me to believe that this experience isnot uncommon among both general practitioners andpsychiatrists. We seldom take much notice of it, save thatwe somehow have the feeling of having handled the patientwell. Is there some other basic factor in psychotherapybeyond the mechanisms of suggestion and insight ?

In the first place, we know that the self-adjustingmechanisms of the mind restore homceostasis in the minornervous upsets of everyday living. In a similar way, it isnot uncommon for a patient to recover spontaneously froma nervous illness as a result of some kind of intrapsychicreadjustment while his environment remains substantiallyunchanged. Other cases remit as a result of a lessening ofexternal stress, or because of some therapeutic experiencein the patient’s life situation. These mechanisms cannotaccount for the unexpected relief of symptoms in the casesto which I refer, because many of these patients had beenill for some time, and there is no reason why spontaneousremission should so frequently coincide with their

attending the doctor.Is it suggestion ? I very well know that the simple fact

of the patient coming to the doctor carries with it a power-ful suggestive effect for the relief of symptoms. But thesepatients have all been subject to the suggestive effect ofattending other doctors without improvement; and theyhave usually been exposed to the additional suggestiveeffect of various tranquillising drugs; and many havealready been given direct verbal suggestion of improve-ment by the referring physician. I do not see how indirect

suggestion can account for the improvement of these cases.Could it be that the patient gains greater insight from

a few talks than I think he does ? If by insight we meansome kind of rational logical understanding of the psycho-dynamics which led to his illness, I am sure that this is notso. In fact, many of these strange remissions have been inpatients with whom I have spoken least.We know that nervous symptoms often subside after

the cathartic effect of abreaction. But this does not applyto my discussion because these unaccountable improve-ments often follow particularly quiet interviews in whichvery little is said by either party. It is not a disguisedreligious experience, because many of these patients havealready sought the help of their church. Nor can the ideaof reliving the traumatic event in the therapeutic setting beinvoked. It seems that the patient simply gets well in theabsence of any clear rational explanation in terms ofcurrent psychological teaching. -

* * *

This has brought me to examine the psychodynamics ofthe recovery of patients whom I have successfully treatedby either suggestion or

" insight " psychotherapy. I often

use suggestive hypnosis with patients whose symptomsare not maintained by active conflict. I find that I haveoften written back to the referring physician saying thatthe patient was relieved of his symptoms by so many ses-sions of hypnotic suggestion. Many of these patients havedone very well and are known to have remained well forsome years. The disquieting matter is that, on furtherthought, I really doubt if suggestion by itself was alwaysthe effective psychological mechanism. These doubtsarise from the fact that many of those patients who didbest received very little verbal suggestion indeed. This, ofcourse, takes no account of the effect of indirect non-verbal suggestion; but if suggestion is the effectivemechanism, it seems strange that the non-verbal formshould be so much more effective than the verbal. In

many successful sessions little was said, but there wasalways a very good positive relationship with the patient.Many patients treated with insight psychotherapy have

done well; but in retrospect two features stand out.

Several patients who appeared to have very completeinsight into the psychodynamics of their illness stillretained their symptoms, but in each case my deeperrelationship with the patient was not satisfactory. On theother hand, several patients receiving insight therapymade apparently complete recoveries; but on looking backit seems that their degree of insight could not logicallyaccount for their recovery. With each of these patients Ihad a satisfactory deeper understanding. Perhaps I canexplain this more clearly by an example:A few years ago I reported the case-history of a schizophrenic

girl of very poor prognosis, who finally recovered completelyfrom her psychosis after psychotherapy around spontaneouslyproduced symbolic paintings. The sequence of the paintingsshows clearly how she gained insight into her castration com-plex. This insight was accompanied by remarkable sympto-matic improvement. The logical reason for her recoverythrough this insight was dramatically expressed in the paintingsfor all to see. But on re-examination of the case, it would seemthat insight was more apparent to the observer than it was realto the patient. It seems that in addition to insight some otherfactor must have been operating. Again with this patient,although she was psychotic, I had a relationship of deepunderstanding.

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This leads us to another point. It is now fairly widelyaccepted that some psychiatrists have the ability to givesuccessful psychotherapy to schizophrenics while othershave not. This ability is not clearly related either toformal psychiatric training or to knowledge of psycho-dynamics. It is usually held that such therapists have ahigh degree of empathy, and work intuitively, and thatthese characteristics cannot be acquired, or at least are notdeveloped by conventional psychiatric training. However,this in itself is not a really adequate explanation. Theintuitive person arrives at a correct conclusion by someprocess other than logical steps of reasoning. But in thesecases there is often remarkably little conscious exchange ofideas. We see this situation in its extreme form when a

schizophrenic improves after forming a relationship withsome understanding but quite untrained person. Suchsituations are by no means uncommon, and might lead usto feel that our relation with the patient is the all-importantfactor, and that the therapeutic effect of contact with theuntrained individual is the result of his intuitive ability tomake appropriate emotional responses.

