Psychotherapy

Repression

Mark Dombeck, Ph.D.

It's been a while since I've made time to do one of these essays. I've been diverted in large part because we've been hard at work on a redesign of the Mental Help Net website. Though the hard part is over, there are lots of odds and ends to clean up and it will be a month or so before we debut the changes. Now that most of the heavy lifting is done writing should become more regular again.

 So far as these essays are concerned, I've been doing a sort of survey of some of the more important schools of psychotherapy recently, focusing as I go along on some of the important technical contributions that each school has made. We left off with a discussion of Transference, an important contribution of the psychoanalytic, and later psychodynamic schools of psychotherapy. Today's essay will cover the topic of Repression, which is a major contribution of the psychodynamic school.

Repression is a pretty simple idea at root. However, the way in which repression becomes a psychological construct gets a little convoluted. I'm therefore going to explain out some details that you might already know about to try to take us step by step through how it all is supposed to work.

To repress something means to put down something that wants to express itself; to make it quiet and contained; to render that thing harmless and controlled. Repression is necessary a social idea by nature (meaning it cannot occur in isolation). It describes a conflict between two or more things. It occurs when one thing puts another down; it is not present when two things cooperate or find a harmonious way to co-exist. Further, repression is necessary a sort of aggressive thing. Repression conveys the idea of the use of force or pressure. It involves a successful struggle between agendas that are not compatible, with one agenda winning out over another and enforcing itself in place of the other on a more or less permanent basis. For repression to successfully occur, one agenda must have struggled against the other, only to succumb to the dominant agenda, lose its public voice, and become submerged and forgotten.

Sounds more like a description of warring nations than a description of the mind, right? Well – right. Repression concerns struggle, capitulation and resistance, and those are very much the sorts of things that waring nations and political factions do to each other. Before repression was a psychological term, it was a political term. That the term was drafted to describe mental processes by Dr. Freud as a core part of his early theory of the mind makes clear the point that Freud saw the mind as a sort of battle ground where waring forces duked it out and a metaphorical repression was seen to occur.

If you've ever taken a college class in abnormal psychology you're probably familiar enough with Freud's early model of the mind to venture a guess as to what the warring parties contained therein were. Freud suggested that the mind could be subdivided into three entities: the ego, the id, and the super-ego. These terms are so familiar today that they go unquestioned. However, they are essentially Latin words with specific meanings. In Latin, I am to understand, ego means "I" and id means "it". The word "super" means "over" or "greater", or "on top of" (as in "superior"). Thus, the super ego translates to something like "the on-top-of-I", or more simply, "society". The use of Latin, then as today, served to translate these relatively simple and understandable terms into a jargon that makes them sound more special and complex than they really are. All sorts of professionals do this sort of thing routinely, then and today, so please don't blame Freud for trying to make things sound complicated. If he hadn't of done it, someone else probably would have.

Freud's three mental forces had three different and opposed characters. The id was characterized as a sort of wellspring of spontaneous, selfish, passionate, emotional and impolite urges which people innately desire to satisfy immediately if not sooner: sex, appetite, aggression, etc. The id was appetite personified; it wanted to be satisfied immediately and it wasn't concerned with the consequences of its actions very much.

In direct opposition to the id was the super-ego; a repository for rules, regulations and guidelines handed down by family, authority, society and culture. Unlike the id which was instinctually present from birth, the super-ego was something learned over time during the developmental process; a permanent memory of all the times parents, clergy and other authorities told someone how to behave and/or punished them for bad behavior while coming up. The super-ego is thus essentially the conscience, always making a person aware of what they should do; and discounting what they want to do.

The opposed characters of the id and super-ego should now be clear. The id is about desire, while the super-ego is about restraint and conformity. The id pulls people in the direction of selfish satisfaction of animal need, and the super-ego pulls the person in the opposed direction of self-less denial of individual needs for the benefit of the "greater good". Where the id is concerned with pleasure, the super-ego is concerned with morality and being good. Where the id wants to have candy (e.g., to satisfy its self), the super-ego wants to be thin (e.g., to satisfy others).

