Early in World War I, the term shell shock emerged to describe the array of psychiatric symptoms soldiers manifested. French and British psychiatrists learned that the symptoms were not the result of a physical shock to the central nervous system, but were psychological reactions to combat experiences. They also learned that the further a psychological casualty was removed from the front, the more intractable his condition became.
Thomas Salmon, surgeon general of the U.S. Army, concluded that soldiers perceived that it was better to be sick than a coward, and shell shock offered an honorable way out of combat. Once evacuated, it became progressively more essential psychologically for the soldier to persevere in his symptoms. Salmon organized psychiatric services for the American Expeditionary Forces along four principles: proximity—treat psychiatric casualties close to the battle zone; simplicity—treat with rest, food, and a shower; immediacy—begin treatment at once; and expectancy—assure the soldier that he would soon return to his unit. Baron Larrey's regimen was resurrected.
At the beginning of World War II, the thrust of military psychiatry was to screen out those susceptible to psychiatric breakdown prior to their entering the armed forces. Examining stations rejected 1.6 million registrants for mental or educational reasons—a rate 7.6 times as high as in World War I. Nonetheless, soldiers were discharged for psychiatric reasons at a rate 2.4 times as high as in World War I. Salmon's doctrine of forward treatment had disappeared from military psychiatric practice. Not until 1943 did Capt. Fred Hanson, applying Salmon's principles, demonstrate that he could return more than 70 percent of battle fatigue casualties to their units with forty‐eight hours of rest in forward areas.
Wartime research revealed that the incidence of psychiatric casualties usually paralleled the number of soldiers wounded; that every man had his breaking point; and that the intensity of combat, duration of exposure, and quality of social supports in the unit were crucial mediating factors. G. W. Beebe and J. W. Appel found that the average soldier's breaking point was eighty‐eight days of combat during which his company suffered one or more casualties. The days need not be consecutive; the effects were cumulative. Concurrently, social psychologists under the leadership of J. A. Stouffer found that cohesive units with competent and supportive leaders had fewer psychiatric casualties, and soldiers endured longer without breaking down.
During the Korean War, Col. Albert J. Glass organized a system of forward treatment by battalion surgeons or medical aidmen. In an effort to prevent psychiatric casualties, the Far East command rotated soldiers in combat units out of Korea after nine months of service, and all service members in Korea received at least one two‐week rest and recuperation leave during their tours. These measures were effective: psychiatric casualties were few, and 90 percent were returned to duty after forward treatment.
By the mid‐1960s, psychoanalytic thinking had penetrated military medicine. But attributing behavior to childhood experiences or unconscious processes was antithetical to military values of responsibility and discipline. Consequently, the primary role of military psychiatrists became examining soldiers prior to court‐martial or administrative discharge. Soldiers who voluntarily sought psychiatric treatment were usually discharged; those who wanted to stay in the army learned that it was unwise to acknowledge that they had symptoms.
During the period of major American involvement in the Vietnam War (1965–72), military psychiatry expanded the range of behavior it addressed. Though the incidence of acute combat fatigue was the lowest in any war up to that time, psychiatrists recognized that substance abuse, some misconduct, and postbattle depression had psychological origins. Alcoholism and drug abuse ceased to be disciplinary matters and were taken over by military medicine. Treatment programs, again reminiscent of those devised by Baron Larrey, were designed for execution by paramedical personnel. Some misbehavior was handled on a quasi‐medical basis; soldiers were eliminated from the service administratively rather than being punished. Service members with persistent psychiatric symptoms that were classified as Post Traumatic Stress Disorder were discharged. Many received treatment from psychiatrists in the Veterans Administration.
With the advent of the All‐Volunteer Force in 1973, senior commanders revised organization, training, and leadership to enhance small‐unit cohesion as one means of strengthening resistance to combat stress. To identify lessons to be learned from combat and training events, after‐action reviews were developed to draw out all of the participants' actions and perceptions. In some units the reviews included emotions as well, and proved effective in reducing Post Traumatic Stress reactions. Military psychiatrists were not involved in these measures. Most military personnel of all ranks continued to fear psychiatrists.
Since the Cold War ended in 1991, U.S. forces have conducted an average of one major armed intervention per year. Military personnel were likely to experience repeated exposure to combat in a single enlistment. Research between 1991 and 1996 revealed that short‐duration combat experiences and noncombat interventions can produce stress reactions. To preserve the psychological readiness of units, it became essential that mental health professionals come out of the hospitals to practice proactive preventive psychiatry. Some psychiatrists took the initiative in peacetime by consulting with commanders and training mental health specialists to provide outreach services in units. As a consequence, during the Persian Gulf War, some combat stress control teams achieved moderate levels of acceptance in line units. They participated in after‐action reviews, conducted post‐trauma debriefings for members of units subjected to severe stress, and trained unit leaders in managing homecoming processes to minimize the likelihood of Post Traumatic Stress Disorder.
[See also Combat Trauma.]
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Faris R. Kirkland