Psycho-Analysis and the War Neuroses · Sándor Ferenczi
SYMPOSIUM
To what an extent the regression can go is shown in those cases, described also in the literature, in which the patients display the conduct of little children. One of my patients who was previously neurotic was thrown into this kind of condition through the terrifying effect of a mine explosion. For a long time he behaved like a terrified little child. For many weeks he could only reply to all questions about his trouble with the two words, “Mine bombs”. He had therefore gone back to the mode of expression of a child hardly two years old. What apparently is an exception to the statement made at the commencement is the following noteworthy case in which a previously healthy, proficient and sexually completely potent young man was taken in the field with a severe astasia-abasia coupled with a very great over-excitability of affect. An explosion had hurled the lower part of his back against the side of the trench; he had therefore suffered a trauma, and had been already treated by various neurologists for “traumatic hysteria”. A careful physical examination showed me undoubted signs of an affection of the Conus Medullaris, manifestly a haematomyelia. The patient remembered that after the trauma he could not retain his urine and faeces, still he continued at his post because he looked upon this condition as the result of terror. These symptoms improved in the following weeks. However, during the same period he noticed the disappearance of all sexual feelings. At first he was not inclined to look upon this condition, which was disquietening to him, at all seriously, having no idea that he had an organic impotence. During leave at home he had to come to the conclusion that the sexual insensitiveness was in no way to be overcome. Now the neurosis appeared, not as the result of the psychic impression of the explosion, but as a reaction to the organic impotence of traumatic origin. This neurosis differed, by the way, from the usual traumatic neuroses through the euphoristic, at times even manic state of mind.
This difference needs special appreciation and explanation. Also other men who have received severe organic injuries show such mental attitudes which must surprise us. For example, I have always found that in the amputation hospitals a strikingly cheerful mood prevails. At the beginning of the war I had my attention drawn to the euphoria of the severely wounded men by a particular occurrence. I had to treat four soldiers in a general hospital, who through the splintering of the same shell had had their eyes severely injured. All four had already had enucleation performed in another hospital. They were in no way depressed but gave themselves up to a careless, serene frame of mind. When they—all at the same time—received their artificial eyes a remarkable scene took place. They jumped, danced, and laughed in boisterous spirits, just like children who work themselves up into a frenzy of joy. Also here there is without doubt a regression to narcissism, it is however of a more partial nature. These patients repress the knowledge that through the mutilation they have experienced a depreciation in a more or less high degree, especially in the eyes of the female sex. What they lose in love from outside they seek to compensate by means of self-love. The damaged part of the body receives for them a significance as an erotogenic zone which did not previously belong to it[5].
All the experiences here communicated speak unanimously in the sense that the war neuroses are not to be understood without taking the sexuality into consideration. This view receives a valuable confirmation by means of the mental disturbances observed in the war, which—like mental troubles in general—very often more easily manifest the latent content of their ideas than the neuroses. The mental disturbances which have broken out in the field, as other observers have confirmed, are associated only in a trifling part with the formation of delusions. However, if there is a delusion then it has even a manifest sexual content. In the cases I have seen the delusions are partly of jealousy, partly of homosexual persecution by comrades. I might mention the paranoid illness of a soldier which broke out when he, after long service in the field, went home on furlough and turned out to be impotent with his wife. A very transparent symbolism and other signs pointed with certainty to the significance of homosexual components as the fundamental cause of the delusion. Another man had the delusion of being, during sleep, infected with syphilis in the hospital by his comrades, the origin of the delusion was here also the result of imperfectly repressed homosexuality. In this connection I should like to mention another remarkable case. In 1915 when I was acting at a surgical station a man was treated there for a gunshot wound of the penis. The operation, which was carried out by a well known surgeon, was quite successful. Two years later the same patient came to my psychiatric station. The man who was previously unaffected psychically now showed a paranoid mental disturbance. On questioning him it appeared that in consequence of the wound there existed entire genital anaesthesia. Also here the psychosis appeared to stand in close connection with the cessation of genital manliness.
