« 上一頁繼續 »
Secondly, there have been, I believe, a certain number of 'shellshock' patients, who, having come into the hands of a medical officer who accepted the principle of ' abreaction,' have been put through their paces again and again, i.e. been made to live through the disturbing experience repeatedly in hypnosis, and have shown increase rather than relief of symptoms.
The crucial question for observation is—Does the revival of the emotion, the re-living of the emotional experience, in itself result in relief? Or is it not true that in all cases in which relief follows, there is also some recovery from some amnesia, paralysis, or other manifestation of dissociation? I am inclined to reply 'No' to the former question and 'Yes' to the latter. These answers are in accordance with my experience. What is the experience of others in respect to this question? Some of those who believe in the value of ‘abreaction' have probably paid no attention to this question, being content to regard the overcoming of the dissociation as an effect of the emotional discharge. I suggest that this is a false assumption; that the essential therapeutic step is the relief of the dissociation; and that the emotional discharge is not necessary to this, though it may play some part in contributing to bring it about. Dr Brown, in reporting his procedure in an earlier paper, has told us
, how, although he attached importance to ‘abreaction,' he energetically strove to secure relief of dissociation by insisting, while the patient was being roused from hypnosis, upon his continuing to remember in the waking state the scenes which he had re-lived and described in the hypnotic state. In this procedure he seems to have recognised practically that the emotional excitement was not in itself the curative process, but that at the most it was contributory only to the essential step in the process of cure, namely the relief of amnesia or dissociation.
That the discharge of emotional excitement plays no essential curative rôle is indicated by those cases in which relief of dissociation and consequent general improvement are effected without any appreciable display of such excitement.
That the emotion accompanying the recollection of the disturbing experience may contribute to the relief of dissociation there is every reason to believe, for it must aid in securing the complete recollection of the experience in all its details; and this in two ways, directly and indirectly. Directly by giving force and vivacity to the whole train of recollection; indirectly by aiding to overcome any repressive tendencies which contribute to maintain the dissociation.
I submit, then, that the observable facts justify us in assigning only
a subordinate rôle to the emotional excitement, a rôle which consists merely in contributing to the relief of dissociation, which is the essential therapeutic step achieved in the alleged 'abreaction process. And I submit further that the principle of 'abreaction' is founded upon a misleading way of describing the facts of our emotional life, namely that which I have characterised above as the conception of packets of emotional energy, capable of becoming attached to, and detached from, ideas, shifted hither and thither according to the will and skill of the psycho-analyst, and repressed or 'abreacted.'
The alternative view, which seems to me perfectly consistent with the facts, is that an emotion of a particular quality, say fear, is always the expression of the operation of a particular disposition, which is an enduring self-identical feature of the structure of the mind (in neural terms—an emotional centre located in the base of the brain). That such an emotional disposition is one of an array of such, each of which may be regarded, according to our taste in such matters, either materialistically as a chemical power station in which nervous energy may be generated or liberated in great volume; or vitalistically, as a channel which, in the course of biological evolution, has become specialized for the direction towards some one great biological end (such as self-preservation or reproduction) of the common life-energy which animates the organism.
According to this view, such a centre or disposition cannot be in itself dissociated; nor can its energies be repressed and rendered latent, or detached and transferred in packets and attached to various ideas. Rather, dissociation, we must believe, though it may occur at various levels of the nervous system, as Dr Brown suggests, never involves an emotional centre or affective disposition as such. It affects rather the various channels through which our intellectual or cognitive processes play upon one another and upon the affective dispositions. In the adult each such affective centre can be reached or brought into action through a multitude of such channels, and, when the memory of an emotionally disturbing incident has become dissociated, this amnesia implies, not that the idea of the incident together with an attached charge or packet of emotional energy has been isolated and detached from the rest of the nervous system, but that the nervous elements concerned in the recollection of this incident are relatively isolated or dissociated from other parts of the cognitive apparatus, from other cortical elements, while retaining their connexion with the affective centre. The dissociated group of cortical elements then forms with the affective centre a relatively isolated couple, or system, within which a circular or reciprocal activity
goes on. The affective centre, far from being thrown out of action, tends rather to be unduly active in virtue of this uncontrolled vicious circle; and, being open to excitement through many other channels, any such excitement of it tends to revive and intensify the activity of this complex. Hence we see, in the soldier who suffers from amnesia for some terrible incident of the battle-field, no incapacity for fear, but rather an undue liability to fear from a great variety of occasions; and a very slight occasion of fear, such as a sudden noise, may start up the vicious circle and so throw the patient into a fit, fugue, somnambulism or dream, in which this vicious circle dominates the organism. In these conditions the patient simply lives through the experience again; and, just because its cognitive content is dissociated, he lives it as in the present, rather than as a memory of the past, or rather without any of that complex higher-level activity involved in the awareness of the timerelations of any experience. But, as soon as the dissociation is overcome, though the same train of recollection may recur, its power to produce emotional distress is greatly weakened by the patient's accompanying awareness of his present surroundings and his knowledge that the experience belongs to the past. The process of readjustment of his emotional attitude can then begin, or, in other words, he makes progress in ‘autognosis.'
