War, trauma, and psychiatry

Hans Pols, University of Sydney

George E. Kearney, Mark Creamer, Ric Marshall, and Anne Goyne, eds, Military Stress and Performance: The Australian Defence Force Experience, Carlton VIC, Melbourne University Press, 2003 (294 pp). ISBN 0-52285-054-5 (paperback) RRP $34.95.

John Raftery Marks of War: War Neurosis and the Legacy of Kokoda, Adelaide SA, Lythrum Press, 2003 (224 pp). ISBN 0-95799-602-0 (paperback) RRP $29.95.

Ben Shephard A War of Nerves: Soldiers and Psychiatrists, 1914–1994, Cambridge, Harvard University Press, 2001 (487 pp). ISBN 0-67401-119-8 (paperback) RRP $38.00.

War injures, destroys, and kills. It can also jar for very different reasons: soldiers have reported long periods of utter boredom and homesickness. War tests the mettle of the hardiest of men, and scars the psyches of soldiers and civilians alike. Battle can unleash violent motives alien to civilian life: soldiers have been known to kill unarmed civilians in barbarous ways, driven by anger, vengeance, and paranoia.

Most of us are repelled by the act of killing and find witnessing acts of violence, torture, or murder greatly distressing. Killing other human beings violates the ethical principle of the sanctity of life—and engaging in warfare requires accepting the possibility of having to kill. The psychological ramifications of this are tremendous. Some soldiers cannot continue fighting after they witness torture and killing, lose close friends in battle, engage in killing, or experience prolonged exposure to enemy fire. Others appear to cope well, only to suffer from nightmares, depression, and anxiety after returning home.

Yet war is not only traumatic. Many soldiers forge solid and enduring friendships in the midst of battle. During the first and second World Wars, many men (and a few women) left behind small towns and saw the world. People in low-paying, dead-end jobs became leaders. After World War II, many soldiers found it difficult to readjust to the blandness of civilian life. In veterans’ associations, ex-soldiers socialise, exchange stories, and revive memories of wars past.

Soldiers react in different ways to the stresses and opportunities of warfare. All must make sense of their war experiences after returning home. Most can put it all behind them and get on with their lives. Others find it much harder to forget. Whatever their reactions, fighting a war profoundly alters the lives of men and women.

During the wars of the twentieth century, psychiatrists have proposed a variety of diagnostic categories for the psychiatric casualties of war, among them shell shock, combat stress, war neurosis, battle fatigue, and Post-Traumatic Stress Disorder (PTSD). The three books under review analyse how psychiatrists have interpreted the traumas of war and how they have attempted to alleviate the symptoms. They also discuss the controversies around these interpretations both within psychiatry and within society at large.

Psychiatry and the Military

In A War of Nerves: Soldiers and Psychiatrists, 1914–1994, Ben Shephard comprehensively surveys military psychiatry during the 20th century. He analyses the psychiatric response to war, medical explanations of war-induced psychiatric syndromes, and psychiatric treatment methods. He relates how psychiatrists have expressed ambiguous and ambivalent attitudes towards war-related psychiatric syndromes and towards the soldiers suffering from them. Most psychiatrists were horrified and appalled when they were confronted with the realities of warfare, for which they were utterly unprepared. Most were also intensely curious about what they observed. According to Shephard, war provided psychiatrists with ‘an extreme environment, a laboratory in which every theory could be tested literally to destruction; war shattered the mind, but in an intellectually absorbing way’ (p. xvii). Initially, psychiatrists were puzzled when confronted with soldiers suffering from paralysis, mutism, blindness, uncontrollable stuttering, trembling, startle reflexes, repetitive nightmares, anxiety attacks, and severe depression. Such unmanly behaviour was generally seen as a sign of emotional weakness or cowardice and in direct conflict with soldierly codes of behaviour. Psychiatrists had the unwelcome task of dealing with men who were despised by military officers and considered undeserving of medical attention.

Soldiers react in different ways to the stresses and opportunities of war.