The so-called “seeking for pension” of many men injured in the war is as little explained by means of the current ideas on the matter as the symptoms of the neurosis. This also stands in connection with the alterations of the sexual hunger (libido), just as do the neurotic symptoms. The patient only apparently fights for compensation for the stiffened wrist, for the shot-off finger, for his neurotic trouble. It is quite overlooked as a rule that the neurotic inwardly perceives the alteration which has taken place as regards his sexual hunger (libido). He is filled with the feeling of an enormous injury. And he is so far right when he actually has suffered loss from his capability for transference of his sexual hunger (libido) and therewith an important basis of the belief in himself. A man injured by an accident before the war once told me that he had come to an agreement with his insurance company for a definite compensation. Hardly had this occurred when the thought came to him that this sum did not even remotely cover his actual injury. Henceforth the sum which according to his idea he ought to have claimed rapidly rose to an enormous amount. The pension compensates only for the diminution of the capacity for earning a livelihood, so far as this is objectively demonstrable, not for that which the patient subjectively feels; he cannot be compensated for his reduced capacity for object-love. Narcissism also explains here the conduct of the patients. Where previously the capability of surrender (in every sense of the word) existed, now the narcissistic avarice dominates. The genital zone has lost its predominance; anal erotism is strengthened. It is clear that the state pension favours the development of the character traits described; this only takes place, however, when the tendency already exists in the injured person to react narcissistically to an external injury to his integrity.
Now as regards the question of the therapy and particularly that of the psycho-analytic. At the commencement of the war one took little notice of the neurotics, they were placed perchance in a convalescent home but practically without treatment. The increasing number of neurotic cases necessitated other measures. The old method of “surprisal” was again dug up. Then came the period of “active” curative procedures, the best known of which is Kaufmann’s. These methods were at first deceptive from the fact that they led to the rapid improvement of a great number of patients. As regards, however, the duration of the cure, they have not yielded what was hoped of them, and, in addition, they produced certain unwished-for phenomena. The military medical authorities therefore display a lively interest in putting on one side the too “active” methods in favour of other effective but less severe ones.
Is psycho-analysis able to step into the breach? Theoretically we are justified in assuming that it is, because psycho-analysis alone of all methods of treatment is a causal one. We also have already practical experience to go upon; I refer to the publications of Simmel. I will now briefly speak of my own therapeutic experiences. We psycho-analysts had to be extremely cautious in our treatment of war neuroses, for the addresses at medical congresses and the literature before the war had demonstrated very clearly the refusal of the medical profession to accept the conclusions of our ideas and efforts. When in 1916 I founded a station for neuroses and mental diseases I abstained entirely from all forcible therapy, likewise from hypnosis and other suggestive means, but allowed the patients to abreact in the waking state and sought to make intelligible to them by a kind of simplified psycho-analysis the origin and nature of their suffering. I aimed at arousing in the patients the feeling of being understood, complete relaxation, and improvement. Later the station became that of a pure observation station, chiefly for mental diseases; hence I could only collect isolated therapeutic experiences. The objection that psycho-analysis works too slowly does not hold good as far as our experience goes up to the present.
Latterly it has appeared that the patients treated accordingly by the Kaufmann method frequently relapsed when they were withdrawn from the influence of the doctor, or were again exposed to the dangers of the front. Time will show whether the psycho-analytic methods will procure more lasting cures. I will communicate in conclusion the result, instructive in this connection, of the recent treatment of a neurosis carried out in my private practice. I was able in a few weeks to remove a severe phobia in a boy twelve years old, which referred to air raids. The cure persisted when the boy returned home; he was there again daily exposed to the risk of air raids and put up with this situation just like a healthy person. Perhaps this result justifies the expectation that psycho-analysis will in fact in the permanence of its cures fill up the gaps that exist at present. Psycho-analysis, which enables us to penetrate deeper than any other method into the structure of the war neuroses, will perhaps take therapeutic precedence also in the sphere of the war neuroses[6]. 3. DR. ERNST SIMMEL, Berlin.
