Freud and the War Neuroses
Freud and Shell Shock
After the war there were reports in Vienna that men suffering from war neuroses had been brutally treated by the army doctors. An enquiry into the matter was instituted by the Austrian War Ministry, and Freud was called upon to give an expert opinion. He submitted a memorandum to the commission responsible for the enquiry, and subsequently appeared before them for oral examination. The original manuscript occupies five and a half of the large foolscap sheets used habitually by Freud, and is dated: Wien, 23.2.20.
Memorandum on the Electrical Treatment of War Neurotics
There were plenty of patients even in peace-time who, after traumas (that is, after frightening and dangerous experiences such as railway accidents, etc.) exhibited severe disturbances in their mental life and in their nervous activity, without physicians having reached an agreed judgement on these states. Some supposed that with such patients it was a question of severe injuries to the nervous system, similar to the haemorrhages and inflammations occurring in non-traumatic illnesses. And when anatomical examination failed to establish such processes, they nevertheless maintained their belief that finer changes in the tissues were the cause of the symptoms observed. They therefore classed these traumatic cases among the organic diseases. Other physicians maintained from the first that these states could only be regarded as functional disturbances, and that the nervous system remained anatomically intact. But medical opinion had long found difficulty in explaining how such severe disturbances of function could occur without any gross injury to the organ.
The war that has recently ended produced and brought under observation an immense number of these traumatic cases. In the result, the controversy was decided in favour of the functional view. The great majority of physicians no longer believe that the so-called war neurotics are ill as a result of tangible organic injuries to the nervous system, and the more clear-sighted among them have already decided, instead of using the indefinite description of a functional change, to introduce the unambiguous term mental change.
Although the war neuroses manifested themselves for the most part as motor disturbances-tremors and paralyses-and although it was plausible to suppose that such a gross impact as that produced by the concussion due to the explosion of a shell near by or to being buried by a fall of earth would lead to gross mechanical effects, observations were nevertheless made which left no doubt as to the psychical nature of the causation of these so-called war neuroses. How could this be disputed when the same symptoms appeared behind the Front as well, far from the horrors of war, or immediately after a return from leave? The physicians were therefore led to regard war neurotics in a similar light to the nervous subjects of peace-time.
What is known as the psycho-analytic school of psychiatry, which was brought into being by me, had taught for the last twenty-five years that the neuroses of peace could be traced back to disturbances of emotional life. This explanation was now applied quite generally to war neurotics. We had further asserted that neurotic patients suffered from mental conflicts and that the wishes and inclinations which were expressed in the symptoms were unknown to the patients themselves- were, that is to say, unconscious. It was therefore easy to infer that the immediate cause of all war neuroses was an unconscious inclination in the soldier to withdraw from the demands, dangerous or outrageous to his feelings, made upon him by active service. Fear of losing his own life, opposition to the command to kill other people, rebellion against the ruthless suppression of his own personality by his superiors-these were the most important affective sources on which the inclination to escape from war was nourished.
A soldier in whom these affective motives were very powerful and clearly conscious would , if he was a healthy man, have been obliged to desert or pretend to be ill. Only the smallest proportion of war neurotics, however, were malingerers; the emotional impulses which rebelled in them against active service and drove them into illness were operative in them without becoming conscious to them. They remained unconscious because other motives, such as ambition, self-esteem, patriotism, the habit of obedience and the example of others, were to start with more powerful until, on some appropriate occasion, they were overwhelmed by the other, unconsciously-operating motives.
This insight into the causation of the war neuroses led to a method of treatment which seemed to be well-grounded and also proved highly effective in the first instance. It seemed expedient to treat the neurotic as a malingerer and to disregard the psychological distinction between conscious and unconscious intentions, although he was known not to be a malingerer. Since his illness served the purpose of withdrawing him from an intolerable situation, the roots of the illness would clearly be undermined if it was made even more intolerable to him than active service. Just as he had fled from the war into illness, means were now adopted which compelled him to flee back from illness into health, that is to say, into fitness for active service. For this purpose painful electrical treatment was employed, and with success. Physicians are glossing over the facts in retrospect when they assert that the strength of this electrical current was the same as had always been employed in functional disorders. This would only have been effective in the mildest cases; nor did it fit in with the underlying argument that a war neurotics illness had to be made painful so that the balance of his motives would be tipped in favour of recovery.
