military mental health · tem for the treatment of shell shock or war neurosis. he recom-mended...

PUBLIC HEALTH THEN AND NOW

American Journal of Public Health | December 2007, Vol 97, No. 122132 | Public Health Then and Now | Peer Reviewed | Pols and Oak

Involvement in warfare can have dramatic consequences for the mental health and well-being of military personnel. During the20th century, US military psychiatrists tried to deal with these consequences while contributing to the military goal of preservingmanpower and reducing the debilitating impact of psychiatric syndromes by implementing screening programs to detect factorsthat predispose individuals to mental disorders, providing early intervention strategies for acute war-related syndromes, andtreating long-term psychiatric disability after deployment.

The success of screening has proven disappointing, the effects of treatment near the front lines are unclear, and the resultsof treatment for chronic postwar syndromes are mixed.

After the Persian Gulf War, a number of military physicians made innovative proposals for a population-based approach, anchoredin primary care instead of specialty-based care. This approach appears to hold the most promise for the future. (Am J Public Health.2007;97:2132–2142. doi:10.2105/AJPH.2006.090910)

WAR&Mental

Health

| Hans Pols, PhD, and Stephanie Oak, BMed, FRANZCP

The US Psychiatric Response in the

20th Century

Military


of extensive expertise in the man-agement of war-related psychiat-ric syndromes but also profoundlyaffected the development of theentire discipline of psychiatry,which incorporated new theoreti-cal perspectives, diagnostic cate-gories, and treatment strategiesfirst proposed and developed bymilitary psychiatrists.

SCREENING PROGRAMS

The screening programs in theUS armed forces during WorldWars I and II were based on theassumption that vulnerability for“nervous breakdown” was relatedto relatively stable characteristicswithin the individual, includingconstitution, genetic makeup, andtemperament, or the effect ofearly childhood experiences. Thechallenge of screening was to de-tect those traits that indicated vul-nerability for mental health prob-lems during deployment.

Screening During World War IThe psychiatrist Thomas W.

Salmon was the main architect ofthe US program of military psy-chiatry during World War I. Hewas the medical director of theNational Committee for MentalHygiene, an organization that pro-moted the modernization of psy-chiatry by advocating prevention,treatment in outpatient clinics,and research into the causes ofmental illness. Salmon advised theUS armed forces to screen recruitsand exclude “insane, feeble-minded,psychopathic, and neuropathic in-dividuals.”4 These individuals in-cluded those with schizophreniaand mental retardation, conditionsthat would clearly limit the abilityto provide adequate service. TheUS armed forces rejected ap-proximately 2% of inductees onthis basis.5 Unfortunately, noevaluation of the efficacy of this

screening program was under-taken. However, by the end of thewar, the general opinion amongboth psychiatrists and military of-ficials was that there had been toomany cases of mental breakdownand that this was because screen-ing had not been sufficiently strin-gent.

Screening During World War IIEven before the United States

became involved in World War II,a number of leading US psychia-trists were contemplating howthey could contribute to the wareffort.6 They focused their atten-tion on selection because they be-lieved that the thorough screeningof volunteers and inducteeswould weed out those individualspredisposed to breakdown, whichwould reduce or even eliminatemental health problems duringdeployment.7 In December 1940,Harry Stack Sullivan, a psychoan-alyst, joined the Selective ServiceSystem as a consultant to developa screening program. Sullivan be-lieved that the US armed forcesshould exclude not only individu-als suffering from mental illnessbut also those with neurosis ormaladjustment.8 He reasoned thatindividuals who had been unableto adjust to the demands ofAmerican society would never ad-just to the demands of army life.Military officials were particularlyinterested in detecting homosexu-ality, which they believed de-stroyed combat effectiveness andmorale.9 In addition, homosexual-ity was an offense for which onecould be court-martialed.

Initially, military officials ap-proved of screening programs be-cause they promised that thearmed forces would be made upof the most able men. Between1941 and 1944, Sullivan’s screen-ing methods excluded 12% (al-most 2 million) of 15 million men

December 2007, Vol 97, No. 12 | American Journal of Public Health Pols and Oak | Peer Reviewed | Public Health Then and Now | 2133

WITNESSING ACTS OF WAR-FARE, including killing, torture,and widespread devastation, canbe severely upsetting. It can alsohave significant mental healthconsequences for military person-nel. Witnessing death, destruction,and torture; experiencing unex-pected and at times continuousthreats to one’s life; or participat-ing in hostilities and killing canpotentially lead to mental healthproblems. During the 20th cen-tury, psychiatrists offered their as-sistance to the military to mitigatethe effects of these and othertraumatic experiences inherent inwarfare. Military officials every-where have displayed a strongambivalence toward the involve-ment of psychiatrists in militaryaffairs. For example, they haveoften labeled soldiers sufferingfrom psychiatric symptoms ascowards lacking moral fiber.1 Mili-tary officials have also been con-cerned that the presence of psy-chiatrists encouraged the displayof psychiatric symptoms. How-ever, military officials have beeninterested in psychiatric issueswhenever they were perceived toaffect the primary mission of thearmed forces. When psychiatristswere perceived to be able to con-tribute to the primary goal of allarmy medical services, which is toconserve the fighting strength, theircontributions were appreciated.2

We examine the attempts of USpsychiatrists during the 20th cen-tury to treat and prevent the psy-chiatric consequences of war byimplementing screening programs,providing early interventionstrategies for acute war-relatedsyndromes near the front lines(“forward psychiatry”), and miti-gating the symptoms of long-termpsychiatric disability after deploy-ment.3 The involvement of psy-chiatrists in military conflicts notonly resulted in the development

The face of a soldier from GhostTroop, 2nd Armored CavalryRegiment, shows strain in the af-termath of the Battle of the 73Easting during Operation DesertStorm, Iraq, February 26, 1991.

Source. Photo by Vince Crawley.Reprinted with permission from Starsand Stripes, 1991, 2006.


examined, which was about 6times the rejection rate of WorldWar I.10 Of all men rejected formedical reasons, 37% were ex-cluded on neuropsychiatricgrounds.11 However, the expectedeffects of screening did not materi-alize during World War II: the re-ported incidence rate for war neu-rosis in the US armed forces wasat least double the rate duringWorld War I. The unexpected anddramatic failure of selection com-bined with the pressing militaryneed for manpower led military of-ficials to severely criticize psychia-trists.12 An order of Gen George C.Marshall abolished screening in1944.13 At that time, a number ofmen who had been recommendedfor rejection on psychiatricgrounds were inducted after all. Ofthis group, a mere 18% was laterdischarged on neuropsychiatricgrounds. Of the remaining group, asurprising 80% gave satisfactoryservice (the percentage for thearmy as a whole was 92%).14

In retrospect, it is not surprisingthat screening programs for psy-chiatric disability had poor predic-tive power. Even today, the men-tal health consequences of warare poorly defined, with ever-shifting diagnostic categories, anuncertain theoretical foundation,and a lack of consensus on therelative contribution of predispos-ing and contextual factors. Thefailure of selection provided a se-rious challenge to the notion thatpredisposing factors were criticalto the development of mentalhealth problems during deploy-ment. It challenged psychiatriststo explore other causes, such asthe stresses of warfare.

