The Repression of War Experience
W.H.R. Rivers, M.D.(Lond.), F.R.C.P.(Lond.), F.R.S., Late Medical Officer, Craiglockhart War Hospital
NB: This document is reproduced from and held at the The Napier University War Poets site, and linked from http://www.panix.com/~iayork/Literary/rivers.shtml. The original was published in The Lancet, 1918.
THE LANCET]
CAPT. W. H. R. RIVERS : THE REPRESSION OF
WAR EXPERIENCE. [FEB.2, 1918
An Address
ON
THE REPRESSION OF WAR EXPERIENCE.
Delivered before the Section of Psychiatry, Royal Society of Medicine,
on Dec. 4th, 1917,
BY W. H. R. RIVERS, M.D. LOND.,
F.R.C.P. LOND., F.R.S.,
LATE MEDICAL OFFICER, CRAIGLOCKHART WAR HOSPITAL.
MR. PRESIDENT AND
GENTLEMEN,--I do not attempt to deal in this paper
with the whole problem of the part taken by repression in the production
and maintenance of the war neuroses. Repression is so closely bound up
with the pathology and treatment of these states that the full
consideration of its role would amount to a complete study of neurosis in
relation to the war.
THE PROCESS OF REPRESSION.
It is necessary at the outset to consider an ambiguity in the
term
'repression,' as it is now used by writers on the pathology of the mind
and nervous system. The term is currently used in two senses which should
be carefully distinguished from one another. It is used for the
process
whereby a person endeavors to thrust out of his memory some part of his
mental content, and it is also used for the state which ensues when,
either through this process or by some other means, part of the mental
content has become inaccessible to manifest consciousness. In the second
sense the word is used for a state which corresponds closely with that
known as dissociation, but it is useful to distinguish mere
inaccessibility to memory from the special kind of separation from the
rest of the mental content which is denoted by the term "dissociation."
The state of inaccessibility may therefore be called suppression in
distinction from the process of repression. In this paper I use
repression for the active or voluntary process by which it is attempted to
remove some part of the mental content out of the field of attention with
the aim of making it inaccessible to memory and producing the state of
suppression.
Using the word in this sense, repression is not in itself a
pathological
process, nor is it necessarily the cause of pathological states. On the
contrary, it is a necessary element in education and in all social
progress. It is not repression in itself which is harmful, but repression
under conditions in which it fails to adapt the individual to his
environment.
It is in times of special stress that these failures of
adaptation are
especially liable to occur, and it is not difficult to see why disorders
due to this lack of adaptation should be so frequent at the present time.
There are few, if any, aspects of life in which repression plays so
prominent and so necessary a part as in the preparation for war. The
training of a soldier is designed to adapt him to act calmly and
methodically in the presence of events naturally calculated to arouse
disturbing emotions. His training should be such that the energy arising
out of these emotions is partly damped by familiarity, partly diverted
into other channels. The most important feature of the present war in its
relation to the production of neurosis is that the training in repression
normally spread over years has had to be carried out in short spaces of
time, while those thus incompletely trained have had to face strains such
as have never previously been known in the history of mankind. Small
wonder that the failures of adaptation should have been so numerous and so
severe.
I do not now propose to consider this primary and fundamental
problem
of the part played by repression in the original production of the war
neuroses. The process of repression does not cease when some shock or
strain has removed the soldier from the scene of warfare, but it may
take an active part in the maintenance of the neurosis. New symptoms
often arise in hospital or at home which are not the immediate and
necessary consequence of the war experience, but are due to repression of
painful memories and thoughts, or of unpleasant affective states arising
out of reflection concerning this experience. It is with the repression
of the hospital and of the home rather than with the repression of the
trenches that I deal in this paper. I propose to illustrate by a few
sample cases some of the effects which may be produced by repression and
the line of action by which these effects may be remedied. I hope to
show that many of the most trying and distressing symptoms from
which the subjects of war neurosis suffer are not the necessary result of
the strains and shocks to which they have been exposed in warfare, but
are due to the attempt to banish from the mind distressing memories of
warfare or painful affective states which have come into being as the
result of their war experience.
THE ATTITUDE OF PATIENTS TO WAR MEMORIES.
