Psychosomatic Medicine 8:204-210 (1946)
© 1946 American Psychosomatic Society

Psychiatric Treatment of Peptic Ulcer Patients

In the light of these cases, it is now feasible to recapitulate and amplify our main points. Let us begin with the interview. Since every person is different, no two interviews will be the same, but certain guiding principles can be followed.

In the first place, we shall concentrate upon the patient himself, and endeavor to discern the major motivations of his life, and his relationships to his main feelings, conflicts and tensions. We shall be especially alert to his needs for love, ease, support, and dependence, and to all those desires which can be considered intaking in nature--i.e., of the same direction as the taking in of food. And we shall watch especially for any frustrations of these desires, whether by external circumstances or by the internal attitudes of the patient himself.

The tempo of the interview is determined predominantly by the patient's personality make-up and by the intensity of his need for help. The physician can rarely force the issue. Rather his effort must be to get the patient to reveal himself. Sometimes, almost all one need do is listen. In other cases, the patient not only resists seeing the pertinent emotional forces, but it may even be dangerous to try to force him to do so.

In the average case it is practicable to begin with discussion of the physical symptoms. In general, first interviews begin very slowly. As the patient's confidence in the psychiatrist mounts and he feels that there is genuine interest and the possibility of being understood, the pertinent emotional material flows more freely. In general, tactful honesty is the best policy, and special tricks and devices are unnecessary and to be shunned. The discussion of the physical condition usually can be led naturally to the emotional setting in which these began, and, once immersed in this discussion, the patient's deeper feelings usually emerge.

If the patient is too resistant at this point, it is, sometimes well to turn to the family background. In the end, one's aim is to elicit the patient's true major motivations and feelings, and how these developed from the emotional pressures of his childhood, on through to their relationship to his present symptoms. While it is impossible to present a list of the questions to ask, one must keep the patient talking, and bring out his feelings in childhood toward those who reared him, and how they shaped his present personality. One estimates the present emotional interplay and organization from his relationships to his family, friends, work, and recreation. One seeks for positive irritants and hardships, as well as for negative factors such as unsatisfied desires. There is no simple method for comprehending the core of the personality, or for estimating the intensity of the feelings and frustrations. This is a matter of psychological sense and psychiatric experience. It is remarkable how much one often learns by merely listening to the patient, while divesting one's self, so far as possible, of one's knowledge and preconceptions.

Dreams are often invaluable in many cases for penetrating rapidly and accurately to the major emotional forces within the person. It is inadvisable for the physician, inexperienced with dreams, to interpret them to the patient, but with a litde interest and study he can often glean simply from the topics of the dreams what is central in the patient's mind: hostility, anxiety, desires for ease and escape, the pressure toward work and accomplishment, needs for superiority, etc. What the dreams tell is usually at least a helpful clue, but more often an invaluable aid, in clarifying one's understanding of the fundamental emotional forces in the case. This understanding is the indispensable basis of rational treatment. In surgery, the cutting is the least. It is the understanding of the pathological physiology and anatomy, and the utilization of the surgical techniques for accomplishing a rational purpose. The analogy between rational psychiatry and surgery is a sound one. Psychiatric techniques, such as suggestion, reassurance, hypnosis, catharsis, and the like, are significant only When one understands the basic emotional situation and applies them rationally for well-defined purposes. Employed without this understanding, they are little more than a medieval laying-on of hands.

We have already mentioned some of the therapeutic elements employed in the ordinary interview. The transference, or relationship to the physician, is always present and can be of great value as a means of emotional support. Neurosis is in essence the persistence of childhood desires and patterns. The patient coming to the physician tends unconsciously to adopt toward him the dependent, help-seeking attitude of a child to its parent. This gives the physician tremendous influence. This reaction is of great importance in the ulcer patients, in whom we deal so largely with needs to be fed emotionally. Usually it is not necessary to discuss the transference with the patient, but the physician must be constantly aware of it.

Insight, properly used, is effective in the vast majority of cases. Like the interview, it must develop slowly and tactfully, at a tempo set by the patient. But where it can be imparted with reasonable completeness it is a powerful instrument, and makes the entire management much easier for the physician; for now the patient himself understands his problem, will himself have ideas for environmental changes, and will endeavor, in the favorable cases, with real therapeutic urge to alter his attitudes. Some patients, who typically are unable to accept anything freely and must be incessantly striving, can be mellowed noticeably in a very few interviews.

In general, where one cannot relieve the patient through insight, changes in the environment, and relatively simple changes in attitude, one faces major surgery, and it is necessary to call in the analytically-trained psychiatrist. This specialist is also effective for diagnosis and for brief causal treatment, in which he can often save much time. His contribution is psychiatric accuracy.

We have only begun to understand the neuroses and their manifestations in all manner of physical symptoms, including gastric disorders and ulcers. The results so far, although insufficient statistically, indicate that with increasing knowledge it will be progressively easier to treat these patients; and even more important, to prevent many ulcers, by relieving the chronic emotional irritation before ulcers form.

Note:
Read at the New York Regional Meeting of the American Society for Research in Psychomatic Problems, May 11, 1945.