EARLY INTERVENTIONPROGRAMS

Aware that screening for illmental health would not preventpsychiatric problems in the USarmed forces, military psychiatristsalso devoted considerable atten-tion to the management of psy-chological distress during deploy-ment. During World War I, Britishpsychiatrists saw a puzzling condi-tion initially named shell shock.15

Its symptoms comprised physicaland psychological components, in-cluding stuttering, crying, trem-bling, paralysis, stupor, mutism,deafness, blindness, anxiety at-tacks, insomnia, confusion, amne-sia, hallucinations, nightmares,heart problems, vomiting, and in-testinal disorders. Soldiers suffer-ing from shell shock were unableto fight and posed difficult prob-lems for the medical corps,morale, and military discipline. Ini-tially, military officials were con-vinced that they were malingerersor cowards. Military physicians, onthe contrary, viewed this conditionas neurological in nature and be-lieved that it was related to directeffects of exploding shells (hence

“shell shock”). A number of lead-ing British psychiatrists and psy-chologists, including Charles S.Myers and W. H. R. Rivers, be-lieved the condition was psycho-logical in nature and introducedpsychotherapeutic interventionsfor its treatment.16

Early Intervention DuringWorld War I

In May 1917, before the UnitedStates became involved in WorldWar I, Salmon visited the UnitedKingdom to survey the treatmentmethods British physicians haddeveloped for shell shock.17 Atthat time, 15% of British soldiershad been discharged because ofthe condition. Salmon’s compre-hensive report became the basisfor military psychiatry in the USarmed forces during World WarI.18 He viewed war neurosis as anunconscious escape from an intol-erable situation characterized bya conflict between the instinct ofself-preservation and the demandsof one’s duty. Shell shock was apsychological reaction to thestresses of warfare rather than theexpression of a predisposition tomental illness. Salmon devotedthe greatest part of his report toplans for hospital facilities thatwould deal with the problem. Heargued that psychiatrists shouldbe placed “as near the front asmilitary exigency will permit.”19

Salmon proposed a 3-tier sys-tem for the treatment of shellshock or war neurosis. He recom-mended that treatment commenceas soon as possible after the onsetof symptoms. Treatment was ide-ally applied in or near casualtyclearing stations, which were lo-cated a few miles behind the lines.Here, nervous soldiers were givena period of rest, sedation, andadequate food. Through relativelysimple forms of supportive psy-chotherapy imbued with optimism


Thomas W. Salmon in his office inFrance during World War I.

Source. Courtesy of Oskar DiethelmLibrary, Institute for the History ofPsychiatry, Weill Medical College ofCornell University.


and characterized by persuasionand suggestion, military physiciansexplained to soldiers that their re-action was normal and would dis-appear in a few days. One front-line psychiatrist estimated that upto 65% of soldiers returned to thefighting lines after 4 or 5 days.20

The second tier consisted of psy-chiatric and neurological wards inbase hospitals, which were located5 to 15 miles behind the frontlines. There, soldiers were treatedfor up to 3 weeks. Salmon himselfwas associated with the third tier,Base Hospital 117, about 50 milesfrom the front line, where severetypes of shell shock were treatedfor up to 6 months. If there wasno improvement during this pe-riod, soldiers were repatriated.21

Treatment near the front linesachieved a dual purpose. First, itgave a clear message to soldiersthat shell shock did not provide aneasy route home. In this way, psy-chiatrists played a significant rolein fighting so-called evacuationsyndromes, in which the display ofa specific set of symptoms led toevacuation and repatriation, whichoften increased the symptoms’ inci-dence.22 Second, psychiatrists initi-ated treatment as soon as possibleafter symptoms appeared. Fromthe British experience, Salmon hadlearned that the symptoms of men-tal distress commonly became in-grained and resistant to treatmentwhen left untreated. Immediatetreatment promised to result inhigh recovery rates and the pre-vention of long-term psychiatricdisability. In line with military de-mands, Salmon’s aim was to returnas many men as possible to thefront line.23

Early Intervention DuringWorld War II

Salmon’s plans for forward psy-chiatry were not considered rele-vant during the first years of

World War II because the mili-tary was convinced that screeningwould eliminate postcombat psy-chiatric disorders. During theTunisian campaign in early 1943,however, up to 34% of all battle-related disorders were labeledneuropsychiatric.24 Because USArmy policy dictated that soldierswith psychiatric disorders had tobe repatriated, attrition rates be-came alarmingly high. As a conse-quence, military officials were re-ceptive to the ideas of a small butoutspoken group of psychoanalyti-cally oriented psychiatrists, includ-ing Roy G. Grinker and WilliamC. Menninger, who proposed toimplement programs of forwardpsychiatry that resembled those ofSalmon.

In 1943, Grinker and John P.Spiegel introduced psychothera-peutic treatment near the frontlines for the US Air Force.25 Theyinjected traumatized soldiers withsodium pentothal, which induceda dream state, and subsequentlyencouraged their patients to reex-perience their traumatic experi-ences, which thereby wouldloosen the experiences’ strangle-hold on their minds. Many sol-diers recovered; Grinker andSpiegel claimed that

the stuporous become alert, themute can talk, the deaf can hear,the paralyzed can move, and theterror-stricken psychotics becomewell-organized individuals.26

They wrote a manual on thetreatment of war neuroses con-taining several illustrative casehistories that was widely distrib-uted among military medical offi-cers.27 Unaware of Salmon’s ini-tiatives during World War I, theneurologist Frederick R. Hanson,who was working in Tunisia andAlgeria, introduced simple andstraightforward treatments (rest,good food, hot showers, and

sedation), which he claimed weresuccessful in returning men to thefighting line in just a few days.28

According to Grinker andSpiegel, soldiers who brokedown after extended exposure tobattle were neither cowards norweaklings—rather, they werenormal individuals who could nolonger cope with the unremittingand horrendous stresses of war.They argued that “it would seemto be a more rational question toask why the soldier does not suc-cumb to anxiety, rather than whyhe does.”29 According to them,every man had his breaking point;they estimated this breaking pointto occur anywhere between 100days and 1 year of active combatduty. Two leading psychiatristslater argued that one of the mostimportant lessons of World War IIwas that it required psychiatrists“to shift attention from problemsof the abnormal mind in normaltimes to problems of the normalmind in abnormal times.”30