Everyone who has had to treat cases of war neurosis, and
especially that
form of neurosis dependent on anxiety, must have been faced by the problem
of what advice to give concerning the attitude the patient should adopt
towards his war experience.
It is natural to thrust aside painful memories just as it is
natural to
avoid dangerous or horrible scenes in actuality, and this natural tendency
to banish the distressing or the horrible is especially pronounced in
those whose powers of resistance have been lowered by the long-continued
strains of trench-life, the shock of shell-explosion, or other catastrophe
of war. Even if patients were left to themselves most would naturally
strive to forget distressing memories and thoughts. They are, however,
very far from being left to themselves, the natural tendency to repress
being in my experience almost universally fostered by their relatives and
friends, as well as by their medical advisors. Even when patients have
themselves realised the impossibility of forgetting their war experiences
and have recognized the hopeless and enervating character of the treatment
by repression, they are often induced to attempt the task in obedience to
medical orders. The advice which has usually been given to my patients in
other hospitals is that they should endeavor to banish all thoughts of war
from their minds. In some cases all conversation between patients or with
visitors about the war is strictly forbidden, and the patients are
instructed to lead their thoughts to other topics, to beautiful scenery
and other pleasant aspects of experience.
To a certain extent this policy is perfectly sound. Nothing
annoys a
nervous patient more than the continual inquiries of his relatives and
friends about his experiences of the front, not only because it awakens
painful memories, but also because of the obvious futility of most of the
questions and the hopelessness of bringing the realities home to his
hearers. Moreover, the assemblage together in a hospital of a number of
men with little in common except their war experiences naturally leads
their conversation far too frequently to this topic, and even among those
whose memories are not especially distressing it tends to enhance the
state for which the term "fed up" seems to be the universal designation.
It is, however, one thing that those who are suffering from
the shocks
and strains of warfare should dwell continually on their war experience or
be subjected to importunate inquiries; it is quite another to attempt to
banish such experience from their minds altogether. The cases I am about
to record illustrate the evil influence of this latter course of action
and the good effects which follow its cessation.
RECORDS OF ILLUSTRATIVE CASES.
Straightforward Example of Anxiety Neurosis.
The first case is that of a young officer who was sent home
from France
on account of a wound received just as he was extricating himself from a
mass of earth in which he had been buried. When he reached hospital in
England he was nervous and suffered from disturbed sleep and loss of
appetite. When his wound had healed he was sent home on leave where his
nervous symptoms became more pronounced, so that at his next board his
leave was extended. He was for a time an out-patient at a London hospital
and was then sent to a convalescent home in the country. Here he
continued to sleep badly, with disturbing dreams of warfare, and became
very anxious about himself and his prospects of recovery. Thinking he
might improve if he rejoined his battalion, he made so light of his
condition at his next medical board that he was on the point of being
returned to duty when special inquiries about his sleep led to his being
sent to Craiglockhart War Hospital for further observation and treatment.
On admission he reported that it always took him long to
get to sleep
at night and that when he succeeded he had vivid dreams of warfare. He
could not sleep without a light in his room because in the dark his
attention was attracted by every sound. He had been advised by everyone
he had consulted, whether medical or lay, that he ought to banish all
unpleasant and disturbing thoughts from this mind. He had been occupying
himself for every hour of the day in order to follow this advice and had
succeeded in restraining his memories and anxieties during the day, but
as soon as he went to bed they would crowd upon him and race through his
mind hour after hour, so the every night he dreaded to go to bed.
When he had recounted his symptoms and told me about his
method of
dealing with his disturbing thoughts I asked him to tell me candidly his
own opinion concerning the possibility of keeping these obtrusive
visitors from his mind. He said at once that it was obvious to him that
memories such as those he had brought with him from the war could never
be forgotten. Nevertheless, since he had been told by everyone that it
was his duty to forget them he had done his utmost in this direction. I
then told the patient my own views concerning the nature and treatment of
his state. I agreed with him that such memories could not be expected to
disappear from the mind and advised him no longer to try to banish them
but that he should see whether it was not possible to make them into
tolerable, if not even pleasant, companions instead of evil influences
which forced themselves upon his mind whenever the silence and inactivity
of the night came round. The possibility of such a line of treatment had
never previously occurred to him, but my plan seemed reasonable and he
promised to give it a trial. We talked about his war experiences and his
anxieties, and following this he had the best night he had had for five
months.