This painful form of treatment introduced in the German army for therapeutic purposes could no doubt also be employed in a more moderate fashion. If it was used in the Vienna Clinics, I am personally convinced that it was never intensified to a cruel pitch by the initiative of Professor Wagner-Juaregg.* I cannot vouch for other physicians whom I did not know. The psychological education of medical men is in general decidedly deficient and more than one of them may have forgotten that the patient whom he was seeking to treat as a malingerer was, after all, not one.
This therapeutic procedure, however, bore a stigma from the very first. It did not aim at the patients recovery, or not in the first instance; it aimed, above all, at restoring his fitness for service. Here Medicine was serving purposes foreign to its essence. The physician himself was under military command and had his own personal dangers to fear - loss of seniority or a charge of neglecting his duty - if he allowed himself to be led by considerations other than those prescribed for him. The insoluble conflict between the claims of humanity, which normally carry decisive weight for a physician, and the demands of a national war was bound to confuse his activity.
Moreover, the successes of treatment by a strong electric current, which were brilliant to begin with, turned out afterwards not to be lasting. A patient who, having been restored to health by it, was sent back to the Front, could repeat the business afresh and have a relapse, by means of which he at least gained time and escaped the danger which was at the moment the immediate one. If he was once more under fire his fear of the electric current receded, just as during the treatment his fear of active service had faded. In the course of the war years, too, a rapidly increasing fatigue in the popular spirit made itself felt more and more, and a growing dislike of fighting, so that the treatment I have described began to fail in its effects. In these circumstances some of the army doctors gave way to the inclination, characteristic of Germans, to carry through their intentions regardless of all else - which should never have happened. The strength of the current, as well as the severity of the rest of the treatment, were increased to an unbearable point in order to deprive war neurotics of the advantage they gained from their illness. The fact has never been contradicted that in German hospitals there were deaths at that time during treatment and suicides as a result of it. I am quite unable to say, however, whether the Vienna Clinics, too, passed through this phase of therapy.
I am in a position to bring forward conclusive evidence of the final break-down of the electrical treatment of the war neuroses. In 1918 Dr. Ernst Simmel, head of a hospital for war neuroses at Posen, published a pamphlet in which he reported the extraordinarily favourable results achieved in severe cases of war neurosis by the psychotherapeutic method introduced by me. As a result of this publication, the next Psycho-Analytical Congress, held in Budapest in September 1918, was attended by official delegates of the German, Austrian and Hungarian Army Command, who promised that Centres should be set up for the purely psychological treatment of war neuroses. This promise was made although the delegates can have been left in no doubt that with this considerate, laborious and tedious kind of treatment it was impossible to count on the quickest restoration of these patients to fitness for service. Preparations for the establishment of Centres of this kind were actually under way, when the revolution broke out and put an end to the war and to the influence of the administrative offices which had hitherto been all-powerful. But with the end of the war the war neurotics, too, disappeared - a final but impressive proof of the psychical causation of their illnesses. Vienna, 23.2.20.
Julius von Wagner-Jauregg was Professor of Psychiatry at the University of Vienna from 1893 to 1928.
Freud wrote little about war neuroses yet the subject had a profound impact on his theory. In 'Beyond the Pleasure Principle' Freud introduced the concepts of 'repetition compulsion' and 'death drive' to account for the impact of overwhelming trauma on the mind. The trauma is repeated and repeated, he says, in order to master the stimuli and bring it under the domination of the 'pleasure-pain principle'. His analysis of children's games showed further that the trauma is mastered through a process of symbolisation, thus hinting at a theory about the origin of human language itself.
These concepts were to have a lasting influence on the subsequent development of psychoanalysis.
Information on this page has been taken from Kurt Eissler (1986) "Freud as an expert witness: The discussion of war neuroses between Freud and Wagner-Jauregg"