Shell-Shock, Trauma, and the influence of W.H.R. Rivers
Tags: War, History, Psychology, PTSD

Shell-Shock, Trauma, and the influence of W.H.R. Rivers

How one man brought mental health treatment into a new era Philanthony Follow Aug 23 · 8 min read

Rare image of actual combat — the 9th Cameronians (Scottish rifles) going over the top under cover of a creeping barrage, near Arras, France, 1917. (Lt. John Warwick Brooke, British Army photographer, via Imperial War Museums)

The publication, in 1922, of a parliamentary enquiry into “shell-shock” was one of the high watermarks of official anguish about the conduct and catastrophes of the First World War. The committee of enquiry — fifteen of the great and good of the army, the War Office and the House of Lords, took evidence from fifty-five experts in the management of military manpower and medical treatments. In addition, four patients who suffered from “war neurosis” contributed their own accounts.

Recriminations, breast-beating, defensiveness and dark sarcastic humour about the unspeakable horrors of the war and cavalier attitudes to the loss of so many lives was already underway. The phrase “Lions led by donkeys”, first attributed to a solder writing home from the Crimean war battle front some fifty years earlier, began to be used more and more during and after the Great War, as the stubbornly repetitive tactics of the military strategists were dutifully executed by thousands of heroic foot soldiers.

Yet, even shortly after the commencement of hostilities, the problems of shell-shock and war neurosis began to be visible. Men who, though physically undamaged by incoming mortars, were confused, hallucinating, deaf, mute, apparently paralysed, unable to manage themselves in the trenches any longer. The initial responses of the front-line officers to these problems were as confused and contradictory as the condition itself: some sufferers were met with sympathy and given time away from the front to recover before returning. A few were sent back home for treatment while others were pushed back into the lines to cope as best as they could. Still others were court-marshalled and shot for cowardice.

So, after the war had run its genocidal course and time for reflection had begun, the question arose as to why so many soldiers should have suffered these mental problems. The best description of the condition, the best treatments for it, the best ways of preventing it in the first place — all these were to tax the military top brass and the medical fraternity.

For the historian these discussions reflected the changing culture of psychiatric care as well as exemplifying stigmatising moral judgements about human nature and social class that continue still, entwining themselves around such topics as drug-addiction and over-eating, healthcare and cowardice.

The approach of many of those from the armed services was summed up by the evidence of Dr Burton Fanning. Soldiers not actually struck by missiles or flying debris often complained of what was termed “commotional disturbance”. Dr Fanning stated his view that this was:

‘“emotional” in reality; and in nearly all cases, whether real or unreal, it was exaggerated. When we cross-questioned the man we usually found that he had not been blown up at all, but had been under heavy fire, that was all’.

Once this view gained currency among officers it was easy to see how much of the calamitous impact of being under fire in the trenches could be dismissed and discounted as weakness of character feeding exaggeration: Of course many men were scared and wanted to be out of the trenches, therefore it was in their interests to embroider their symptoms or even to fabricate them completely. Several officers giving evidence referred to “skrim-shamking” — a popular and derogatory synonym for malingering.

When questioned about what might lead to so many complaints of shell-shock there were a number of responses: First, that there were men being conscripted who were of weak character or already unduly nervous. Indeed as Dr Fanning alleged:

‘If the neurotic element had been kept out instead of forced in there would have been very much less “shell-shock”’

Many of the witnesses agreed with this assessment, adding that the problems of the weak-minded conscripts were compounded by lack of adequate training which contributed to low morale. Then, when one person complained of shell-shock and sympathetic relief away from the front was granted, he would be followed by more men with exactly the same problem. The underlying fear of the commanding officers that they would be left without fighting men at all was dealt with by forcing men back to the trenches and denying the reality of their problems.

The committee did not explore what became a later scandal, which was the medical treatment of those who experienced this shell-shock. Specialist treatment facilities were established and some of those individuals with hysterical paralysis were treated. This too included punitive treatments such as the “faradic” shocks administered to some by Dr Yealland: If an individual who had become mute received an electric shock to the jaw and then shouted out due to the pain, then this was proof positive that the individual was perfectly able to speak and could be returned to the front line.

