The twentieth century brought with it a change in the character of warfare leading to military psychiatry becoming increasingly prominent and to its development throughout the First, Second and Vietnam wars. In the First World War, ‘military and political authorities persistently argued that shell shocked men were not mad’ (F. Reid, 2010) or at the very least they should not be treated as such. It however, soon became the norm to treat men in such as way and it took until the 1980s for post-traumatic stress disorder (PTSD) to gain awareness. The development and prominence of military psychiatry tells us much about the nature and character of war throughout the twentieth century and how soldiers have been affected by changes in technology, politics and levels of violence and duration of battle.
First World War
Throughout the First World War it was ‘believed that those with a predisposition to psychological disorder would not have volunteered or have been rejected during recruitment’(E. Jones & S. Wessely, 2006) and training soldiers received was designed to enable men to cope with combat and with fear. The First World War, however, brought with it a change in the character of war and an increased violent nature and duration. Men were engaged in a war of attrition and with technological changes including weapons developments, chemical warfare and air warfare, there were huge changes in military strategy . This coupled with growing populations 'gave the potential for mass mobilization, destruction and psychological traumatization’ (P. Leese, 2002).
The First World War became an industrial war on a scale that has not been seen before. Jones and Wessely (2006) state that at the start of the First World War ‘doctors and administrators did not anticipate an epidemic of traumatic neurosis' due to obvious expectation of battle but the character and horrors of war was something that many men were unprepared for and the war was ‘unprecedented in terms of its scale and the suffering experienced by combatants’ (E. Jones & S. Wessely, 2014). Military psychiatry became prominent due to ‘a new disorder (shellshock) and a new treatment (forward psychiatry)’(E. Jones & S. Wessely, 2014). Captain Frederick Mott hypothesized that shellshock was the result ‘from proximity to explosion’ and according to Jones and Wessely (2014), it was characterised by a range of 'functional physical symptoms, such as exhaustion, palpitations, shortness of breath, tremor, joint and muscle pain’. as well as a range of sleep disorders. Doctors however opted to use the term ‘war neurosis, based on the assumption that the conflict evoked a pre-existing or latent psychological disorder’(E. Jones & S. Wessely, 2006) . Men were therefore believed to have already had a form or psychological condition before going to the front, rather than their trauma and mental state being a result of the war itself. This assumption aided the government and army when it came to compensation which had been ‘of little consequence to the Army before the age of mass conscription’ (P. Leese, 2002). The violent nature of war began to increase and the men at the front were fighting a war of attrition and the development of strategy meant that men were taking part in ‘large-scale battles such as the Somme or Verdun, or their precursors such as Neuve Chapelle, where dramatic attacks were intended to destroy troops, take trenches and create strategic advantage in capturing the ground behind the enemy lines’ (P. Leese, 2002) as well as in, ‘small-scale attrition such as sniping or bombing raids, where ritualized exchanges maintained trenches and blocked the strategic advantage of capturing the ground behind the enemy lines’(P. Leese, 2002). These informed soldiers experience of war. The men were taking part in ‘intense, unpredictable and dangerous forms of work. To engage in this toil meant making the best of enforced circumstances, and like peacetime labouring, its main constituents were boredom, exhaustion and submission to authority, with the additional fear of mutilation or death’ (P. Leese, 2002) and 'the hard labour of fighting and surviving, meant a constant physical struggle against exhaustion; feelings of isolation, helplessness and extinction imposed a further psychological strain’(P. Leese, 2002). The idea around why men fought had yet to be developed but it was clear that rather than just king and country men fought for those men around them and there was even an increasing bond between officers and men.
What also became clear was that ‘shell shock’ did not just affect those that had been in intense combat. Men experienced ‘physical fatigue and long bouts of intense combat between periods of calm and boredom: these were the everyday stresses of the war, and even the strongest constitution might eventually be twisted by such conditions and finally snap’ (P. Leese, 2002). Forward Psychiatry based on three principles: proximity to battle, immediacy, and expectation of recovery , known as the PIE method was put in place to help those suffering from shell shock. Believing that shellshock could be cured by keeping men the proximity to battle it was decided that units were set up within the atmosphere of the front. Along side this doctors developed the 7Rs 'Recognition, Respite, Rest Recall, Reassurance , Rehabilitation, Return to duty' (IP Palmer, 2003). What forward psychiatry did by keeping men close to the front lines, was designed remind them that they were soldiers, by the constant noises and military instruction, and that their duty was to fight. What is not clear is how men men were 'cured' or actually fit enough to go back to the front. French neurologists were accused by Joseph Grasset of having to ‘whitewash trauma victims and to send them back to the front completely uncured’ (E. Jones,& S. Wessely, 2003). Forward psychiatry’s aim was to get men back to the front and to prevent a man-power crisis, rather than being directly about the mental state of the men. It provided a place where soldier avoided being labelled with psychiatric disorders or mental health issues and soon being evacuated to a hospital became ‘associated with a sense of failure and stigma’ (E. Jones,& S. Wessely, 2003). The reality of suffering from shell shock was that it often caused moral shame for the individual and a manpower crisis and pension bills for the army and government. The political nature and character of war meant Britain, France and Germany could not afford for men to be suffering from any kind of trauma and there was a fear that it would lead to malingerers and those claiming to be suffering. Therefore, ‘mental health and illness were judged according to the military requirements for manpower, as well as by rank and class, which were seen as rough measures of social distinction and dutiful trustworthiness’(P. Leese, 2002). The non-labelling of psychiatric illness also provided the governments of Britain and France with the ability to indicate that war was not the cause of any trauma.