For the past eighteen months I have been in charge of a special hospital for war neuroses, and the mass treatment necessary in such an institution has enabled me to make a comparative study of the different so-called psycho-therapeutic methods. Apart from the serious objections that can be raised with regard to all forcible and restrictive methods, which for the most part produce new psychic injuries, there are serious doubts as to the use of pure suggestion in the form of hypnosis when carried out indiscriminately as a blind technique for war neurotics. The removal of the symptom, which is done regardless of the remaining psychic constellations of the patient, generally produces at the same time a considerable general disturbance with marked subjective symptoms, such as headache, feelings of pressure on the head, insomnia, diminution of intellectual capacity, sexual impotence, etc. On the other hand, the frequently observed fact that with the disappearance of the manifest symptom the neurosis appears in another form, has proved that with all these kinds of palliative measures the root cause of the suffering has not been touched.
A medical treatment that is to be effective can only be built up on the pathogenesis of a disease. The psycho-pathogenesis of the war neurosis, (and no intelligent man any longer doubts its psychic origin), obviously can be elucidated only by means of psycho-analysis. It is intelligible that a hospital regime necessitating the simultaneous treatment of a large number of cases and calling for rapid curative results, would allow a more extensive individual analysis only in a few cases. On account of this I had from the beginning to cut down the length of the treatment. A combination of analytical-cathartic hypnosis with analytical conversations during the waking state, and dream interpretation carried out both in the waking state and in deep hypnosis, has given me a method which on an average of two or three sittings brought about relief of the symptoms. This mode of treatment implies a systematic investigation of the symptoms that have appeared in consequence of the incongruity of the war experience and the psychic preparedness of the patient; such investigation being both aetiologically conditioned as to its nature and automatically effective as to its working. With the disappearance of the symptoms the essential treatment of the war neurotics, according to modern hospital methods, was looked upon as being at an end. An analytical cure of the entire personality by a shortened and combined method will have to be reserved for the psychological clinic of the future.
The psycho-analytical explanation of the war neuroses has proved with wonderful clearness the correctness of the Freudian views on hysteria, according to which all physical symptoms represent conversions of something psychical. The body is the instrument of the mind upon which it (the mind) allows its unconscious to manifest itself in plastic and mimic expression. The functions of the unconscious are the deciding factor in the formation and building up of the war neuroses, also the frequently observed instances of the forgetting of events accompanied by feelings hostile to the ego, even when these events are very recent, permits us to recognise from the outside alone the submergence and repression of ideas and affects of a painful nature. It is comprehensible that under the pressure of years of discipline, which limits the personality and thereby prevents every individual reaction to events, the disposition to repression is extraordinarily favoured. To what degree an enforced sexual abstinence further increases this could not be tested.
The unconscious meaning of the _symptoms_ of the war neurotics, as we may state by anticipation, is for the most part of a non-sexual nature, there being exhibited in them all those war-produced affects of terror, anxiety, rage, etc. associated with ideas corresponding with the actual occurrences of the war. Stekel is quite wrong in concluding from my statements that I categorically deny a sexual basis for neuroses in general, since at present only the _symptomatology_ of the war neuroses is explained on the basis of these analytical investigations. The fact of the predisposition to neuroses is still a long way from being exhausted. The fact that in the midst of the self-same experiences one soldier remains well while another becomes a neurotic may, so far as my experience goes, be very well connected with the psycho-sexual constellation of the particular person. The systematic investigation of the dream-life of the soldier, even after the removal of the war neurotic symptoms, has indeed made it possible to recognise quite frequently threads that lead down to the primordial network of infantile sexuality.
