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HYPNOTHERAPY OF WAR NEUROSES
CLINICAL PSYCHOLOGIST'S CASEBOOK
By
JOHN G. WATKINS, Ph.D.
ASSOCIATE PROFESSOR OF PSYCHOLOGY
STATE COLLEGE OF WASHINGTON.
FORMERLY CHIEF CLINICAL PSYCHOLOGIST
WELCH CONVALESCENT HOSPITAL
DAYTONA BEACH, FLORIDA
To the many veterans
WHOSE WOUNDS, THOUGH REAL, ARE INVISIBLE
PREFACE
This is a report of psychotherapy done by the author in the neuro- psychiatric division of an Army convalescent hospital during the recent war. The men whose treatment is described in the case studies were combat veterans who had broken under the stress of war, men needing individual therapy to get them well.
These patients received individualized attention in a Special Treatment Company. They differed widely in native abilities, education, and social background. What they had in common was that all had become neurotically ill during their Army service and that hypnosis was used as an integral part of their treatment. These cases have been selected from a much larger number in order to illustrate the different forms which war neurosis the "shells hock" of 1918 may take and the variations of therapeutic attack which were necessary to bring about improvement. These case reports are presented for their interest to other clinicians and as an aid to the professional student who wishes to learn hypnotherapy.
The cases are introduced by a brief account of the nature and purpose of wartime psychotherapy, the theoretical basis of the authors work, and the nature and practical application of hypnotherapeutic techniques.
Although this book is directed in general to clinical psychologists, psychiatrists, and students in these specialties, some of the materials in it should be of interest to those from related disciplines such as general medicine, education, sociology, and anthropology.
JOHN G. WATKINS
"Pullman, Washington
October, 1949.
ACKNOWLEDGMENTS
To credit adequately each individual whose cooperation and assistance helped in producing this work would be an impossible task. Services were rendered by many of the patients and staff members of Welch Hospital, including members of the secretarial staff who donated extra time to copy the first drafts of the manuscript. Throughout almost the entire period covered by the cases, Sergeant Henry P. Lampman acted as Psychiatric Social Worker for the Company. His untiring and skilful therapeutic efforts on behalf of the patients won the respect and admiration of patients and staff alike. His use of progressive relaxation and non-directive therapy was closely coordinated with the hypnotherapy. His insight and tactful contact were often crucial in turning a case in a favourable direction. The writer feels privileged to have had his assistance in the handling of these cases.
Among the Army doctors to whom the author is indebted, special acknowledgment is made to Major Lawrence J. Roose, MC, and Battalion Psychiatrist. Major Roose served with the writer in Company F, later becoming Clinical Director for the Neuropsyciatric Division of the Hospital, and made many therapeutic suggestions in the treatment of the cases described. Special thanks are likewise due to Major Norman R. Shulack, MC, and Psychiatrist, who first as Battalion Commander and later as Director of the Neuropsyciatric Division provided the encouragement, facilities, and medical backing which made possible the hypnotherapeutic activities in Company F. During the last half of the period Lieutenant Millard B. MeGee, MC, served as Psychiatrist for Company F. The writer is very grateful for his assistance and close collaboration in the handling of the cases. His personal support and constructive review of the early drafts of the manuscript provided a great stimulus for the furtherance of this work. Finally, the writer wishes to give special thanks to his wife, Doris, for her steady support and help in the revision of the manuscript, retyping of the text, and editing and correcting of proof.
J. G. W.
CHAPTER 1
INTRODUCTION
Shell shock or battle neurosis was first recognized as a major combat problem in the First World War our veterans' hospitals still contain many chronic, uncured cases from that war. The advent of the recent war with its increase of bombs as well as shells brought, as had been expected, a larger number and proportion of neuropsyciatric (NP) casualties. This increase was even greater than anticipated. A flood of incapacitated men poured to the rear, while facilities and personnel for treating them proved highly inadequate.