In the middle of this tug-of-war between id and super-ego is the ego which forms as a means of satisfying the tension between the opposed forces. Because the ego bridges the demands of the id and the super-ego, it ends up having characteristics of both sides inherent in itself.

A wonderful illustration of the ego, in relation to the id and super-ego was provided in the 1978 college comedy movie Animal House. There is a scene in Animal House where a young fraternity brother is faced with a decision as to whether to ravish a young woman who has just passed out in front of him. A little angel and a little devil pop into existence, one on each of his shoulders and start giving him advice. The devil tells him to ravish the girl, while the angel tells him to be a good boy. If we take this scene as an analogy for id/ego/super-ego, the devil is the id, the boy is the ego and the angel is the super-ego. When confronted with a tension between what is desired, and what is morally acceptable, the ego can go either way, depending on which force (id or super-ego) is better developed in each individual.

It says something about Freud's character and the society that shaped his thinking that he referred to id forces as "it" and ego forces as "I". By doing this, he was essentially identifying himself with the rational appearing ego and disowning the instinctual animal urges that all people share. In effect, he was suggesting that the animal urges were foreign things that were fundamentally separate from the ego – the self or "I". I've never liked this formulation very much. This sort of attitude suggests a fear of the animal nature which is unnecessary, and doesn't help people to take responsibility for their actions too well either. Sexual and other selfish appetites are very much a part of most people's definition of self, and for good reason, as they are a fundamental part of human nature. Self-acceptance of these appetites is an important part of maturation too. You can't easily grow into a mature independent adult if you spend your entire life delaying self-gratification in favor of being "good" all the time. Such a person is too easy to manipulate and too conforming to be considered adult. We'll come back to this theme when we deal with humanistic techniques in another essay. For now, I'll simply point out that Freud's desire to disown the animal nature was consistent with the larger judeo-christian moral and cultural environment he was raised within – complete with its personification of the devil as an animal-like being (e.g., with fur, horns, hooves and a tail) and of angels as spirit beings of great morality, rationality and power. This consistency is probably part of why Freud's theory became as popular as it did. It is also why when the Animal House writers went looking to put words in their angle and devil characters' mouths, the angel talked like the super-ego and the devil like the id.

What does this have to do with repression? A whole lot actually. If the ego, id and super-ego are the parts of the mind, repression is one of the main ways that these parts were said to interact. The structures of the mind are not static or solid, but rather fluid and dynamic. They are constantly in motion and constantly maneuvering for advantage throughout each person's life. It is not like the ego develops as means of managing id and super-ego demands and that is the end of the story. It is more like the ego is a piece of taffy being pulled back and forth by competing demands. It changes its shape as the demand landscape changes from moment to moment.

One of the main ways that the ego changes its shape to accommodate super-ego and id demands is by changing its degree of awareness. If the id comes up with a desire that is in conflict with a dictate from the super-ego, the ego can resolve the tensions that would otherwise be created by disowning or repressing that desire. Freud thought the ego accomplished this by refusing to acknowledge and accept that the desire existed, and by distorting and misinterpreting perceptions and evidence that might suggest that the desire existed. The desire is not so much smacked down by force in this way of thinking, as it is ignored until it goes way. By refusing to acknowledge the existence of a desire, the ego relegated that desire to the "unconscious"; which was simply the place where unacknowledged things lived. They don't stop existing just because they are not looked at, mind you. They just aren't noticed. Many id-generated desires were thought to be relegated to the unconscious, as many of those urges were considered shameful or otherwise unacceptable.

In Freud's way of thinking, repressed id desires are energetic things that worked tirelessly for their expression. They are not content to lie there and be ignored. Instead, they continually exerted pressure on the ego to acknowledge their existence The ego must thus continually spend energy to keep itself insulated from repressed desires. There are varying ways that this energy gets expended, but typically, people either keep themselves busy and distracted so that they don't have to think about what they don't want to think about, or they make either impulsiveness or self-control into a fetish and thus protect themselves from id-desires through excessive devotion to spontaneity or to order.

