THE TRAUMATIC NEUROSES OF WAR The reality of psychological trauma was forced upon public consciousness once again by the catastrophe of the First World War. In this prolonged war of attrition, over eight million men died in four years. When the slaughter was over, four European empires had been destroyed, and many of the cherished beliefs that had sustained Western civilization had been shattered. One of the many casualties of the war’s devastation was the illusion of manly honor and glory in battle. Under conditions of unremitting exposure to the horrors of trench warfare, men began to break down in shocking numbers. Confined and rendered helpless, subjected to constant threat of annihilation, and forced to witness the mutilation and death of their comrades without any hope of reprieve, many soldiers began to act like “hysterical women.” They screamed and wept uncontrollably. They froze and could not move. They became mute and unresponsive. They lost their memory and their capacity to feel.

The number of psychiatric casualties was so great that hospitals had to be hastily requisitioned to house them. According to one estimate, mental breakdowns represented 40 percent of British battle casualties. Military authorities attempted to suppress reports of psychiatric casualties because of their demoralizing effect on the public.43 Initially, the symptoms of mental breakdown were attributed to a physical cause. The British psychologist Charles Myers, who examined some of the first cases, attributed their symptoms to the concussive effects of exploding shells and called the resulting nervous disorder “shell shock.” 44 The name stuck, even though it soon became clear that the syndrome could be found in soldiers who had not been exposed to any physical trauma. Gradually military psychiatrists were forced to acknowledge that the symptoms of shell shock were due to psychological trauma. The emotional stress of prolonged exposure to violent death was sufficient to produce a neurotic syndrome resembling hysteria in men. When the existence of a combat neurosis could no longer be denied, medical controversy, as in the earlier debate on hysteria, centered upon the moral character of the patient. In the view of traditionalists, a normal soldier should glory in war and betray no sign of emotion. Certainly he should not succumb to terror. The soldier who developed a traumatic neurosis was at best a constitutionally inferior human being, at worst a malingerer and a coward. Medical writers of the period described these patients as “moral invalids.” 45 Some military authorities maintained that these men did not deserve to be patients at all, that they should be court-martialed or dishonorably discharged rather than given medical treatment. The most prominent proponent of the traditionalist view was the British psychiatrist Lewis Yealland. In his 1918 treatise, Hysterical Disorders of Warfare, he advocated a treatment strategy based on shaming, threats, and punishment. “Hysterical” symptoms such as mutism, sensory loss, or motor paralysis were treated with electric shocks. Patients were excoriated for their laziness and cowardice. Those who exhibited the “hideous enemy of negativism” were threatened with court martial. In one case, Yealland reported treating a mute patient by strapping him into a chair and applying electric shocks to his throat. The treatment went on without respite for hours, until the patient finally spoke. As the shocks were applied, Yealland exhorted the patient to “remember, you must behave as the hero I expect you to be. . . . A man who has gone through so many battles should have better control of himself.” 46

Progressive medical authorities argued, on the contrary, that combat neurosis was a bona fide psychiatric condition that could occur in soldiers of high moral character. They advocated humane treatment based upon psychoanalytic principles. The champion of this more liberal point of view was W. H. R. Rivers, a physician of wide-ranging intellect who was a professor of neurophysiology, psychology, and anthropology. His most famous patient was a young officer, Siegfried Sassoon, who had distinguished himself for conspicuous bravery in combat and for his war poetry. Sassoon gained notoriety when, while still in uniform, he publicly affiliated himself with the pacifist movement and denounced the war. The text of his Soldier’s Declaration, written in 1917, reads like a contemporary antiwar manifesto: I am making this statement as an act of wilful defiance of military authority, because I believe that the war is being deliberately prolonged by those who have the power to end it. I am a soldier, convinced that I am acting on behalf of soldiers. I believe that this war, upon which I entered as a war of defence and liberation, has now become a war of aggression and conquest. . . . I have seen and endured the sufferings of the troops, and I can no longer be a party to prolong these sufferings for ends which I believe to be evil and unjust.47 Fearing that Sassoon would be court-martialed, one of his fellow officers, the poet Robert Graves, arranged for him to be hospitalized under Rivers’s care. His antiwar statement could then be attributed to a psychological collapse. Though Sassoon had not had a complete emotional breakdown, he did have what Graves described as a “bad state of nerves.” 48 He was restless, irritable, and tormented by nightmares. His impulsive risk-taking and reckless exposure to danger had earned him the nickname “Mad Jack.” Today, these symptoms would undoubtedly have qualified him for a diagnosis of post-traumatic stress disorder. Rivers’s treatment of Sassoon was intended to demonstrate the superiority of humane, enlightened treatment over the more punitive traditionalist approach. The goal of treatment, as in all military medicine, was to return the patient to combat. Rivers did not question this goal. He did, however, argue for the efficacy of a form of talking cure. Rather than being shamed, Sassoon was treated with dignity and respect. Rather than being silenced, he was encouraged to write and talk freely about the terrors of war. Sassoon responded with gratitude: “He made me feel safe at once, and seemed to know all about me. . . . I would give a lot for a few gramophone records of my talks with Rivers. All that matters is my remembrance of the great and good man who gave me his friendship and guidance.” 49 Rivers’s psychotherapy of his famous patient was judged a success. Sassoon publicly disavowed his pacifist statement and returned to combat. He did so even though his political convictions were unchanged. What induced him to return was the loyalty he felt to his comrades who were still fighting, his guilt at being spared their suffering, and his despair at the ineffectiveness of his isolated protest. Rivers, by pursuing a course of humane treatment, had established two principles that would be embraced by American military psychiatrists in the next war. He had demonstrated, first, that men of unquestioned bravery could succumb to overwhelming fear and, second, that the most effective motivation to overcome that fear was something stronger than patriotism, abstract principles, or hatred of the enemy. It was the love of soldiers for one another. Sassoon survived the war, but like many survivors with combat neurosis, he was condemned to relive it for the rest of his life. He devoted himself to writing and rewriting his war memoirs, to preserving the memory of the fallen, and to furthering the cause of pacifism. Though he recovered from his “bad case of nerves” sufficiently to have a productive life, he was haunted by the memory of those who had not been so fortunate. 