Also many soldiers who have broken down solely under the pressure of discipline show even in this abortive form of analysis an attitude of father defiance in consequence of an infantile mother fixation as the subconscious condition of their need for opposition. In some cases even the sexual trauma of childhood becomes evident as the latent basis of the war neurosis just in the quick and deep view which is gained by hypnosis in the combined form of treatment. The war affects and ideas which form the symptoms have, on the other hand, a certain intrinsic relation to sexuality inasmuch as they are closely bound with the most primitive instincts in man,—those connected with the self-preservation instinct. If the sexual affect in the last resort originates in the instinct which is directed towards the preservation of the species, the affects of anxiety, horror, rage, etc. produced by the war are connected with the elementary urging of the preservation of the individual, and not, as superficial observers imagine, solely for the purpose of preserving the physical existence, but above all that of the psychic existence. The war neuroses are essentially interposed guarantees, the object of which is to protect the soldier against a psychosis. Anyone who has examined a great number of patients for eighteen months with perception that has been analytically sharpened, must recognise that the proportionately small number of war psychoses is only to be explained by the proportionately large number of war neuroses.
One must have experienced the war occurrences themselves or their recapitulation under analytical-cathartic hypnosis in order to understand to what attacks the mental life of a man is exposed in time of war. For instance, a man after being wounded several times has to return to the front, or is separated from important events in his family for an indefinite time, or finds himself exposed irretrievably to that murderous monster, the tank, or to an enemy gas attack which is rolling towards him; again, shot and wounded by shrapnel he has often to lie for hours or days among the gory and mutilated bodies of his comrades, and, not least of all, his self-respect is sorely tried by unjust and cruel superiors who are themselves dominated by complexes, yet he has to remain calm and mutely allow himself to be overwhelmed by the fact that he has no individual value, but is merely one unimportant unit of the whole. It is now explicable why the war neurosis of the officer does not generally exhibit such gross symptoms as that of the ordinary soldier. The officer has raised himself above the crowd, and, with a higher mental development, has more possibilities of individually sublimating his own particular injuries. Nevertheless, the neuroses in officers will claim our psycho-therapeutic treatment in a far higher degree as soon as our colleagues agree not to look upon them from moral standpoints and to consider their comrades of the officer class under the courtesy diagnoses of Neurasthenia, Ischia, Neuralgia, etc.
The war neurosis, like the peace neurosis, is the expression of a splitting of the personality. The conditions for such a splitting are brought about by the consistent narrowing of the personality complex as a result of the compulsory discipline and above all by the psychic and physical exhaustion of one or more years of war. The soldier severely burdened with undischarged mental material is compelled to meet abnormally heavy demands. An accident or a disastrous event then causes the obstructed personality to break down. Complexes with accentuated feelings held down in the unconscious become unduly powerful, and the neurosis becomes manifest. The passage from the psychical to the physical, however, signifies here more than a self-preserving process of the psyche. The act of falling ill is, in my opinion, at the same time the commencement of the healing process. The consistent use of analytic hypnosis has repeatedly shown that the physical symptoms in their mute expression strive to bring to the notice of the man the elements that are disturbing his personality and which are imprisoned and obstructed in his unconscious. Since the union between conscious and unconscious is interrupted within by the strong barrier of the resistance, a detour by way of external physical paths is necessary in order to re-establish the harmonious fitting together of the personality.
If the predominant physical symptoms of the war neuroses are modes of expression of unconsciously determined ideas, the more psychic forms of these neuroses, the states of inhibition or excitement, are due to an effort on the part of the repressed affects to re-establish the disturbed psychic balance. A strict demarcation between aetiologically effective ideas and sensations is naturally not conceivable. The relationship can only be a quantitative one. All ideas obviously stand in a quite special relationship to the ego of the patient through their accentuation of feelings; on the other hand, the affects are bound to their causative ideas. The first part of our mental analytic therapy is to recognise the meaning of the neurotic healing tendency, the second, to convey our knowledge to the patient. The crowning point of our treatment consists in securing the spontaneous cooperation of the neurotic who, freed of his emotional inhibition, and now in harmony with himself, has, through his wider mental field of vision, a greater scope for the activity of his will power. Man can only desire what he knows. By reason of this the analyst comes to realise that the diagnosis, “mala voluntas”, which so often brings the doctor who is untrained in analysis into conflict with his patient, mostly betokens a “mala potentia” of the doctor who knows nothing about the functions of the unconscious.
