Part 6

Another very prevalent misconception, one strengthened by the official use of that unfortunate catch-word “shell-shock”, is that war neuroses constitute a more or less unitary syndrome. It is so often forgotten that the term “shell-shock” can only mean, and no doubt was originally intended to mean, a certain ætiological factor, and not the disease itself. I have preferred to use the less ambiguous and more obviously ætiological term “war-shock,” one coined, I think, by Eder[9]. Even when the term “shell-shock” is avoided, its place is usually taken by the all-embracing expression “neurasthenia”—in most cases, in fact, where there are no physical symptoms of hysteria present. True neurasthenia in its strict sense, on the contrary, is a relatively rare complaint, certainly in anything like a pure form; I have not come across a single case myself in connection with the war. The results of war strain are anything but unitary; most of the diverse forms of neurosis and psychoneurosis are found to be represented, and until these are adequately distinguished one from another it is impossible to make any satisfactory study of their individual pathology. A further point still more often overlooked, and perhaps even more important, is that not only are the results diverse, but the ætiological factors concerned in war strain are much more complex than is sometimes realised. Careful study of the cases shews that what was the most important pathogenetic agent with one patient had nothing to do with the neurosis of a second patient, although he may have been equally exposed to its influence. For instance, the sight of a near friend being killed may have greatly affected one soldier and been closely related to his subsequent neurosis, whereas with a second patient who has gone through the same experience there may be no connection between it and _his_ neurosis; the same applies to the other painful features of warfare, the tension of waiting under shell fire, the experience of being buried alive, and so on. These considerations indicate the great importance of the individual factor predisposing to particular neurotic reactions, and point to the necessity for careful dissection of the various pathogenetic factors in a number of cases before making generalisations as to the way in which the numerous separate influences grouped together as war strain may operate.

Coming now to the points of contact between war experience and Freud’s theory, one may remark, to begin with, how well the facts of the war itself accord with Freud’s view of the human mind as containing beneath the surface a body of imperfectly controlled and explosive forces which in their nature conflict with the standards of civilisation. Indeed, one may say that war is an official abrogation of civilised standards. The manhood of a nation is in war not only allowed, but encouraged and ordered to indulge in behaviour of a kind that is throughout abhorrent to the civilised mind, to commit deeds and witness sights that are profoundly revolting to our æsthetic and moral disposition. All sorts of previously forbidden and buried impulses, cruel, sadistic, murderous and so on, are stirred to greater activity, and the old intrapsychical conflicts, which, according to Freud, are the essential cause of all neurotic disorders, and which had been dealt with before by means of “repression” of one side of the conflict, are now reinforced, and the person compelled to deal with them afresh under totally different circumstances.

It is plain, as MacCurdy has well pointed out[10], that men entering the Army, and particularly on approaching the battle-field, have to undergo a very considerable readjustment of their previous attitudes of mind and standards of conduct, a readjustment which is much greater in the case of some men than in that of others, and also one which some men find it much more easy to accomplish satisfactorily than do others. The man’s previous standards of general morality, of cleanliness and æsthetic feeling, and of his relation to his fellow-man, have all to undergo a very considerable alteration. In all directions he has to do things that previously were repugnant to his strongest ideals. These ideals are ascribed by some—e.g., Trotter[11], and, following him, MacCurdy—to the operation of the herd instinct, in other words to the influence of the social _milieu_ in which he may happen to have been brought up. I think personally that behind this influence there are still deeper factors at work of a more individual order, derived essentially from hereditary tendencies and the earliest relation of the child to its parents. However this may be, it is certain that every one has such ideals, though he may not describe them under this name, and that in the course of development he insensibly builds up a series of standards of which his ego approves—and which I therefore propose to refer to by Freud’s term of the “ego ideal”—together with a contrasting series of which his ego disapproves.

