Book Review | Published:

The psychological toll of battle

Nature volume 409, pages 135136 (11 January 2001) | Download Citation


A War of Nerves: Soldiers and Psychiatrists 1914–1994


  Jonathan Cape: 2000. 480 pp. £20

The limits of human endurance have been the theme of many books, plays, dramas and the visual arts, as well as providing a living laboratory for psychology researchers and scientists. The worst of these situations is warfare, as it involves not just extreme physical stress, but also an agonizing mental conflict between duty and personal survival. Although this has produced a huge literature, there has been no comprehensive overview of the phenomenon of 'shell-shock' and its associated disorders. Ben Shephard has now provided this.

It was not until 1914, with the vast numbers of combatants involved in the First World War, that the fearful effects of battle were seen to become epidemic, and no army had prepared itself for this. Within the first few weeks, soldiers unable to continue fighting were being evacuated to England in large numbers, and 'shell-shock' was the label devised by the men themselves for their condition. “Of all the things that preyed on the nerves and senses,” Shephard writes, “shellfire was the worst.” Trench warfare took a terrible psychological toll because it meant “powerless waiting for an impersonal death”.

In the medical services, there was no agreement on either the causes of the problem or what should be done about it. Many of the affected men showed bizarre disturbances — paralysed limbs, loss of speech or sight, or uncontrollable shaking, while others were denied sleep by terrifying nightmares. This 'hysteria' was in fact an unconscious compromise to the dilemma faced by men whose moral code would not allow them to run away but who nevertheless needed to be removed from the trenches. Sigmund Freud had described such a “conversion” of symptoms earlier, but had to admit that his exclusive concern with sexual factors was disproved by the war: fear of death had become the overwhelming influence.

The British Army turned first to neurologists, who had a selective interest in psychiatric disorders and more prestige than asylum doctors. They initially looked for microscopic damage to the brain, but found nothing; the same fruitless search was going on in France and Germany. In all these countries, neurologists used electric-shock treatment to try to dispel the hysterical disturbances. Whatever the rationale for this punitive approach, men generally preferred to return to the front line rather than face the pain of constantly increasing shocks.

A kinder therapy was being developed by British psychologists, notably Charles Myers, together with some psychologically minded doctors. Outstanding among these was W. H. R. Rivers (hero of the first book and the film of Pat Barker's Regeneration Trilogy, published by Penguin), whose psychotherapeutic technique — mainly for officers — had a Freudian basis. He accepted that experience not directly accessible to consciousness could have profound effects, and that symptoms were often the expression of mental conflict.

Luck of the war: a 'coward' is shot in Regeneration; others who acted the same way received pensions. Image: ARTIFICIAL EYE

Regimental medical officers were torn between humane concern for their men and the need to keep units up to strength. One officer, trying to gain some respite for a depleted and exhausted battalion, was told by his army commander that the men showed “an utter want of manly spirit and courage”. Yet distinguishing between men suffering genuine terror or numbing from mere cowards or malingerers was a daunting task. A shell-shocked man might be given a wound stripe and a pension, be told to pull himself together, or be shot for cowardice — sometimes it seemed largely a matter of chance which of these it was. Altogether, the British Army executed 307 men, the French 700 and the German Army only 48. After 1918, though, undue sympathy for war neurotics was widely condemned in Germany as contributing to the German defeat. It would be different next time.

But there was a virtual consensus that shell-shocked men who were evacuated far from the battle zone were unlikely ever to return to it. From this experience, the idea of 'forward psychiatry' emerged. Casualties would be dealt with as near to the front line as possible; in many cases, a few days' rest and food were effective enough. Only more serious cases were evacuated further away.

When peace came, every combatant nation had an enormous legacy of psychiatric casualties, with a corresponding burden of pensions — Britain was still paying 40,000 in 1939. Although the war had given a slight boost to the development of psychotherapy in Britain, mental hospitals largely returned to their pre-war torpor.

During the Second World War, psychiatry no longer played second fiddle to neurology — except in the Royal Air Force. Shephard says it is still almost impossible to obtain any information about the degree of psychiatric breakdown that occurred in aircrew. But even rigorous selection among these volunteers failed to pick out every vulnerable one. Meanwhile, the army had to relearn the need for forward psychiatry, finding that when the Allies were winning, psychiatric casualties (and desertions) were far fewer. Psychiatrists also played a major role in the selection of personnel, although without the approval of Winston Churchill. Germany, on the other hand, executed 15,000 men, and over 20,000 more killed or maimed themselves. Whether psychiatric breakdown in war is contagious and whether executions discourage it remain unresolved questions.

The US Army had to start from scratch in learning to deal with psychiatric casualties, which made up some 30% of total casualties when the US Army first encountered the Wehrmacht in Tunisia. Vicious fighting in the Pacific also took a heavy toll. The United States had always been generous to veterans, and ample free services were provided for both physical and psychiatric impairment — in Shephard's view, the generosity may often have prolonged the disability.

The Vietnam War was another matter. Morale was low, drug addiction rife (though with uncertain effects) and the enemy was everywhere. Many people who fought in the war seemed to develop persisting or even permanent mental damage. The key to understanding this was the nature of the 'stress' — the unresolved threat to the integrity of the organism and its biological coping mechanisms. Vietnam coincided with growing concern in civilian life about the effects of accidents, violence (particularly rape) and abuse of all kinds. The concept of post-traumatic stress disorder was formulated out of all this and is now an inescapable but controversial part of everyday life.

Ben Shephard has exhaustively combed through literature of all kinds concerning psychiatric breakdown in war, although he found both the Falklands and Gulf campaigns deplorably unresearched. His book will be the standard work on the subject for a long time ahead, and it is as remarkable for its humanity and absorbing narrative as for its historical accuracy. It is a notable achievement.

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  1. Hugh Freeman, former editor of The British Journal of Psychiatry, is at Green College, Oxford OX2 6HG, UK.

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