Part 1 – A History of Post Traumatic Stress Disorder
Introduction
Let’s face it, life can be traumatic. One has only to read religious texts about wars, famines plagues and other catastrophes to realise that trauma is part of the human condition. Deuteronomy 20:1-9 reminds us that military leaders were quite aware that soldiers had to be sent home from the battlefield because of the stress they experienced:
“When thou goest out to battle against thine enemies, and seest horses, and chariots, and a people more than thou… the officers shall say, what man is there that is fearful and fainthearted? Let him go and return unto his house, lest his brethren’s heart faint as well as his heart.”
Flip through any history book and you will find traumatic experiences too many to mention. Volcanoes obliterating whole cities, millions dying of pestilence, persecutions, war, rape, burnings at the stake, beheadings, Inquisitions, pillaging; the list is long and bloody. And until quite recently, people were just left to deal with their traumas without any real help. In fact, oftentimes those suffering the effects of trauma were branded as weak and ridiculed.
It was only since the development of modern psychology that ways have been developed to diagnose the extent of the trauma and methods implemented with which to alleviate it, some more successful than others. While some people get to deal with their trauma in their own way and move on, others aren’t so lucky and end up with lifelong psychological scars, which might haunt them until they die, that is if they cannot find an effective treatment. When you realize that some one in eleven people will develop a debilitating condition which will cause intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended, you may start to see the extent of the problem.
In this series of articles I will investigate what has become known as Post Traumatic Stress Disorder (PTSD). In Part 1 I will briefly look at the history of how we have come to understand what it is. In Part 2 we will break down what PTSD is and what effect it has on those who suffer because of it. Then we will examine a number of other stress disorders that need mentioning, as well as the types of trauma that lead to it. How PTSD can be managed and treated will receive attention in Part 3, including various techniques that hypnotherapists can use to help a client who comes for help with this problem.
These articles are based on a number of research studies and for the sake of readability references have been left out of the text. A full bibliography is provided at the end for those interested in reading more on this fascinating topic.
Pierre Janet and Dissociation
There are clinical reports and observations that go back some 200 years that clearly indicate that hypnosis can be successfully used to help people who have PTSD. The most noteworthy name associated with this is Pierre Janet (1859 – 1947). He was the first clinician to describe the successful initiation of stepwise hypnotic techniques in PTSD symptom reduction. In order to understand his contribution, we have to understand the kind of patient he was working with at the time.
During the 19th century, stressful life events were usually followed by a condition called hysteria. This included a broad range of mental disorders. In modern times they are included under dissociative disorders, namely somatization disorder, conversion disorder, borderline personality disorder and PTSD. Janet was the first person to describe the role that dissociation plays in posttraumatic hysteria.
The term dissociation was most probably first used by an US physician called Benjamin Rush (1912). He wrote about it in the context of patients who were diagnosed as ‘flighty’, ‘hair-brained’ or ‘a little cracked’. It is most probable that these kinds of afflictions were actually manic attacks or schizophrenic excitement.
It was however in France, where Janet worked, that hypnosis and dissociation became linked. In a previous article I wrote, which dealt with the history of hypnosis, it was mentioned that the ‘father’ of modern hypnosis, Franz Mesmer, believed that he could magnetise his subjects and so manipulate their ‘animal magnetism’. At the time that Janet was actively studying at the Psychological Laboratory in the Pitié-Salpêtrière Hospital in the late 1800’s, hypnotists were therefore known as magnetisers.
During the 18th and first part of the 19th century, magnetisers were quite aware of hysteria and were frequently working with patients who suffered from it. What they observed was that during a state of uninduced or artificial somnambulism (as deep hypnosis was known at the time), hysterics often spoke of themselves in the third person, as if they were two different people. When in a waking state, the patient was usually unaware of the experiences of the other self in the somnambulistic state. The self in somnambulism was however aware of both and had memories of both.
Important questions were being raised about how a person could remember in one state but not the other. This led Janet to the forming of the concept of dissociation.
What is dissociation?
Dissociation is a kind of coping mechanism or a defense mechanism in order to minimize, tolerate or overcome stress. Daydreaming is a kind of dissociation, and so is hypnosis. At the other extreme would be something like loss of memory (amnesia), assuming a new identity of self (fugue), or even separate streams of consciousness.
It was Janet who observed that there is a correlation between dissociation as a result of trauma and hypnotic suggestibility. It was through working with a patient by the name of Lucie that Janet first encountered dissociation. While conducting sessions with her, he realized that “she could perform several actions and perceive a number of sensations apparently unconsciously”. Janet later discovered that there were in fact three ‘versions’ of Lucie, what he called three ‘parallel streams of Lucie’. When he hypnotised Lucie 1 and she entered the state of somnambulism, Lucie 2 appeared, interrupting the first stream. Lucie 2 had her own memories as well as those of Lucie 1. Then Lucie 3 appeared, interrupting the previous two streams, having memories from all three of the personality states.