William C. Menninger, thechief of the division of neuropsy-chiatry in the Surgeon General’sOffice of the US Army starting inDecember 1943, was a tirelessadvocate of psychoanalysis, scien-tific research within psychiatry,and a wider application of psychi-atric knowledge in the solution ofpersonal and social problems. Heinformed all military medical offi-cers of the principles of forwardpsychiatry.31 Psychiatrists claimedthat they were able to return40% to 50%, and at times evenup to 80%, of neuropsychiatriccases to duty within a week.32

After the war, these figures wereadjusted downward, when it wasacknowledged that the percentageof personnel able to return to thefront lines was disappointinglylow (generally, such personnelcould only function in noncombatroles).33 In total, there were more



than 1 million neuropsychiatricadmissions to the medical servicesof the US armed forces, constitut-ing 6% of all admissions.34

The research of social scientistsreinforced the shift in psychiatry’stheoretical focus from individualpredisposition toward broadly in-fluential environmental factors(such as the stresses of warfare).Herbert X. Spiegel, one of the firstpsychiatrists to observe soldierssuffering from war neurosis inTunisia, was convinced that sol-diers were not primarily moti-vated by hatred for the enemy orthe ideals of liberty and democ-racy, but by the bonds with theirbuddies and regard for their offi-cers.35 He believed that group co-hesion was an essential factor inmaintaining morale. These viewswere confirmed by a team of so-cial scientists led by Samuel Stouf-fer, who investigated motivationaland social factors in the US Army.Stouffer concluded that moralewas inversely related to break-down incidence and intimatelylinked to the trust soldiers had intheir officers, their training, theiroutfit, their weapons, and theirfellow soldiers. Morale was alsoassociated with the degree of per-ceived support from the homefront. Most significantly, it was re-lated to the strength of the emo-tional bonds among soldiers andbetween soldiers and their com-manders.36 This research led theUS military psychiatrist AlbertGlass to conclude that

perhaps the most significant con-tribution of World War II mili-tary psychiatry was recognitionof the sustaining influence of thesmall combat group or particularmembers thereof, variouslytermed ‘group identification,’‘group cohesiveness,’ ‘the buddysystem,’ and ‘leadership.’37

Research conducted afterWorld War II demonstrated that

only around 40% of all cases ofnervous breakdown took placeoverseas (and only a fraction ofthese in personnel at the frontlines), whereas around 60% oc-curred in the armed forces withinthe United States.38 These findingsindicate that psychiatric disorderwas not primarily related to ex-tended frontline duty but to a vari-ety of other factors, including lackof morale. African American sol-diers, whose battalions were segre-gated from the rest of the armedforces, recorded a high incidenceof psychiatric syndromes, whichwas most likely related to theirlow status and the discriminationthey suffered in the army.39 Thesefindings are further reinforced byrecent research into the etiologyof post-traumatic stress disorder(PTSD), which has deemphasizedthe role of the original traumaticevent and has highlighted the im-portance of a variety of contextualfactors, among them the percep-tion of social support, preexistinganxiety or depression, and a fam-ily history of anxiety.40

Early Intervention in Koreaand Vietnam

In the initial phase of the Ko-rean War, military officials re-ported very high rates of neu-ropsychiatric casualties (250 per1000 per year).41 Because of thenature of the conflict, character-ized by quickly shifting front linesand widely dispersed battle fields,it was difficult to implement pro-grams of forward psychiatry.After the determined implemen-tation of these programs, how-ever, more than 80% of neu-ropsychiatric victims returned tobattle.42 From the inception ofthe Vietnam War, extensive andwell-equipped psychiatric serviceswere available to treat mentallydistressed soldiers.43 During thatconflict, the incidence of combat

stress was reported to be verylow (less than 5% of all medicalcases). On the recommendationof military psychiatrists duringWorld War II, Vietnam War sol-diers had a tour of duty limitedto 1 year and frequent periods ofrest and relaxation. Military psy-chiatrists believed that both fac-tors decreased the incidence ofmental breakdown.44

Since the Vietnam War, mentalhealth teams have become an in-tegral part of the fighting forces.On the basis of the experience ofmilitary psychiatrists of previouswars, the US armed forces haveimplemented extensive strategiesto target combat stress, in linewith the belief that all servicepersonnel are potential stress ca-sualties. “Combat stress controlteams” staffed by specialist mentalhealth professionals are responsi-ble for prevention, triage, andshort-term treatment with thepurpose of retaining manpowerand maintaining operational effi-ciency. These teams provide arange of services, including con-ducting surveys of the interper-sonal climate within units, educat-ing unit command, providingbriefings on suicide preventionand reintegration advice for re-turning home, and providing in-formal support to soldiers.45 Criti-cal incident stress debriefing(specialist intervention as soon aspossible after potentially traumaticevents) has also been enthusiasti-cally incorporated by modernstress control teams, which aredeployed after natural disasters orterrorist action. Unfortunately, re-search has not adequately sup-ported approaches with a focuson frontline intervention.46 Re-cent critical reviews have shownthat critical incident stress debrief-ing does not decrease the devel-opment of symptoms and that, insome cases, it exacerbates them.47


the presence of an understandingand supportive community, a per-ceived appreciation of the servicethat had been rendered, andabove all, employment and theperception of social support.52

In 1945, Gen Omar N. Bradley,who was greatly respected amongsoldiers and veterans, was ap-pointed as the head of the Veter-ans Administration. Bradley hiredPaul Hawley, the chief surgeon ofthe European Theater of Opera-tions, to direct the Division ofMedicine. Hawley hired morethan 4000 physicians and initi-ated an extensive hospital-buildingprogram. Under the policies ofHawley and Bradley, new Veter-ans Administration hospitals wereestablished in affiliation with med-ical schools, guaranteeing that thebest medical services would beprovided to veterans. The Veter-ans Administration system also en-couraged clinical psychologists tobecome psychotherapists and pro-vided a large number of trainingpositions.53 In June 1947, a littleless than half a million patients

with neuropsychiatric disabilitiesreceived pensions from the Veter-ans Administration, and approxi-mately 50000 of these weretreated in Veterans Administrationhospitals. Many of these sufferedfrom chronic conditions that didnot respond well to treatment.

