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Wednesday, 11 April 2012

War-Related Psychiatric Injury was Treated in Many Ways During WW1. How Effective Were These Methods?

The British Army was overwhelmed by the epidemic proportions of psychiatric breakdown during World War One (WW1). Soldiers were evacuated from fighting positions in their thousands, which caused a manpower crisis. ‘As early as 1917, it was recognised that war neuroses accounted for one-seventh of all personnel discharged for disabilities from the British Army…[and] emotional disorders were responsible for one-third of all discharges.’[1] Stemming the flow of ‘permanent ineffectives’ became of primary importance, and there was a concentrated drive to find effective treatments for war neuroses. Effective referred to the quickest possible return of soldiers to combat duties. However, ‘with the neurotic war casualty, to a much greater extent than with the private patient of peace-time, treatment [had] to be limited by practical possibilities,’[2] and treatment focused primarily on the removal of symptoms, rather than curing the root issues.

Prior to 1914, (military) psychiatry was embryonic, and treatment was limited and simple. In the early years of WW1, traditional methods were employed, including exercise, rest and games, but lack of understanding meant soldiers were often accused of malingering and punished; some 306 British soldiers were allegedly shot for cowardice or malingering. By 1915 however, numbers of psychiatric casualties had reached epidemic proportions, which forced the issue of treatment to the forefront of medical consciousness. Doctors were faced with a wide spectrum of disorders, expressed through symptoms including tics, deafness, paralysis and mutism. This paper will focus on the efficacy of the treatment of syndromes that revealed some objective disorder, such as deafness or paralysis, and showed no sign of organic root cause. Designate

WW1 spearheaded the development of military psychiatry and in Britain many public lunatic asylums, private mental institutions and disused buildings were re-assigned as hospitals for cases of psychiatric issues. Patients displaying symptoms were originally evacuated to base hospitals for treatment, although it became apparent that long stays in these hospitals could be detrimental to recovery, and deplete a soldier’s desire to recover. Statistics from Moss Side Military Hospital at Maghull revealed that only 21% of 731 discharged patients returned to combat duty, while even fewer returned to the front line.[3] These results demonstrated the ineffectiveness of the treatments, and also supported the theory that psychiatric conditions become progressively harder to treat once established: Salmon concluded: ‘much can be done in dealing with [shell-shock] cases if they can be treated within a few hours after the onset of severe nervous symptoms’.[4]

As a result of such statistics, ‘Forward Psychiatry’ units using the PIE treatment method were established close to the front lines to treat cases of war neuroses. ‘Forward psychiatry’ was comprised of three elements: proximity to battle, immediacy of treatment, and expectation of recovery. The further a soldier was from the front line, the less likely he was to be cured, and in 1916Myers thus established four NYDN (Not Yet Diagnosed, Nervous) centres approximately ten  miles from the front line, designed to treat soldiers quickly and effectively.[5]  An ‘environment of recovery’ was cultivated and treatment at these centres consisted primarily of hot food, rest, outdoor occupations, and graduated exercise, culminating in complete route marches. Physicians believed it was impossible to recover from psychiatric injury unless the patient was of sound physical constitution. In more developed cases, physical treatments were used, including ‘hot-water bottles and fomentations for occipital pain, and ice-bags and evaporating lotions for frontal pain’.[6]

Abreaction was utilised by a few physicians, namely Brown and Dillon, although the majority dismissed the treatment as too time-consuming, and potentially counter-productive. Instead, PIE centres had a fairly short admission length, with the average soldier staying twenty-five days. They were effective in returning soldiers to working life, although ‘forward psychiatry was not effective in returning combat troops to fighting units. But, by allocating soldiers to support roles, it prevented discharge from the armed forces.’[7] Hadfield recorded that 15 percent of patients at forward psychiatry centres returned to fighting positions, while 45 percent showed ‘improvement’.[8]

Severe or chronic cases of war neuroses were still evacuated to base hospitals where treatments were varied and experimental. As in the PIE centres, patients received standard treatments including rest, hot food, and light outdoor occupation, but additional treatment methods depended on whether the breakdown was due to paralysis of nerves, or if a psychological source was indicated. Hospitals ascribed to varying theories concerning psychiatric issues, and thus operated differently, experimenting with methods of treatment. The Maghull focused primarily on the psychodynamics of environmental factors, while the Maudsley preferred physicalist hypotheses. Van der Hart distinguished between two branches of treatment available to soldiers affected by war neuroses; either symptomatic treatments or exploratory therapy.