As every student of genetic psychology knows, this gradual building up is never performed smoothly, but always after a number of both conscious and unconscious internal conflicts between the conscious ego on the one side and various impulses and desires on the other, after a series of partial renunciations and compromises. Further, it is exceptional for the whole result to be satisfactory; there always remain certain fields—more especially in the realm of sex—where the resolution of the conflict is an imperfect one, and it is just from this imperfect resolution that, according to Freud, neurotic affections arise. The question whether a neurosis will result in a given case is essentially a quantitative one. The mind has the capacity of tolerating without harm a certain amount of stimulation from these internal impulses and desires that are not in unison with the ego, and when this limit is passed the energy derived from them flows over into neurotic manifestations. The mind has several methods for dealing with the energy of the anti-ego impulses successfully—that is to say, without the impairment of mental health—and it is only when these methods are inadequate to deal with the whole that neurosis ensues. Two of these methods may especially be noted. One is the deflection of the energy in question from its primitive and forbidden goal to another one in harmony with the more social standards of the ego; as every schoolmaster knows, sport is an excellent example of this. When the primitive goal was a sexual one, this process of deflection, here on to a non-sexual goal, has been given the name of “sublimation”, but there are similar refining and modifying processes at work in connection with all anti-ego impulses—e.g., cruelty. A second method is to keep the energy in a state of repression in the unconscious, the conscious mind refusing to deal directly with it and guarding itself against its influence by erecting a dam or barrier against it, known as a reaction-formation. Thus in the case of primitive cruelty, a cruel child may develop into a person to whom the very idea of inflicting cruelty is alien and abhorrent, the original impulse having been quite split off from the ego into the unconscious, and its place taken in consciousness by the reaction-formation barrier of horror and sensitiveness to pain and suffering. In such ways as these a state of practical equilibrium is attained in the normal, the power of the ego-ideal having proved sufficient either to utilise for its own purposes (by means of modifying) or to keep at bay, the impulses and desires that are out of harmony with it. In some people the state of equilibrium thus attained is of considerable stability, they have what is popularly called a reserve of mental and moral force with which they can meet disappointments, difficulties, and emergencies of various kinds in life, which means in practice that their capacity for readjustment to radically new situations is fairly elastic.

Now, on approaching the field of war the readjustment necessary is one of the more difficult ones experienced in life, although it is by no means so difficult as can arise in various situations appertaining to the field of sex. It is an adjustment which practice shews is possible to the large majority of men, but there is no doubt that the success with which it is carried out is extremely variable in different people; and it probably varies in the same person from time to time for either internal reasons or for external reasons relating to the precise environment at the moment, to the precise war experiences through which they may be passing. It is further clear that the readjustment is likely to vary in its success almost entirely with the success with which the earlier adjustments were made during the development of the individual. This statement is meant to carry more than its obvious meaning that the more stable a man is the more surely can he meet the problems and difficulties of warfare; it has a deeper implication. Namely, there is an important relationship between the two phases of difficult adjustment, the current one and the older one. Fundamentally it is the same difficulty, the same conflict; it is only the form that is different. Let us suppose, for instance, that the original difficulty in adjustment was over the matter of cruelty, that in childhood the conflict between strong tendencies of this kind and perhaps specially strong ideals of the contrary sort was an exceptionally sharp one, so that it was never very satisfactorily resolved, though a working equilibrium may have been established on the basis of powerful reaction-formations and various protective devices for avoiding in every possible way contact with the subject of cruelty. Such a man may well have unusual difficulty in adapting himself to the cruel aspects of war, which really means that his long-buried and quite unconscious impulses to cruelty, impulses the very possibility of whose existence he would repudiate with horror, are stimulated afresh by the unavoidable sights and deeds of war. In bayonet practice, for instance, the man is taught how best to inflict horrible injuries, and he is encouraged to indulge in activities of this order from the very thought of which he has all his life been trying to escape. He now has to deal afresh with the old internal conflict between the two sides of his nature, with the added complication that there has to take place an extensive revaluation of his previous standards, and in important respects an actual reversal of them. He has to formulate new rules of conduct, to adopt new attitudes of mind, and to accustom himself to the idea that tendencies of which he had previously disapproved with the whole strength of his ego-ideal are now permissible and laudatory under certain conditions. One would get a very erroneous view of the picture I am trying to draw if one imagined that the process of readjustment in question goes on in the person’s consciousness. This is never entirely true, and often not at all true; the most important part of the readjustment, and often the whole of it, is quite unconscious. We thus see that to obtain a proper understanding of the problems of an individual case, and to be able to deal with them practically in therapeutics, it is often necessary to appreciate the relation between a current conflict and an older one, for the real strength and importance of the current one is often due to the fact that it has aroused buried and imperfectly controlled older ones.

