Editing W. H. R. Rivers (section)

==The Great War==
When Rivers returned to England in spring 1915, he had trouble at first finding a place for himself in the war effort.<ref name=":0" /> Following the footsteps of his former student—the current director of the Cambridge Psychology Laboratory—[[Charles Samuel Myers|C. S. Myers]], the 51-year-old Rivers signed up to serve as a civilian physician at the [[Maghull Military Hospital]] near Liverpool.<ref name="slobodin" /> Upon his arrival in July 1915, Rivers was appointed as a psychiatrist and thus he re-entered into the study of "insanity".<ref name="slobodin" />

"Insanity" in this case entailed working with soldiers who had been diagnosed with any of a wide range of symptoms, which were collectively referred to as "[[shell shock]]". These soldiers were known to demonstrate symptoms such as temporary blindness, memory loss, paralysis, and uncontrollable crying.<ref>{{Cite book|title = Europe Since 1914: Encyclopedia of the Age of War and Reconstruction|publisher = Charles Scribner's Sons|year = 2006|location = Detroit, MI|chapter-url = http://ic.galegroup.com/ic/whic/ReferenceDetailsPage/ReferenceDetailsWindow?zid=68e38a773150a58e15b8ce0ae86c33fa&action=2&catId=&documentId=GALE%7CCX3447000901&userGroupName=mlin_m_cambrls&jsid=610181483d9a5e64da4b8aa0cd26a8a5|chapter = War Neuroses|editor-last = Merriman|editor-first = John|volume = 5|editor-last2 = Winter|editor-first2 = Jay|pages = 2699–2705}}</ref> As such, by the time Rivers was assigned to Maghull War Hospital, it was known as the "centre for abnormal psychology", and many of its physicians were employing techniques such as dream interpretation, psychoanalysis and hypnosis to treat shell shock, also known as the war neuroses.<ref name="slobodin" />

Rivers himself was a well-read psychologist and so was already quite familiar with [[Sigmund Freud|Freud]], [[Carl Jung|Jung]], and other [[Psychoanalytic theory|psychoanalysts]].<ref name="slobodin" /> In fact, Rivers was quite sympathetic to some of Freud's ideas.<ref name=":0" /> As such, Rivers joined the band of doctors at Maghull who devoted themselves to understanding the origins and treatment of the "war neuroses" under the guidance of R. G. Rows.<ref name=":1">{{Cite journal|url = http://www.kcl.ac.uk/kcmhr/publications/assetfiles/historical/jones2010-shellshockatmagull.pdf|title = Shell Shock at Maghull and the Maudsley: Models of Psychological Medicine in the UK|last = Jones|first = Edgar|date = July 2010|journal = Journal of the History of Medicine and Allied Sciences|doi = 10.1093/jhmas/jrq006|pmid = 20219728|access-date = 29 November 2015|volume = 65|issue = 3|pages = 368–95|s2cid = 2353339}}</ref>

After about a year of service at Maghull War Hospital, Rivers was appointed a [[Captain (British Army and Royal Marines)|captain]] in the [[Royal Army Medical Corps]], and his two youthful dreams—to be an army doctor and to "go in for insanity"—were realized when he was transferred to [[Craiglockhart War Hospital]] near [[Edinburgh]], Scotland in order to help "clean house" following a scandal.<ref name="slobodin" /><ref name=":0" /> There, Rivers treated officers who had been diagnosed with "shell shock", and he also began formulating his theory regarding the origin and treatment of the war neuroses. {{blockquote|Rivers, by pursuing a course of humane treatment, had established two principles that would be embraced by American military psychiatrists in the [[World War II|next war]]. He had demonstrated, first, that men of unquestioned bravery could succumb to overwhelming fear and, second, that the most effective motivation to overcome that fear was something stronger than patriotism, abstract principles, or hatred of the enemy. It was the love of soldiers for one another.<ref>{{cite web|author=Arthur Anderson|url=http://anxiety-panic.com/history/h-1900.htm|title=Anxiety and Panic History 1900 — 1930|access-date=8 January 2007|date= 25 March 2006}}</ref>}}

[[Image:rivers2.jpg|left|frame|W. H. R. Rivers outside Craiglockhart]]

Rivers's methodology for treating the war neuroses are often, and somewhat unfairly, said to have stemmed from [[Sigmund Freud]]. While it is true that Rivers was aware of and was influenced by Freud's theories and by the practice of psychoanalysis, he did not blindly subscribe to all of Freud's premises.<ref name="slobodin" /><ref name="instinct" /> Most importantly, Rivers saw the instinct of [[self-preservation]] rather than the sexual instinct, as the driving force behind war neuroses.<ref name="instinct" /><ref>{{cite journal | url = http://muse.jhu.edu/login?uri=/journals/history_workshop_journal/v058/58.1raitt.html |last=Raitt |first=Suzanne |title=Early British Psychoanalysis and the Medico-Psychological Clinic History Workshop Journal |issue=58 |date=Autumn 2004 |pages=63–85 }}</ref> (Essays such as [http://www.freud.org.uk/education/topic/10574/subtopic/41837/ Freud and the War Neuroses: Pat Barker's "Regeneration"]  further compare Freud and Rivers' theories; see also the subsection on Rivers' ''Instinct and the Unconscious'' below; see also Rivers' ''Conflict and Dream'' for his own opinion on Freudian theory.)