During the following week he had a good deal of difficulty in
sleeping,
but his sleeplessness no longer had the painful and distressing quality
which had been previously given to it by the intrusion of painful thoughts
of warfare. In so far as unpleasant thoughts came to him, these were
concerned with domestic anxieties rather than with the memories of war,
and even these no longer gave rise to the dread which had previously
troubled him. His general health improved; his power of sleeping
gradually increased and he was able after a time to return to duty, not in
the hope that this duty might help him to forget, but with some degree of
confidence that he was really fit for it.
The case I have just narrated is a straightforward example of
anxiety
neurosis, which made no real progress as long as the patient tried to keep
out of his mind the painful memories and anxieties which had been aroused
in his mind by reflection on his past experience, his present state, and
the chance of his fitness for duty in the future. When in place of
running away from these unpleasant thoughts he faced them boldly and
allowed his mind to dwell on them in the day they no longer raced through
his thoughts at night and disturbed his sleep by terrifying dreams of
warfare.
Another Case of Improvement after Cessation of Repression.
The next case is that of an officer, whose burial as the result
of a
shell explosion had been followed by symptoms pointing to some degree of
cerebral concussion. In spite of severe headache, vomiting, and disorder
of micturition, he remained on duty for more than two months. He then
collapsed altogether after a very trying experience, in which he had gone
out to seek a fellow officer and had found his body blown into pieces,
with head and limbs lying separated from the trunk.
From that time he had been haunted at night by the vision of
his
dead and mutilated friend. When he slept he had nightmares in which his
friend appeared, sometimes as he had seen him mangled on the field,
sometimes in the still more terrifying aspect of one whose limbs and
features had been eaten away by leprosy. The mutilated or leprous
officer of the dream would come nearer and nearer until the patient
suddenly awoke pouring with sweat and in a state of the utmost terror.
He dreaded to go to sleep, and spent each day looking forward in painful
anticipation of the night. He had been advised to keep all thoughts of
war from his mind, but the experience which recurred so often at night
was so insistent that he could not keep it wholly from his thoughts,
much as he tried to do so. Nevertheless, there is no question but that
he was striving by day to dispel memories only to bring them upon him
with redoubled force and horror when he slept.
The problem before me in this case was to find some aspect
of the
painful experience which would allow the patient to dwell upon it in such
a way as to relieve it horrible and terrifying character. The aspect to
which I drew his attention was that the mangled state of the body of his
friend was conclusive evidence that he had been killed outright and had
been spared the long and lingering illness and suffering which is too
often the fate of those who sustain mortal wounds. He brightened at once
and said that this aspect of the case had never occurred to him, nor had
it been suggested by any of those to whom he had previously related his
story. He saw at once that this was an aspect of his experience upon
which he could allow his thoughts to dwell. He said he would no longer
attempt to banish thoughts and memories of his friend from his mind, but
would think of the pain and suffering he had been spared.
For several nights he had no dreams at all, and then came a
night in
which he dreamt that he went out into No Man's Land to seek his friend and
saw his mangled body just as in other dreams, but without the horror which
had always previously been present. He knelt beside his friend to save
for the relatives any objects of value which were upon the body, a pious
task he had fulfilled in the actual scene, and as he was taking off the
Sam Browne belt he woke with none of the horror and terror of the past,
but weeping gently, feeling only grief for the loss of a friend.
Some nights later he had another dream in which he met his
friend, still
mangled, but no longer terrifying. They talked together and the patient
told the history of his illness and how he was now able to speak to him in
comfort and without horror or undue distress. Once only during his stay
in hospital did he again experience horror in connexion with any dream of
his friend. During the few days following his discharge from hospital the
dream recurred once or twice with some degree of its former terrifying
quality, but in his last report to me he had only one unpleasant dream
with a different content, and was regaining his normal health and
strength.
Case in which Method was not Applicable.
