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Several of Freud's disciples treated soldiers. Freud even complained the outbreak of peace in 1918 was bad news for the popularity of his burgeoning movement: "No sooner has it begun to interest the world because of the war neuroses than the war comes to an end."
* * *A War of Nerves makes the case that psychiatry and psychoanalysis flourished in the U.S. and U.K. in large part because they were legitimized and popularized by their use in the two world wars. The government also pumped money into the field with the National Mental Health Act of 1946. In 1940, there were 2,423 psychiatrists in this country, but a decade later, that number had more than doubled. The horrors of World War II created a rich harvest of psychologically maimed veterans ripe for treatment, with a succession of theories and therapies holding sway.
Twentieth-century soldiers routinely served as guinea pigs, used to test new cures from hypnosis and drugs to group therapy. While some of these practices retain an aura of rationality, many have the whiff of quackery or cruelty: insulin-induced comas, shock treatment, lobotomy. Shephard describes a shell-shocked World War I soldier who'd "been strapped in a chair for 20 minutes at a time while strong electricity was applied to his neck and throat; lighted cigarettes had been applied to the tip of his tongue, and 'hot plates' had been placed at the back of his mouth."
While psychiatrists were interested both in studying the nooks and crannies of their subjects' shattered minds and helping them to recover some semblance of psychological wholeness, the military had a different agenda. The goal was to eliminate "wastage"—to cure superficial disabling symptoms as quickly as possible and get soldiers back on the battlefield.
This split still exists, with two types of wartime psychiatry practiced in different settings. Less severe cases of trauma undergo triage on the front lines, in the form of rest and pep talks (what the army calls "three hots and a cot"—i.e. three hot meals and some sleep).
"The expectation there is that you're going to send them back into battle," explains Shephard. "It's about confronting people with their responsibilities—saying, 'Your unit is doing so well. You don't want to miss out on this, do you?' The other kind is more like conventional psychiatry, and it's practiced at the base hospital. The expectation with these more serious cases is that they're not going back into combat, so you're trying to salvage them as people who can function either in the military in non-combat roles or in civilian life."
Wartime psychiatrists make decisions whose implications can extend well beyond the medical realm into a political and judicial minefield. They have the miserable job of sorting the genuinely incapacitated from the malingerers (a heavy responsibility given that desertion or cowardice is a punishable offense) and decreeing who is sufficiently psychologically crippled to warrant a veteran's disability pension. Pensions have always been a charged subject—and not just because the government is tightfisted. Many in the psychiatric world argue that they actually hamper recovery. As Shephard describes it, "If you put the soldier back into battle you're effectively putting him back on the horse from which he's been thrown. That may backfire, but if you send him home, he then becomes a medical case. There's strong pressure on him to maintain his symptoms because he knows that if he doesn't maintain them, he'll get sent back to the combat. So these people tend to become professional patients—that can become their identity for the rest of their lives if you're not careful.
"That's the real dilemma of military psychiatry when you're working close to the front line," Shephard continues. "Are you doing the soldier more of a favor sending him back to the battle from which he's just retreated or sending him home? There is this terrible moral dilemma at the heart of it."
* * *
Psychiatrists in 20th-century wars had other dilemmas to deal with, too. Therapists such as Sarah Haley sometimes felt repulsed by the confessions of their patients. How was she to answer the question "Was the man who committed crimes in Vietnam a perpetrator or a victim?" Other doctors babied their vets; after World War II, psychiatrist Roy Grinker once held court at a luxurious Florida hotel and allowed his patients to regress (with the help of the barbiturate narcosynthesis), explaining that they needed "replenishing affection, consideration and attention, as a small child needs to be praised and comforted after a particularly strenuous and exhausting activity."
The last quarter of A War of Nerves traces how the concept of trauma leaked into the American popular imagination after Vietnam, fueling both the PTSD and recovered-memories movements. Shephard believes this turn of events had disastrous consequences, both for the soldiers and the culture at large.
"The normal expectation in World War II was that most people would get through, and there would be people who don't and who need help," he says. "What PTSD did was assume there was always a connection between an event and trauma."
Thus, whenever there's an event like Sept. 11, the prevailing assumption is that everyone involved will suffer from trauma. But Shephard insists that's not true. "The number of people who actually get PTSD in these circumstances are quite small, and there's nothing inevitable about it. The entirety of Europe went through something horrendous twice in the first half of the 20th century," he says with exasperation. "But the American psychiatric industry has never taken on board the fact that whole societies were occupied, bombed, and they came through the other side."
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