Treatment After the Vietnam War

Before the Vietnam War, psy-chiatric consensus held that sol-diers who recovered from anepisode of mental breakdownduring combat would suffer noadverse long-term consequences.Psychiatric disability commencingafter the war was believed to berelated to preexisting conditions.54

As a consequence, military psy-chiatrists devoted relatively littleattention to postwar psychiatricsyndromes. A major shift in psy-chiatric interest in war-relatedpsychiatric disability took placeafter the Vietnam War. Fifteenyears after the United States with-drew from Vietnam, an epidemio-logical survey concluded that


TREATMENT PROGRAMS

Treatment After World War IAfter World War I, Salmon

worked closely with the AmericanLegion and recommended the es-tablishment of specialized treat-ment facilities for neuropsychiatricwar casualties. He strongly advisedagainst placing these soldiers inmental hospitals because of thestigma attached to these institu-tions and because the veteranswere not affected by severe formsof mental illness. He believed thatoutpatient treatment was moreappropriate.48 In 1921, 27% ofall hospitalized ex-servicemenwere defined as neuropsychiatriccases (in 1927, this number wasestimated to be 46.7%).49 TheAmerican Legion was convincedthat these soldiers deserved thebest possible treatment and wereentitled to a pension. After 1925,however, psychiatrists began todoubt the wisdom of providingpensions, because they believedpensions reinforced disability. Psy-chiatrists wondered whether theirefforts had contributed to theproblem of the large number ofex-servicemen who still sufferedfrom psychiatric disability afterthe war.50

Treatment After World War IIAfter World War II, most psy-

chiatrists considered aiding re-turning soldiers to integrate intosociety primarily a job for familiesand the local community. Thebenefits of the GI Bill of Rights(the Servicemen’s ReadjustmentAct),51 which included funding forhigher education and easier ac-cess to mortgages, aided manyveterans. In addition, the boomingpostwar economy provided fullemployment. As psychiatrists latertheorized explicitly, the develop-ment of psychiatric problems afterwars could be counteracted by


A soldier relieves tensions during apsychiatric interview.

Source. US National Archives andRecords Administration, Washington, DC.


480 000 (15%) of the 3.15 mil-lion Americans who had servedin Vietnam were suffering fromservice-related PTSD. In addition,between one quarter and onethird (nearly 1 million ex-servicepersonnel) displayed symptoms ofPTSD at one time or another.55

The recognition that many vet-erans suffered from chronic psy-chiatric disorders was the out-come of a long process that beganin 1970 when Chaim Shatan andRobert J. Lifton adopted the cause

of a group called Vietnam Veter-ans Against the War. In theirmeetings, they discussed veterans’health and well-being, which theyconsidered to be poor.56 Shatanand Lifton lobbied for increasedmental health services for Viet-nam veterans. Their efforts werereinforced by the acceptance ofthe diagnostic category of post-traumatic stress disorder in the3rd edition of the American Psy-chiatric Association’s Diagnostic

and Statistical Manual of MentalDisorders at the 1980 annualmeeting.57 The criteria for this di-agnostic category included theconcept of delayed onset: psychi-atric symptoms could appear sev-eral years after the initial trauma.

A range of explanations havebeen offered to explain the ex-traordinarily high rate of PTSDafter the Vietnam War. Mediaportrayals emphasized that sol-diers entered and left the war asindividuals instead of in close-knitunits, returning to a polarizedUnited States where they wereoften reviled instead of celebratedas heroes, in addition to sufferingthe pains of stigma and high un-employment. There are severalreasons to develop a more nu-anced explanation of this situa-tion. Since 1980, the PTSD diag-nosis has remained controversial;disagreements over its definitionand measurement persist. Esti-mates of the incidence of PTSDin Vietnam veterans range from3.5% to 50%. Some critics haveargued that providing veteranswith a diagnostic label was theonly way to give poor Americans,who were recruited in unusuallylarge numbers in the Vietnamconflict compared with earlier20th century US wars, an entitle-ment to a pension and medicalcare and that, after a diagnosiswas conferred, symptoms weresolidified and disability ingrainedto maintain these entitlements.58

Because of the perceived sizeof the problem, US psychiatristsand psychologists have initiatedan impressive number of researchprojects on treatment strategiesfor PTSD. Proposed specialisttreatments have included the useof antidepressant medication andindividual and group psychothera-pies. There is now an extensiveevidence base for the efficacy oftrauma-focused cognitive behavior

therapies administered to individ-uals or groups of veterans.59 Nev-ertheless, there is still debateamong psychiatrists whetherPTSD constitutes a separate diag-nostic entity that is independentfrom other anxiety and depres-sion states.60

Treatment After the PersianGulf and Iraq Wars

During the past few years, anumber of studies have reportedprevalence rates between 15.6%and 17.1% for PTSD amongthose who have returned from thePersian Gulf War and the IraqWar.61 Surveys have indicatedthat military personnel are nottaking full advantage of the med-ical and psychiatric resources attheir disposal. Within the military,the view that displaying psychiat-ric symptoms indicates weaknessof character or cowardice is stillgenerally held.62 Soldiers most inneed of mental health care do notseek it because of fear of embar-rassment, difficulties with peers orofficers, or interference with ca-reer opportunities within the mili-tary. It appears that the accumu-lated wisdom of psychiatry andincreasingly efficient and sophisti-cated psychiatric treatment meth-ods generally do not reach thosewho need them most.

After the conclusion of the Per-sian Gulf War, the media mainlyfocused on Gulf War Syndromeand gave relatively little attentionto PTSD. After returning fromservice, a number of Persian GulfWar veterans reported symptomsof fatigue, cognitive impairment,headaches, depression, anxiety,insomnia, dizziness, joint pains,and shortness of breath, whichthey related to the specific condi-tions of that conflict, including ex-posure to environmental hazardssuch as burning oil wells and de-pleted uranium, pesticides, and


Operation Georgia, in which USMarines blew up bunkers and tun-nels used by the Viet Cong.

Source. US National Archives andRecords Administration, Washington, DC.


the side effects of vaccinations. Inthe United States, $250 million hasbeen spent on research, yet nospecific set of symptoms indicat-ing the existence of a war-relatedsyndrome has been found and noclear cause has been identified.63

Some psychiatrists have sug-gested that the symptoms experi-enced by veterans have a signifi-cant and persistent psychogeniccomponent, although the specificsymptoms seem to vary from warto war and most veterans, like pa-tients in general, tend to resistpsychogenic explanations for theircondition and prefer somatogenicones. In an interesting study, thehistorian Edgar Jones comparedthe reported symptoms of nearly1500 veterans who received pen-sions for postcombat disordersfrom 1900 to the Korean Warwith those of 400 veterans of thePersian Gulf War. No syndromespecific to any war could be iden-tified.64 According to Jones, theexplanation given to war-relatedsyndromes reflects broader cul-tural concerns as well as the stateof medical knowledge and theway physicians categorize and in-terpret functional somatic presen-tations. After the Persian GulfWar, a number of outspoken vet-eran groups aspired to gain recog-nition for the medical problems ofveterans by claiming that theywere related to a number of spe-cific conditions related to that de-ployment rather than subsumingthem under a diagnosis of PTSD.