It is on this belief regarding the origins of the war neuroses that he formed his "talking cure". Rivers' "talking cure" was primarily based on the ancient belief of [[catharsis]]: the idea that bringing repressed memories into the light of consciousness rids memories and thoughts of their power.<ref name=":2" /> As a result, Rivers spent most of his days talking with the officers at Craiglockhart, guiding them through a process Rivers referred to as autognosis.<ref name="slobodin" /><ref name=":2" /><ref name=":3">{{Cite book|title = Modern nostalgia: Siegfried Sassoon, trauma and the Second World War I|last = Hemmings|first = Robert|publisher = Edinburgh University Press|year = 2008|location = Edinburgh|pages = 54–55|chapter = Witnessing and survival: The challenge of 'autognosis' in the interwar years}}</ref> Rivers' autognosis consisted of two parts. The first part included "re-education", or educating the patient about the basics of [[psychology]] and [[physiology]]. River's method also consisted of helping a soldier comprehend that the illness he was experiencing was not "strange" nor permanent.<ref name="slobodin" /><ref name=":2" /> To Rivers, the war neuroses developed from ingrained ways of reacting, feeling, or thinking: namely, the attempt to wittingly [[Repression (psychological)|repress]] all memories of traumatic experiences or unacceptable emotions.<ref name=":2" />  Once a patient could understand the source(s) of his troubles (which could be conscious, unconscious, environmental, or a combination), Rivers could then help him contrive ways to overcome these patterns and thus free himself from, or at least adjust to, the illness.<ref name="slobodin" /><ref name=":2" /><ref name=":3" />

Rivers' approach to treating the war neuroses made him a pioneer in his day; while he was not the first to advocate humane treatment methods for the war neuroses,<ref name=":1" /> he was one of the few to do so in a time when there was much debate over the cause and thus the "correct" treatment for [[shell shock]].<ref>{{Cite book|title = Report of the War Office Committee of enquiry into "shell shock|publisher = Imperial War Museum|year = 1922|location = London|edition = 2004}}</ref> (See the Wikipedia article on [[Lewis Yealland]] and faradization for an alternative treatment method.)  Furthermore, Rivers encouraged his patients to express their emotions in a time when society encouraged men to keep a "[[Stiff upper lip|stiff upper-lip]]". River's method, and his deep concern for every individual he treated, made him famous among his clients. Both [[Siegfried Sassoon]] and [[Robert Graves]] wrote highly of him during this time.<ref name="slobodin" /><ref name=":3" />

=== Rivers and Sassoon ===
Sassoon came to Rivers in 1917 after publicly protesting against the war and refusing to return to his regiment, but was treated with sympathy and given much leeway until he voluntarily returned to France.<ref>{{cite book | first = Max | last = Egremont | title = Siegfried Sassoon: a Life | url = https://archive.org/details/siegfriedsassoon0000egre | url-access = registration | publisher = Farrar, Straus and Giroux | location = New York | year = 2005 | isbn = 0-374-26375-2 }}</ref> For Rivers, there was a considerable dilemma involved in "curing" his patients simply in order that they could be sent back to the [[Western Front (World War I)|Western Front]] to die. Rivers's feelings of guilt are clearly portrayed both in fiction and in fact. Through Pat Barker's novels and in Rivers's works (particularly ''Conflict and Dream'') we get a sense of the turmoil the doctor went through. As Sassoon wrote in a letter to [[Robert Graves]] (24 July 1918):

{{poemquote|O Rivers please take me. And make me
Go back to the war til it break me...}}

Rivers did not wish to "break" his patients, but at the same time he knew that it was their duty to return to the front and his duty to send them. There is also an implication (given the pun on Rivers's name along with other factors) that Rivers was more to Sassoon than just a friend.  Sassoon called him "father confessor", a point that [[Jean Moorcroft Wilson]] picks up on in her biography of Sassoon; however, Rivers's tight morals would have probably prevented a closer relationship from progressing:

{{blockquote|Rivers's uniform was not the only constraint in their relationship. He was almost certainly homosexual by inclination and it must quickly have become clear to him that Sassoon was too. Yet neither is likely to have referred to it, though we know that Sassoon was already finding his sexuality a problem. At the same time, as an experienced psychologist Rivers could reasonably expect Sassoon to experience "transference" and become extremely fond of him. [[Paul Fussell]] suggests in ''[[The Great War and Modern Memory]]'' ({{ISBN|0195019180}}) that Rivers became the embodiment of the male "dream friend" who had been the companion of Sassoon's boyhood fantasies. Sassoon publicly acknowledged that "there was never any doubt about my liking [Rivers]. He made me feel safe at once, and seemed to know all about me".