However valiant they may be, efforts spent on ignoring desires are often not enough to keep those desires down fully. If repressed desires cannot find direct expression and acknowledgment, they may find ways of expressing themselves indirectly, in the form of dreams, undesired thoughts and feelings, or irresistible compulsions. There may be no awareness of a particular desire per se, but the body knows what it wants and the body reacts even when the mind is clueless. A good example illustrating this principle comes from a study of male homophobia I read some years ago. Multiple men varying in their self-reports of tolerance for homosexuality were shown erotic pictures of men while fitted with a device that measured the width of their penises (penises get wider as they get erect, so a measure of penile width is also a measure of sexual arousal). You can probably guess the result of this study. There was a direct relationship between expressed intolerance for homosexuality and erections, with men who were most intolerant having the largest erections in response to the erotic pictures. There are several ways you can interpret this result, but one way is to assume that the intolerant men "protested too much" (to riff on Shakespeare) as a means of pushing down or repressing their shameful actual attraction to male erotica.

Repression in Psychotherapy

Repression is a significant technical contribution to psychotherapy, not because it is a technique in of itself for manipulating people, but rather because it offers a framework for understanding how certain types of psychological problems occur, a set of guidelines for making sense of a therapy patient's behavior, and an abstract therapy goal towards which to work. Freud thought that many forms of psychopathology (that's a fancy term for "mental illness") were caused by repression. For example, the whole spectrum of "neurotic" (mild) mental problems (e.g., anxiety, hysterical dissociation, depression) were thought to be due to repression gone awry. For instance, depression might be caused due to unacceptable feelings of anger felt towards a spouse or a parent that were not allowed to be expressed but which nevertheless leaked out and colored the patient's experience. The original basic cure was therefore to analyze the patient's mental process so as to understand what was being repressed in the first place, and then to interpret that repressed material back to the patient so as to make the patient become aware of the repressed material. By making the unconscious conscious, the patient would have to actually come to terms with the conflict rather than avoiding it, which ought to remove or reduce the illness itself. Freud was about half right in this assumption.

So far as I am aware (and while I am an expert, I don't hold myself out as an expert's expert), uncovering repressed desires and making them conscious can have a therapeutic effect – for some people with particular kinds of problems. For other people, the various methods psychoanalytic therapists might use to uncover patient's repressed desires won't help, or might even make things worse.

Consider these factors. First, not all problems are caused by intrapsychic conflicts and repression. Emotions like shame and guilt are, but other emotional problems may not be. Some instances of depression and anxiety may be caused by physical issues having nothing to do with repression. Secondly, successful analysis of repression depends heavily on patients having good language skills and a capacity for self-examination. To the extent that patients aren't much for language, or are extremely impulsive, they are not going to be good candidates for an "insight therapy". Third, insight therapies like this sort of analysis of repression are inherently passive in nature. The best a therapist can hope for when analyzing a patient's repressions back to them (assuming that is all they do) is that the patient will become more aware of their conflicts. Mere awareness will not teach patients how to cope with those conflicts in a better way than repressing them, however. Patients who don't know better ways of coping with their conflicts might actually get worse when those conflicts are rubbed in their faces if further steps are not taken to teach alternative coping methods.