I have taken the one instance of cruelty, but there are many others in connection with warfare. It may, indeed, be said in general that the process of re-adaptation in regard to war consists of two distinct sides: on the one hand, war effects an extensive release of previously tabooed tendencies, a release shewn in endless ways—for instance, even in the language of camps; and on the other hand the acquiring of a strict discipline and self-control along lines widely different from those of peace-times. The one is a correlative of the other, and we have perhaps in these considerations a psychological explanation of the feature of military life that is so puzzling to most civilians—namely, the extraordinary punctiliousness that a rigid discipline attaches to matters which to the outsider appear so trivial. An indisciplined army has always been the bane of commanders, and perhaps the risks attaching to indiscipline are related to the release of imperfectly controlled impulses that war deliberately effects.

The way in which a relative failure in war adaptation may lead to a neurosis can be illustrated by a parallel drawn from the more familiar problems of peace neuroses. Imagine a young woman who has never been able to reconcile the sexual sides of her nature with her ego ideal, and whose only way of dealing with that aspect of life has been to keep it at as great a distance from her consciousness as possible. If now she gets married, it may happen that she will find it impossible to effect the necessary reconciliation, and that, being deprived of the _modus vivendi_—namely, the keeping sexuality at a distance—which previously made it possible to maintain a mental equilibrium, she develops a neurosis in which the repressed sexual desires achieve a symbolic and disguised expression. Similarly in a war neurosis when the old adjustment between the ego-ideal and the repressed impulses is taken away, it may prove impossible to establish a fresh one on the new conditions, and then the repressed impulses will find expression in some form of neurotic symptom.

So far as I can judge, the specific problems characteristic of the war neuroses are to be found in connection with two broad groups of mental processes. One of these relates to the question of war adaptation considered above, the other to that of fear. The latter is hardly to be regarded as a sub-group of the former, inasmuch as there is no readjustment or transvaluation of values concerned, as there typically is with the former. The moral attitude towards fear, and the conflicts arising in connection with it, remain the same in war as in peace. In both cases it is considered a moral weakness to display or be influenced by fear, and especially to give in to it at the cost of not doing one’s duty. The soldier who would like to escape from shell fire is, so far as moral values are concerned, in the same position as a man in peace-time who will not venture his life to save a drowning child. Indeed, the conflict cannot be as sharp in the case of the soldier, for he would find very widespread and thorough sympathy for his quite comprehensible desire, and there would be much less social blame or guilt attaching to him than to the man in the other situation mentioned. So that the problem of fear, which we all agree plays a central part in connection with the typical war neuroses, seems to be apart from that of war adaptation in general as expounded above.

Before discussing the problem of fear, however, I should like at this point to review the position and see how far we have got in the attempt to approximate the facts of war neuroses to the psycho-analytical theory. This theory of the neuroses is a very elaborate one, including many problems of unconscious mechanisms, distinctions between the predispositions and mechanisms characteristic of the different neuroses, and so on, but it is possible to formulate the main principles of it along fairly simple lines, and I now propose to do this in a series of statements.

(1) The first principle in Freud’s theory of neurotic symptoms is that they are of volitional origin. This principle, long suspected by both the medical and the lay public, and the real reason why in the past they have been so confounded with malingering, would be at once evident were it not for the fact that it is not true of volition in the ordinary sense of conscious deliberate voluntary purpose. In other words, it is not true of the will as a whole, but only of a part of it—namely, a part that the patient is not aware of. Thus, neuroses are not diseases or accidents that happen to a person, as the French school of psychopathology maintains, but are phenomena produced and brought about by some tendency in the person’s mind, and for specific purposes. Freud distinguishes three classes of motives that operate in this way, one essential, the other two not. The indispensable one is an unconscious desire to obtain pleasure by gratifying in the imagination some repressed and dissociated impulse, a motive, therefore, arising in the part of the mind that is not in harmony with the ego-ideal. A second motive is to achieve some end in the outer world; for instance sympathy from an unkind husband, which the person finds easier to do by means of a neurosis than in other ways. The third set of motives has the same purpose as the last, but may be distinguished from it in that they concern the making use of an already existing neurosis rather than the helping to bring one about. Both the latter sets are usually, but not always, unconscious: more strictly, they are preconscious—that is, they do not relate to deeply buried tendencies, and so are correspondingly easy to reveal; Freud terms them the primary and secondary “gain of illness” respectively. Now I take it that this principle of volitional origin is no longer very widely questioned by modern psychopathologists, and in the case of war neuroses the main motives are visible and comprehensible enough—namely, the desire to find some good reason for escaping from the horrors of warfare.

