The Lived Experience of War

15 Feb

How have modern armies dealt with the phenomenon of war-induced mental illness?

 War is for many of those involved, but not all, a highly traumatic experience. Factors associated with an abnormally stressful environment such as constant threats to one’s life, witnessing death and destruction and the act of killing itself coupled with feelings of homesickness, the disciplined nature of life in the armed forces and the aftermath of coming home resulted in significant numbers of soldiers experiencing war-induced mental illness. The phenomenon of war-induced mental illness has been identified under multiple, changing labels throughout the long 20th century. From nostalgia, effort syndrome and soldier’s heart in the American Civil War, to shell shock in the Great War, battle fatigue and war neurosis in the Second World War, to Post-Traumatic Stress Disorder (PTSD) in the Vietnam War. The prevalence of war-induced mental illness has led to greater interaction between the discipline of psychiatry and the armed forces with increasing recognition in the latter half of the 20th century and the early 21st century of the importance of good mental health in those serving and the validity of the role mental health practitioners can have. This paper will address the changes in treatment which occurred after the First World War, the Second World War, and the Vietnam War, closing with contemporary treatment methods in the Iraqi War in order to analyse how modern armies have dealt with war-induced mental illness.

The Great War was the first war in history which utilised industrialised warfare. The prevalence of war-induced mental illness in the First World War is often attributed to the more lethal nature of industrialised warfare leading to battles of longer duration placing intensive stress upon the human mind. World War One saw the implementation of mental health screening in the selection of candidates, to supposedly remove those with a predisposition to mental illness. Mental breakdown was perceived as a failure of moral character, suffering soldiers were viewed as ‘cowards lacking moral fibre.’[1] It was also concerning to military officials that ‘the presence of psychiatrists encouraged the display of psychiatric symptoms.’[2] The discipline of psychiatry was unprepared for the degree of mental illness occurring in the armed forces as the duration and nature of the warfare resulted in an increasing number of cases. Uncertain of where or how to treat the phenomenon psychiatrists lost their credibility with military officials, whose response was the court-martialling of soldiers for cowardice, solitary confinement, and disciplinary treatment. According to Simon Wessely ‘at the end of the [first world] war the ascendant view was that the war-traumatized veteran was weak and selfish.’ [3] Psychiatrists turned to the methodology of psychoanalysis, somatic treatments and physical re-education near the front lines, as mental hospitals on the home front proved incapable of effectively stabilising returned soldiers, who continued to suffer severe, sustained forms mental illness.

Commissions after the First World War concluded the best way to prevent breakdowns was not to grant the phenomenon recognition, but rather to ‘ensure that troops were properly trained, properly equipped and properly led.’[4] Consensus suggested more stringent selection processes, as well as further efforts to maintain morale and patriotic spirit needed to be implemented; however, there was recognition of the necessary role of psychiatry and an expansion of the medical field.[5] An expansion in the role of psychiatry in the military, more sites for treatment including the beginnings of forward psychiatry, where treatment occurred near the front lines, as well as an expansion of social mandate of psychiatry in society through literary and cultural writing resulted from the military’s attempts to deal with the epidemic of shell shock.

By 1943 the damaging duration of the Second World War forced the recognition of the ineffectiveness of the selection policy. The policy was abandoned in a shift from belief in prevention to acknowledgement that everyman had his breaking point.[6] Roy Grinker and John Spiegel were the proponents behind this concept, which they labelled war neurosis.  Hans Pols argues ‘army psychiatrists were treating not pathological conditions in abnormal individuals but normal reactions of perfectly healthy and previously well-adjusted individuals who had been exposed to extraordinarily stressful situations’; there was a readjustment to recognise that mental breakdown was not the result of pre-existing conditions but rather the result of environmental stresses, in which every man had a breaking point.[7] Hans Pols and Stephanie Oak argue ‘the failure of selection provided a serious challenge to the notion of that predisposing factors were critical to the development of mental health problems during deployment’, challenging psychiatrists to explore ‘other causes, such as the stresses of warfare.’[8] Military psychiatrists during the later years of the Second World War began to implement systematic treatment methods with some success.[9] William Menninger introduced the concept of stress, as impacting negatively on mental health when occurring for extensive periods. These progressions led to advancements in forward psychiatry, with the implementation three tiered recovery systems based on the idea of PIES (Proximity, Immediacy, Expectancy, Simplicity), treating soldiers suffering mental illness close to the front line with effective results.

Post World War Two there were significant changes to existing doctrines. Military psychiatry recognised the close relationship between physical and psychiatric casualties. There was a significant shift in the understanding of combat motivation with small group psychology replacing the primary group explanation of moral reasoning and patriotism.  Also, there was an understanding that refusing to grant legitimacy to the phenomenon of war-induced mental illness by denying its existence was impossible to sustain, especially for the democracies.[10] Wessely argues the ‘real “watershed”  in the conceptualization of war-induced breakdown was not reached until the second world war and the acknowledgement of the almost inescapable impact on the psyche of industrialized warfare, and not until after Vietnam that a medical label for breakdown again found favour.’[11] After the war there was a return to the concept of predisposition with the prevalence of the work of Edward Strecker, perceiving war as ‘a great leveler’[12], who placed the blame for the phenomenon of war-induced mental illness on overprotective maternal relationships.