Because no specific set of med-ical symptoms can be identifiedafter each war, and because eachwar has given rise to an increasein unexplained medical symptomsamong service personnel, Engel etal. have argued that investigatingthe exact nature of postwar syn-dromes will not yield constructiveresults.63 Instead, they propose theintroduction of a population-based

health care model to mitigatetheir impact. Because the major-ity of veterans first seek medicalattention in primary care settings,the mitigation of the symptoms ofpostwar medical syndromesshould be provided there insteadof being based on specialist inter-vention, psychiatric or otherwise.Care should be patient centeredand focus on regaining and main-taining functioning, therebyavoiding medicalizing traumaticdistress and reinforcing illness be-havior. If symptoms persist, spe-cialists will become involved.Engel’s model introduces gradu-ated levels of care, which offer arange of interventions, includingpreclinical prevention, symptommitigation in routine primarycare, symptom reduction and dis-ability prevention in collaborativeprimary care, and intensive reha-bilitation with specialist interven-tion only if significant disabilitypersists.65 It is a significant devia-tion from the emphasis on spe-cialist care by psychiatrists devel-oped after the Vietnam War. It islikely that this model will delivermedical care that is more com-prehensive to veterans.

IMPLICATIONS

As with all branches of medi-cine, psychiatry’s involvementwith the military during the warsof the 20th century had a signifi-cant effect on the discipline.66 Itstimulated the development ofnew perspectives that were subse-quently adopted by the disciplineas a whole and suggested newmodels of mental health care. Be-fore World War I, virtually allAmerican psychiatrists workedwithin mental asylums, which in-stitutionalized individuals with se-vere and persistent forms of men-tal illness. At the time, there wereno specific treatment methods

available for these conditions andthe professional status of psychia-try as a medical specialty waslow.67 On the basis of his experi-ences during World War I,Salmon proposed to expand thescope of psychiatry to include thetreatment of individuals with awide variety of mental disordersin community-based clinics andprimary care settings.

Recognizing that the majorityof individuals with early symptomsof mental illness would not attendspecialist physicians or psychiatrists,Salmon suggested that all generalpractitioners should be educatedin the principles of psychiatry toimprove their skills in treatingthese patients.68 In addition, heemphasized the importance ofholistic or patient-centered healthcare over disease- centered andspecialist health care.69 At thetime, his proposals were not im-plemented.

In 1940, the majority of Amer-ican psychiatrists were still basedin mental hospitals. In the open-ing days of World War II, only 35psychiatrists were involved in theUS armed forces. By the end of thewar, this number had risen tonearly 1000, just short of onethird of all American psychia-trists.70 As Edward A. Streckernoted in his presidential addressto the American Psychiatric Asso-ciation in 1944, “Practically everymember not barred by age, dis-ability or ear-marked as essentialfor civilian psychiatry is on activeduty.”71 During the war, a greatnumber of physicians received 6-month training courses in psychia-try that equipped them to treatsoldiers suffering from war neuro-sis. Because of the perceived suc-cess of forward psychiatry duringthe war, the participation inWorld War II had a tremendouseffect on postwar American psy-chiatry. As a consequence of the



efforts of Menninger and a num-ber of psychoanalysts, psycho-analysis and psychodynamic ex-planations became the dominanttheoretical perspective of Ameri-can psychiatry. In addition, therewas a strong interest in psychoso-matic medicine. The concept ofstress was central in Grinker andSpiegel’s reinterpretation of theirwar experience.72 Because of itswidespread use in the work ofmilitary psychiatrists, the conceptof stress became enormously pop-ular in the medical profession andamong the public. These changesin perspective stimulated a shiftfrom treatment and care in men-tal hospitals to psychotherapeutictreatment on an outpatient basisin community clinics.73 For 2 to 3decades after World War II,American psychiatrists focused onthe psychotherapeutic treatmentof relatively benign states in rela-tively normal individuals. Severalprograms were initiated to traingeneral practitioners in psy-chotherapeutic methods.74 Somepsychiatrists even argued that psy-chiatry should provide the foun-dation for all medical education.75

The Vietnam War inspired arevision of the views on the na-ture of acute war neurosis andlong-term psychiatric disability.Before the Vietnam War, psychia-trists generally focused on acutepsychological reactions and ex-pected soldiers to recover rela-tively quickly. Psychiatrists be-lieved long-term psychiatricdisability reflected individual fac-tors that predated the war, suchas a predisposition for mental ill-ness. The emergence of the diag-nostic category of post-traumaticstress disorder changed that bylinking long-term psychiatric dis-ability to the trauma of war. Awide variety of specialist treat-ment strategies have been devel-oped for its treatment. However,

since its introduction to the DSMclassification system of psychiatricdiagnosis, PTSD has remained acontroversial diagnosis that ap-pears to be applied to an ever-in-creasing number of conditions,leading to its trivialization. Criticshave labeled Western society asociety enamored and obsessedwith trauma.76 We can now ex-pect counselors to be deployedafter terrorist acts or other majorupheavals.

After the Persian Gulf War, anumber of physicians and psychi-atrists abandoned the attempt toidentify specific war-related med-ical or psychiatric syndromes. In-stead, they proposed an approachanchored in primary health caresettings to replace the emphasison specialist medical intervention.Interestingly, many of the propos-als made by Engel and his col-leagues resemble those made bySalmon after World War I and anumber of American psychiatristsafter World War II. These propos-als emphasized the importance ofeducating general practitioners inthe principles of psychiatry,thereby integrating psychiatric ap-proaches in primary health caresettings.

Military psychiatrists have gen-erally been concerned with themental health of the fightingforces rather than that of civiliansin areas affected by war, eventhough the extent of civilian traumasignificantly exceeds that of mili-tary personnel.77 There has beena dearth of research on the mentalhealth of civilians in areas affectedby war; only a handful of preven-tive or treatment programs havebeen developed. As an alternativeto providing specialist medicalcare, aid to rebuild infrastructureand fostering naturally occurringcommunal processes of healingand social support appear to bethe most promising strategies.

Extrapolating from the work ofEngel and his colleagues, support-ing or promoting primary healthcare systems could provide thebest response to the psychiatricsyndromes in civilian populations.■

About the AuthorsHans Pols is with the University of Sydney,Sydney, Australia. Stephanie Oak is withthe Hunter New England Mental HealthServices, Newcastle, Australia, and theSchool of Medicine and Public Health atthe University of Newcastle, Newcastle.

Requests for reprints should be sent toHans Pols, Unit for History and Philosophyof Science, Carslaw F07, University of Syd-ney NSW 2006, Australia (e-mail:[email protected]).

This article was accepted October 23,2006.

ContributorsBoth authors conceptualized ideas, inter-preted historical developments, and re-viewed drafts of the article equally.

AcknowledgmentsH. Pols was supported by a DiscoveryProject grant of the Australian ResearchCouncil (DP0450751).

Human Participant ProtectionNo protocol approval was needed for thisstudy.

Endnotes1. Lack of moral fiber was introducedby the British Royal Air Force at the be-ginning of World War II to stigmatizeand discharge aircrew that refused to flymissions without a medical excuse. Weuse the phrase here in its more generalmeaning. For the British Royal AirForce use, see Edgar Jones, “‘LMF’: TheUse of Psychiatric Stigma in the RoyalAir Force During the Second WorldWar,” Journal of Military History 70(2006): 439–58.

