F e a t u r e s
The Injured Mind
in the Armed Forces
Professor Neil Greenberg is Surgeon Commander in the Royal Navy and the Defence Professor of
Mental Health. He is a leading authority on Military Psychiatry. What follows is an extract from a paper written by Greenberg et al, exploring mental health within the Armed Forces.
T
he mental health of the UK Armed Forces is a topic much debated by healthcare
professionals, politicians and the media. Whilst the current operations in Afghanistan, and the recent conflict in Iraq, are relevant to this debate, much of what is known about the effects of war upon the psyche still derives from the two World Wars. But why is it that some Service personnel suffer psychological injuries during their military service and others do not? And what strategies have been put in place to mitigate the effects of sending today’s military personnel into danger?
The twentieth century view Before WW1 there were few studies that specifically related to the mental health of the Armed Forces. However, the sheer scale of the ‘shell shock’ epidemic brought the issue of psychological casualties to the fore.
Research into the lasting effects of war upon the mind suggested that post-combat disorders come in two varieties: overt, short term, psychological presentations (such as battle exhaustion, flying stress, combat stress reaction and post-traumatic stress disorder or PTSD); and longer term post- conflict syndromes characterised by medically
16 Autumn 2010
unexplained symptoms (soldier’s heart, aviator’s neurasthenia, effort syndrome, Gulf War syndrome). ‘Shell shock’, an ill-defined term introduced in 1915, included both the short-term psychological effects of battle and chronic cases.
War generates some of the most intense stressors known to man. During WW1, it was believed that a healthy individual who was well-trained and integrated into a unit with high morale was resistant to psychological pressures. It was acknowledged, however, that an exceptional event could lead to breakdown in a healthy soldier but a full recovery was expected once he had been removed to a place of safety. Shell shock cases were initially conceptualised as only affecting men who suffered from hereditary weaknesses. As a result, psychiatric casualties were considered preventable by selection, training and leadership. War was not thought to be the cause of psychological breakdown but merely a trigger.
The experiences of WWII did little to change these views. However, as the war progressed, important exceptions were identified and it was accepted that successful soldiers had a breaking point. Captains of escort vessels, bomber crews and commandos, many with decorations for valour, found themselves referred to psychiatric units suffering from
what was then called ‘battle exhaustion’. However, because these examples were a minority, and expected to return to full health, most psychiatric casualties continued to be attributed to pre-existing vulnerabilities or failures of selection and training.
It was not really until the Vietnam War that this position reversed. With the recognition of PTSD, causation was turned on its head. The traumatic event became primary, while family history and personality characteristics were relegated to secondary roles. PTSD has become the psychiatric diagnosis most readily associated with the Armed Forces. Evidence from both World Wars suggests that the ways in which Service personnel communicate distress is culturally determined and that the development of PTSD may be one more phase in the evolving picture of human reaction to adversity.
Psychiatry and military culture Psychiatry has not always dovetailed neatly into military culture. During both World Wars psychiatrists were viewed with suspicion by commanders and medical colleagues who believed that they lacked effective treatments, whilst offering malingerers an easy escape route from the battlefield. Stigma of mental illness was widespread and some senior officers, argued that shell shock ‘must be
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