WHR Rivers at Craiglockhart Hospital, 1917

William Halse Rivers (WHR) Rivers was born in Kent in 1864. He overcame a childhood stammer and severe typhoid in his late teens to graduate from medical school at the University of London. After a period as a ship's surgeon (and part-time career as an anthropologist), he became a member of the Royal College of Physicians and developed an interest in neurology and psychological medicine. During World War I, he was a Captain in the Royal Army Medical Corps and was based at Craiglockhart Hospital near Edinburgh, where he treated British officers afflicted with ‘shell shock’. Rivers' treatment of his patients was inspired by Freud's concepts of intrapsychic conflict (Reference Freud and Strachey1). Rather than subscribe to the view that his patients' suffering arose from the conflicts surrounding repressed sexual urges, Rivers took the approach that the minds of his patients were conflicted over the instinct of self-preservation (Reference Rivers2). In essence, Rivers saw his patients' suffering as derived from terrifying internalised experiences from the battlefields of the Western Front. Rivers published an account of his work in the Lancet in 1918, arguing:

The humanising effect of this approach to traumatic stress was evident amongst the patients of Craiglockhart. Rivers' legacy and his celebrity were assisted by the fact that he numbered amongst his patients the war poets Siegfried Sassoon and Wilfred Owen, who wrote fondly of their therapeutic relationship with him. Many of Rivers' colleagues did not share his compassionate view of shell shock, viewing it as a moral failing. Psychiatrists on the other side of the trenches of the Western Front took a similar view of such presentations (Reference Brunner4).

The story of the work of WHR Rivers highlights the contextual nature of the concept of psychological traumatic stress. Rivers' work took place within a highly politicised and fragmented scientific setting. The healers of the minds of British officers were tasked with returning their patients to the front and discrediting any anti-war sentiments that may have emerged in the course of their suffering. This contextual importance to traumatic stress persisted in the field of ‘traumatology’ throughout the last century.

The evolution of post-traumatic stress disorder (PTSD) from other concepts such as ‘shell shock’ and ‘railway spine’ has been described elsewhere (Reference Shepherd5–Reference Young and Rosen8). The construct of PTSD appears to have its conceptual roots in the writings of Abraham Kardiner (Reference Kardiner9), whose work with soldiers who had served in World War II emphasised their disrupted ego function and psychosocial impairment following exposure to combat stress. Horowitz later defined distinct psychopathological processes following traumatic stress (Reference Horowitz10). Kardiner's and Horowitz's work provided the conceptual basis of the diagnostic criteria of PTSD in the Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM-III).

The current paradigm of conceptualising psychological trauma as PTSD dates from the Vietnam War era. The appearance of PTSD in DSM-III is linked to the advocacy of Robert J. Lifton (Reference Lifton11) and Chaim Shatan, whose landmark New York Times article ‘The Post Vietnam Syndrome’ (Reference Shatan12) stimulated a socio-political movement, which crystallised the confluence of society, politics and medicine evident in the DSM project. The highly political process in which PTSD emerged has clearly been a source of great concern outside the insular world of psychiatric academia, with one writer describing Lifton and Shatan's midwifery of PTSD as ‘a tragedy, a disastrous incursion of politics into medicine, the hijacking of traditional values by a small minority of activists' (Reference Shepherd5). Despite the obvious dominance of the military discourse of trauma, other writers had identified distinctive psychopathological responses following natural disasters (Reference Erickson13) and domestic violence perpetrated against women (Reference Walker14). At the same time, American psychologists and psychiatrists were beginning to recognise distinct psychopathological states affecting survivors of the Nazi Holocaust and their children (Reference Ettinger15–Reference Jaffe17), culminating in the seminal work of Henry Krystal, who first described alexithymia in concentration camp survivors (Reference Krystal18).

Judith Herman argued that traumatology had always been a politicized process. Three periods in the 20th century saw a vigorous investigation of psychological trauma – the Great War, the Vietnam War and the women's movement of the 1970s. The sociologist Allan Young has recently argued that, in the wake of the ‘9/11’ terrorist attacks and the observation of putative psychopathology in individuals who had merely watched the attacks on TV, we are witnessing a new era of ‘virtual PTSD’ (Reference Young, Sarat, Davidovitch and Alberstein19). Military psychiatry has also had separate eras, with clinical manifestations of combat-related psychopathology varying over time, from neurasthenic presentations to more florid forms of phobic anxiety and dissociation (Reference Jones, Hodgins-Vermaas, Everitt, Beech, Poynter and Palmer20).

In the period following the advent of PTSD, interest in the field of traumatology grew in scientific circles. In 1985, the psychologist Charles Figley established the International Society for Traumatic Stress Studies (ISTSS). An official history of the ISTSS argues that the organization was ‘born out of the clashing ideologies that became so well articulated in the 1960s and 1970s' (Reference Bloom21). The founding members of the ISTSS represented a coalescence of narratives of the Vietnam War, the Holocaust and the Israeli experience. Figley harboured concerns that the ISTSS would become an elitist organization (Reference Figley22). This, indeed, has emerged as a potential problem for the organization and the field of traumatology. In the early 1990s, many clinician members of the ISTSS split from the organization and formed the rival Association for Traumatic Stress Specialists (ATSS). Whilst there is no formal account of the ATSS members' grievance, the split appeared to arise along clinician-academic lines. The ISTSS's official history notes that some members of the ISTSS expressed the feeling that the organization had ‘lost (its) soul’. In 2006, a former President of the ISTSS, Dean Kilpatrick, highlighted that many viewed it is an organization that is dominated by researchers who do not care about clinical practice; that its focus is exclusively on combat- and disaster-related trauma; that its sole concern is PTSD in adults and not other forms of psychopathology in children or adults with complicated post-traumatic syndromes; and that it is US centric (Reference Kilpatrick23). Such an approach to the clinical science of traumatic stress presents significant ethical concerns (Reference Robertson, Walter, Bloch and Green24).

The story of the work of WHR Rivers, like the story of PTSD, is one of society, politics and science. Traumatic stress remains a divisive issue – from the basic definition of traumatic stress itself to formulating evidence-based treatments for those affected. What has remained constant from Rivers' work at Craiglockhart is the importance of humanistic engagement with the traumatised patient and the meaning of their experiences.