In the two cases I have described there can be little question
that the
most distressing symptoms were being produced or kept in activity by
reason of repression. The cessation of the repression was followed by the
disappearance of the most distressing symptoms and great improvement in
the general health. It is not always, however, that the line of treatment
adopted in these cases is so successful. Sometimes the experience which a
patient is striving to forget is so utterly horrible or disgusting, so
wholly free from any redeeming feature which can be used as a means of
readjusting the attention, that it is difficult or impossible to find an
aspect which will make its contemplation endurable.
Such is the case of a young officer who was flung down by the
explosion
of a shell so that his face struck the distended abdomen of a German
several days dead, the impact of his fall rupturing the swollen corpse.
Before he lost consciousness the patient had clearly realised his situation
and knew that the substance which filled his mouth and produced the most
horrible sensations of taste and smell was derived from the decomposed
entrails of an enemy. When he came to himself he vomited profusedly and
was much shaken, but carried on for several days, vomiting frequently and
haunted by persistent images of taste and smell.
When he came under my care several moths later, suffering form
horrible
dreams in which the events I have narrated were faithfully reproduced, he
was striving by every means in his power to keep the disgusting and
painful memory from his mind. His only period of relief had occurred when
he had gone into the country far from all that could remind him of the
war, and this experience, combined with the utterly horrible nature of his
memory and images, not only made it difficult for him to discontinue the
repression, but also made me hesitate to advise this measure with any
confidence. The dream became less frequent and less terrible, but it
still recurred, and it was thought best that he should leave the Army and
seek the conditions which had previously given him relief.
Effect of Long-continued Repression.
A more frequent cause of failure or slight extent of
improvement is met
with in cases in which the repression has been allowed to continue for so
long that it has become a habit.
Such a case is that of an officer above the average age who,
while
looking at the destruction wrought by a shell explosion lost consciousness,
probably as a result of a shock caused by a second shell. He was so ill
in France that he could tell little about his state there.
When admitted to hospital in England he had lost power and
sensation in
his legs and was suffering from severe headache, sleeplessness, and
terrifying dreams. He was treated by hypnotism and hypnotic drugs and was
advised neither to read the papers or talk with anyone about the war.
After being about two months in hospital he was given three months' leave.
On going home he was so disturbed by remarks about the war that he left
his relatives and buried himself in the heart of the country, where he saw
no one, read no papers, and resolutely kept his mind from all thoughts of
war. With the aid of aspirin and bromides he slept better and had less
headache, but when at the end of his period of leave he appeared before a
medical board and the president asked a question about the trenches he
broke down completely and wept. He was given another two months' leave,
and again repaired to the country to continue the treatment by isolation
and repression.
This went on till the order that all officers must be in
hospital or on
duty led to his being sent to an inland watering-place, where no inquiries
were made about his anxieties or memories; but he was treated by baths,
electricity, and massage. He rapidly became worse; his sleep, which had
improved, became as bad as ever, and he was transferred to Craiglockhart
War Hospital. He was then very emaciated, with a constant expression of
anxiety and dread. His legs were still weak, and he was able to take very
little exercise or occupy his mind for any time. His chief complaint was
of sleeplessness and frequent dreams in which war scenes were reproduced,
while all kinds of distressing thoughts connected with the war would crowd
into his mind as he was trying to get to sleep.
He was advised to give up the practice of repression, to
read the
papers, talk occasionally about the war, and gradually accustom himself to
thinking of, and hearing about, war experience. He did so, but in a
half-hearted manner, being convinced that the ideal treatment was that he
had so long followed. He was reluctant to admit that the success of a
mode of treatment which led him to break down and weep when the war was
mentioned was of a very superficial kind. Nevertheless he improved
distinctly and slept better. The reproduction of scenes of war in his
dreams become less frequent and were replaced by images the material of
which was produced by scenes of home life. He became able to read the
papers without disturbance, but was loth to acknowledge that his
improvement was connected with this ability to face thoughts of war,
saying that he had been as well when following his own treatment by
isolation, and he evidently believed that he would have recovered if he
had not been taken from his retreat and sent into hospital. It soon
became obvious that the patient would be of no further service in the
Army, and he relinquished his commission.