[He wrote:] 'How many a brief bombardment had its long-delayed aftereffect in the minds of these survivors, many of whom had looked at their companions and laughed while inferno did its best to destroy them. Not then was their evil hour; but now; now, in the sweating suffocation of nightmare, in paralysis of limbs, in the stammering of dislocated speech. Worst of all, in the disintegration of those qualities through which they had been so gallant and selfless and uncomplaining—this, in the finer types of men, was the unspeakable tragedy of shell-shock'.

In the name of civilization these soldiers had been martyred, and it remained for civilization to prove that their martyrdom wasn’t a dirty swindle.50 Within a few years after the end of the war, medical interest in the subject of psychological trauma faded once again.

Though numerous men with long-lasting psychiatric disabilities crowded the back wards of veterans’ hospitals, their presence had become an embarrassment to civilian societies eager to forget. In 1922 a young American psychiatrist, Abram Kardiner, returned to New York from a year-long pilgrimage to Vienna, where he had been analyzed by Freud. He was inspired by the dream of making a great discovery. “What could be more adventurous,” he thought, “than to be a Columbus in the relatively new science of the mind.” 51 Kardiner set up a private practice of psychoanalysis, at a time when there were perhaps ten psychoanalysts in New York. He also went to work in the psychiatric clinic of the Veterans’ Bureau, where he saw numerous men with combat neurosis. He was troubled by the severity of their distress and by his inability to cure them. In particular, he remembered one patient whom he treated for a year without notable success. Later, when the patient thanked him, Kardiner protested, “But I never did anything for you. I certainly didn’t cure your symptoms.” “But, Doc,” the patient replied, “You did try. I’ve been around the Veterans Administration for a long time, and I know they don’t even try, and they don’t really care. But you did.” 52 Kardiner subsequently acknowledged that the “ceaseless nightmare” of his own early childhood—poverty, hunger, neglect, domestic violence, and his mother’s untimely death—had influenced the direction of his intellectual pursuits and allowed him to identify with the traumatized soldiers.53 Kardiner struggled for a long time to develop a theory of war trauma within the intellectual framework of psychoanalysis, but he eventually abandoned the task as impossible and went on to a distinguished career, first in psychoanalysis and then, like his predecessor Rivers, in anthropology. In 1939, in collaboration with the anthropologist Cora du Bois, he authored a basic anthropology text, The Individual and His Society. It was only then, after writing this book, that he was able to return to the subject of war trauma, this time having in anthropology a conceptual framework that recognized the impact of social reality and enabled him to understand psychological trauma. In 1941 Kardiner published a comprehensive clinical and theoretical study, The Traumatic Neuroses of War, in which he complained of the episodic amnesia that had repeatedly disrupted the field: The subject of neurotic disturbances consequent upon war has, in the past 25 years, been submitted to a good deal of capriciousness in public interest and psychiatric whims. The public does not sustain its interest, which was very great after World War I, and neither does psychiatry. Hence these conditions are not subject to continuous study . . . but only to periodic efforts which cannot be characterized as very diligent.

