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.
(5) The principle of the psycho-analytical theory that has aroused the
strongest opposition is that the primary repressed wish ultimately
responsible for the neurosis is always of a sexual nature, so that the
conflict is between the two groups of instincts that go to make up
the whole personality, those concerned respectively with preservation
of the self and of the species. Dr. MacCurdy has suggested to me
that this is so only because, apart from war, there is no instinct
that comes into such strong conflict with the ego-ideal as does the
sexual one, but that in war the conflict between the instinct for
self-preservation and the ego-ideal is enough to lead to a neurosis.
This may seem very plausible, but I shall be surprised if it is
confirmed by future research. That a neurosis, which after all is a
disorder of the unconscious imagination, should arise from a conflict
between two states of mind that are fully in contact with reality would
be something entirely contradictory of our past experience, as would
also a neurosis arising from a conflict between two tendencies both
belonging to the ego. I shall venture to put forward an alternative
hypothesis presently when discussing the subject of fear, which we
have next to consider.