A Therapy of
Dr William H.R. Rivers in
Dr W.H.R. Rivers made his revolutionary ideas on the treatment of shell shock public in a speech on 4th December 1917, speaking for the Section of Psychiatry of the Royal Society of Medicine. The subject was: On the Repression of War Experience. Two months later, in February 1918, his paper was published in the medical journal The Lancet.
The text below is taken from The Lancet.
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 realized 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 connection 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 realized 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 profusely 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.
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 recognizes 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 realized.
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 thoughts 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.
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.
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.
To the Article on Shell Shock.
Sources for this article.
If you want to read more about doctor William Rivers, his therapy, his patients and the Craiglockhart War Hospital, we advise you Pat Barker's novel trilogy Regeneration, The Eye in the Door and The Ghost Road (Booker Prize winner 1995).
To the frontpage of The Heritage of the Great War