Blindness. Deafness. Amnesia. Paralysis. Vomiting. Hallucinations. Impotence. Stuttering. Uncontrollable twitching. Inability to taste, smell or urinate. Funny walks.
These are just some of the crushing psychosomatic symptoms that have afflicted soldiers during the era of modern warfare, from the trenches of World War I to the Kuwait desert in 1991. Over the past century, military medicine has coined a variety of terms to describe the psychological costs of combat—shell-shock, war neurosis, effort syndrome, battle fatigue, acute combat stress, post-traumatic stress disorder (PTSD) and, most controversially, Gulf War syndrome—but they all essentially describe the same phenomenon: the human mind buckling from intolerable stress and the psychic wear-and-tear of witnessing and committing dehumanizing acts.
The current war was supposed to be different—swift, surgically precise, almost bloodless. "This will be no war," liberal-hawk cheerleader Christopher Hitchens asserted earlier this year at a public debate. "There will be a fairly brief and ruthless military intervention. . . . [The attack] will be rapid, accurate and dazzling." Delivered from on high, "shock and awe" was supposed to eliminate or disable the bad guys, leaving invading ground troops the feel-good task of rounding up grateful Iraqi soldiers and basking in the warm welcome offered by an overjoyed populace.
Instead of this slick 21st-century war, our boys (and girls) find themselves back in the messy 20th, waging old-fashioned tank battles and girding themselves for street-to-street fighting through the bazaars of Baghdad and Basra. Instead of the disengaged, remote-control war that was sold to the American public and rank-and-file alike, the reality is turning out to be horribly intimate and potentially prolonged.
The current situation now points to calamitous historical reference points: the Battle of Stalingrad, Vietnam, the occupations of Northern Ireland and the West Bank. In these conditions—rife with civilian casualties, suicide bombers and death by friendly fire, not to mention the potential of chemical attack (a flashback to World War I-era mustard gas)—it's not just the physical injuries that threaten to escalate, but the psychological damage, too.
British writer and documentary producer Ben Shephard spent 10 years researching the history of military psychiatry for his book A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century. Shephard believes there are certain conditions that improve the chances of soldiers coming away from battle mentally intact.
"It's a good thing to feel it's a just, necessary war," he explains over the phone from England. "It's a good thing to feel your comrades did not die in vain, and it's a good thing that they should not face the prospect of chemical or nuclear warfare. And if you get the ending right, that's good, too. If you had a messy ending, like Germany in 1918 or Vietnam, you'll have a terrible poisonous aftercloud hanging over soldiers. All of those things are basics, and if you get the basics down, you'll have a lower incidence of psychiatric casualties."
When asked about the current situation, Shephard offers, "It's all very well for the military to say, 'We're going to get it right this time.' If the fundamentals are wrong, they're still going to have problems, and in this case—well, the fundamentals are not great."
Already three British soldiers have been sent home to face court martial, allegedly for complaining about the way the war is being fought and refusing to endanger more Iraqi civilians. And just days after the bombing began, an American sergeant tossed four grenades into officers' tents, killing two men and wounding more than a dozen others.
"That was pretty common in Vietnam, when it was called fragging," says Shephard. "But it's not a sign of good morale. Not at all."
* * *
Shephard didn't write A War of Nerves with Iraq in mind; the bulk of it focuses on the two world wars and Vietnam, with a short section on the Falklands and the 1991 Gulf War at the end. But its unflinching look at the awkward intersection of psychiatry and the military offers a fascinating left-field perspective on war and its hidden costs. Weaving together a panoramic array of source materials (official reports, soldiers' diaries, interviews with doctors, Pentagon memos, snatches from novels and academic treatises), he catalogs 20th-century attempts to lessen the agony of war, at least for the troops—an unenviable task.
War excited and appalled psychiatrists over the past century, Shephard writes in his book's introduction, because it provided "a laboratory in which every theory could be tested literally to destruction. . . . [E]ven as the doctors record the horrors, they marvel at the way the mind refracts and mediates them." Writing to a colleague in 1915, less than a year into World War I, an Oxford professor of medicine said, "I wish you could be here in this orgy of neuroses and psychoses and gaits and paralyses."
Initially, doctors dubbed the mysterious assortment of symptoms that gripped huge numbers of soldiers "shell-shock." For a while, they assumed it was a physical condition caused by the unprecedented intensity of bombardment enabled by all kinds of newfangled explosives before switching to a psychological diagnosis that painted shell-shock as a kind of male hysteria. In World War I, Freudian ideas entered the fray. One World War I military hospital became "a society in which the interpretations of dreams and the discussion of mental conflicts formed the staple subjects of conversation."
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."
Shephard actually believes the best way of dealing with war trauma may be the traditional British stiff-upper-lip solution: bottling it all up, pulling yourself together. America's touchy-feely therapeutic culture—with its industries of counseling and recovery that exalt the confessional imperative—is damaging in itself.
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"The soldier is left with nothing but people telling him war is trauma. If you treat people as medical patients, they will become patients."
But what will happen to the soldiers of the current conflict, once the battles are over and they're shipped back home? Shephard says there are dozens of factors that will decide how many soldiers suffer from mental problems after the war, including "what kind of cards soldiers are dealt. If you have nice clean fighting and no incident where you blew your friend's head off, then you're more likely to come out of this all right."
The social environment they return to will make a difference. At the moment, most Americans support the war, and even the most fervent anti-war protesters lavish sympathy on the troops. But as the gulf grows between the official version of why and how the war is being waged and the ground-floor reality of occupation and Iraqi bitterness, it's easy to see that this conflict could exact a terrible toll on the soldiers themselves. The combination of what Shephard calls "this media fog of trauma culture" and the dawning sense that they fought an unjust war could be devastating for the troops. He says sharply, "You may be getting the worst of all possible worlds."
A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century by Ben Shephard; Harvard University Press. Paperback, 487 pages, $15.95.