I cite this case not so much as an example of failure or
relative
failure of the treatment by removal of repression, for it is probable that
such relaxation of repression as occurred was a definite factor in his
improvement. I cite it rather as an example of the state produced by long
continued repression and of the difficulties which arise when the
repression has had such apparent success as to make the patient believe in
it.
Dissociation.
In the cases I have just narrated there was no evidence that
the process
of repression had produced the state of suppression or dissociation. The
memories or other painful experience were at hand ready to be recalled or
even to obtrude themselves upon consciousness at any moment. A state in
which repressed elements of the mental content find their expression in
dreams may perhaps be regarded as the first step towards suppression or
dissociation, but, if so, it forms a very early stage of the process.
There is no question that some people are more liable to
become the
subjects of dissociation or splitting of consciousness than others. In
some persons there is probably an innate tendency in this direction; in
others the liability arises through some shock or illness; while other
persons become especially susceptible as the result of having been
hypnotized.
Not only do shock and illness produce a liability to
dissociation, but
these factors may also act as its immediate precursors and exciting
causes. How far the process of voluntary repression can produce this
state is more doubtful. It is probable that it only has this effect in
persons who are especially prone to the occurrence of dissociation. The
great frequency of the process of voluntary repression in cases of war
neurosis might be expected to provide us with definite evidence on this
head, and these is little doubt that such evidence is present.
As an example I may cite the case of a young officer who had
done well
in France until he had been deprived of consciousness by a shell explosion.
The next thing he remembered was being conducted by his servant towards
the base, thoroughly broken down. On admission into hospital he suffered
from fearful headaches and had hardly any sleep, and when he slept he had
terrifying dreams of warfare. When he came under my care two months later
his chief complaint was that, whereas ordinarily he felt cheerful and keen
on life, there would come upon him at times, with absolute suddenness, the
most terrible depression, a state of a kind absolutely different from an
ordinary fit of the blues, having a quality which he could only describe as
"something quite on its own."
For some time he had no attack and seemed as if he had not a
care in the
world. Ten day after admission he came to me one evening pale and with a
tense anxious expression which wholly altered his appearance. A few
minutes earlier he had been writing a letter in his usual mood when there
descended on him a state of deep depression and a despair which seemed to
have no reason. He had had a pleasant and not too tiring afternoon on
some neighbouring hills, and there was nothing in the letter he was
writing which could be supposed to have suggested anything painful or
depressing. As we talked the depression cleared off and in about ten
minutes he was nearly himself again.
He had no further attack of depression for nine days, and
then one
afternoon, as he was standing idly looking from a window, there suddenly
descended upon him the state of horrible dread. I happened to be away
from the hospital and he had to fight it out alone. The attack was more
severe than usual and lasted for several hours. It was so severe that he
believed he would have shot himself if his revolver had been accessible.
On my return to the hospital some hours after the onset of the attack he
was better, but still looked pale and anxious. His state of reasonless
dread had passed into one of depression and anxiety natural to one who
recognises that he has been though an experience which has put his life in
danger and is liable to recur.
The gusts of depression to which this patient was subject were
of the
kind which I was then inclined to ascribe to the hidden working of some
forgotten yet active experience, and it seemed natural at first to think
of some incident during the time which elapsed between the shell explosion
which deprived him of consciousness and the moment when he came to himself
walking back from the trenches. I considered whether this was not a case
in which the lost memory might be recovered by means of hypnotism, but in
the presence of the definite tendency to dissociation I did not like to
employ this means of diagnosis, and less drastic methods of recovering any
forgotten incident were without avail.
It occurred to me that the soldier who was accompanying the
patient on
his walk from the trenches might be able to supply a clue to some lost
memory. While waiting for an answer to an inquiry I discovered that
behind his apparent cheerfulness at ordinary times the patient was the
subject of grave apprehensions about his fitness for further service in
France, which he was not allowing himself to entertain owing to the idea
that such thoughts were equivalent to cowardice, or might, at any rate, be
so interpreted by others. It became evident that he had been practising a
systematic process of repression of these thoughts and apprehensions, and
the question arose whether this repression might not be the source of his
attacks of depression rather than some forgotten experience.