2. The dual role of military psychia-trists who serve the military and treattheir patients can lead to ethical con-flicts. These ethical conflicts for militaryphysicians in general are explored in:Victor W. Sidel and Barry S. Levy,“Physician-Soldier: A Moral Dilemma?”in Military Medical Ethics, ed. T.E. Beamand L.R. Sparacino (Washington, DC:Borden Institute, Walter Reed ArmyMedical Center, 2003).

3. For general overviews see: EdgarJones and Simon Wessely, Shell Shock toPTSD: Military Psychiatry from 1900 to

the Gulf War (London: Psychology Press,2005); Ben Shephard, A War of Nerves:Soldiers and Psychiatrists, 1914–1994(London: Jonathan Cape, 2000); and Rocket al., “U.S. Army Combat Psychiatry.”

4. Thomas W. Salmon, The Care andTreatment of Mental Diseases and WarNeuroses (“Shell Shock”) in the BritishArmy (New York: War Work Committeeof the National Committee for MentalHygiene, 1917), 47.

5. Edward A. Strecker, “Military Psy-chiatry: World War I, 1917–1918,” inOne Hundred Years of American Psychia-try, ed. J. K. Hall (New York: ColumbiaUniversity Press for the American Psy-chiatric Association, 1944).

6. For a short overview see AlbertDeutsch, “Military Psychiatry: WorldWar II,” in One Hundred Years of Ameri-can Psychiatry, ed. J. K. Hall (New York:Columbia University Press for the Amer-ican Psychiatric Association, 1944). Fora comprehensive overview, see Albert J.Glass and Robert J. Bernucci, eds., Neu-ropsychiatry in World War II, vol 1,Overseas Theaters (Washington, DC:Government Printing Office, 1966); Al-bert J. Glass and Robert J. Bernucci,eds., Neuropsychiatry in World War II,vol 2, Zone of the Interior (Washington,DC: Government Printing Office, 1966).

7. See, for example, William C.Porter, “Military Psychiatry and the Se-lective Service,” War Medicine 1, no. 3(1941): 364–71; and other articles inthe special issue on psychiatric aspectsof military medicine published in thesecond issue of War Medicine in 1941.

8. Harry Stack Sullivan, “Mental Hy-giene and National Defense: A Year ofSelective-Service Psychiatry,” MentalHygiene 26, no. 1 (1942): 7–14; HarryStack Sullivan, “Psychiatry and the Na-tional Defense,” Psychiatry 4 (1941):201–17.

9. Nevertheless, a significant numberof homosexual men and women wereable to enlist. See Allan Berube, ComingOut Under Fire: The History of Gay Menand Women in World War Two (NewYork: Free Press, 1990).

10. Albert J. Glass, Francis J. Ryan,Ardie Lubin, C. V. Ramana, and An-thony C. Tucker, “Psychiatric Predictionand Military Effectiveness, Part I & II,”US Armed Forces Medical Journal 7, no.10 (1956): 1427–43, 1575–88; seealso Eli Ginzberg, James K. Anderson,Sol W. Ginsburg, and John L. Herma,The Lost Divisions (New York: 1955).

11. John W. Appel, “Incidence of Neu-ropsychiatric Disorders in the UnitedStates Army in World War II (Prelimi-nary Report),” American Journal of Psy-chiatry 102, no. 3 (1945): 434.

12. Carl H. Jonas, “Psychiatry Has



Growing Pains,” American Journal ofPsychiatry 102, no. 6 (1946): 819–21.

13. For a historical overview of screen-ing in the military that draws the sameconclusion, see Edgar Jones, Kenneth C.Hyams, and Simon Wessely, “Screeningfor Vulnerability to Psychological Disor-ders in the Military: An Historical Sur-vey,” Journal of Medical Screening 10,no. 1 (2003): 40–46.

14. John R Egan, Lionel Jackson, andRichard H. Eanes, “A Study of Neu-ropsychiatric Rejectees,” Journal of theAmerican Medical Association, 145(1951): 466–69.

15. The literature on shell shock is vo-luminous. See, for example, Peter Leese,Shell Shock: Traumatic Neurosis and theBritish Soldiers of the First World War(New York: Palgrave MacMillan, 2002);and Martin Stone, “Shell-Shock and thePsychologists,” in The Anatomy of Mad-ness, ed. William F. Bynum, Roy Porter,and Michael Shepherd. The Anatomy ofMadness: Essays in the History of Psy-chiatry (London: Tavistock, 1985).

16. W. H. R. Rivers, “An Address onthe Repression of War Experience,” TheLancet 1 (1918): 173–77; Charles S.Myers, “A Contribution to the Study of‘Shell Shock,’” The Lancet 188 (1915):316–20; Charles S. Myers, Shell Shockin France, 1914–1918, Based on a WarDiary (Cambridge: Cambridge Univer-sity Press, 1940).

17. For Salmon, see Earl D. Bond andPaul O. Komora, Thomas W. Salmon:Psychiatrist (New York: Norton, 1950).For a comprehensive overview of Amer-ican psychiatry and World War I, seeThomas W. Salmon and Norman Fen-ton, eds., Neuropsychiatry: In the Ameri-can Expeditionary Forces, vol 10, TheMedical Department of the United StatesArmy in the World War (Washington,DC: US Government Printing Office,1929); Pearce Bailey, Frankwood E.Williams, and Paul O. Komora, eds.,Neuropsychiatry: In the United States, volX, The Medical Department of the UnitedStates Army in the World War (Washing-ton, DC: US Government Printing Of-fice, 1929).

18. Salmon, Care and Treatment of WarNeuroses; parts of this report appearedas Thomas W. Salmon, “War Neuroses(‘Shell Shock’),” Military Surgeon, Dec1917; Thomas W. Salmon, “Care andTreatment of Mental Diseases and WarNeuroses (‘Shell Shock’) in the BritishArmy,” Mental Hygiene 1, no. 4 (1917):509–47.

19. Salmon, Care and Treatment ofMental Diseases, 42.

20. Edward A. Strecker, “Experiencesin the Immediate Treatment of WarNeuroses,” American Journal of Insanity76 (1919): 45–69.

21. Thomas W. Salmon and NormanFenton, eds., Neuropsychiatry: In theAmerican Expeditionary Forces; see alsoStrecker, “Military Psychiatry: WorldWar I.”

22. Strecker, “Military Psychiatry:World War I.”

23. Salmon’s approach could be char-acterized by the principles of proximity,immediacy, expectancy, and simplicity(or PIES, as the principles of forwardpsychiatry were summarized after theKorean War). Recently, these principleshave been reformulated as BICEPS,which stands for brevity, immediacy,centrality or contact, expectancy, prox-imity, and simplicity. US Department ofthe Army, Combat Stress: Field Manual6-22.5 (Washington, DC: Departmentof Defense, 2000).

24. John W. Appel, Gilbert W. Beebe,and David W. Hilger, “Comparative In-cidence of Neuropsychiatric Casualtiesin World War I and World War II,”American Journal of Psychiatry 103, no.2 (1946): 196–99.