 Military psychiatrists implemented the lessons learnt in World War Two in the Vietnam War with successful results during combat but disastrous effects in the aftermath. Limited tours of duty to theatres of war, small groups for combat motivation, forward psychiatric treatment following the PIES strategy worked effectively during the war but the number of soldiers suffering from mental illness after returning home succeeded those of World War Two dramatically. A crucial legacy of the Vietnam War was a new diagnosis by military psychiatrists in Vietnam veterans. Post-Traumatic Stress Disorder brought about a major shift in psychiatric thinking, ‘the new orthodoxy was that long-term psychiatric casualties were no longer the fault of genes or upbringing, but the insanity of war itself.’[13]  The phenomenon of war induced mental illness was recognised as the result of the inherently ‘traumatogenic’ nature of war itself.[14]

Therefore, it can be surmised that the ways in which modern armies have dealt with the phenomenon of war-induced mental illness have changed extensively over the 20th century and continue to do so in the 21st century; from viewing war as a trigger to pre-existing genetic or predisposed mental illness to recognition of the abnormality of war and the stresses it places upon the human mind. The mental health consequences of war are still inadequately defined. Diagnoses remain uncertain with a lack of consensus in military psychiatry and a stigma of weakness continues to persist around displaying psychiatric symptoms in the military. The psychological consequences of traumatic experiences must be accepted as an unchanging reality and continue to be studied to not only minimise the impact of war but also understand its costs.

 

 

 

 

 

Bibliography

Pols, Hans, “War, Trauma and Psychiatry”, Australian Review of Public Affairs, (2 February 2004),              [online] Availability:  <http://www.australianreview.net/digest/2004/02/pols.html&gt; viewed                 18 August 2010.

Pols, Hans, “War Neurosis, Adjustment Problems in Veterans and an Ill Nation: The Disciplinary                 Project of American Psychiatry During and After World War Two”: pp. 72-92.

Pols, Hans, and Stephanie Oak, “War and Military Mental Health: The US Psychiatric Responses in            the 20th Century”, American Journal of Public Health, 97, no 12 (Dec. 2007): pp. 2132-42.

Pols, Hans, “Waking Up to Shellshock: Psychiatry is the US Military During World War II”, Endeavour,       30, no. 4 (2006): pp. 144-9.

Stone, Martin, “Shell-shock and the Psychologists”, in William F Bynum et al. (eds), The Anatomy Of       Madness: Essays in the History of Psychiatry, pp. 242-271.

Wessely, Simon, “Twentieth Century Theories on Combat Motivation and Breakdown”, Journal of          Contemporary History, 41, no. 2 (2006): pp. 271-82.


[1] Hans Pols and Stephanie Oak, “War and Military Mental Health: The US Psychiatric Responses in the 20th Century”, American Journal of Public Health, 97, no 12 (Dec. 2007): p. 2133.

[2] Hans Pols and Stephanie Oak, “War and Military Mental Health: The US Psychiatric Responses in the 20th Century”: p. 2133.

[3] Simon Wessely, “Twentieth Century Theories on Combat Motivation and Breakdown”, Journal of Contemporary History, 41, no. 2 (2006): p. 271.

[4] Simon Wessely, “Twentieth Century Theories on Combat Motivation and Breakdown”: pp. 271 – 272.

[5] Stone, Martin, “Shell-shock and the Psychologists”, in William F Bynum et al. (eds), The Anatomy Of Madness: Essays in the History of Psychiatry, p. 247.

[6] Simon Wessely, “Twentieth Century Theories on Combat Motivation and Breakdown”: p. 274.

[7] Hans Pols, “War Neurosis, Adjustment Problems in Veterans and an Ill Nation: The Disciplinary Project of American Psychiatry During and After World War Two”, Osiris, 22, (2007):p. 78.

[8] Hans Pols and Stephanie Oak, “War and Military Mental Health: The US Psychiatric Responses in the 20th Century”: p. 2134.

[9] Pols, Hans, “Waking Up to Shellshock: Psychiatry is the US Military During World War II”, Endeavour, 30, no. 4 (2006): p. 144.

[10] Simon Wessely, “Twentieth Century Theories on Combat Motivation and Breakdown”: p. 279.

[11] Simon Wessely, “Twentieth Century Theories on Combat Motivation and Breakdown”: p. 273.

[12] Hans Pols, “War Neurosis, Adjustment Problems in Veterans and an Ill Nation: The Disciplinary Project of American Psychiatry During and After World War Two”: p. 91.

[13] Simon Wessely, “Twentieth Century Theories on Combat Motivation and Breakdown”: pp. 281-282.

[14] Hans Pols, “War, Trauma and Psychiatry”, Australian Review of Public Affairs, (2 February 2004), [online] Availability:  <http://www.australianreview.net/digest/2004/02/pols.html&gt; viewed 18 August 2010.

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