But Sassoon's description of the doctor in ''Sherston's Progress'', lingering as it does on Rivers's warm smile and endearing habits – he often sat, spectacles pushed up on forehead, with his hands clasped around one knee – suggests that it was more than liking he felt. And privately he was rather franker, telling Marsh, whom he knew would understand, that he "loved [Rivers] at first sight".}}

Not only Sassoon, but his patients as a whole, loved him and his colleague [[Frederic Bartlett]] wrote of him 
{{blockquote|Rivers was intolerant and sympathetic. He was once compared to [[Moses]] laying down the law. The comparison was an apt one, and one side of the truth. The other side of him was his sympathy. It was a sort of power of getting into another man's life and treating it as if it were his own. And yet all the time he made you feel that your life was your own to guide, and above everything that you could if you cared make something important out of it.<ref>{{cite journal | author = Bartlett, F. C. | year = 1922 | title = Obituary notice of W. H. R. Rivers | journal = [[The Eagle (magazine)|The Eagle]] | pages = 2–14 }}</ref>}}

Sassoon described Rivers's [[Doctor-patient relationship#Bedside manner|bedside manner]] in his letter to Graves, written as he lay in hospital after being shot (a head wound that he had hoped would kill him – he was bitterly disappointed when it did not):

{{poemquote|But yesterday my reasoning Rivers ran solemnly in,
With peace in the pools of his spectacled eyes and a wisely omnipotent grin;
And I fished in that steady grey stream and decided that I
after all am no longer the Worm that refuses to die.<ref>Letter to Robert Graves, 1917, The War Poems of Siegfried Sassoon, Faber and Faber.</ref>}}

Rivers was well known for his compassionate, effective and pioneering treatments; as Sassoon's testimony reveals, he treated his patients very much as individuals.

=== Instinct and the Unconscious: A Contribution to a Biological Theory of the Psycho-Neuroses ===
Following his appointment at Craiglockhart War Hospital, Rivers published the results of his experimental treatment of patients in ''[[The Lancet]]'', "On the Repression of War Experience",<ref name=":2">{{cite journal|url=http://net.lib.byu.edu/~rdh7/wwi/comment/rivers.htm|journal=The Lancet|title=The Repression of War Experience|author=W. H. Rivers|date=2 February 1918|volume=11|issue=Sect Psych|pages=1–20|issn=0140-6736 |doi=10.1016/S0140-6736(01)23233-4 |pmid=19980290|pmc=2066211}}</ref><ref>{{cite web|url=http://www.firstworldwar.com/features/rivers1.htm|author=Michael Duffy|title=Feature Articles: The Repression of War Experience by W. H. Rivers|access-date=8 January 2007|date=9 February 2003}}</ref> and began to record interesting cases in his book ''Conflict and Dream,'' which was published a year after his death by his close friend [[Grafton Elliot Smith]].<ref name="ConflictDream" />

In the same year he published his findings in ''The Lancet'', Rivers also composed an article on the various types of "[[Psychotherapy|psycho-therapeutics]]" in practice at the time.<ref name="slobodin" /><ref>{{Cite book|title = Encyclopædia of Religion and Ethics: Picts-Sacraments|last = Rivers |first=W. H. R. |publisher = Charles Scribner's Sons|year = 1919|location = New York|pages = 433–440|editor-last = Hastings|editor-first = James|volume=10 |chapter=Psycho-therapuetics}}</ref> Rivers' personal and complete theory on the origin of the "psycho-neuroses", including the war neuroses, was not to be published until 1920 with the publication of ''Instinct and the Unconscious: A Contribution to a Biological Theory of the Psycho-Neuroses''.<ref name="instinct" />

River's theory of the neuroses incorporates everything he had researched up until this point and was designed to "consider the general biological function of the process by which experience passes into the region of the unconscious...."<ref name="instinct" /> (pp.&nbsp;5–6). In other words, Rivers' goal was to outline an umbrella theory which would both explain neuroses and neurological issues as he had encountered them (see the subsection "A Human Experiment in Nerve Division" above).