Janet was of the opinion that Lucie 3 “represented the total and complete individual consciousness”. It is was only Lucie 3 who could remember the traumatic event that occurred when Lucie was 7 years old, which Janet considered to be the root cause of her affliction. She was on holiday and two men were hiding behind a curtain. This terrified her and brought about her trauma.
Janet published his findings and it formed the basis for subsequent studies on hysteria. One of his more important goals was to show how a person could form psychological automatism. By automatism he meant a behavior that was regular and predetermined, while being psychological, as it was associated with consciousness. His biggest discovery was that those suffering from hysteria also suffered from unresolved, and therefore dissociative, traumatic memories. In fact, what was happening to hysterical patients was that they were restricting what he termed their field of consciousness, becoming less aware of psychological activities that occur at the periphery. It was the restricted field of consciousness and dissociation that were the main characteristics of hysteria.
Fixed ideas
Janet surmised that traumatic memories could cause fixed ideas, such as an image, a thought, or a statement, accompanied by feelings, posture and bodily movements. In its worst form dissociation could alter personalities. Fixed ideas were enacted in real life when they became dominant in consciousness. Patients who were hysterics could be aware of part of a fixed idea, for instance by feeling regret but not knowing why. It was only under hypnosis that Janet could discover the true scope of such a fixed idea and pinpoint its source.
Patients who suffered from hysteria were found to be generally highly suggestible. (This is as true today of people suffering from PTSD and we will return to this point in a next article.) When examining the meaning of suggestion, he found Bernheim’s definition of 1886 too vague: “I will define suggestion as the action by which an idea is introduced into the brain and accepted by it.” Janet felt more comfortable with the idea that suggestion was a “specific manner of addressing the subconscious”.
Janet discovered that hysterical patients most often experienced extreme emotions in response to traumatic events. These emotions caused patients to be exhausted, to experience a lack of will power and inertia, being overly emotional and having a strong need for guidance and support. Janet emphasized that phenomena such as traumatic memories reside in the subconscious. He noted that therapists should be wise not to get stuck with either the symptoms or psychodynamics when addressing dissociated fixed ideas.
For Janet, resolving trauma ultimately depended on three key factors: The therapist had to form a stable therapeutic relationship with the patient; traumatic memories had first of all to be retrieved before they could be transformed into meaningful experiences; and the learned helplessness could only be overcome by taking effective action.
Because of his deep insights, Janet is considered to be the father of modern psychology. He was also the first person to use the term ‘subconscious’. His work had the effect of breaking from previous beliefs that consciousness and the mind had religious connotations. Janet was also the first psychologist to describe transference, which is when a patient expresses feelings toward the therapist that are seemingly based on how the patient felt about another person in the past. Other notable names in psychology, such as Freud and Jung, owe much of their insights from the work of Pierre Janet and acknowledged his theories as having a big influence on their work.
A shell-shocked world at war
Soon after ‘the war to end all wars’ broke out, reports started surfacing of soldiers who were experiencing “cases of nervous and mental shock”. There were a number of such cases reported in the British press in 1914 and it was seen as an uncommon phenomenon. At the time some authors were of the opinion that wars were in fact invigorating for their participants:
“It is not the great tragedies of life that sap the forces of the brain and wreck the psychic organism. On the contrary, it is small worries, the deadly monotony of a narrow and circumscribed existence, the dull drab of a life without joy and barren of an achievement, the self-centred anaemic consciousness, it is these experiences that weaken and diminish personality and so leave it a prey to inherited predispositions or to the slings and arrows of outrageous fortune.”
These advocates of the benefits of war were soon confronted with a rising number of reports of soldiers being functionally paralysed following shell explosions. Some soldiers became blind, others deaf or dumb, while yet others “may be seized by a violent and coarse tremor that shakes his body for days; or he may be paralysed with a hemiplegia or paraplegia.” What was surprising was that these soldiers suffered no obvious injury. It seemed that their condition was caused only because they were close to the explosions. The term ‘shell shock’ originated from the way soldiers spoke about it in the trenches.
Charles Somerset Myers (1873 – 1946) issued instruction to restrict this term and instead labelled these kind of suspected mental cases as Not Yet Diagnosed (Nervous) (NTDN) until such a time as a professional could diagnose them. There was much discussion about this condition until well into the 1920’s.
Hypnosis to treat shell shock
An article in the Guardian newspaper dated 3 February 1920 reported that soldiers suffering from shell shock were responding well to an unusual form of therapy, namely hypnosis. The report went on to detail 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 in the chronic stages”, as advocated in a book published by professors Elliot-Smith and Pear,
In the article a Dr William Brown, “Reader in Psychology at the University of London, and late medical officer in charge of Craiglockhart Hospital for Neurasthenic Officers” is quoted as saying that:
“…while normal psychology is concerned with the association of ideas on which the mind is built up, the psychotherapist has to consider the facts of dissociation, of the splitting up of the mind.