The patient had already become familiar with the idea that his
gusts of
depression might be due to the activity of some submerged experience, and
it was only necessary to consider whether we had not hitherto been
mistaken the repressed object. Disagreeable as was the situation in which
he found himself, I advised him that it was one which it was best to face,
and that it was of no avail to pretend that it did not exist. I pointed
out that this procedure might produce some discomfort and unhappiness, but
that it was far better to suffer so than continue in a course whereby
painful thoughts were pushed into hidden recesses of his mind only to
accumulate such force as to make them well up and produce attacks of
depression so severe as to put his life in danger from suicide. He agreed
to face the situation and no longer continue his attempt to banish his
apprehensions.
From this time he had only one transient attack of morbid
depression
following a minor surgical operation. He became less cheerful generally
and his state acquired more closely the usual characters of anxiety
neurosis, and this was so persistent that he was finally passed by a
medical board as unfit for medical service.
Variety of Experiences leading to Repression.
In the cases I have recorded the elements of the mental
content which
were the object of repression were chiefly distressing memories. In the
case just quoted painful anticipations were prominent, and probably had a
place among the objects of repression in other cases. Many other kinds of
mental experience may be similarly repressed. Thus, after one of my
patients had for long baffled all attempts to discover the source of his
trouble, it finally appeared that he was attempting to banish from his
mind feelings of shame due to his having broken down. Great improvement
rapidly followed a line of action in which he faced this shame, and
thereby came to see how little cause there was for this emotion. In
another case an officer had carried the repression of grief concerning the
general loss of life and happiness through the war to the point of
suppression, the suppressed emotion finding vent in attacks of weeping,
which came on suddenly with no apparent cause. In this case the treatment
was less successful, and I cite it only to illustrate the variety of
experience which may become the object of repression.
I will conclude my record of cases by a brief account which is
interesting in that it might well have occurred in civil practice.
A young officer after more than two years' service had
failed to
get to France, in spite of his urgent desires in that direction. Repeated
disappointments in this respect, combined with anxieties connected with
his work, had led to the development of a state in which he suffered from
troubled sleep with attacks of somnambulism by night and "fainting fits"
by day. Some time after he came under my care I found that, acting under
the advice of every doctor he had met, he had been systematically
thrusting all thought of his work out of his mind, with the result that
when he went to bed battalion orders and other features of his work as an
adjutant raced in endless succession through his mind and kept him from
sleeping. I advised him to think of his work by day, even to plan what he
would do when he returned to his military duties. The troublesome night
thoughts soon went, he rapidly improved, and returned to duty. When last
he wrote he had improved so much that his hopes of general service had at
last been realised.
CAUSATION AND TREATMENT.
In the cases recorded in this paper the patients had been
repressing
certain painful elements of their mental content. They had been
deliberately practising what we must regard as a definite course of
treatment, in nearly every case adopted on medical advice, in which they
were either deliberately thrusting certain unpleasant memories or thoughts
from their minds, or were occupying every moment of the day in some
activity in order that these thoughts might not come into the focus of
attention. At the same time they were suffering from certain highly
distressing symptoms which disappeared or altered in character when the
process of repression ceased. Moreover, the symptoms by which they had
been troubled were such as receive a natural, if not obvious, explanation
as the result of the repression they had been practising.
If a person voluntarily represses unpleasant thoughts during
the day it
is natural that they should rise into activity when the control of the
waking state is removed by sleep or lessened in the state which precedes
or follows sleep or occupies its intervals. If the painful thoughs have
been kept from the attention throughout the day by means of occupation, it
is again natural that they should come into activity when the silence and
isolation of the night make occupation no longer possible. It seems as if
the thoughts repressed by day assume a painful quality when they come to
the surface at night, far more intense than is ever attained if they are
allowed to occupy the attention during the day. It is as if the process
of repression keeps the painful memories or thoughts under a kind of
pressure during the day, accumulating such energy by night that they race
through the mind with abnormal speed and violence when the patient is
wakeful, or take the most vivid and painful forms when expressed by the
imagery of dreams.