25. The interest of the American mili-tary in psychotherapy is described, fromthe military’s perspective, in Elliot Dun-can Cooke, All But Me and Thee: Psychi-atry at the Foxhole Level (Washington,DC: Infantry Journal Press, 1946). Thechapters of this book had appeared asarticles in the Infantry Journal. RoyGrinker had been in analysis with Sig-mund Freud under a stipend of theRockefeller Foundation. For his career,see Daniel Offer and Daniel X. Freed-man, Modern Psychiatry and Clinical Re-search: Essays in Honor of Roy R.Grinker, Sr. (New York: Basic Books,1972). For an excellent overview of therole of psychoanalysts during and afterWorld War II, see Nathan G. Hale,Freud and the Americans, 1917–1985:The Rise and Crisis of Psychoanalysis inthe United States (New York: Oxford Uni-versity Press, 1995), 187–210.

26. Roy R. Grinker and John P.Spiegel, War Neuroses (Philadelphia:Blakiston, 1945), 82.

27. Roy R. Grinker and John P.Spiegel, War Neurosis in North Africa:The Tunisian Campaign, January–May1943 (Washington, DC: Josiah MacyFoundation, 1943). This manual waslater printed, with a number of changes,as Grinker and Spiegel, War Neurosis.

28. Frederick Hanson, ed., Combat Psy-chiatry: Experiences in the North Africanand Mediterranean Theaters of Operation,American Ground Forces, World War II,vol 9 supplement, Bulletin of the USArmy Medical Department (Washington,DC, 1949).

29. Grinker and Spiegel, War Neurosis,115.

30. Malcolm J Farrell and John W.Appel, “Current Trends in Military Neu-ropsychiatry,” American Journal of Psy-chiatry 101, no. 1 (1944): 19.

31. Deutsch, “Military Psychiatry:World War II.”

32. Leo H. Bartemeier, Lawrence S.Kubie, Karl A. Menninger, John Ro-mano, and John C. Whitehorn, “CombatExhaustion,” Journal of Nervous andMental Disease 104 (1946): 358–89;489–525.

33. Normal Q. Brill, Mildred C. Tate,and William C. Menninger, “EnlistedMen Discharged from the Army Be-cause of Psychoneurosis: A Follow-upStudy,” Journal of the American MedicalAssociation, June 30, 1945; Normal Q.Brill and Gilbert W. Beebe, A Follow-upStudy of War Neuroses (Washington, DC:Veterans Administration, 1955).

34. Appel, “Incidence of Neuropsychi-atric Disorders,” 434.

35. Herbert X. Spiegel, “PreventivePsychiatry With Combat Troops,” Amer-ican Journal of Psychiatry 101, no. 3(1944): 310–15. See also Herbert X.Spiegel, “Silver Linings in the Clouds ofWar: A Five-Decade Retrospective,” inAmerican Psychiatry after World War II,ed. Roy W. Menninger and John C. Ne-miah (Washington, DC: American Psy-chiatric Press, 2000).

36. Samuel A. Stouffer, Edward A.Suchman, Leland C. DeVinney, ShirleyA. Star, and Robin M. Williams, TheAmerican Soldier: Adjustment DuringArmy Life, vol 1, Studies in Social Psy-chology in World War II (Princeton, NJ:Princeton University Press, 1949);Samuel A. Stouffer, Edward A. Such-man, Leland C. DeVinney, Shirley A.Star, and Robin M. Williams, The Ameri-can Soldier: Combat and Its Aftermath,vol 2, Studies in Social Psychology inWorld War II (Princeton, NJ: PrincetonUniversity Press, 1949).

37. Albert J. Glass, “Mental HealthPrograms in the Armed Forces,” in Childand Adolescent Psychiatry, Socioculturaland Community Psychiatry, ed. GeraldCaplan, American Handbook of Psychia-try (New York: Basic, 1972), 995.

38. Appel, “Incidence of Neuropsychi-atric Disorders,” 435.

39. Ellen Dwyer, “Psychiatry and RaceDuring World War II,” Journal of theHistory of Medicine and Allied Sciences61, no. 2 (2006): 117–43.

40. Rachel Yehuda and Alexander C.McFarlane, “Conflict Between CurrentKnowledge About Posttraumatic StressDisorder and Its Original ConceptualBasis,” American Journal of Psychiatry152, no. 12 (1995): 1705–13; RachelYehuda, ed., Risk Factors for Posttraumatic

Stress Disorder (Washington, DC: Ameri-can Psychiatric Press, 1999); Paula P.Schnur, Carole A. Lunney, and AnjanaSengupta, “Risk Factors for the Develop-ment Versus Maintenance of Posttrau-matic Stress Disorder,” Journal of Trau-matic Stress 17, no. 2 (2004): 85–95.

41. Elspeth Cameron Ritchie and MarkOwens, “Military Issues,” PsychiatricClinics of North America 27 (2004):460.

42. Ibid.

43. For a general overview, see WilburJ. Scott, The Politics of Readjustment:Vietnam Veterans Since the War (NewYork: Aldine de Gruyter, 1992).

44. See, for example, Peter G. Bourne,Men, Stress, and Vietnam (Boston: Little,Brown, 1970); Peter G. Bourne, “Mili-tary Psychiatry and the Vietnam Experi-ence,” American Journal of Psychiatry127, no. 4 (1970): 481–88.

45. US Department of the Army, Com-bat Stress Control in a Theater of Opera-tions: Tactics, Techniques, Procedures:Field Manual 8-51 (Washington, DC:Department of Defense, 1994); US De-partment of the Army, Leaders’ Manualfor Combat Stress: Field Manual 22-51(Washington, DC: Department of De-fense, 1994).

46. See Simon Wessely, “Forward Psy-chiatry in the Military: Its Origins andEffectiveness,” Journal of TraumaticStress 16 (2003): 411–19. A study pub-lished in 1982 on the effectiveness offorward psychiatric programs in the Is-raeli army during the invasion ofLebanon demonstrated that soldierswho had been treated according to theprinciples of proximity, immediacy, ex-pectancy, and simplicity did better inthe short and medium term than thosewho had been evacuated to base hospi-tals. See Z. Solomon, S. Rami, and M.Mikulincer, “Frontline Treatment ofCombat Stress Reaction: A 20-Year Lon-gitudinal Evaluation Study,” AmericanJournal of Psychiatry 162 (2005):2309–14; Z. Solomon and R. Benben-ishty, “The Role of Proximity, Immedi-acy, and Expectancy in Frontline Treat-ment of Combat Stress ReactionsAmong Israelis in the Lebanon War,”American Journal of Psychiatry 143(1986): 613–17.

