Shell shock and its lessons

The Therapeutic Value of Work.

It should be unnecessary to emphasise the desirability of preventing the neurasthenic from dwelling upon his subjective troubles by occupying his mind with other things. This end may often be achieved by the provision of suitable occupation, and where possible, for many obvious reasons, this occupation should take the form of useful work. The worker then feels that he is not a mere burden upon the hospital which is treating him: the institution in its turn benefits materially. But it is necessary to sound a note of warning against the indiscriminate prescription of work as a panacea. First of all it should be certain that the work is of such a kind as really to interest the patient and to occupy his mind. There are many varieties of work, especially of manual labour, which can be performed mechanically, and do not succeed in distracting the attention from worries and anxieties. But more important even than this is the consideration that there are some mental troubles from which no form of work will distract the patient. Especially is this the case in many of the psychoneuroses caused by the war. The sufferer is often haunted day and night by memories which torture him not merely by their horror but also by another aspect which is even worse: the ever-increasing moral remorse which they induce. A patient may be troubled not only by the terrible nature of the memory but by the recurring thought, “If I had not done” this or that, “it might never have happened.” The reader will easily see how such a thought may arise in the mind, especially of a nerve-stricken officer or “N.C.O.” after weeks of brooding in private upon the memory of a disaster. Now, such self-reproaches are frequently based upon entirely insufficient evidence, and if the medical officer is given the opportunity of calmly discussing their foundations with the patient, the result is often to reassure him and to enable him to view his past in an entirely new light. It is then, and not before then, that he will be able cheerfully to enter upon useful occupation and to benefit by it. To suppose that the mere physical fatigue induced by a day’s hard work will banish all forms of insomnia betrays an ignorance of one of the most important causes of this malady; viz., mental conflict. It is well known that bodily fatigue in the case of a mentally excited patient may merely increase his unrest at night. Again, anyone who has had a few months’ experience of receiving the confidence of these nerve-stricken soldiers will know that some of their troubles are so poignant that the attractions of the (apparently) most interesting kinds of occupation leave them cold.

To sum up, the physician may confidently prescribe work when, by investigating the history of any particular case, he has satisfied himself that such occupation will be likely successfully and profitably to distract the patient’s mind from his worries. But 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.