from "The Repression of War Experience" by W.H.R. Rivers, M.D. Published in THE LANCET, Feb. 2, 1918
NB: This document is reproduced from and held at the The Napier University War Poets site.
"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."
"…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."
"a young officer…he was nervous and suffered from disturbed sleep and loss of appetite…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
"…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 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…
"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."
"The next case…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 its 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."
"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…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."
"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."