When you add these factors up, what you find is that a therapy based on analysis of repression is going to be best suited for use in helping people who are already quite capable and resourceful but who are nevertheless stuck or hung up in some manner due to internal conflicts that are keeping them from being happy. The classic conflict where analysis of repression will be useful is one between desire and duty, and the classic patient will be one who has been choosing duty over desire for a long time and it just isn't working out for them, perhaps resulting in mild depression or anxiety. The analysis of repression will be useful to bright people stuck in developmental crises that inhibit them. It may prove useless or even harmful to less verbal people, or to people who have biologically driven mental illnesses (such as bipolar disorder or schizophrenia), serious debilitating forms of anxiety or depression (where insight will not be enough to effect a cure), trauma-based disorders (where uncovering of conflicts might trigger some sort of re-traumatization if done carelessly) and under-controlled emotion conditions such as an anger problem. In the latter instances, a more active approach to therapy that takes care to teach alternative means of coping, and/or provides medical intervention, perhaps in combination with the insight approach, would be wiser choices.

I should mention that the original version of psychoanalysis as conceived by Freud and partially described above is largely a historical relic today so far as I can tell. Hugely influential, the therapy has been reworked and reinterpreted countless numbers of times so as to emphasize the insights of new thinkers and to respond to the changing needs of the therapy environment. My incomplete understanding of modern psychoanalytic theories (there are several) suggests to me that repression is not as prominent an idea anymore as it used to be. Modern practitioners seem more concerned with analysis of patients' social relationships and "object relations" (e.g., transference) than with intrapsychic battles between id and ego. Repression is still an important and critical idea, but it doesn't seem to be the center of attention within psychodynamic circles these days.

Other Understanding of Repression

I've framed repression in psychodynamic and psychoanalytic terms in this essay thus far, mostly because those folks invented the concept and made it prominent, and also because it is my desire here today to talk about psychodynamic technical contributions to therapy. I don't want to let the essay end, however, without pointing out that other schools have also dealt fairly extensively with the idea of repression, and that the whole concept has been enriched by this cross-pollination. For example, there is a whole non-psychodynamic literature concerning coping styles that has extensively examined repression. Within this literature, repression is thought of as part of a coping spectrum called "repression-sensitization". Everyone can be placed somewhere on this spectrum, either towards the repression side of things, towards the sensitization side, or somewhere in the middle.

In this "repression-sensitization" literature, repression is regarded as a strategy that some people use for coping with disturbing, stressful information. This is a trait-like strategy, meaning that it is a habitual style that people become dependent upon and use preferentially over other possible coping strategies. People who employ a repressive coping strategy basically react to disturbing information by employing denial, avoidance and a carefully honed failure to pay attention. They might avoid conversations that convey disturbing news, or prefer to maintain uncomfortable silences even when a confrontation might clear the air. They make extensive use of distraction as a means of coping; if they are worried about something they'll go do something else to occupy their minds. Their motto is "It's not happening", and their basic assumption about danger is that what they don't know won't hurt them.

The polar opposite coping method to repression is called sensitization Where repressors avoid learning disturbing news, sensitizers go the opposite direction and seek out more disturbing news until they know everything. It's not that sensitizers don't find the news disturbing (they do); rather, it has to do with their basic assumption towards danger, which is that the more they know about dangers, the better they can navigate them so as to minimize damage to themselves and those they love. Sensitizers seek out as much information as they can in an attempt to keep themselves more informed, and thus more in control and ultimately safer. Just as repressors go overboard in the avoidance department, sensitizers frequently go overboard in the worry department. They tend to play "what if" games to try to figure out what might happen in every possible circumstance. Their basic motto is "information is power". They will pursue this motto even when the consequence to them is information overload and a whole lot of unnecessary worry and strain.

