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