In part, this is due to the declining status of the veteran after a war. . . . Though not true in psychiatry generally, it is a deplorable fact that each investigator who undertakes to study these conditions considers it his sacred obligation to start from scratch and work at the problem as if no one had ever done anything with it before.54 Kardiner went on to develop the clinical outlines of the traumatic syndrome as it is understood today. His theoretical formulation strongly resembled Janet’s late nineteenth-century formulations of hysteria. Indeed, Kardiner recognized that war neuroses represented a form of hysteria, but he also realized that the term had once again become so pejorative that its very use discredited patients: “When the word ‘hysterical’ . . . is used, its social meaning is that the subject is a predatory individual, trying to get something for nothing. The victim of such a neurosis is, therefore, without sympathy in court, and . . . without sympathy from his physicians, who often take . . . ‘hysterical’ to mean that the individual is suffering from some persistent form of wickedness, perversity, or weakness of will.” 55 With the advent of the Second World War came a revival of medical interest in combat neurosis. In the hopes of finding a rapid, efficacious treatment, military psychiatrists tried to remove the stigma from the stress reactions of combat. It was recognized for the first time that any man could break down under fire and that psychiatric casualties could be predicted in direct proportion to the severity of combat exposure. Indeed, considerable effort was devoted to determining the exact level of exposure guaranteed to produce a psychological collapse. A year after the war ended, two American psychiatrists, J. W. Appel and G. W. Beebe, concluded that 200–240 days in combat would suffice to break even the strongest soldier: “There is no such thing as ‘getting used to combat.’ . . . Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare.” 56 American psychiatrists focused their energy on identifying those factors that might protect against acute breakdown or lead to rapid recovery. They discovered once again what Rivers had demonstrated in his treatment of Sassoon: the power of emotional attachments among fighting men. In 1947 Kardiner revised his classic text in collaboration with Herbert Spiegel, a psychiatrist who had just returned from treating men at the front. Kardiner and Spiegel argued that the strongest protection against overwhelming terror was the degree of relatedness between the soldier, his immediate fighting unit, and their leader. Similar findings were reported by the psychiatrists Roy Grinker and John Spiegel, who noted that the situation of constant danger led soldiers to develop extreme emotional dependency upon their peer group and leaders. They observed that the strongest protection against psychological breakdown was the morale and leadership of the small fighting unit.57

The treatment strategies that evolved during the Second World War were designed to minimize the separation between the afflicted soldier and his comrades. Opinion favored a brief intervention as close as possible to the battle lines, with the goal of rapidly returning the soldier to his fighting unit.58 In their quest for a quick and effective method of treatment, military psychiatrists once again discovered the mediating role of altered states of consciousness in psychological trauma. They found that artificially induced altered states could be used to gain access to traumatic memories. Kardiner and Spiegel used hypnosis to induce an altered state, while Grinker and Spiegel used sodium amytal, a technique they called “narcosynthesis.” As in the earlier work on hysteria, the focus of the “talking cure” for combat neurosis was on the recovery and cathartic reliving of traumatic memories, with all their attendant emotions of terror, rage, and grief. The psychiatrists who pioneered these techniques understood that unburdening traumatic memories was not in itself sufficient to effect a lasting cure. Kardiner and Spiegel warned that although hypnosis could expedite the retrieval of traumatic memories, a simple cathartic experience by itself was useless. Hypnosis failed, they explained, where “there is not sufficient follow-through.” 59 Grinker and Spiegel observed likewise that treatment would not succeed if the memories retrieved and discharged under the influence of sodium amytal were not integrated into consciousness. The effect of combat, they argued, “is not like the writing on a slate that can be erased, leaving the slate as it was before. Combat leaves a lasting impression on men’s minds, changing them as radically as any crucial experience through which they live.” 60 These wise warnings, however, were generally ignored. The new rapid treatment for psychiatric casualties was considered highly successful at the time. According to one report, 80 percent of the American fighting men who succumbed to acute stress in the Second World War were returned to some kind of duty, usually within a week. Thirty percent were returned to combat units.61 Little attention was paid to the fate of these men once they returned to active duty, let alone after they returned home from the war. As long as they could function on a minimal level, they were thought to have recovered.

With the end of the war, the familiar process of amnesia set in once again. There was little medical or public interest in the psychological condition of returning soldiers. The lasting effects of war trauma were once again forgotten. Systematic, large-scale investigation of the long-term psychological effects of combat was not undertaken until after the Vietnam War. This time, the motivation for study came not from the military or the medical establishment, but from the organized efforts of soldiers disaffected from war. In 1970, while the Vietnam War was at its height, two psychiatrists, Robert Jay Lifton and Chaim Shatan, met with representatives of a new organization called Vietnam Veterans Against the War. For veterans to organize against their own war while it was still ongoing was virtually unprecedented. This small group of soldiers, many of whom had distinguished themselves for bravery, returned their medals and offered public testimony of their war crimes. Their presence contributed moral credibility to a growing antiwar movement. “They raised questions,” Lifton wrote, “about everyone’s version of the socialized warrior and the war system, and exposed their country’s counterfeit claim of a just war.” 62 The antiwar veterans organized what they called “rap groups.” In these intimate meetings of their peers, Vietnam veterans retold and relived the traumatic experiences of war. They invited sympathetic psychiatrists to offer them professional assistance. Shatan later explained why the men sought help outside of a traditional psychiatric setting: “A lot of them were ‘hurting,’ as they put it. But they didn’t want to go to the Veterans’ Administration for help. . . . They needed something that would take place on their own turf, where they were in charge.” 63 The purpose of the rap groups was twofold: to give solace to individual veterans who had suffered psychological trauma, and to raise awareness about the effects of war. The testimony that came out of these groups focused public attention on the lasting psychological injuries of combat. These veterans refused to be forgotten. Moreover, they refused to be stigmatized. They insisted upon the rightness, the dignity of their distress.