Research examining the repression-sensitization coping spectrum suggests that repression may be best thought of as a mild variety of dissociation; that same mental process that is responsible for some forms of amnesia and for multiple personality disorder, and for the phenomena of hypnotism. Dissociation occurs when some mental contents become cut off from the main stream of consciousness and hang out in a kind of bubbled off existence For instance, dissociation can occur during a traumatic event. When this occurs, the trauma victim finds himself spaced out and kind of not in reality, even while the trauma event continues to unfold. A rape victim might find herself watching herself getting raped as though it was a movie, for example. Trauma dissociations can sometimes become "repressed memories", meaning that they get avoided so aggressively and for so long that they are successfully forgotten. This kind of thing sometimes happens to abuse victims and also to combat veterans. Repressed or dissociated memories are not so much put into a special place called the "unconscious" as they become so strongly avoided that the entryways to those memories get forgotten (or are quickly and automatically diverted to safer thoughts through a distraction mechanism). Since nothing is allowed to bring those memories to mind, they appear to cease to exist. They don't really cease to exist, however. Sometimes they reappear unbidden after years of disuse. I recall one case where a combat veteran reported that after many years of normal existence he one day walked into a store and was triggered into remembrance of a dissociated trauma memory when a clerk's last name (on his name badge) was the same as the last name of the officer who had run his combat unit. That officer had apparently been blown into bits in front of my patient. Once the bridge back to the old memory was reestablished, the memory came back vividly, making his life very difficult, and leading to his diagnosis with Posttraumatic Stress Disorder (PTSD).

That repression is likely a mild form of dissociation casts light on the ways that psychologically traumatized patients (with PTSD) are treated. Trauma memories involve death and dismemberment, horrible abuse or violation, torture, and similar intense and horrible occurences. Trauma memories are avoided and pushed out of consciousness as best as possible because they are truly too horrible and too intense for a given patient to digest and process. The path of 'repression' (e.g., avoidance) is chosen for dealing with trauma memories because there are no other alternatives for such patients in their naive state; they would otherwise be in a near-constant state of anxiety if they didn't try to push this stuff away. Breaking down the power of trauma memories is the goal of any therapy for traumatized people. This is typically accomplished in multiple ways, but all of those ways attempt to accomplish the goal of therapeutic "titration", which is a fancy way of saying that you want to simultaneously gently push patients to address their trauma memories and thereby process and digest them when those memories can be tolerated, and also help them to avoid and dampen those memories when they become overwhelming. Dampening is accomplished with medication, by teaching self-soothing and relaxation techniques, and through supportive psychotherapy that addresses problems in living unrelated to trauma. The pushing to address and process trauma memories is accomplished by providing a safe environment, either individually or in a group setting, where trauma memories can be discussed. This latter task is not exactly like the sort of analysis of repression intervention that a psychodynamic therapist might provide a client, but both interventions similarly seek to help patients make their unconscious avoided material conscious again. I think that is worth noting.

My Personal Research Story About Repression

I said above that some research suggested that habitual repression was likely a mild form of dissociation, but I didn't describe what that evidence looked like. It looks something like this. In the early years of repressor-sensitizer study, a particular questionnaire was used to identify who was a repressor and who was a sensitizer. A large body of research was conducted, and then all called into question, when the validity of that questionnaire was itself questioned. It seemed that the questionnaire was measuring how willing people were to describe themselves as anxious, and not measuring repression per se. There ought to have been a way to differentiate people who were truly low in anxiety from repressors, who should be people who were dealing with some emotional arousal by denying the basis for that arousal. The old questionnaire couldn't make that distinction, however, so a new means of measuring repression needed to be developed.

The new means that ultimately was developed took this form. A group of researchers was able to differentiate a group of truly low anxious people from repressors through the use of two separate questionnaires, one asking people to rate how anxious they are, and the other a measure of how rigidly they followed social conventions and rules (e.g., such as "if you found a wallet with money in it, would you return it to the owner without taking any money out of that wallet first?"). The questions this test contained were all geared to be things people were supposed to do but often didn't do in practice. This latter questionnaire was called a measure of people's degree of "social desirability" but it actually seemed to measure a kind of defensiveness and desire to conform and be seen as a moral person.

