Psycho-Analysis and the War Neuroses

by Sándor Ferenczi; Karl Abraham; Sigmund Freud; Ernest Jones; Ernst Simmel

It would be easy to criticise the standpoint thus adopted, though that is in no sense my purpose here. Two points alone may be raised. If, as some writers assert, the strain of war conditions is in itself sufficient to account for the development of a psychoneurosis without the introduction of any other factor, then how is one to explain the actual incidence of war neuroses? Neurotic symptoms amounting to a definite clinico-pathological condition are by no means so common as is sometimes stated. I do not know of any statistics on the matter, but I should be surprised to hear that more than 2 per cent. of the Army serving in France are affected in this way. This consideration in itself shews that some other factors than war strain must be involved, factors relating to the previous disposition of the men affected, and the problem is to determine what these are. In the second place, as to the dogmatic assertion that Freud’s theory of the psychoneuroses cannot apply to those arising under war conditions. An essential feature of this theory is that psychoneuroses result from unconscious mental conflicts. To ascertain whether these are operative in a given case, therefore, it is obviously necessary to employ some method, such as psycho-analysis, which gives access to the unconscious. It may, I think, be taken as certain that those who deny the action of these conflicts in either the war neuroses or in what, by way of contradistinction, must be called the peace neuroses, have not thought it necessary to use any such method, and they thus place themselves in a position very similar to that of a writer who would on a priori grounds deny the details or even the existence of histology without ever having looked through a microscope, the only avenue to histology. I choose this simile because it seems to me that the relation of psycho-analysis to clinical psychiatry is not at all inaptly described[8] as being like that of histology to anatomy. Or one might draw an analogy from a strictly medical field. If some one were to take a series of cases of tuberculosis supervening on measles or typhoid, and then maintain that because this ætiological factor was present therefore no microorganism could be, so that Koch’s views as to the causation of tuberculosis were entirely unfounded, one would surely have the right to ask whether any search for the bacillus had been made in the cases in question, and to satisfy oneself that the observer had grasped the difference between essential and merely exciting causes of disease. If the answer to both these inquiries were in the negative, I think it will be agreed that no great weight would be attached to the claim that Koch’s theory of the nature of tuberculosis had been demolished. Yet this is precisely the order of scientific thinking evinced by those who maintain that Freud’s theory of the neuroses has been demolished by the simple observation that they may manifest themselves under the stress of warfare.

I do not mean, however, to assert the contrary of this proposition—namely, that the validity of Freud’s theory has been proved in the case of war neuroses, as I should maintain it has been in the case of peace neuroses. I simply hold that the matter is at present sub judice, and must remain so until sufficiently extensive investigations shall have settled the question one way or the other. It so happens that the traumatic neuroses are the field in psychopathology that has hitherto been the least explored by psycho-analysis even in peace time, while the opportunity of psycho-analytic investigation of the war neuroses has, in this country at least, been so meagre that the time is not ripe for any generalisation on the subject. Personally I have examined a considerable number of cases in the cursory way that is usual in hospital work, but I have been able to make an intensive study in only some half-dozen cases, and I do not know of any other cases that have been investigated by the psycho-analytic method. In spite of this paucity of material, a feature inherent in intensive work, the critic of psycho-analysis may legitimately demand of the analyst, who advances considerable pretensions in regard to understanding the pathology of neurotic affections in general, that he should be able to formulate some tentative conception of the relation between the phenomena commonly observed in the war neuroses and the psycho-analytical theory. In the following remarks an attempt will be made to meet this demand, although, as has just been explained, there can be no question of solving the numerous and as yet unstudied problems raised by the observations made in connection with war shock.

It is desirable in the first place to clear away some general misconceptions on the subject. The task of assimilating our new experiences in connection with the war with any previously held theory of neurotic affections has undoubtedly been rendered more difficult by the attitude of those workers whose interest in such problems is of contemporary origin. They lay much too much emphasis on the newer and perhaps more sensational aspects of the phenomena observed, instead of trying to correlate the more familiar and better understood ones. This attitude has been so pronounced with some writers that one might almost imagine that before the war there had never been such calamities as wrecks, earthquakes, and railway accidents, and that men had never been tried to the limit of their endurance with privation, fatigue, and danger, while familiar symptoms like hysterical blindness and paralysis are thought worthy of detailed description and are treated almost as novelties in psychological medicine. So far as I know, however, although some symptoms—e.g., dread of shells—assume a form that is coloured by war experiences, no symptom, and hardly any grouping of symptoms, occurs in war neuroses that is not to be met with in the neuroses of peace, a fact which in itself would suggest that fundamentally very similar agents must be at work to produce the neurosis in both cases.

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.