The former included disciplinary techniques, persuasion, suggestions (e.g., for hypnosis)…behavioural exercises, physiotherapy, hydrotherapy, gymnastics, manual work, faradism (the application of – often painful electric currents to the afflicted body parts: one of the most popular treatment techniques), isolation and rest...In contrast, exploratory techniques “consisted of uncovering traumatic experiences supposedly underlying the symptoms and letting the patient more of less relive these events.[9]

Adrian and Yealland considered faradism (electric shock therapy) a successful method of suggestion to treat functional symptoms such as mutism,[11] deafness, and paralysis. It involved the application of electric currents of varying strengths, to afflicted areas of the body, which usually produced reflex actions to convince patients they could achieve recovery. For example, a faradic current would be applied to the spine of a man experiencing localised paralysis, or to the ears of a patient experiencing functional deafness. Mott considered it successful as it produced quick and seemingly effective results – anaesthetic limbs would often jerk involuntarily when an electric current was applied, and similarly, mute throats would produce reflex phonation when tickled. Such developments comprised the first stage in recovery, and convinced the individual that complete cure was possible. Many physicians employed the theory of suggestion, and claimed that once a patient had faith in the treatments’ effectiveness, (even if the physical sensation or motion was simply reflex), their recovery rate was usually quick.

However, faradism had negative elements and many physicians avoided using it. Electric shock treatment could be excruciating, for, ‘if it is to be effective [the faradic current] must be strong enough to be painful’.[12] If a new patient had previously received unsuccessful electric treatment, psychiatrists would increase the voltage, claiming stronger currents were more effective. This element of pain meant faradism was also applied as a disciplinary aid to soldiers whose recovery process was slow, or if they displayed little motivation to recover. It was also used in defiant cases of functional symptoms, where the psychological barrier was particularly rigid. In such cases the success rate was greatly enhanced when the electricity was used in conjunction with a vigorous application of the theory of suggestion, as shocks alone were relatively useless in functional cases. Faradism was considered a useful tool by some psychiatrists, although it was not ideal as  a long-term treatment as patients could become immune to the effects, if electricity was administered too frequently. This naturally produced no results, which in turn reinforced beliefs of  incurability.

Isolation was another method of disciplinary treatment, designed to stimulate a soldiers’ desire to recover by rendering their illness synonymous with tedium and seclusion. This was a harsh treatment that attempted to forced to force soldiers to refute their claims of psychiatric upset, or claim recovery. Similar theories were practised in hospitals to encourage soldiers to overcome their issues as the ‘treatment’ was so unpleasant.  ‘Finding out the main likes and dislikes of patients and then ordering them to abstain from the former and apply themselves diligently to the latter,’[13] was one such method. ‘Patients who had a fear of noise were given rooms looking onto a main road, men who had been teachers or writers before the war were refused access to the library and men who feared being alone were put into isolation.’[14]

These methods were considered successful in suitable subjects, but could only be applied to particular cases. For example, in relation to isolation, individuals suffering from anxious neurasthenia or ‘shell shock’, relished the relative peace of solitude instead of viewing it as incentive to recover. This immediately rendered a large section of servicemen unsuitable candidates for isolation treatment. Additionally, if patients became accustomed to isolation, (which was relatively common if treatment was prolonged), additional issues were created when they attempted to reintegrate into society; which could  easily precipitate a relapse. Finally, like many treatments, isolation could not stand alone as a method of therapy, but worked best when in conjunction with a regime of additional techniques:

