An Address



Delivered before the Section of Psychiatry, Royal Society of Medicine,
on Dec. 4th, 1917,


  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.


  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.


  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 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.


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.