The weakening of the personality complexes of the soldier, as just described, his subjection to other ideas with accentuated feelings which are held down in the subconscious and thus connected with the constant readiness to subordination under the strivings of ego-hostile feelings, represents the so-called morbid suggestibility. To make use of this suggestibility for curative purposes without exposing its foundations is to increase the illness instead of bringing about a cure. The neurotic, in my opinion, succumbs in the first instance to auto-suggestion, that is to say, to over-strong emotionally toned ideas which have arisen in him at a time when the ego-complex is weakened in power or completely suspended. According to my observations, narrowings and suppressions of consciousness represent the initial stages of the war neuroses. In the smallest loss of consciousness, the shock effects of terror, up to the severe fainting attacks and the long continued loss of consciousness after being buried, we see the self-conscious of the personality more or less obliterated and the way opened to the unconscious. Here undoubtedly at the commencement are operating those teleological mechanisms which constitute the foundation of the neuroses and their formation of symptoms. Consciousness refuses to take up ideas or to assimilate at the moment those things which are too horrible in their reality to be consciously tolerated. Therefore those psychic shocks, those fainting attacks and profound loss of consciousness denote, provided there is no injury _in cerebro_, a power of the unconscious that attracts to itself the entire psychosis in a salutary manner.
Hypnosis gives us a clear picture of these processes. It shows us the patient in the same state of consciousness as that in which during the war he had acquired the origin of the illness. During hypnosis the soldier relates, or once again lives through, all the things that he had experienced in former circumstances only unconsciously. We learn of distressing pains of which, when he was buried, he never became conscious. In such a hypnosis we see his anxiety displayed, his anger arise, feelings which at the moment of the excitation were benumbed and like lightning were dragged violently into the unconscious. I can best illustrate what I have said by a few examples. For instance, the simplest cases, which occurred so often, of a flaccid paralysis of the arm after a slight gunshot wound that had been well healed for a long time and which seemed to be of a purely physical nature, showed its unconscious connections very quickly in one sitting. Consciousness only knows, “I cannot move my arm”, and no amount of reasoning was of any avail. However, the unconscious spoke during hypnosis: “In the excitement of the attack my mind became a blank. When I was hit the impact of the shrapnel was so great that my arm felt as though it was pulled violently backwards, and I immediately thought it was torn off”. The correction of the unconscious idea in hypnosis which again united the idea of the torn off arm with consciousness here quickly settled the question of an organic basis of the symptom, It can be easily understood that an arm which is no longer recognised as existing is also completely analgesic.
The neurotic symptoms which owe their origin to such suddenly occurring events we can consequently regard in their effects as realised post-hypnotic auto-suggestions. I have confirmed this view by numerous examples, I might mention the case of a soldier who suffered from a severe facial tic by which he was constantly making a grimace, and who at the same time had a contracture of the right knee joint, both of which symptoms had proved quite refractory to the usual treatment by suggestion. Hypnosis, which restored the conscious situation of the initial blowing up, very soon yielded the following information. While the patient lay unconscious under a wreckage of stones and while scenes of his native place appeared to him as in a dream, he was constantly compelled to make grimaces in order to remove the mass of sand which lay on his face and also for the purpose of breathing freely. At the same time a sharp stone was pressing on his right heel which compelled him to keep his leg bent. This compulsion which was united with unconscious ideas acted therefore as a post-hypnotic suggestion for more than a year afterwards, until at last the command which the unconscious had imposed on the patient could be annulled during hypnosis by means of my correction. In this way was the removal of these symptoms brought about. I could quote further similar examples in which these kinds of contractures represent a compulsory holding of a part in a position of ease which is based on unconscious sensations of pain.
Ideas discussed in this chapter
Text from Project Gutenberg, public domain in the United States.