When such distressing, if not terrible, symptoms disappear or
alter in
character as soon as repression ceases, it is natural to conclude that the
two processes stand to one another in the relation of cause and effect,
but so great is the complexity of the conditions with which we are dealing
in the medicine of the mind that it is necessary to consider certain
alternative explanations.
Catharsis.
The disappearance or improvement of symptoms on the
cessation of
voluntary repression may be regarded as due to the action of one form of
the principle of catharsis. This term is generally used for the agency
which is operative when a suppressed or dissociated body of experience is
brought to the surface so that it again becomes re-integrated with the
ordinary personality. It is no great step from this to the mode of action
recorded in this paper, in which experience on its way towards suppression
has undergone a similar, though necessarily less extensive, process of
re-integration.
There is, however, another form of catharsis which may have
been operative in some of the cases I have described. It often happens in
cases of war neurosis, as in neurosis in general, that the sufferers do
not repress their painful thoughts, but brood over them constantly until
their experience assumes vastly exaggerated and often distorted importance
and significance. In such cases the greatest relief is afforded by the
mere communication of these troubles to another. This form of catharsis
may have been operative in relation to certain kinds of experience in some
of my cases, and this complicates our estimation of the therapeutic value
of the cessation of repression. I have, however, carefully chosen for
record on this occasion cases in which the second form of catharsis, if
present at all, formed an agency altogether subsidiary to that afforded by
the cessation of repression.
Re-education.
Another complicating factor which may have entered into the
therapeutic
process in some of the cases is re-education. This certainly came into
play in the case of the patient who had the terrifying dreams of his
mangled friend. In his case the cessation of repression was accompanied
by the direction of the attention of the patient to an aspect of his
painful memories which he had hitherto completely ignored. The process by
which his attention was thus directed to a neglected aspect of his
experience introduced a factor which must be distinguished from the
removal of repression itself. The two processes are intimately
associated, for it was largely, if not altogether, the new view of his
experience which made it possible for the patient to dwell upon his
painful memories.
In some of the other cases this factor of re-education
undoubtedly
played a part, not merely in making possible the cessation of repression,
but also in helping the patient to adjust himself to the situation with
which he was faced, thus contributing to the recovery or improvement which
followed the cessation of repression.
Faith and Suggestion.
A more difficult and more contentious problem arises when we
consider
how far the success which attended the cessation of repression may have
been, wholly or in part, due to faith and suggestion. Here, as in every
branch of therapeutics, whether it be treatment by drugs, diet, baths,
electricity, persuasion, re-education, or psycho-analysis, we come up
against the difficulty raised by the pervasive and subtle influence of
these agencies working behind the scenes.
In the case before us, as in every other kind of medical
treatment, we
have to consider whether the changes which occurred may have been due, not
to the agency which lay on the surface and was the motive of the
treatment, but at any rate in part to the influence, so difficult to
exclude, of faith and suggestion. In my later work I have come to believe
so thoroughly in the injurious action of repression and have acquired so
lively a faith in the efficacy of my mode of treatment that this agency
cannot be excluded as a factor in any success I may have. In my earlier
work, however, I certainly had no such faith and advised the
discontinuance of repression with the utmost diffidence. Faith on the
part of the patient may, however, be present even when the physician is
diffident. It is of more importance that several of the patients had
been under my care for some time without improvement until it was
discovered that they were repressing painful experiences. I was only when
the repression ceased that improvement began.
Definite evidence against the influence of suggestion is
provided by the
case in which the dream of the mangled friend came to lose its horror,
this state being replaced by the far more bearable emotion of grief. The
change which followed the cessation of repression in this case could not
have been suggested, for its possibility had not, so far as I am aware,
entered my mind. So far as suggestions, witting or unwitting, were given,
these would have had the form that the nightmares would cease altogether,
and the change in the affective character of the dream, not having been
anticipated by myself, can hardly have been communicated to the patient.
It is, of course, possible that my own belief in the improvement which
would follow the adoption of my advice acted in a general manner by
bringing the agencies of faith and suggestion into action, but these
agencies can hardly have produced the specific and definite form which the
improvement took. In other of the cases I have recorded faith and
suggestion probably played their part, that of the officer with the sudden
and overwhelming attacks of depression being especially open to the
possibility of these influences.
