Feature Articles - The Repression of War Experience by W. H. Rivers
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 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 loath 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.
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