I believe that dissociation may be produced suddenly by emotional shock, or gradually by a more or less long-continued process of repression, which may be more or less conscious or unconscious. And I believe that, in either case, the dissociation may be actively maintained by repressing forces. But the recognition of this does not, I think, require any modification of what I have said of the part played by the emotional factor in neurosis and of the criticism I have offered of the notion of 'abreaction.'
I will add in conclusion that I see no reason to distinguish in principle such symptoms as amnesia for a more or less extensive tract of experience, from simple functional paralyses of limbs, of the voice, or of purely sensory functions. They may all be usefully and legitimately regarded as amnesias depending upon functional nervous dissociation, at various levels of the nervous system, whether induced by shock or by repression. The one important difference between the extensive high-level amnesias and those of low level, the simple paralyses and anaesthesias, seems to be that, in the former class of cases, the dissociated dispositions retain their connexions with the emotional centres; while in the latter class, the simple paralyses, the dissociation occurs at so low a level in the nervous system that the dissociated elements are no longer able to reach or to affect the emotional centres. If this be true, then the emotional calm of the soldier suffering from a well-marked functional paralysis is due not merely, as we might be inclined to suppose, to his consciousness of possessing a disability which secures him from a return to the battlefield, but also is due to his freedom from that circular reciprocal selfmaintaining activity between the dissociated disposition and the emotional centre, which is the ground of most of the symptoms of those patients who suffer from dissociations of a higher level.
Since these brief notes were written, Dr Brown has been so kind as to send me a copy of an article in the British Medical Journal of Jan. 31st, 1920. In this article he reports a case which he describes as “a crucial case of the value of abreaction, or the working off of emotion under hypnosis.” It is the case of a gunner who, for a period of two years ensuing upon 'shell-shock’ in the field, had suffered from ‘tremor of the right hand. Under hypnosis he vividly and emotionally recalled the incidents preceding and leading up to the critical moment, when his gun exploded. During the recital of these incidents the tremor of his right hand increased and spread throughout his body and limbs, and then suddenly ceased and did not recur. On being roused from hypnosis his memory of the incidents was clear.
Dr Brown argues that the relief of the tremor cannot have been due to suggestion. There I agree. But when he goes on to say-since the relief was not due to suggestion, it must have been due to ‘abreaction,' to the working off of a pent-up charge of emotion—I beg leave to differ. Is there no third possibility? Dr Brown himself in the earlier part of the article referred to, and elsewhere, has emphasized the importance of the relief of dissociation. I suggest that, in this crucial case, the essential step in bringing about relief was neither suggestion nor ‘abreaction, but just the abolition of the dissociation.
Let us note that there is evidence that the emotion was not pent up. The continued tremor of the hand shows rather that the emotion was continually discharging itself through this channel. Why exactly this discharge took this direction it is not possible to say; but a more minute study of the circumstances might show that, at the moment of emotional shock, the right hand was making some violent spasmodic effort1.
The condition was then, I suggest, as follows: the memory of the shock and of the preceding incidents was dissociated, i.e. the corresponding cortical dispositions were disconnected from all others of the
Dr Brown informs me that this was actually the case.
higher or cortical levels; but they retained their connexion with the fear centre in the basal ganglia; and, through this, also with the motor centres of the right arm. The cortical disposition with the emotion centre formed a couple of circular self-sustaining activity, the excitement of which found an outlet more or less continuously through the nerves of the right arm, whose motor centres are also in partial dissociation and form part of the dissociated system. I suggest that the moment at which the tremor ceased was the moment at which the dissociation was overcome. The emotional energy of the system, instead of remaining confined to the one narrow system, was then able to take a more normal course, spreading over to many cortical dispositions; the mental accompaniment being the realisation of the terrifying incident in its past setting and in its true relations to present circumstances. Hence the return of power of voluntary control, i.e. the control of the whole psychophysical system over the dissociated part.
So long as the dissociated couple remains dissociated, there is no possibility of breaking the vicious circle. But the overcoming of the dissociation at synaptic junctions is ipso facto the breaking of the circle by the discharge of energy from the system in directions previously barredi.
I would add that the constant discharge of emotional excitement by way of some such symptom as tremor of a limb, as in Dr Brown's case, is presumably one of the factors that maintain the condition of general asthenia which is the rule in such cases. For it involves a perpetual wasteful expenditure of the vital energy.
1 The system then becomes subject to inhibition according to the principle of ‘drainage.'