Isolation, even accompanied by rest and overfeeding, is never enough." It is merely an adjunct, though, under certain circumstances, a necessary one, of the treatment by persuasion. But "it would be irrational to look upon the isolation of neuropaths as a therapeutic necessity from which one might never depart.[15]

Pharmacology referred to a more complete method that treated symptoms by drug administration. For amnesiacs, Slater suggested that, ‘the slow intravenous administration of a suitable narcotic (such as sodium amytal gr. 5-7.5) is quick, effective, and of particular use to those unversed in hypnotic and analytic techniques’.[16] Stammering and tremors could also be treated with sodium, while chloroform was used as an alternative to hypnosis when treating hysterical mutism.

Sleep therapy was considered important when curing psychological issues, and although it was not effective as a single treatment, it aided recovery when used in conjunction with other methods. An early variation of insulin treatment, was often combined with rest to relieve patients of anxiety issues, while the sedatives phenol-barbitone, somnifen, and paraldehyde, were also used. However, whilst sedatives provided patients with longer and deeper sleep, hypnosis-induced narcosis was considered preferable wherever possible, as it was toxin-free and ‘in that state one can reinforce the effect of the sleep itself by giving suggestions of perfect rest of mind in dreamless sleep’.[17] During World War Two, pentothal narcosis was used in the belief it would encourage the release of repressed emotion, but it could not be utilized as a reliable treatment as it became toxic after frequent use. Hypnosis again became the preferred method, as it could be repeated as often as necessary with no adverse effects.

Methods of treatment differed if psychological sources to the neuroses were indicated, and different hospitals ascribed to varying treatment methods. Two base hospitals in the U.K. – Craiglockhart and the Maghull – became pioneers in psychotherapy and experimentation in the developing field of psychological medicine. They prescribed light physical labour to neurasthenic patients to divert their attention away  from their own issues to other tasks. Physical occupation also beneficial to their physical wellbeing, which was important for recovery, although ‘the prescription of work for the patient must be regarded as a sequel to, not as a substitute for, the performance of work by the doctor.’[18] Craiglockhart was an important treatment centre which promoted the use of cognitive therapy (either individual or group), delivered in a calming environment. It was one of the first hospitals in England to practise psychotherapy, although doctors at the Maghull military hospital were also versed in the benefits of therapy. Rivers claimed: if ‘individual treatment is given there are good prospects of restoration to health; if not, the patients are liable to drift into chronic insanity’.[19] Neither hospital implemented military discipline or culture as they felt it was counterproductive to recovery, which  contrasted with Mapother’s (of the No 2 Western General in Stockport) belief  that military culture and regime was necessary for recovery.

Cognitive and psychotherapy was the preferred methods of treatment used by doctors at the Maghull and Craiglockhart: Rivers treated Siegfried Sassoon using psychotherapy whilst he was a patient at Craiglockhart. The two would meet daily and discuss Sassoon’s traumatic experiences of warfare, and attempt to realign his anxious mind. This early form of therapy often yielded good results (although there was no guarantee against relapse if the individual was exposed to traumatic experiences). However, many physicians refused to use it as it was extremely time consuming and would often take patients years to recover, while only a small minority returned to combat duties. It also required more human resources than hospitals had to offer as treatment often required one-to-one attention. Debenham did not advocate the use of therapy for these reasons and claimed that it was impossible, even using ‘radical psychotherapy’, to free an individual from their psychiatric tendencies and reconstitute their personality. 

Abreaction was another therapeutic method used to treat neuroses that worked by encouraging patients to relive their traumatic experiences of warfare,  which were usually the root cause of the breakdown. It was primarily used as a method for treating post-traumatic amnesia (once the acute symptoms had abated), although it was not a highly favoured method as it was time consuming and recovery rates were low.  Brown pioneered a model for treatment of PTA using a repression-abreaction approach, which used a combination of abreaction and suggestive hypnosis to cure patients. As with most symptoms, amnesiacs had a better chance of recovery if they received treatment as soon as possible, before the PTA had a chance to develop and establish itself.