In 1922, the War Office Commission of Inquiry into Shell-Shock was chaired by Lord Southborough. Charles Wilson, a witness at the Inquiry and a medical officer on the Western Front, 'came to believe that eventually the strongest nerves would crack under the strain of trench warfare'(S. Wessely, 2006) and that despite the courage and bravery the men had it would inevitably be expended under the conditions on the front, indicating that ‘every man had his breaking point’(S. Wessely, 2006). It was however concluded by the committee that ‘Breakdown was not inevitable, some men made better soldiers than others and some were more resilient than others’(S. Wessely, 2006). What shellshock did was bring psychological disorders to the forefront for the first time in the twentieth century and many in the medical community began to acknowledge that a persons environment was a key factor in the formation of psychological disorders. However, it was still seen as only part of the problem and therefore ‘the personality of the soldier remained the primary explanation why soldiers broke down in combat’(E. Jones & S. Wessely, 2014). They preferred the view that ‘shell-shock was a regrettable weakness, and never present in crack units. The Commission concluded that the best way to prevent breakdown was to correctly lead, train, equip and prepare men for combat and therefore ‘a medical label such as shell shock should not be applied to breakdown in battle’ (S. Wessely, 2006). This was also aimed to prevent cases of malingering and self induced harm or injuries.
The legacy of the First World War meant that Britain entered the Second World War with policies on military psychiatry that were stricter and harsher that before. This meant that those suffering mental breakdown and trauma caused by war, suffered even more. What was viewed as rewarding mental breakdown ‘needed to be removed, and so there was no medical label, no discharges and no pension payable during wartime for those suffering psychiatric breakdown’(F. Reid, 2010). This also remained the case in France, Germany and the Soviet Union. Cited by Simon Wessely (2006), William Sargent observed after Dunkirk: ‘Experts had decided that war neurosis could best be abolished by simply pretending it did not exist, or at least were not caused by man’s war experience but an inherited predisposition’ meaning that thinking behind psychological trauma had not come much further since the First World War. As Jones and Wessely (2014) state, in Britain, the idea that ‘World War I ushered in an era of psychological enlightenment’ is inaccurate and that commanders and the government failed to learn from the mistakes of the First World War, as the conclusion drawn by the Southborough Committee shows.
Second World War
It took until 1941 and the subsequent manpower crisis, like that of the First World War, for forward psychiatry to be reintroduced. In 1941, in the port of Tobruk, a ‘war neurosis clinic’ was set up, however doctors ‘adopted a policy of not regarding acute psychological disorders as medical casualties and treated them close to the battle'(E. Jones,& S. Wessely, 2003). By 1943, there was a greater shift in the prominence of military psychiatry. American psychiatrists ‘concluded that in the conditions of intense industrial warfare every man could indeed reach breaking point if he fought long or hard enough'(S. Wessely, 2006) and as the character of war developed and the intensity and duration of war increased, many soldiers were indeed reaching this point. For the first time in the twentieth century, psychiatric issues and the breakdown of men had been linked directly to the character of war. War and its character and nature, industrial, violent and relentless, was the cause of the mental issues of men rather than their issues stemming from their past.
Another change that occurred during the Second World War was the understanding of the reason why men fight and what motivates men in battle. The idea that men were fighting for moral purposes such as ‘patriotism, esprit de corps, pride and leadership’ (S. Wessely, 2006) was beginning to change and ‘in came the core role of small-group psychology’ and ‘the primary group’(S. Wessely, 2006). As the nature of war grew more violent and the character of war was changing, men, especially British, French and American men, were no longer fighting for these reasons or for an ideology. They were fighting ‘because they belonged to a group of fighters. They fight for their friends, their buddies. They fight because they have been trained to fight and because failure to do so endangers not just their own lives but those of the people immediately around them’(S. Wessely, 2006). The friendships and bond created by the nature and character of war have given men a different reason to fight. This notion was overlooked during the First World War but as war changed character the idea that groups and morale within them helped to prevent breakdown of men and it remains the standard view today. One US military psychiatrist stated that ‘the main characteristic of the soldier with a combat-induced neurosis is that he has become a frightened, lonely helpless person whose interpersonal relationships haven been disrupted… he had lost the feeling that he was part of a powerful group’(S. Wessely, 2006). The group mentality had become an essential part of the reason men were fighting and helped to prevent breakdown in the field to some degree but after the Second World War, the doctrines developed and the idea of men fighting in groups, with strong ties to each other and fighting for each other still ‘remained a paradox’ (S. Wessely, 2006).