Shephard documents how the emotional costs of warfare first became apparent to physicians and military officials during the Great War. In 1917, Charles Myers, a British physician, introduced shell shock as a diagnostic category (which has since entered the vernacular and has become something of a cultural icon). During World War II, American psychiatrists introduced new diagnostic categories such as combat stress, war neurosis, and battle fatigue. After the Vietnam War, the diagnosis of Post-Traumatic Stress Disorder was introduced to describe a wide array of psychiatric symptoms which generally revealed themselves long after soldiers had returned home. The 1991 Gulf War brought with it the still controversial Gulf War Syndrome. It is interesting to notice that so many different diagnostic categories have been proposed to describe and explain war-related psychiatric syndromes. These diagnoses have always been controversial at the time they were proposed. As a consequence, they have been remarkably unstable.

At the beginning of the 20th century, most psychiatrists viewed war-related psychiatric syndromes as expressions of a pre-existing mental illness, a weak constitution, cowardice, or lack of moral fibre. According to them, battle conditions only revealed the true character of soldiers by hastening the appearance of symptoms but could not be considered to be the ultimate cause. The psychiatric casualties of war were nothing new to medical science: they resembled peace-time psychiatric conditions. Consequently, soldiers suffering from psychiatric symptoms could not claim pensions or other benefits. During the Great War, however, some British and American psychiatrists came to view shell shock as the normal response of normal individuals to the extraordinary stresses of warfare. According to them, environmental stresses rather than predisposition were responsible for nervous breakdown. In this view, war itself is inherently traumatogenic. After the war was over, these new ideas disappeared. Predisposition again became the prime explanation for shell shock.

During World War II, most American psychiatrists came to the view that nervous breakdown after prolonged battle constituted a normal reaction of normal and previously well-adjusted individuals to the extraordinary stresses of warfare. They named this condition war neurosis, combat stress, or combat fatigue, and introduced forms of short-term psychotherapy near the front lines which successfully alleviated symptoms. According to these psychiatrists, psychotherapeutic treatment should be provided as soon as possible after the onset of symptoms, as close as possible to the front-lines, and be imbued with the expectation of recovery. These ideas have since been formulated as the principles of immediacy, proximity, and expectancy, and have been part and parcel of the response of mental health care professionals to traumatic experiences. During World War II, many British psychiatrists shared these ideas; Australian psychiatrists, however, were hardly aware of these views and continued to explain nervous breakdown by referring to predisposition or cowardice.

After World War II, most American psychiatrists changed their mind about the nature of war neurosis. They had observed that a great number of soldiers who had not been even near the front-lines displayed the symptoms of war neurosis. Some soldiers already broke down during training before they were sent abroad. Most psychiatrists felt sympathy for soldiers suffering from combat fatigue after prolonged exposure to battle. They felt decidedly less sympathetic about the soldiers who had broken down without cause.

During the Vietnam War, most American psychiatrists congratulated themselves about the low rate of nervous breakdown in the American army. Many soldiers returned home in good mental health, only to start suffering from anxiety and depression years later. The advocacy of veteran’s groups and a number of outspoken psychiatrists in the United States eventually led to the inclusion of Post-Traumatic Stress Disorder in the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association in 1980. According to many commentators, this recognition of the traumatogenic effects of war was a triumph of humanity. The picture becomes much more complicated when one realises that not only soldiers who had lost comrades or who had witnessed atrocities reported symptoms of PTSD. Soldiers who had committed atrocities reported the same symptoms as well.

Psychiatrists have debated whether war exposes mental illness, or creates it.

According to Shephard, the record of military psychiatry is not impressive. Military psychiatrists saw it as their duty to return as many men as possible to the fighting lines. The mental health and well-being of soldiers was decidedly of lesser importance. Only a minority of soldiers received adequate psychiatric care. The therapies psychiatrists administered were often ineffective and at times punitive. Interestingly enough, most military officials viewed psychiatrists with suspicion. Many military officials felt strong contempt towards soldiers suffering from psychiatric disorders (American General George Patton slapping soldiers suffering from war neuroses during World War II serves as a telling example). They also feared that a psychiatric diagnosis provided an all-too-easy way out of the unpleasant conditions of battle to soldiers eagerly looking for one. Rewarding the display of psychiatric symptoms with a medical discharge would only increase their incidence. Seen this way, the presence of psychiatrists rather than harrowing battle conditions could cause epidemics of mental breakdown.