Into the enquiry room came Dr Rivers

W.H.R. Rivers (from whrrivers.com)

During the course of the war Dr Rivers had been a consultant in psychological medicine to the Royal Air Force and established a reputation for providing humane care and treatment to those who had been psychologically damaged by their experiences. His most famous patients were at Craiglockhart hospital near Edinburgh, and included the poets Siegfried Sassoon and Wilfred Owen. His work has been brought to life in Regeneration, the inspirational novel by Pat Barker.

In his evidence Rivers began, like others, by objecting to the term shell-shock. Unlike others, however, his objection was not based on the lack of specificity in its use. He wanted to use the term “trauma”, recognising that in this situation the cause was less relevant than the effect: “Any disturbance”, he argued “might have caused the same result”. He then went on to distinguish between those who broke down soon after they reached the front lines because they were simply unprepared for what they were about to experience. These were people who could get well quite quickly with proper care.

A second group broke down after a long period of stress and strain. Such soldiers commonly had early experiences of being shelled but struggled on and continued through many further such assaults. After they finally broke down, Rivers reported, they would typically answer questions about the cause of their problem with reference to a relatively trivial event that had recently happened, not focussing on the serial bombings and explosions that had peppered their service at the front since they arrived.

By outlining this view Rivers was touching on his own theories about stress and repression. This was a contrast to Freudian theories that some had sought to apply, which utilised unconscious responses but traced them back to sexual drives — an avenue which did not commend itself to many of the moralising members of the armed forces. Rivers’ repression theory was very directly drawn from his observations of airmen and went like this:

There were pilots, observers, and balloon sections attached to the air force during the war. Now, the real key to understanding how much stress was experienced was the ability to engage in “manipulative activity”. Thus, pilots under attack could at least attempt evasive action and although they might need treatment, they were generally less severely affected and more readily treated. Observers, with less to occupy them and no opportunity to take evasive steps when under attack (since that was down to the pilot), had a more difficult time of it. The balloon section, however, were effectively sitting ducks all the time and could not engage in such evasive actions. Their trauma was the worst of all.

Unable to take evasive action in the face of attack, how does a person deal with the experience? Rivers’ answer was that he must take steps to repress it. Typically, others would advise “putting it out of your mind; think about something else”, and this would be a pretty normal human response. At some stage, however, in the face of continued incidents, the capacity for repression would be exhausted and the final incident — perhaps somewhat trivial — would tip the individual over into a traumatised response, triggering the acute reactions — nightmares, paralysis and the rest — so often reported by sufferers.

The approach adopted by Rivers stood in marked contrast to others giving evidence. The sense of detached yet empathic understanding he conveys, the absence of moral judgements about behaviour and “weak character”, the refusal to fall into simplistic explanations of human reactions, and the search for a meaningful theory to assist in treating patients, all bespeak a man of intelligence and compassion.

“The Eyes of Madness” A shell-shocked soldier. [Photo Unknown / Rare Historical Photos / No restriction (Ranker.com)]

The report was published

Being a parliamentary report there were a range of recommendations attached. The very first of these was to discontinue any use of the term “shell-shock”. Many of the other recommendations were based around the idea of how to proceed in the event that the war happened again in exactly the same form. Of course, it is always easier to re-fight the last war than the next one.

Sadly, however, by the time the report was published Dr Rivers had died. Patients and students at Cambridge alike mourned his passing deeply.

Postscript

As we know, the term trauma and post-traumatic stress disorder are now standard terms used to understand and work with those who experience cataclysmic personal incidents. There have been significant developments with respect to what treatments can be beneficial and what is to be avoided.

Searching on Medium I find many useful articles about the experiences of people with PTSD and indications of promising new treatments. These include the article by Ryan Fan quoting statistics that 15% of male and 9% of female Vietnam Veterans have been estimated to have PTSD.

Patient suffering from “War Neurosis” as shell-shock was also referred to (Photo: Wellcome Images / Wikimedia Commons / CC BY 4.0)

So while our understanding of PTSD and its treatments may be progressing — at least in part due to the pioneering work of Rivers, our readiness to fling human materiel into bloody conflicts seems to have altered very little.