Psychological Injuries Pre-PTSD
Despite the abundance of literature documenting the relatively effective treatment of psychological injuries over the past two centuries, psychiatrists and psychologists often disregarded these lessons. Major changes in treatments were in response to societal pressures and subsequent treatments always reverted to successful treatments employed in previous wars with the exception of the Vietnam War.
Although military psychiatry did not exist as its own discipline during the Civil War nor were psychological injuries treated by any official prescriptive measures, the military, medical professionals, and society effectively treated soldiers who suffered from “nostalgia” or “irritable heart”. Quite simply, soldiers underwent a short recovery period where nurses and fellow comrades administered rest, food, and encouragement. Soldiers were expected and encouraged to return to the fray unless the symptoms were severe and debilitating.
Although Civil War medical professionals clearly acknowledged and treated psychological wounds, World War I was the first war wherein psychiatrists seriously considered psychological breakdown in relation to combat exposure. Psychiatrists learned for the first time the consequences of medicalizing non-specific symptoms. By 1917, Thomas Salmon established procedures that successfully treated psychologically injured soldiers as near to the front as possible. Similar to the non-prescriptive methods employed during the Civil War, this practice, also referred to as forward psychiatry, consisted of a few days of rest, food, and positive motivation. The medicalization of “shell-shock” resulted in its rapid rate of growth and an increase in opportunities to malinger and seek secondary gain. These concerns, compiled with an ever-increasing strain on the budget, caused combatant nations to reconsider their policies on psychiatric breakdown. World War I gave us our first official treatment policy to be used in subsequent wars and demonstrated that medicalization in the form of “shell-shock,” did more harm than good and added to its chronicity.
The profusion of World War I “shell-shock” diagnoses resulted in World War II establishing policies that emphasized the transient nature of psychological war wounds and the expectation of recovery. Terms such as “combat fatigue” and “battle fatigue” purposely replaced “shell-shock” to emphasize that reaction to combat was common, but short-lived in order to minimize its chronicity. This resulted in a successful treatment program with fewer chronic cases of mental breakdown.
The Korean War did not begin with an official military psychiatric treatment program. Almost immediately, the military realized the consequences in mounting psychological casualties. The implementation of a forward psychiatry program during the first few months of the war resulted in a 40 percent increase in recovery. Forward psychiatry during the Korean War continued to emphasize the importance of group cohesion and the role of the psychiatrist as a preserver of the fighting strength. By the end of the Korean War, the perception of psychological injuries mirrored those of the Civil War. Once again, evidence proved that men broke down in the face of combat, they were treated, and they were expected to recover and return to duty. (Albert Glass, 2006)
The Vietnam War was the only war that began with a successful psychiatric program. This resulted in a low rate of chronic cases of psychological injury. In 1967, Army psychiatrist Colonel William Tiffany reported that neuropsychiatric illness cases in Vietnam during the years of 1965 and 1966 were estimated at 6 percent and lower than any previous wars in which psychological casualties were recorded. A variety of factors attribute to the low rate of chronicity: the rotation policy, the intensity of fighting, the quality of training that added to esprit de corps, and the establishment of a forward psychiatry program with an emphasis on the expectation of recovery. It is even more interesting that Spencer Bloch, another well-known psychiatrist, assigned to the 935th Medical Detachment between August 1967 and July 1968 – two of the three deadliest years of the war – noted a similar success rate. By 1970, even the chief of the neuropsychiatry section on the U.S. Army Medical Research Team–Vietnam was confident that the implementation of forward psychiatry in Vietnam was a success and believed that the average soldier was capable of adapting to his combat environment. In fact, Albert Glass, considered in the medical field as the leading military psychiatrist of the post-World War II era, recognized military psychiatry’s success during the war and commented on its impressive record in preserving the fighting force. Ironically, the Vietnam War was the ideal proving ground for all previous lessons learned in military psychiatry. Despite this success of military psychiatry during the Vietnam War and the decades of trial and error it took to get there, anti-war rhetoric influenced a major shift in psychiatric thinking that has had profound effects on future wars. (Ben Shephard, 2000)
The military and medical communities effectively treated psychological injuries as far back as the Civil War concluding with the Vietnam War. Treatments consisted primarily of forward psychiatry in terms of food, rest, and positive motivation. Psychiatrists avoided medicalizing human emotions and emphasized the transient nature of the body’s responses to combat and recovery. World War I was the only war up until Vietnam’s aftermath that psychological injuries became chronic. The primary reason for this was that mental breakdown was medicalized as shell-shock. World War II and the Korean and Vietnam Wars all successfully reduced chronic cases of psychological breakdown through simple treatment methods and expectations of recovery. It was not until the end of the Vietnam War that anti-war rhetoric began to influence and change our beliefs about recovery from psychological injuries.