Abstract
Shephard, an historian, has written this splendid book after years of dedicated research. Though of specific interest to military psychiatrists, the core subject is not of war, but of persons traumatised, and this is of interest to clinicians and researchers across a wide spectrum of psychiatric sub-specialities.
The epidemic of ‘shell shock’ after the Battle of the Somme on the 1st July 1916 is the pivotal moment in the history of war neuroses. It culminated in a military crisis caused by the loss of man power and confronted the British Armies with the real prospect of military defeat. Charles Myers, a researcher in the tiny Cambridge University Psychology Department investigating Australian Aboriginal music, who had qualified in medicine but had not practised it, had sequestered himself in clinical practice in France, and persuaded the Army to allow him to establish acute psychiatric services near the Front to psychologically manage the bewildering array of clinical states known to the general public across the Channel as ‘shell shock’. Myers' superior was Gordon Holmes, an organic and doctrinaire neurologist. This clash of the ‘tender’ view and the ‘tough’ view of managing traumatised victims was typical of the recurring conflict between psychiatrists (and communities) prior to and subsequent to this War. Holmes eventually prevailed by forcing a differentiation of what we now term acute stress disorder from post-traumatic stress disorder by frontline medical staff at the Battle of Passchendaele, remembered for the horrendous loss of life but not for epidemics of hysteria. Ironically the British Army was drawn to the psychological and analytical conceptualisation of ‘shell shock’, the view propagated by Myers, for ultimately it reasoned that it would be relieved of the burden of compensation of veterans disturbed by their developmental histories rather than their experiences in the trenches. By 1918 the Allied Armies in Europe were a very efficient and effective force, and likewise by this stage the Front line medical services well understood and probably capably managed psychiatric casualties.
The best account of World War I psychiatry is that written by the Australian, A.G. Butler and Shephard acknowledges the brilliance of Butler's medical descriptions. The conflicting conceptualisations of shell shock by Mott, Brown, Salmon, WHR Rivers and Yealland are better known, partly because of Pat Barker's wonderful but not particularly factually correct trilogy. The biopsychosocial theory of war neurosis conceptualised by Ronald Rows, predated similar views of Kardiner (and the APA) by a world war. Shephard demonstrates so clearly the recurring cycle of the initial denial of the problem of war neurosis then exaggeration, then understanding, and then forgetting. Despite the forgetting of the efforts of the World War I generation of ‘psychiatrists’, and the post-war supremacy of the analytical movement in psychiatry, Shephard maintains that war neuroses were comparatively better managed during World War II. World War I had forced psychiatry from the asylums, unsurped neurologists' dominance over anxiety disorders, and begun the process of aligning psychiatry with medicine, processes all reinforced by the terror and destruction of World War II.
The primary dilemma for psychiatry in the military is the conflict of role between caring for the individual and caring for society. Psychological or psychiatric First Aid may assist the Army, but is it fair to re-expose a traumatised victim again to danger? This conflict is the very same one that psychiatrists face consulting for employers, police departments, or insurance companies. War provides a fascinating and appalling laboratory to study the extremes of human experience but it also has provided a rather sad history of petty professional squabbles between colleagues and the abandonment of the patient/ doctor relationship if the States' demands dominate.
Shephard's anecdotes regarding the psychiatrists of World War II are compelling, amusing and horrifying. Kardiner's contributions were clearly very influential, a gritty character such as Harold Palmer less well acknowledged, the medical aristocrats Roy Grinker and William Sargant well known albeit for a somewhat limited perspective of the management of sick soldiers. The retrospectively almost amusing Army selection protocols by the Tavistock Clinic, and the disturbing portrayal of gay Harry Stack Sullivan interviewing naked soldiers for 15 minutes to ascertain their fitness for military service, makes for embarrassing reading. It is difficult not to feel great sympathy for RD Gillespie who struggled to challenge the imperious views of Charles Symond's concept of ‘lack of moral fibre’. The German analyst, Michael Foulkes (or Fuchs) at Northfield Hospital practising in an early ‘therapeutic community’ contrasts with Brigadier Morrison who denied landing rights to any psychiatrist in the early stages of the siege of Malta.
The Korean War is nearly always forgotten. Shephard tackles the Vietnam War, however the memories are probably still too raw to provide perspective other than it initiating another cycle of tender care, which we are now just beginning to revolt against. Execution of psychiatrically ill soldiers and faradism for conversion muteness we must not ‘re-invent’ yet concepts such as ‘NYDN’ (Not Yet Diagnosed Nervous) or acute stress disorder, and the principals of immediate intervention have proved to be workable and sustainable principles of clinical military psychiatry. Progress has been made. It is the chronicity of the ravages of trauma and the insoluble conflicts over compensation that are proving to be enduring difficulties for modern psychiatry, as they also were for our forebears.
This is a fine study, beautifully written (except for the spelling of my home town on page 229), sorely needed, and of tremendous relevance to our profession even in times of relative peace, for traumatic experiences are not confined to the battlefield.