Hypnosis was another suggestive method of treatment for psychiatric issues, whose effectiveness has been hotly debated. Practitioners encouraged patients to live through their past experiences after being lightly hypnotised, which was designed to induce a sense of closure and calm.  However, it often took years to cure patients using hypnosis, and Rivers reported a minimal success rate. In 1917 Adrian claimed, the ‘limited experience of the method has led us to believe that it is slow and uncertain in comparison with vigorous suggestive treatment and re-education’.[20] He continued, saying that while patients displaying hysterical symptoms were usually easy to hypnotise and very susceptible to its suggestive powers, they did not comply with any requests relating to their disability. Physicians reported encountering ‘mental blocks’ when attempting to focus on patient’s problem areas. Smith and Pear disagreed, claiming hypnosis was an efficient tool in curing early cases of shell shock and subjective troubles including insomnia and nightmares. They did concede that in more developed cases of neuroses, it could not be used as the sole method of treatment. ‘We are of the opinion that hypnotic treatment, when used with skill, discretion, and discrimination, has its place in the treatment of shell-shock and similar conditions, both in the acute and chronic stages.’[21]

Thousands of men received treatments for psychiatric issues throughout the First World War, and the question arose: were they effective, and if so, to what degree? The answer is debatable as medical records provide conflicting reports, and the lack of data concerning relapse rates also makes conclusion difficult. Statistics were often exaggerated to prove the effectiveness of treatments, as military psychiatrists did not have the respect or support of their medical peers. They were under pressure to prove their worth, and the temptation to inflate their return-to-duty rates was often strong. For example, ‘in World War I, British psychiatrists argued that 80% of men were returned to active duty; while their counterparts in WWII were less optimistic, they regularly quoted  return to duty rates of over 50%.’[22] There was also stiff competition between the NYDN units as to which had the highest return-to-duty rates,[23] and patients were often discharged before properly cured, to prove efficiency and increase successful statistics. Hadfield stated:

A number of patients were “cured”, and by this much-abused term we mean that the patient was rid of his much grosser neurotic symptoms, that he could be returned to duty or to work in civil life…the majority of cases were regarded as “improved”.[24]

Grasset added: ‘It seems proven that too often [neurologists] are content to merely ‘white-wash’ trauma victims and to send them back to the front incompletely cured’.[25]

The available treatments were essentially rooted in trial and error, and while some produced success, many others did not have the desired effect, or were even counter-productive. The most positive outcome of the phenomenon psychiatric casualties in WW1 was that it became the catalyst for further developments in military medicine. Moral treatment for psychological issues developed and forms of therapy took prominence, as harsher methods were phased out.

[2] Slater et al. (1941), p.107
[3] Shephard (1996), p.445
[4] Salmon (1917), pp.539-540
[5] Jones, Thomas & Ironside (2007), p.217
[6] Carmalt-Jones (1919), p.182
[7] Jones, Thomas & Ironside (2007), p.215
[8] Hadfield (1942), p.322
[9] Knutsen (2010), p.152
[10] Adrian & Yealland (1917), p.868
[11] It was sometimes only necessary to use a mirror or tongue depressor to tickle a mute patients’ throat to promote reflex phonation. This was also true for patients suffering from aphonia, where there was no need for faradism.
[12]  Adrian & Yealland (1917), p.870
[14] Ibid
[16] Slater et al. (1941), p.108
[17] Hadfield (1942), p.322
[19] Jones (2010), p.8
[20] Adrian & Yealland (1917), p.869
[22] Jones & Wessely (2003), p.411
[23] Carmalt-Jones (1919), p.199
[24] Hadfield (1942), p.322
[25] Jones & Wessely (2003), p.412


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