Battle Neurosis in the Second World War
A neurosis may look like an organic illness, but it isn't. Furthermore, it requires special methods of treatment. The neuroses are extremely complex illnesses and among the most difficult to cure. Studies in the etiology and therapy of nervous maladjustments have been made by psychoanalysts, psychiatrists, and psychologists. Yet, even before the war, when cases were much less numerous and the specialist could spend almost unlimited time with each individual, therapy was unsure and "cures" were problematical. No rapid method of therapy had been developed. Not only did clinicians differ in their points of view and approach to treatment, but there was also wide disagreement on diagnosis and diagnostic terminology. Thus, during the war the greatest number of casualties was occurring in an area in which medical science had made the least advance. To meet this problem the United States Army, somewhat belatedly, mustered all the psychiatrically and psychologically trained personnel available, and professional literature was widely disseminated among these specialists, who served within the medical corps under command of the Surgeon General's Office. Considerable latitude for research was granted. As a result, new therapeutic methods and procedures were developed. Advances were made in both drug therapies and psychotherapies. In many cases, a startling remission of symptoms occurred. First-aid treatments improved to the point that a large number of neurotic casualties could be immediately saved and returned to combat duty after a few days (Grinker and Spiegel, 1944').
Still others seemed to develop a chronicity in their symptoms. Months after their breakdown they continued to be ill, exhibiting little or no improvement in spite of a wide variety of treatments. These cases were evacuated to the United States. They ultimately reached a convalescent hospital for extended treatment preparatory to re entrance on limited duty or discharge to civilian life. It is with these cases that this book is concerned-the neuroses that were tough and unresponsive to superficial treatments.' We' shall be concerned with the "whys" and with the "What can be done about it?" in the treatment of battle neurosis. Why does George continue to remain ill months after hospitalization, while his buddy, Bill, is well enough in a few days to return to the line? They both had the same amount of service and spent the same period of time under heavy combat conditions. They looked equally healthy, and both appeared in the same good physical condition on previous medical examinations. Yet, Bill is back fighting, while George seems hopelessly ill. He is depressed and "blue." He "knows" that he will "never be any good any more," and he is worried that he may commit suicide or go insane. Why?
If we could find out "why," there was still the question, "What can we do about it?" How could George's condition be improved? Perhaps the psychiatrist would recommend an analysis. This might indeed do the job and untangle George's badly scrambled nervous system. Still, there was no certainty that it would, and an analysis would cost George or his parents several thousands of dollars. It might take years. Few there were who could afford an analysis, and fewer who were prepared to treat those who could. The crying need of the time was for a quicker method of therapy which could show a reasonable percentage of success one that required only a few weeks, not years.
Need for New Methods in Psychotherapy
The psychoanalytic approach to treatment is generally recognized as the most successful therapy for deep seated neuroses. The traditional techniques of psychoanalysis however are so time-consuming as to preclude their use in the vast majority of cases. Psychoanalysts themselves have recognized this limitation to their method and some have eagerly experimented with possible short cuts (Ferenczi, 1928), unfortunately many other analysts have taken the conservative viewpoint that no substantial, enduring alterations in personality structure can be achieved without the time-consuming working-through of neurotic resistances by the traditional methods developed by Freud. They have written off the therapeutic successes achieved by Stekel (1926, 1927) through brief, active analytic methods as superficial and as "a quick relief from symptoms and not attempting a cure of the underlying pathologic process" (Oberndorf, 1948). Stekel, a student and associate of Freud who became a dissenter from the strict Freudian approach, wrote (1949) that he was convinced that "Freud's psychoanalysis may become detrimental to the patient if it extends over several years," and that "the most orthodox Freudians will realize the disproportion between effort and result." Recent trends in psychotherapy have tended to bear out Stekel's prediction. There is today considerable interest in developing brief, active methods of treatment. Coincidentally there are many who do not hold to the pessimistic belief that enduring results can be secured only by long, time-consuming procedures. Among the analytic group this experimental viewpoint seems to be following two lines of approach. In Chicago a group of analysts (Alexander and French, 1946) has been developing a flexible therapeutic plan which replaces the daily analytic sessions with meetings at less frequent intervals, determined by the current tactics of treatment and following a more active manipulation and interpretation of transference reactions. They report generally favourable results in cases treated for brief periods ranging from one to sixty-five sessions. Considering that traditional analysis usually requires a minimum of at least two hundred sessions, this is indeed a great saving in time. The other approach to treatment which attempts to achieve results in a brief period is through the use of hypnosis. There appears to be growing a new interest in using the hypnotic technique, not only as it has been traditionally employed but also in conjunction with .other therapeutic methods, including psychoanalysis (Wolberg, 1945; Brenman and Gill, 1947).