Military officials felt strongly ambivalent about the presence of psychiatrists in the army. Most psychiatrists felt strongly ambivalent about soldiers suffering from the psychiatric syndromes associated with warfare. Shephard’s encyclopaedic work provides an excellent overview of the ambiguous position of psychiatrists in the armies of the 20th century and the often uneasy relationships between psychiatrists, military officers, and shell-shocked soldiers.

Life After the War

In The Marks of War, John Raftery, a clinical psychologist, explores the Australian psychiatric reaction to war-related psychiatric syndromes during both World Wars by analysing psychiatric writing on the subject. He concludes that Australian psychiatrists rarely attributed the suffering of the soldiers in their charge to the conditions of warfare. Instead, they blamed pre-existing mental illness, a weak constitution, or lack of character. According to Raftery, Australian psychiatrists failed to see that war itself could induce trauma. The Australian government did not recognise psychiatric disability as a ground for pension payments until the late 1950s. A telling cartoon, reproduced in the book, provides a sinister commentary on this state of affairs. The cartoon, which appeared in Smith’s Weekly in 1948, displays a physician remarking about a case of war neurosis to a colleague: ‘He’s in very bad shape.’ His colleague answers: ‘If we take a leg off we might be able to get him a pension.’ (p. 121).

Raftery is very critical of Australian military psychiatry. Australian psychiatrists repeatedly stated that the psychiatric casualties of war presented nothing new to medical science—breakdown in battle was in principle the same as breakdown under peace-time conditions. However, his book is not just an attempt to put the record straight. Raftery is not interested in symptom checklists or the finesses of psychiatric diagnoses. Instead, he aims to explore the different ways in which soldiers integrated their war-time experiences in their life narratives. He followed a group of 65 Australian veterans who fought during the Kokoda trail campaign in New Guinea in 1942 for a period of ten years. He became acquainted with these veterans and their families, conducted several long and open-ended interviews with them, and attended several of their reunions. By exploring their life narratives, Raftery investigates how these veterans dealt with the horrific conditions of the Kokoda trail campaign, how they remembered their experiences, how they made sense of the war, and how they integrated their war-time memories into their lives after they returned home.

Initially, Raftery encountered reticence. Many veterans were only willing to discuss humorous anecdotes, and stories of courage and friendship. It took most veterans several years before they started to relate the dark hours during the war and the panic attacks and nightmares they had for years after they had returned home.

In WWII, Australian psychiatrists failed to see that war itself could induce trauma.

The military campaigns on New Guinea certainly were potentially very traumatic. Soldiers engaged in heavy combat for long periods of time. They witnessed atrocities and acts of extraordinary violence. They were at high risk of contracting debilitating diseases such as malaria and scrub typhus. Tropical temperatures added to the extreme discomfort they experienced. In addition, the Kokoda campaign appeared to have been poorly planned. At times, soldiers were left to fend for themselves for weeks on end. Often starving during those weeks, they did not know when and whether they would rejoin their units or whether rescue operations had been organised. Because of poor military planning, the battle of Gona, probably the bloodiest fought on New Guinea, exacted needlessly high casualty rates. Decisions appeared to be based on political expediency rather than military strategy. Despite the harrowing conditions during the Kokoda trail campaign, very few soldiers broke down during deployment. Surviving soldiers rarely spoke about their experiences and, after they returned home, tried to leave the war behind them.

Because Australian psychiatrists did not acknowledge the toxic effect of war they did not help returning veterans to make sense of their nightmares, their depression, and their anxiety attacks. The reticence of returning veterans was reinforced by psychiatry and public opinion alike. Only a few veterans Raftery came to know well had ever discussed their memories of the war before. Under the surface, however, even the most successful men at times suffered from nightmares and panic attacks. Many men suffered in silence and found some way keep going. Family members typically bore the brunt of their sometimes difficult and erratic behaviour. A few veterans could not adjust to peace-time society. Raftery provides rich composite portraits of the life histories of the men in his study, superbly illustrating the diverse ways in which their war experiences shaped their lives.

Performance Enhancement During Deployment

Shephard and Raftery relate how soldiers were often short-changed by psychiatrists. Only a small number of soldiers received the psychiatric care they needed, most received inadequate psychiatric attention or none at all. At the same time, military officials have often been suspicious of psychiatrists and resisted their presence in the army. Military Stress and Performance: The Australian Defence Force Experience, edited by George E. Kearney, Mark Creamer, Ric Marshall, and Anne Goyne, paints an entirely different image. The authors represented in this volume are psychiatrists, psychologists, and military officials who draw on their experience in the Australian Defence Force during the 1990s. They relate insights gained during past conflicts, and how these insights can be applied to minimise traumatic reactions and enhance performance during deployment in future conflicts.