Military and political leaders were still worried about malingerers, as they had been previously, and he political nature of war meant that many feared that it would cause a man power crisis if soldiers believed that there was something to gain if the were indicated to have psychological disorders. Despite this, the lack of ‘rewards’ for those suffering from psychiatric issues, that has been in place since the First World War, could only in reality ‘be sustained only in totalitarian states such as Germany and the Soviet Union’. In Britain ‘public opinion and pressure from doctors, Trade unions and MPs forced the government to abandon its embargo on war pensions for psychological disorders in June 1941’(E. Jones & S. Wessely, 2006), showing that society wanted to support the men coming back from war. Based on evidence ‘British doctors came to believe by 1943 that all servicemen, however carefully selected, well-trained or led, had a breaking point’ (E. Jones & S. Wessely, 2006) and that ‘Removing the so called ‘rewards’ did not prevent breakdown either, not did it have popular support’(S. Wessely, 2006). What the development in military psychiatry and the development in the understanding of combat motivation showed was that, even if it was still possible to prevent, labelling psychiatric breakdowns , it was not possible to ignore or deny by shaming men.
Vietnam War
The Vietnam War brought with it an increased prominence in military psychiatry. Forward psychiatry was seen as success up until the Vietnam wat but this was later questioned as there were ‘high rates of substance abuse and evacuations of character and behaviour disorders’(E. Jones,& S. Wessely, 2003) among those who had served in Vietnam. At the start of the Vietnam war, America responded to the ‘links between combat exposure and physical and psychological casualties’(S. Wessely, 2006). by limiting the length of time soldiers served in the theatre of war to one year. This did help to reduce combat stress and fatigue. After the Vietnam war there was, however, a higher percentage of men claiming to have PTSD who had not seen action. This could be due to the compensation culture that had begun to form and part of the groups of malingerers and that had always been a fear of governments since the First World War. Moral injury, now a prominent feature of PTSD, became a more prominent feature as a result of the Vietnam War, even though it has been noted since the First World War, and the ‘impact that a moral and ethical dilemma might have on an individual’s wellbeing’ (E. Jones, 2018) was brought into focus in military psychiatry.
The Vietnam War highlighted that soldiers were ‘witnessing or taking part in acts that violated deeply held beliefs about “what’s right” and this had an enduring impact on their mental health’ (E. Jones, 2018). As a result of the Vietnam War and blame placed on soldiers, many Americans had seemingly turned against the military as the character of society changed. For many veterans of Vietnam ‘toll of war went far beyond the battlefield’(E. Jones & S. Wessely, 2006) and felt abandoned by society. Many people in American society used ‘the image of the disturbed veteran as a symbol of the insane war’(S. Wessely, 2006) and turned the mental state of these soldiers a political issue and an anti-war statement . What developed was the phenomenon of ‘soldiers now willingly admitting to atrocious behaviour’(S. Wessely, 2006) which had not happened before in the 20th century. Many men began to have flashbacks of battle which would become one of the key features of PTSD. Many Vietnam veterans did not bond with others in war as with the First and Second World Wars and did not feel part of a strong military group. Instead their experience of returning to American society and the blame and attacks they received mean that ‘veterans may have experienced more sustained fellow feeling with their comrades after returning from war than they ever had while they fought it’(S. Wessely, 2006) . The experience of veterans of the Vietnam War was therefore very different to that of the First and Second World Wars. Despite the ever-growing prominence of military psychiatry, PTSD, did not gain importance in Britain for some time due to a view that it was more of a US problem as result of the war in Vietnam.
Ultimately the change in prominence of military psychiatry in the twentieth century is due to the nature and changing character of war. The violent, interactive and political nature of war has meant that its character has changed and these developments have led to trauma and psychological issues in those involved and ultimately informed soldiers experience. The First World War showed that the nature and character of war is fundamentally political and the unwillingness of governments to wholly acknowledge a label or a name of psychological breakdown until after the Second World War indicates this. The need to prevent a man power crisis, the fear of malingerers and the lack of pensions and financial support after the First World War show that ‘labelling’ was detrimental to the war effort and this ultimately informed men’s experience. The Second World War and the Vietnam War ultimately changed the view of military psychiatry and increased its prominence. By the end of the Vietnam War, the First World War view that trauma during war was caused by a pre-existing condition had long since passed and the reasons behind trauma have begun to be understood. Forward psychiatry had shown that many men need psychological help during war and that the PIE method does help in getting men back to their units and is they it is still used to day. What it fails to do is help men after conflict and back in society. The realisation during the Second World War that men were fighting for each other rather than for their country or an ideology increased the prominence of military psychiatry and has informed military psychiatry up to the present day. Cultural change and social views in the twentieth century have also aided the increased prominence in military psychiatry men after the First and Second World wars were seen as heroes and after the Second war, given pensions due to pressure on the government from society. The Vietnam War brought with it an anti-war society that increased prominence of military psychiatry in a different way. Trauma was increasing after the conflict had ended due to social pressure and men were experiencing psychiatric issues that had not been seen before. PTSD has continued to develop and become increasingly prominent since the Vietnam war, through the Gulf war, Israeli conflicts and the war in Iraq and Afghanistan and has shown that as character of war and men’s experience of war begin to change, so does the prominence, importance and development of military psychiatry.
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