(2) The second principle is that all neurotic symptoms are the product of an intrapsychical conflict which the person has failed satisfactorily to resolve, and that they constitute a compromise formation between the two conflicting forces. Here, again, I think that those who have been investigating the psychology of war neuroses will agree with this principle. MacCurdy,[12] in particular, has described in great detail the conflict that arises in soldiers between, on the one hand, the motives actuating to continuance at duty and concealment of growing sense of incapacity and apprehension, and, on the other, the awful sense of failure accompanying the sometimes almost overwhelming desire to escape from the horrors of their position. The neurosis offers a way out of this dilemma, the only way that the particular person is able to find, and the actual symptoms, which are often grossly incapacitating, such as blindness, represent the fulfilment of the desire against which the man has been fighting. We reach, therefore, the wish-fulfilment part of Freud’s theory.

(3) The third principle is that the operative wish that leads to the creation of the neurosis is an unconscious one. Freud means this in the full sense of the word, and in this sense the principle has not yet been confirmed from the experience of the war neuroses. There are, however, different degrees of unconsciousness of a mental process, and the important point to Freud is not so much the degree of the unawareness in itself—this being largely an index of the repression—as the repression or dissociation that has led to the unawareness. What he maintains is that the wish producing the neurosis is one that is not in harmony with the ego-ideal, and which is therefore kept at as great a distance as possible from it. Anyone who has read the touching accounts given by MacCurdy or Rivers[13] of the shame that soldiers feel at their increasing sense of fear, and the efforts they make to fight against it, to conceal it from others, and if possible from themselves, will recognise that the wish in question is one alien to the ego-ideal and is well on in the first stages of repression, even if it is half-avowed.

(4) The fourth principle is that current repressed wishes cannot directly produce a neurosis, but do so only by reviving and reinforcing the wishes that have been repressed in older unresolved conflicts. According to Freud, a pathogenetic disappointment or difficulty in readjustment leads first to an introversion or turning inwards of feeling, and the wish that has been baulked seeks some other mode of gratification. It tends to regress back to an older period of life, and thus to become associated with similarly baulked and repressed wishes belonging to older conflicts. It is the combination of these two, the present and the old, that is the characteristic mark of the pathogenesis of neurotic disorders as distinct from other modes of reaction to the difficulties of life.

Freud considers that there are probably always three factors in the causation of any neurosis: a specific hereditary predisposition, secondly an unresolved infantile conflict which means that the person has not satisfactorily developed past a given stage of individual evolution—in other words, that he has been subjected to what is called an “infantile fixation” at a given point in development, and thirdly the current difficulty. There is a reciprocal relationship between these three factors, so that if any one is especially pronounced the others may be correspondingly less important. For instance, if the hereditary factor is very pronounced then a person may become neurotic from the quite ordinary experiences of childhood and adult life, for he is incapable of dealing adequately with them. In the case of war neuroses it is evident that the current factor is of the greatest importance, being, indeed, the only one that so far has attracted attention. The only traces of infantile factors I have seen noted have been the instances where the localisation of hysterical symptoms seems to have been determined in part by the site of old injuries, and in a general way the many traits of childhood, such as sensitiveness to slights, self-centredment, and desire to be guarded, protected, and helped, which are sometimes very evident in the cases of war neurosis.

We thus see that only one half of the psycho-analytical theory has so far been confirmed by the observations of war neuroses. According to this theory, there are typically two sets of wishes concerned in the production of any neurosis. One of these, the “primary gain of illness”, a current one, alien to the conscious ego ideal, and therefore half repressed and only half conscious—if that—has not only been demonstrated by a number of observers, but has been shewn to be of tremendous importance, and certainly the effects of treatment largely turn on the way in which it is dealt with. The other factor, the infantile and altogether repressed and unconscious one, which, according to psycho-analysis, is also essential to the production of a neurosis, has not been systematically sought for, though I have found it in the few cases of which I have been able to make a full study. Its presence or absence is a matter of greater theoretical importance than might perhaps appear, even though its practical importance may often not be great. For my own part I have the utmost difficulty in believing that a current wish, however strong that is half conscious and sometimes fully conscious can ever in itself produce a neurosis, for it contradicts all one’s knowledge concerning the nature of neuroses, as well as my experience, such as it is, of war neuroses themselves. I would therefore urge that no conclusion is possible on the matter one way or the other until adequate investigations have been carried out. That it has its practical side also will be pointed out when we come to consider the chronic cases where war neuroses pass over into peace ones.