In attempting to construct such an umbrella theory, Rivers accepted that the unconscious exists and that the contents of the unconscious are entirely inaccessible to a person except through the processes of hypnosis, dreaming, or psychoanalysis. Rivers further defined the unconscious as a repository of instincts and associated experiences (i.e. memories) which are painful or not useful to the organism.<ref name="instinct" />

"Instincts", in this regard, are actions which an organism performs without learning and which are executed without the mediating influence of thought. As such, the action has an "all-or-none" aspect to it: it either does not occur at all or it occurs with all of its force. To this end, Rivers included the protopathic sensations,<ref name="NerveDivision" /> mass-reflex actions (as observed in spinal-cord injury patients), and basic emotions (i.e. anger, fear) as instincts.<ref name="instinct" />

Rivers further asserted that all painful or un-useful instincts are naturally kept out of conscious awareness (i.e. in the unconscious) by suppression. Suppression—in this view—is a natural and "unwitting" (unintentional) method for removing painful instincts from consciousness and confining them in the unconscious. Neuroses, therefore, develop when something in the natural process of suppression is disrupted so that a suppressed instinct and its associated emotion are released from the unconscious. Rivers cites two possible reasons for the "escape" of such instincts from the unconscious: either the instinct became too strong to contain, or the normal reserves which typically suppress it were weakened. It is important to note, however, that the etiology of war neuroses is not simply the escape of instincts from the unconscious and the ensuing conflict. More often than not, Rivers believed that the way in which such conflict is resolved (or is attempted to be resolved) also greatly influences the manifestation of the neuroses.<ref name="instinct" />

In regards to the war neuroses, Rivers believed that the disease's manifestation stems from the escape of the "self-preservation" or "danger instincts" from the unconscious. These "danger instincts", as Rivers conceives of them, include at least five types of reflexive reactions to danger: (i) fear as manifested by flight, (ii) aggression as manifested by fighting, (iii) the suppression of all emotion in order to complete complex tasks which leads to safety, (iv) terror as manifested by immobility, and (v) the suppression of all physical resources as manifested by collapsing. Typically, reactions i, ii, iv, and v are suppressed so that humans can remain calm in the face of fear and can complete complex actions which lead to safety. When all five "self-preservation" instincts are repeatedly aroused for long periods of time, such as during exposure to war, the instincts gain power and eventually "escape" from the unconscious. As such, the emotions of fear, aggression, and terror arise into consciousness, as do their associated responses. These emotions and their suggested actions create great conflict in the consciousness, however: "fear" and "terror" are far from socially acceptable in war. In order to deal with the conflict created by the "escaped" instincts, Rivers posited that the mind must do something to provide immediate relief.  It is this attempt to achieve relief from mental conflicts that leads to war neuroses.<ref name="instinct" />

For example, Rivers proposed that officers and soldiers who have night terrors do so because they are trying to wittingly repress emotions and their associated instincts back into the unconscious.<ref name=":2" /> Repression, according to Rivers, is never adequate for removing conflict; it is only fruitful when a person can exert a conscious effort to do so. As a result, the repressed instincts, along with their associated emotions and memories, seep into consciousness when soldiers are sleeping.<ref name="instinct" /><ref name=":2" /> The result is night terrors.

In an alternative scenario, wartime hysteria can be explained as the body's suppression of normal physiological functioning in order to avoid the scenario which activates the danger instincts and releases the associated emotion of fear into consciousness. Hysterical soldiers often presented with symptoms of paralysis and diminished or lost sensory capacities, even in the absence of anxiety or depression. These physiological symptoms, although distressing in themselves, make it impossible for a soldier to be returned to the front line. Thus, the body compensates for its inability to suppress the danger instincts in the face of war by making it so that the soldier must avoid warfare altogether.<ref name="instinct" />

Overall, Rivers attributed the neuroses to both (i) the escape of painful instincts and their associated emotions from the unconscious and (ii) the mind's unsuccessful efforts to force such instincts and their emotions back into the conscious.<ref name="instinct" /> While Rivers' theory contains some [[Freudian]] elements,<ref name="slobodin" /> it is not simply a restatement of psychoanalytic theory; Rivers' theory of the neuroses draws heavily on the neurological observations and conclusions Rivers and [[Henry Head]] drew from their work on nerve regeneration.<ref name="NerveDivision" />

In retrospect, Rivers' particular method of treating the war neuroses and his theory of the origin of neuroses—while pioneering in their day—have failed to leave a huge mark on the history of psychology.<ref name=":4" /> However, the ''general'' contributions of [[Shell shock|psychiatrists treating war neuroses]], in combination with the overwhelming prevalence of the neuroses during the [[World War I|Great War]], led to a revolution in the British perspective of [[Mental Illness|mental illness]] and its treatment.