Such complicating factors as I have just considered can no
more be
excluded in this than in any other branch of therapeutics, but I am
confident that their part is small beside that due to stopping a course
of action whereby patients were striving to carry out an impossible
task. In some cases faith and suggestion, re-education, and sharing
troubles with another undoubtedly form the chief agents in the removal
or amendment of symptoms of neurosis, but in the cases I have recorded
there can be little doubt that they contributed only in a minor degree to
the success which attended the giving up of repression.
FITNESS FOR MILITARY SERVICE.
Before I conclude a few words must be said about an aspect
of my subject
to which I have not so far referred. When treating officers or men
suffering from war neurosis we have not only to think of the restoration
of the patient to health ; we have also to consider the question of fitness
for military service. It is necessary to consider briefly the relation of
the prescription of repression to this aspect of military medical
practice.
When I find that a soldier is definitely practising repression
I am
accustomed to ask him what he thinks is likely to happen if one who had
sedulously kept his mind from all thoughts of war, or from special
memories of warfare, should be confronted with the reality, or even with
such continual reminders of its existence as must inevitably accompany
any form of military service at home. If, as often happens in the case of
officers, the patient is keenly anxious to remain in the Army, the
question at once brings home to him the futility of the course of action
he has been pursuing. The deliberate and systematic repression of all
thoughts and memories of war by a soldier can have but one result when he
is again faced by the realities of warfare.
Several of the officers I have described or mentioned in this
paper were
able to return to some form of military duty, with a degree of success
very unlikely if they had persisted in the process of repression. In
other cases, either because the repression had been so long continued or
for other reason, return to military duty was deemed inexpedient. Except
in one of these cases no other result could have been expected with any
form of treatment. The exception to which I refer is that of the patient
who had the sudden attacks of reasonless depression. This officer had a
healthy appearance and would have made light of his disabilities at a
medical board. He would certainly have been returned to duty and sent to
France. The result of my line of treatment was to produce a state of
anxiety which led to his leaving the Army. This result, regrettable
though it be, is far better than that which would have followed his return
to active service, for he would inevitably have broken down under the
first stress of warfare, and might have produced some disaster by failure
in a critical situation or lowered the morale of his unit by committing
suicide.
NECESSITY OF ADOPTING A MIDDLE COURSE.
In conclusion, I must again mention a point to which reference
was made
at the beginning of this paper. Because I advocate the facing of painful
memories and deprecate the ostrich-like policy of attempting to banish
them from the mind, it must not be thought that I recommend the
concentration of the thoughts on just such memories. On the contrary, in
my opinion it is just as harmful to dwell persistently upon painful
memories or anticipations and brood upon feelings of regret and shame as
to banish them wholly from the mind.
It is necessary to be explicit on this matter when dealing
with patients. In a recent case in which I neglected to do so, the
absence of any improvement led me to inquire into the patient's method of
following my advice. I found that, thinking he could not have too much
of a good thing, he had substituted for the system of repression he had
followed before coming under my care one in which he spent the whole day
talking, reading, and thinking of war. He even spent the interval
between dinner and going to bed in reading a book dealing with warfare.
There are also some victims of neurosis, especially the very young, for
whom the horrors of warfare seem to have a special fascination, so that
when the opportunity presents itself that cannot refrain from talking by
the hour about war experiences, although they know quite well that is bad
for them to do so.
Here, as in so many other aspects of the treatment of
neurosis, we have
to steer a middle course. Just as we prescribe moderation in eating,
drinking, and smoking, so is moderation necessary in talking, reading,
and thinking about war experience. Moreover, we must not be content
merely to advise our patients to give up repression ; we must help them
by every means in our power to give up repression ; we must help them by
every means in our power to put this advice into practice. We must show
them how to overcome the difficulties which are put in their way by
enfeebled volition and by the distortion of experience when it has long
been seen exclusively from some one point of view. It is often only by a
process of prolonged re-education that it becomes possible for the
patient to give up the practice of repressing war experience.
I am indebted to Major W. H. Bryce, R.A.M.C., for
permission to publish
the cases recorded in this paper, and for his never-failing support and
interest while working under his command in Craiglockhart War Hospital.