W.H.R.Rivers

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 ”

“ 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. ”

“ 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 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. ”

“ 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. ”