“Almost every bad case of shell-shock […] in the war years has been marked by some dissociation of power or powers from the mind, which may take the form of loss of memory, of voice, of walking, or of hearing. By hypnotising such a patient and recalling to him the circumstances of his injury it is often possible to reassociate the lost powers. If he has been paralysed, movement will occur in his limbs.
“I do not say that he will at once take up his bed and walk, but his limbs will move about, showing that there is power in them… We have reassociated him by bringing up lost memories. With the memories we have brought up the lost functions, and by repetition of the treatment a complete cure is often made.”
According to the good doctor, the hypnosis works on the fear that was repressed because of the trauma. He makes an example of a soldier who suffered from a hand tremor that was the result of ‘bottled-up’ emotion. In hypnosis this emotion was worked off and in his opinion this was the cause of his cure.
World War 2 and combat exhaustion
Armies taking part in World War 2 were completely “unprepared for the great number of psychiatric casualties and psychiatrists [that] were often viewed as a useless burden, as exemplified by a memorandum addressed by Winston Churchill to the Lord President of the Council in December, 1942, in the following terms:
I am sure it would be sensible to restrict as much as possible the work of these gentlemen [psychologists and psychiatrists] … it is very wrong to disturb large numbers of healthy normal men and women by asking the kind of odd questions in which the psychiatrists specialise.”
It seems that all the insights gained during WW1 were completely forgotten, especially by the US military. The number of soldiers who were suffering from ‘combat exhaustion or fatigue’ was simply staggering: “For the total overseas forces in 1944, admissions for wounded numbered approximately 86 per 1000 men per year, and the neuro-psychiatric rate was 43 per 1000 per year.” The US military had thought that pre-screening conscripts would reduce the traumatic effects of war, but sadly they were mistaken.
It was no better in Germany, where there were reports of soldiers who had suffered acute combat stress that were prescribed milk and chocolate cookies, accompanied by some rest. Russian soldiers too suffered from what was described as cardiovascular and vasomotor symptoms. We can’t even begin to imagine the kind of trauma suffered by survivors of the Holocaust.
Neuroses resulting from combat were termed combat exhaustion. Hypnosis was again used later in the war. A full-time program in hypnotherapy was developed for battle trauma cases and using a number of hypno-analytic techniques, good results were obtained.
Vietnam War
Almost 25% of the US soldiers who participated in the Vietnam War required some form of psychological intervention after returning home. This was because of the delayed effects of being exposed to combat. The prevalence of PTSD came as a big shock to the authorities. It was specifically because of the effects of the trauma that was experienced during the 1970’s (which has been the topic of countless Hollywood movies) that PTSD was formally adopted as a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition in 1980.
Conclusion
It is clear from just this brief history of PTSD that there have been many attempts to understand what it is, specifically during wartime situations, when large groups of people were affected by it at the same time. Pierre Janet laid a solid foundation with his ground-breaking research into hysteria. His insights and use of hypnosis as a treatment set an important precedent for future studies and influenced a great number of psychologists who followed in his footsteps.
It has taken several major war experiences for the effects of traumatic stress that has lasting effects on its sufferers to be studied in all its aspects and for it to be finally described in detail as an official mental disorder. It has been argued that the shell shock of WW1 cannot be compared to modern PTSD, mainly because of relatively subtle changes in culture affecting how mental illness forms, manifests, and is treated. It is clear that our understanding of trauma has developed dramatically over the past 100 years.
Interestingly, the research into hypnosis started by Janet has had an effect on the way severe trauma has been treated at various times in the past century, but unfortunately it is not yet the preferred method of treatment. Other talk therapies have been prescribed that may not be as affective, as we will see in Part 3. In the next article (Part 2), I will investigate exactly what PTSD is, what the symptoms are and detail some of the effects it can have on a person.
Bibliography
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van der Hart, O., Brown, P. and van der Kolk, B.A. (1989), Pierre Janet’s treatment of post‐traumatic stress. J. Traum. Stress, 2: 379-395. https://doi.org/10.1002/jts.2490020404
Watkins JG. The psychodynamic treatment of combat neuroses (PTSD) with hypnosis during World War II. Int J Clin Exp Hypn. 2000 Jul;48(3):324-35; discussion 336-41. doi: 10.1080/00207140008415250. PMID: 10902297.
The Guardian (1920). Hypnotism used to treat shell shock victims. https://www.theguardian.com/world/2016/feb/03/hypnotism-shell-shock-first-world-war
Steele, K & van der Hart, O. The Hypnotherapeutic Relationship with Traumatized Patients: Pierre Janet’s Contributions to Current Treatment
Kathy Steele, MN, CS Metropolitan Psychotherapy Associates Atlanta, Georgia, USA & Onno van der Hart, PhD Department of Clinical Psychology Utrecht University Utrecht, The Netherlands
Corresponding Address: Kathy Steele, MN, CS, Metropolitan Psychotherapy Associates 2801 Buford Hwy NE Suite 470 Atlanta, GA 30329, USATel: 1 (404) 321- 4954, ext. 305 Fax: (404) 321-1928 E-mail: kathysteelemn@gmail.com
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