47. Simon Wessely, “Psychological De-briefing Is a Waste of Time,” BritishJournal of Psychiatry 183 (2003):12–13.; Beverley Raphael and SallyWooding, “Debriefing: Its Evolution andCurrent Status,” Psychiatric Clinics ofNorth America 27 (2004): 407–23.

48. Caroline Cox, “Invisible Wounds:The American Legion, Shell-ShockedVeterans, and American Society,1919–1924,” in Traumatic Pasts:



History, Psychiatry, and Trauma in theModern Age, 1870–1930, ed. Mark S.Micale and Paul Lerner (New York:Cambridge University Press, 2001).

49. Thomas W. Salmon, “The InsaneVeteran and a Nation’s Honor,” Ameri-can Legion Weekly, January 28 (1921):1; Pearce Bailey, “Detection and Elimi-nation of Individuals with Nervous orMental Disease: Principles UnderlyingNeuropsychiatric Examinations,” in Neu-ropsychiatry, ed. Pearce Bailey,Frankwood E. Williams, and Paul O.Komora, The Medical Department of theUnited States Army in the World War(Washington, DC: US GovernmentPrinting Office, 1929), 57.

50. Strecker, “Military Psychiatry:World War I.”

51. An act to provide Federal Govern-ment aid for the readjustment in civilianlife of returning World War II veterans,June 22, 1944. United States Statutes atLarge 58 Stat. L. 284.

52. See, for example, Schnur, Lunney,and Sengupta, “Risk Factors for the De-velopment.”

53. Wade Pickren and Stanley F.Schneider, Psychology and the NationalInstitute of Mental Health (Washington,DC: American Psychological Associa-tion, 2005).

54. Simon Wessely, “Twentieth-Cen-tury Theories on Combat Motivationand Breakdown,” Journal of Contempo-rary History 41, no. 2 (2006): 281–82.

55. Richard A. Kulka, William E.Schlenger, John A. Fairbank, Richard L.Hough, B. Kathleen Jordan, Charles R.Marmar, and Daniel S. Weiss, Traumaand the Vietnam War Generation: Reportof Findings from the National VietnamVeterans Readjustment Study (New York:Brunner/Mazel, 1990); Richard A.Kulka, William E. Schlenger, John A.Fairbank, Richard L. Hough, B. Kath-leen Jordan, Charles R. Marmar, andDaniel S. Weiss, The National VietnamVeterans Readjustment Study: Tables ofFindings and Technical Appendices (NewYork: Brunner/Mazel, 1990).

56. Robert J. Lifton, Home From theWar: Vietnam Veterans, Neither Victimsnor Executioners (New York: Simon andSchuster, 1973).

57. Wilbur J. Scott, “PTSD in DSM-III :A Case in the Politics of Diagnosis andDisease,” Social Problems 37, no. 3(1990): 294–310.

58. Simon Wessely and Edgar Jones,“Psychiatry and the Lessons of Vietnam:What Were They and Are They StillRelevant?” War & Society 22, no. 1(2004): 89–103.

59. J. Bisson and M. Andrew, “Psycho-logical Treatment of Posttraumatic

Stress Disorder (PTSD),” The CochraneDatabase of Systematic Reviews, no. 3(2005).

60. Simon Wessely, “Risk, Psychiatryand the Military,” British Journal of Psy-chiatry 186 (2005): 459–66.

61. Charles W. Hoge, Carl A. Castro,Stephen C. Messer, Dennis McGurk,Dave I. Cutting, and Robert L. Koffman,“Combat Duty in Iraq and Afghanistan,Mental Health Problems, and Barriersto Care,” New England Journal of Medi-cine 351, no. 1 (2004): 13–19.

62. Matthew J. Friedman, “Acknowl-edging the Psychiatric Cost of War,”New England Journal of Medicine 351,no. 1 (2004): 75–77. This editorial dis-cusses the findings of Hoge, Castro,Messer, McGurk, Cutting, and Koffman,“Combat Duty in Iraq and Afghanistan.”

63. Charles C. Engel, Kenneth C.Hyams, and Ken Scott, “Managing Fu-ture Gulf War Syndromes: InternationalLessons and New Models of Care,”Philosophical Transactions of the RoyalSociety, Biological Sciences 361 (2006):708.

64. Edgar Jones, Robert Hodgins-Ver-maas, Helen McCartney, et al., “Post-Combat Syndromes from the Boer Warto the Gulf War: A Cluster Analysis ofTheir Nature and Attribution,” [pub-lished correction appears in BMJ 324(2002): 397] BMJ 324 (2002):321–24; see also Edgar Jones, “Histori-cal Approaches to Post-Combat Disor-ders,” Philosophical Transactions of theRoyal Society, Biological Sciences 361(2006): 533–42.

65. Engel, Hyams, and Scott, “Manag-ing Future Gulf War Syndromes.”

66. Mark Harrison, Medicine and Vic-tory: British Military Medicine in the Sec-ond World War (Oxford: Oxford Univer-sity Press, 2004).

67. Gerald N. Grob, Mental Illness andAmerican Society, 1875–1940 (Prince-ton, NJ: Princeton University Press,1983).

68. See, for example, Thomas W.Salmon, “The Prevention of Mental Dis-eases,” in Preventive Medicine and Hy-giene, ed. Milton J. Rosenau (New York:Appleton, 1913).

69. Thomas W. Salmon, Mind andMedicine (New York: Columbia Univer-sity Press, 1924).

70. William C. Menninger, “PsychiatricExperience in the War, 1941–1946,”American Journal of Psychiatry 103, no.5 (1947): 578.

71. Edward A. Strecker, “PresidentialAddress [to the American PsychiatricAssociation],” American Journal of Psy-chiatry 101, no. 1 (1944): 1.

72. Roy R. Grinker and John P.Spiegel, Men Under Stress (Philadelphia:Blakiston, 1945).

73. Gerald Grob, “The Lessons of War,1941–1945,” in From Asylum to Com-munity: Mental Health Policy in ModernAmerica (Princeton, NJ: Princeton Uni-versity Press, 1991); Gerald N. Grob,“World War II and American Psychia-try,” Psychohistory Review 19 (1990):41–69.

74. See, for example, Helen LelandWitmer, ed., Teaching PsychotherapeuticMedicine, an Experimental Course forGeneral Physicians, Given by WalterBauer and Others (New York: Common-wealth Fund, 1947).

75. Kenneth E. Appel, John M.Mitchell, and William T. Lhamon, “Psy-chiatric Values in a New Method ofMedical Education,” American Journal ofPsychiatry 109, no. 2 (1952): 102–7.

76. See, for example, Frank Furedi,Therapy Culture: Cultivating Vulnerabilityin an Uncertain Age (London: Rout-ledge, 2004).

77. Gary King and Lisa L Martin, “TheHuman Cost of Military Conflict” (paper,Conference on Military Conflict as Pub-lic Health Problem, Cambridge, Mass,September 29, 2001).


military mental health · tem for the treatment of shell shock or war neurosis. he recom-mended...

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