Psychiatry and the War

by W.H.R.Rivers

The influence of the war upon psychiatry in Great Britain has been profound and shows itself in many different directions. A most important effect has been to draw psychiatry into closer relations with neurology. As an indirect result of the stringency of the lunacy laws there had come into existence in Great Britain a state unknown in other countries, in which a deep gulf existed between those who deal with the insane and those who treat the neuroses, the latter affections usually coming under the care of physicians otherwise occupied with the treatment of organic nervous disease. This gulf has been largely bridged as a result of the war. Both groups of practitioners have been called upon to deal with the enormous mass of psycho-neurosis which the war has produced, with the result that the outlook of each has looked greatly widened.

One, and perhaps the most important outcome of this combined activity has been the general recognition of the essential part taken in the production and maintenance of the psycho-neuroses by purely mental factors. In the early stages of the war especial stress was laid on the physical effects of a shell explosion, an attitude which found expression in the term shell-shock. As the war has progressed the physical conception of war-neurosis has been gradually replaced by one according to which the vast majority of cases depend on a process of causation in which the factors are essentially mental. The shell explosion or other catastrophe of war, which forms in so many cases the immediate antecedent of the illness, is only the spark which releases deep seated psychical forces due to the strains of warfare. It has also become clear how large a part is taken in the causation of neurosis by physical factors which only come into action after the soldier has been removed from the scene of warfare.

Not only has war-experience shown the importance of purely mental factors in the production of neurosis, but it has also shown the special potency of certain kinds of mental process, the closely related emotional and instinctive aspects. This knowledge is already having, and will have still more, profound effects upon the science of psychology. This science has hitherto mainly dealt with the intellectual side of mental life and has paid far too little attention to the emotions. Students of certain aspects of mind, and especially those engaged in the study of social psychology, were coming to see how greatly psychologists had over-estimated the intellectual factor. The results of warfare have now compelled psychiatrists to consider from the medical point of view the conflicts between the instinctive tendencies of the individual and the forces of social tradition which workers in other fields have come to recognise as so potent for good and evil in the lives of mankind.

Closely related to this movement is another which has left those dealing with psycho-neurosis to recognise far more widely than hitherto the importance of mental experience which is not directly accessible to consciousness. Warfare has provided us with numberless examples of the process of dissociation and suppression by means of which certain bodies of experience become shut off from the general mass making up the normal personality, but yet continue to exist in an active state, producing effects of the most striking kind, both mental and physical.

An interesting by-product of this increased attention to the instinctive, emotion and unconscious aspects of mind has been a great alteration in the attitude of psychiatrists towards the views of the psychoanalytic school. Before the war many psychologists were coming to see the importance of Freud’s work to their science, bit within the medical profession, the general attitude was one of uncompromising hostility. This state of affairs has been wholly altered by the war. The partisans of Freud have been led by experience of the war-neurosis to see that sex is not the sole factor in the production of psycho-neuroses, but that conflict arising out of the activity of other instincts, and especially that of self-preservation, takes an active if not the leading role. On the other hand, independent students who, partly though lack of opportunity, had not previously committed themselves to either side, have been forced by the facts to see how great an extent the nature of psycho-neuroses of warfare support the views of Freud have made it their business to soft the grain from the chaff and distinguish between the essential and the accidental in his scheme. To such an extent has the reconciliation gone that it has recently been possible for the chief adherent of Freud to read a communication before the leading medical society of London without exciting any trace of acrimony and only such opposition as must be expected when dealing with a subject as new and complex as that under discussion. There are many signs that the end of the war will find psychiatrists and psychologists ready to consider dispassionately the value of Freud’s scheme as a basis for the study of psychoses as well as of the psycho-neuroses of civil life, ready to accept the good and reject the false without the ignorant prejudice and bitter rancour which characterised every discussion of the subject before the war.

Concurrently with the general recognition of the essentially psychical of neurosis, there has taken place a great development on the therapeutical side. As a result of the war psycho-therapy has taken its place among the resources of the physician. There is still far from general agreement concerning the value of different forms of psycho-therapeutic treatment, but work is steadily going on in testing the value of different methods. In the early stages of the war extensive use was made of hypnotism and hypnoidal suggestion, and owing to the striking character of its immediate results this mode of treatment still has a considerable vogue. The general trend of opinion, however, has been against its employment as tending to undermine the strength of character which is needed to enable the victim of neurosis to combat the forces which have temporarily overcome him. Many of those who used hypnotism largely in the early days of the war have given it up in favour of other less rapid and dramatic but more efficacious modes of treatment.

The treatment which has had most success consists of a form of mental analysis which resembles to some extend the psycho-analysis of Freud, but differs from it in making little attempt to go deeply into the unconscious, except in so far as any dissociation present has been the result of recent shocks of warfare. Attention is paid especially to those parts of experience which without any special resistance become accessible to the memory of the patient, and to seek by means of the knowledge so acquired to demonstrate to the patient the essentially psychical nature of his malady. By a process of re-education he is then led to adjust himself to the conditions created by his illness.

The knowledge already gained, and still more that which will become accessible when those at present fully occupied with the needs of the moment have leisure to record their experience, will be of the utmost importance to the future of psychiatry. Already before the war a movement was on foot to bring about reforms in the treatment of mental disorder, the measures especially favoured being the establishment of psychiatric clinics and the removal of curable and slight examples of psychosis from association with the more chronic cases. This movement will be greatly assisted by the knowledge and experience gained by the war. Those in the medical profession who are moving towards reform will gain a large body of support from many members of the laity who have come through the war to recognise the gravity of the problem. A large body of exact knowledge will be available to assist those whose business it will be to set the care and treatment of mental disorder on a new footing. Psychiatry will emerge from the war in a state very different from that it occupied in 1914. Above all it will be surrounded by an atmosphere of hope and promise for the future treatment of the greatest of human ills.

W.H.R Rivers

University of Cambridge