Use of Hypnosis in Relieving Neurotic Symptoms
In this book some brief methods of treatment are described which owe their time-saving contribution to their integration with the hypnotic process. Between the past rejection of hypnosis by many therapists (because simple, direct suggestion under hypnosis does not permanently cure) and the advanced re integrative techniques of the psychoanalyst lies an intermediate field. In this area psychiatrists and clinical psychologists can utilize hypnotherapeutic methods to effect reasonably permanent symptomatic relief. They make no attempt to rebuild the patient's basic personality structure but are content within the space of a few sessions to relax, if not resolve, a few of the major unconscious conflicts and to strengthen the ego so that it can handle the remainder without excessive anxiety and suffering. It is in this area that this work hopes to make its contribution.
Plan of This Book
In this book we will first make a brief survey of the usual group and "educative" therapies employed in Welch and other military hospitals in order to describe the background and "climate" in which hypnotherapy was practiced by the author. We will then turn to an objective conceptualization of neuroses, their structure and treatment. This brief theoretical outline serves to give purpose to the various therapeutic tactics that were employed in the treatment of the cases described thereafter. It indicates the general frame of reference which acted as a guide to the therapy. This treatment might be called "analytic-type" because it is psychoanalytically oriented and has borrowed heavily from Freudian theory and practice. However, it is not psychoanalysis, as it has also departed widely from this theory both in techniques and in the psychological definition of many of its terms. At the risk of oversimplification, but in the interests of a better understanding by the lay patient, this theory has been diagrammatically presented with the simplest and fewest number of factors possible. This scheme or analogy was found very useful in bringing the patient to an intellectual understanding of his disorder as one of the steps in attaining deer insights. The aim in developing this concrete analogy has not been to improve dynamic theory but to offer a practical working formula to the practicing psychotherapist.
The particular contribution in this book lies, it is believed, in the fact that the therapy represents an amalgamation of concepts and practices from three widely differing schools in the classical psychiatric literature, psychoanalytic theory, hypnosis, and motivational psychology have been largely divorced from one another. The psychoanalysts first began with hypnosis and then later rejected it, while studies in motivational psychology have been made largely by psychologists rather than by medical men. The point of view presented here is eclectic. It prefers a therapy that will work (regardless of how many disciplines it must borrow from) to any neat, theoretical system.
In reviewing various therapeutic tactics, we will consider the use and misuse of hypnosis, the reasons why it was prematurely rejected, and the apparent slowness in its full development. The actual methods used for inducing trance will also be discussed for the benefit of those professional psychiatrists and psychologists who wish to utilize it in their therapy or research. Non professional people are warned against tinkering with hypnosis. There are certain dangers involved which will be brought out in the course of the discussion. The cases which will be presented illustrate different types of neuroses and the therapy applied. These histories have been selected for their interest both as types of neurosis and as illustrations of therapeutic technique. No attempt has been made to select only those in which "cures" or symptomatic relief were effected. In the large majority there appears to have been a considerable improvement in the patient. If it were not so, there would be no justification for the writing of this book. Of course, only a fraction of the total number of cases receiving therapy in the Special Treatment Company could be so described. The hypnoanalysis of a deep-seated neurosis presented at the end of the book describes the rather extended treatment of a case in which a number of advanced and complex methods were employed. Some unusual results occurred which may stimulate further research and study. General implications and findings from the case studies are integrated in the final summary chapter, which is intended to contribute to a better understanding of the problems of neurosis and the development of better methods of treating these disorders.