The authors of Military Stress and Performance all assume that military deployment is stressful and potentially traumatic. They present the latest research on the causes of stress and its influence on the performance of soldiers. From the chapters in this book, one can conclude that the Australian Defence Force is keenly aware of the potentially traumatic impact of deployment and has developed a great variety of strategies for minimising it. The authors propose preventive measures and stress management strategies to limit the impact of stress and trauma (among them critical incident stress debriefing, which is now routinely applied in civilian life as well). Several chapters contain flow-charts detailing multi-level models of stress management and performance enhancement. The chapters quote extensive research on how stress affects behaviour and performance. For example, we learn that perceptions of loss of control and cognitive overload are ‘critical precursors to performance decrements’ (p. 24), while role clarity, team structure, and role assignments are critical to good team performance.

The stresses of peace-keeping equal or surpass those of conventional warfare.

The most interesting chapters in the book deal with the stressors unique to peace-keeping operations. During the past decade or so, the Australian Defence Force has participated in such operations in the former Yugoslavia, Somalia, Rwanda, and East Timor. As a consequence, Australian soldiers have witnessed destruction, suffering, and cruelty. They have been exposed to dead bodies some of which bore the clear marks of torture. The role of the military is often ambiguous in peace-keeping operations because of the distinct constraints on the use of force. These conditions can lead to stressful situations requiring special preparation and strategies of stress management. According to several authors in this volume, the stresses of peace-keeping operations equal and at times even surpass those of conventional warfare.

The authors represented in this volume emphasise performance enhancement and prevention over trauma and treatment. They analyse the stresses of deployment and propose methods to minimise its impact by systematic preparation of troops and by systematically debriefing them before they return home. The psychological research reviewed by the authors deals with motivation, factors determining resilience, and stress management strategies. The emphasis on resilience and performance enhancement has probably greatly aided the acceptance of psychiatrists and psychologists in the Australian Defence Force. After all, the research presented in this volume emphasises ways to improve performance instead of drawing attention to trauma, PTSD, and the psychological costs of warfare.

However, there are many reasons to assume that the authors of Military Stress and Performance paint too rosy a picture. Recently, the value of critical incident stress debriefing has been called into question, with reports of its ineffectiveness and adverse reactions. Further, recent news reports have thrown doubt on the general acceptance of psychiatry and psychology within the Australian army. It appears that there is a culture of denigration and harassment, particularly towards injured soldiers, in many training camps. The suicide of Private Jeremy Williams has drawn attention to bullying, humiliation, and brutalisation in the Australian army. One would hope, both for ethical and medical reasons, that this culture could be made to disappear. Military officers, however, probably consider this type of social environment character building and conducive to military discipline. When this is the case, there is little that psychiatrists and psychologists can do.

Today, psychiatrists generally acknowledge that war is inherently traumatogenic. Whether modern armies accept the presence of psychiatrists and psychologists, the potential of warfare to inflict trauma has increased steadily during the last several decades. Psychiatrists and psychologists can attempt to minimise the impact of trauma. There are, however, limits to what mental health professionals can do. During the advent of the 2003 Gulf War, the traumas of war were hardly mentioned at all and most likely were not part of the considerations in the preparation for the invasion of Iraq. I hope that politicians, military officials, and the public in general would take the emotional costs of warfare into account before entertaining future deployment. In the case of peace-keeping operations, things are more ambiguous. There are often pressing moral reasons to participate in deployments aiming at maintaining peace and preventing civil war and genocide. Soldiers, army officials, and physicians should be fully aware of the potentially traumatogenic nature of these operations and cooperate to minimise their emotional impact.

Hans Pols is lecturer in the Unit for History and Philosophy of Science at the University of Sydney. He is interested in the history of psychiatry, mental hygiene, and the psychiatric response to warfare. He received an ARC Discovery Grant for his project on War, Trauma, and Rehabilitation: The Army, Psychiatry, and World War II.