While both repressors and truly low anxious people described themselves as low anxious on the anxiousness questionnaire, the repressors scored very highly on the social desirability questionnaire, while the truly low anxious group did not. Here is the kicker. In addition to giving these folks questionnaires, the researchers also hooked them up to machines that measured their heart rate and skin conductance. Heart rate and skin conductance are measures of body arousal that cannot be consciously controlled (by most people). These body measures tend to go up when you are anxious whether you want to hide the fact that you are anxious or not. While the truly low anxious group didn't show much in the way of body arousal, the repressor group did become aroused. The interesting finding was the discrepancy (or dissociation) between the repressors' verbal denial of anxiety in the face of their volatile body arousal measurements. The repressors were either lying about being anxious or they were really not paying attention to what their bodies were doing. Long story short, further research studies seemed to suggest that as a group the repressors were not lying, but rather really were just not very much in tune with what their bodies were doing. Like they weren't paying attention to their inner sensations and feelings much at all.

I became fascinated with this whole line of research as a young psychology student and assistant professor back in the 90s and made some attempts to add to the literature before getting frustrated and going on to a new career. Here is more or less what I came up with:

The method for differentiating repressors from truly low anxious people that I described above required the administration of two questionnaires, one about anxiety and one about social desirability, and using the scores on these tests to differentiate the groups. The method basically created four groups of people based on high and low scores which looked something like this table just below:

 Low AnxietyHigh Anxiety
Low Social DesirabilityLow Anxious GroupHigh Anxious Group
High Social DesirabilityRepressorsThe "Tricky" Group

As you can see, those folks who produced high anxiety scores, but low social desirability or defensive scores were considered to be truly high anxious people, those folks who scored low on both questionnaires were considered to be truly low anxious people, and those who scored low on the anxiety test and high on the social desirability test were considered to be repressors. Then there was this tricky group who were supposed to score high on both tests. I say that they were a tricky group because you'd never notice that they didn't really exist if you didn't try to give these tests and identify a group of these people, but the long and short of it was that you could never really identify a group of these people try as you might. They didn't exist in reality; they were just implied by the table you see above. The table above implies that there is no relationship between measures of anxiety and social desirability, but there actually is. If you are defensive enough to score high on the measure of social desirability, you are very much unlikely to identify yourself as a highly anxious person. Apparently, it just isn't cool to be anxious (duh!).

There had to be a better way to think about who was a repressor and who wasn't a repressor than this misleading table. My proposal for a better way looked like an inverted triangle rather than a square table. Think about this: If you are a low anxious person by nature (by genetic inborn temperament), you really don't ever get motivated to develop a way of coping with stressful events, because you are naturally prone to let them roll off your back. Low anxious people (people who personality psychologists refer to as being low in the trait called "Neuroticism") just don't get aroused easily. Naturally high anxious people (high in Neuroticism), on the other hand, are easily aroused and prone to anxiety and depression. Such folk are very reactive to bad news, and would tend to figure out a way to cope with stress so as to minimize their discomfort. What shape would those stress coping methods take? Why, none other than the repression-sensitization spectrum of coping methods we talked about above. Some would become repressors while others would go the sensitization route. The natural triangular shape that emerges from this more naturalistic view of the repression phenomenon avoids the problem of having to account for the "Tricky Group" entirely.

RepressionHigh NeuroticismSensitization
(AKA: the High Anxious Group)
 Low Neuroticism
(AKA: the Low Anxious Group)
 

I had a set of fancy tests set up designed to help me demonstrate that my triangle model fit the phenomenon better than the square model, but alas, while designing experiments was always quite fun for me, I wasn't the best person for writing them up and my data tended to come out squigly. By the time my experiments had born (partial, inconclusive) fruit, however, I had already decided that I no longer wanted an academic career. I was pretty sure my triangular model idea was right, but the whole enterprise no longer seemed worthwhile enough to bring to a conclusion. I went off to the next phase of my life and left that research behind, unpublished and probably unpublishable. I was heartened some years later, however, when my friend from graduate school (who is still a professor) told me that he encountered some researchers at a conference who were (a decade later) coming to more or less the same conclusion based on their own studies that I had come up with years before. I don't know who these researchers were or where they published their work (if they ever did), but knowing that I probably was on the right track way back when made me feel good just the same.




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