I should like to quote one further personal experience:A few months ago I made a trip to Burma, India, Kashmir,

1. Meares, A. The Door of Serenity. London, 1958.

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and Nepal, in an attempt to find out something of the controlof pain by Yoga. In Katmandu I saw quite a lot of an ancientYogi who spoke perfect English. This man was half saint, halfphilosopher. He had an extraordinary calm about him-a deepserenity which I have never seen in any Western person. Italked with him daily for eight days. During this period Imyself took on a much greater calm than I normally have, andI also became much more tolerant of frustration. But my own

personal life was never even indirectly discussed with the Yogi,nor did he make any emotional response either to me or to thecontent of our conversation. As a Yogi he practised andachieved non-attachment, which is really a complete absence ofaffective response to persons, things, or ideas, and therefore I donot think that his influence on me was mediated through themechanism of the appropriate emotional response.Few of us talk with Yogis, but it is not altogether uncom-mon to experience this phenomenon in less degree.Sometimes when talking with a very calm person, onefinds that one’s own anxiety is lessened.These observations seem to indicate that some other

factor besides suggestion and insight, and their subsidiarymechanisms, operates in the therapeutic situation. It maybe that this factor can be resolved into some particularaspect of the physician’s relationship with the patient, ormore likely this relationship is the milieu which allowsthis other mechanism to operate.We have the observed fact that disturbed patients often

regain their mental equanimity after vastly different typesof psychotherapy. There is not even any close relationbetween clinical diagnosis and the type of successfulpsychotherapy. For instance, different patients with

anxiety states may lose their symptoms and remain wellafter simple suggestion, insight psychotherapy, suppor-tive therapy, relationship psychotherapy, simple explana-tion, or hypnotic suggestion. Although we often like tothink so, the actual psychodynamics of the condition donot even provide a really reliable guide in this matter. Inother words, many patients who appear to have a deep andcomplex disorder of the psyche still lose their symptomsafter remarkably superficial psychotherapy. I used tobelieve that all the various approaches and techniques ofpsychotherapy fell into two great classes-those whichhelped the patient by increasing repression, and thosewhich helped him by increasing his insight. Thus reassur-ance, simple suggestion, supportive therapy, relationshiptherapy, religious therapy, and hypnotic suggestion allseemed to work towards increasing repression. Explana-tion, abreaction, analytical psychotherapy, psychoanalysis,and hypnoanalysis all seemed to help the patient by givinghim greater insight. This classification is neat, and wouldappear logical enough. But is it really valid ? I doubt it.Where do these unexpected remissions fit in ? What ofthe therapeutic effect of the vivid experience of the moment- oaf existence ?

I have a great abhorrence of those who write destruc-tively. That is not my purpose. I am not trying to say thatall we have gained is no good. Rather am I trying to saythat surely there must be another way of looking at things.I feel that there is some basic mechanism which, so far,eludes us. Is there some other factor in psychotherapywhich is beyond our present theoretical constructs, andwhich operates unbeknown to the therapist ?

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PS.—As this is really a very personal communication,perhaps a postscript is not inappropriate:Some months ago a physician telephoned, asking me to see

an acutely distressed and impulsively suicidal young woman.She had been disturbed for some years, and she had made past

suicidal attempts. She had had many months of analyticalpsychotherapy and narcoanalysis, and, more recently, electro-convulsive therapy (E.C.T.). She refused to see any of herformer psychiatrists.

" Can’t you get her into hospital quickly ? She will need B.C.T.straight away."But the disturbed young woman became one of those patientswho present this theoretical problem of getting better withoutadequate logical reason.

It is difficult to write to the referring physician saying thathis patient is better, when you are unable to explain what youdid for her or why she got well. I dawdled about the letter.A month later the physician telephoned me again:

" I have just seen that patient I sent you. She is really marvellous.She has not been as well as this for three or four years. I believe youfixed her without H.C.T."

" Yes."" One of the new tranquillisers ? "" No. I told her she need not take any drugs."" She told you something that she had kept from the other

psychiatrists ? " .

" No. She really told me very little."" You hypnotised her ? " ,

" No. I could not hypnotise anyone as distressed and hostile asshe was."" What did you talk to her about ?

"

" Really I hardly talked to her at all."" This is crazy. I am going to stick to proper medicine. Anyhow,

I am glad you fixed her."

Perhaps it is good to laugh at such incidents. But then weoften laugh when we are on the verge of some truth thatwe do not quite understand.

1. Lancet, 1936, i, 379.2. Physiological Responses to Hot Environments: Spec. Rep. Ser. med. Res.

Coun., Lond. 1960, no. 298. 35s.3. Yaglogou, C. P., Miller, W. E. J. Amer. Soc. Heat. Vent. Engrs, 1924,

30, 515.

Occasional Survey

COMFORT AND EFFICIENCY INTHE TROPICS

TWENTY-FIVE years ago The Lancet reflected on the lossof efficiency suffered by white inhabitants of the tropics.!Since then improved treatment and control of infectiousdiseases have shown climatic heat to be a relativelyuncommon cause of morbidity and-so it would seemto the casual observer-of impaired efficiency. Studieson healthy young men have revealed, however, that abovecertain levels of surrounding temperature and humidityboth physical and mental performance deteriorate: a manwho is uncomfortably hot is measurably less efficient athis job. Much of the work which has helped to provethis was undertaken under the aegis of the Royal NavalPersonnel Research Committee of the Medical ResearchCouncil; and a collective account, based on reports sub-mitted up to 1953 to the committee by associated workersin London and at the Royal Naval Tropical ResearchUnit in Singapore, has been compiled admirably byDr. R. K. Macpherson. 2

Broadly speaking, environmental heat stress can be assessedby two methods. In both, the air temperature and humidity,radiant heat, and air movement are all measured and recorded.At the same time in the first, or subjective, method individualsexposed to the climate are asked to say how they feel-forexample, whether they are comfortable or too hot-whereasin the second, or objective, method their sweat loss or bodytemperature is measured. The first method was developed inthe laboratories of the American Society of Heating andVentilating Engineers by the late Prof. C. P. Yaglou (thenYaglogou) 3; and he and his colleagues devised thereby a scaleon which simultaneous readings of temperature, humidity,