In the words of a marine veteran, Michael Norman: Family and friends wondered why we were so angry. What are you crying about? they would ask. Why are you so ill-tempered and disaffected. Our fathers and grandfathers had gone off to war, done their duty, come home and got on with it. What made our generation so different? As it turns out, nothing. No difference at all. When old soldiers from “good” wars are dragged from behind the curtain of myth and sentiment and brought into the light, they too seem to smolder with choler and alienation. . . . So we were angry. Our anger was old, atavistic. We were angry as all civilized men who have ever been sent to make murder in the name of virtue were angry.64

 By the mid-1970s, hundreds of informal rap groups had been organized. By the end of the decade, the political pressure from veterans’ organizations resulted in a legal mandate for a psychological treatment program, called Operation Outreach, within the Veterans’ Administration. Over a hundred outreach centers were organized, staffed by veterans and based upon a self-help, peer-counseling model of care. The insistent organizing of veterans also provided the impetus for systematic psychiatric research. In the years following the Vietnam War, the Veterans’ Administration commissioned comprehensive studies tracing the impact of wartime experiences on the lives of returning veterans. A five-volume study on the legacies of Vietnam delineated the syndrome of post-traumatic stress disorder and demonstrated beyond any reasonable doubt its direct relationship to combat exposure.65 The moral legitimacy of the antiwar movement and the national experience of defeat in a discredited war had made it possible to recognize psychological trauma as a lasting and inevitable legacy of war. In 1980, for the first time, the characteristic syndrome of psychological trauma became a “real” diagnosis. In that year the American Psychiatric Association included in its official manual of mental disorders a new category, called “post-traumatic stress disorder.” 66 The clinical features of this disorder were congruent with the traumatic neurosis that Kardiner had outlined forty years before. Thus the syndrome of psychological trauma, periodically forgotten and periodically rediscovered through the past century, finally attained formal recognition within the diagnostic canon.

THE ORDINARY RESPONSE TO ATROCITIES is to banish them from consciousness. Certain violations of the social compact are too terrible to utter aloud: this is the meaning of the word unspeakable. Atrocities, however, refuse to be buried. Equally as powerful as the desire to deny atrocities is the conviction that denial does not work. Folk wisdom is filled with ghosts who refuse to rest in their graves until their stories are told. Murder will out. Remembering and telling the truth about terrible events are prerequisites both for the restoration of the social order and for the healing of individual victims. The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma. People who have survived atrocities often tell their stories in a highly emotional, contradictory, and fragmented manner which undermines their credibility and thereby serves the twin imperatives of truth-telling and secrecy. When the truth is finally recognized, survivors can begin their recovery. But far too often secrecy prevails, and the story of the traumatic event surfaces not as a verbal narrative but as a symptom. The psychological distress symptoms of traumatized people simultaneously call attention to the existence of an unspeakable secret and deflect attention from it. This is most apparent in the way traumatized people alternate between feeling numb and reliving the event. The dialectic of trauma gives rise to complicated, sometimes uncanny alterations of consciousness, which George Orwell, one of the committed truth-tellers of our century, called “doublethink,” and which mental health professionals, searching for a calm, precise language, call “dissociation.”

Witnesses as well as victims are subject to the dialectic of trauma. It is difficult for an observer to remain clearheaded and calm, to see more than a few fragments of the picture at one time, to retain all the pieces, and to fit them together. It is even more difficult to find a language that conveys fully and persuasively what one has seen. Those who attempt to describe the atrocities that they have witnessed also risk their own credibility. To speak publicly about one’s knowledge of atrocities is to invite the stigma that attaches to victims. The knowledge of horrible events periodically intrudes into public awareness but is rarely retained for long. Denial, repression, and dissociation operate on a social as well as an individual level. The study of psychological trauma has an “underground” history. Like traumatized people, we have been cut off from the knowledge of our past. Like traumatized people, we need to understand the past in order to reclaim the present and the future. Therefore, an understanding of psychological trauma begins with rediscovering history. 

Dr J Herman