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Weeding out terrorism on the home front

Abstract Involvement in warfare can have dramatic consequences for the mental health and well-being of military personnel. During the 20th century, US military psychiatrists tried to deal with these consequences while contributing to the military goal of preserving manpower and reducing the debilitating impact of psychiatric syndromes by implementing screening programs to detect factors that predispose individuals to mental disorders, providing early intervention strategies for acute war-related syndromes, and treating long-term psychiatric disability after deployment.

The success of screening has proven disappointing, the effects of treatment near the front lines are unclear, and the results of treatment for chronic postwar syndromes are mixed. After the Persian Gulf War, a number of military physicians made innovative proposals for a population-based approach, anchored in primary care instead of specialty-based care. This approach appears to hold the most promise for the future. Photo by Vince Crawley. Reprinted with permission from Stars and Stripes, 1991, 2006.

It can also have significant mental health consequences for military personnel. During the 20th century, psychiatrists offered their assistance to the military to mitigate the effects of these and other traumatic experiences inherent in warfare.

Military officials everywhere have displayed a strong ambivalence toward the involvement of psychiatrists in military affairs. For example, they have often labeled soldiers suffering from psychiatric symptoms as cowards lacking moral fiber. However, military officials have been interested in psychiatric issues whenever they were perceived to affect the primary mission of the armed forces.

When psychiatrists were perceived to be able to contribute to the primary goal weeding out terrorism on the home front all army medical services, which is to conserve the fighting strength, their contributions were appreciated. The challenge of screening was to detect those traits that indicated vulnerability for mental health problems during deployment. He was the medical director of the National Committee for Mental Hygiene, an organization that promoted the modernization of psychiatry by advocating prevention, treatment in outpatient clinics, and research into the causes of mental illness.

However, by the end of the war, the general opinion among both psychiatrists and military officials was that there had been too many cases of mental breakdown and that this was because screening had not been sufficiently stringent.

Sullivan believed that the US armed forces should exclude not only individuals suffering from mental illness but also those with neurosis or maladjustment. Military officials were particularly interested in detecting homosexuality, which they believed destroyed weeding out terrorism on the home front effectiveness and morale. Initially, military officials approved of screening programs because they promised that the armed forces would be made up of the most able men.

The unexpected and dramatic failure of selection combined with the pressing military need for manpower led military officials to severely criticize psychiatrists. Marshall abolished screening in 1944.

Salmon in his office in France during World War I. In retrospect, it is not surprising that screening programs for psychiatric disability had poor predictive power. Even today, the mental health consequences of war are poorly defined, with ever-shifting diagnostic categories, an uncertain theoretical foundation, and a lack of consensus on the relative contribution of predisposing and contextual factors. The failure of selection provided a serious challenge to the notion that predisposing factors were critical to the development of mental health problems during deployment.

It challenged psychiatrists to explore other causes, such as the stresses of warfare. During World War I, British psychiatrists saw a puzzling condition initially named shell shock.

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  • After the Persian Gulf War, a number of outspoken veteran groups aspired to gain recognition for the medical problems of veterans by claiming that they were related to a number of specific conditions related to that deployment rather than subsuming them under a diagnosis of PTSD.

Soldiers suffering from shell shock were unable to fight and posed difficult problems for the medical corps, morale, and military discipline. Initially, military officials were convinced that they were malingerers or cowards.

A number of leading British psychiatrists and psychologists, including Charles S. Rivers, believed the condition was psychological in nature and introduced psychotherapeutic interventions for its treatment.

Shell shock was a psychological reaction to the stresses of warfare rather than the expression of a predisposition to mental illness.

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Salmon devoted the greatest part of his report to plans for hospital facilities that would deal with the problem. He recommended that treatment commence as soon as possible after the onset of symptoms.

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Treatment was ideally applied in or near casualty clearing stations, which were located a few miles behind the lines. Here, nervous soldiers were given a period of rest, sedation, and adequate food.

Through relatively simple forms of supportive psychotherapy imbued with optimism and characterized by persuasion and suggestion, military physicians explained to soldiers that their reaction was normal and would disappear in a few days.

There, soldiers were treated for up to 3 weeks. Salmon himself was associated with the third tier, Base Hospital 117, about 50 miles from the front line, where severe types of shell shock were treated for up to 6 months. If there was no improvement during this period, soldiers were repatriated.

First, it gave a clear message to soldiers that shell shock did not provide an easy route home. From the British experience, Salmon had learned that the symptoms of mental distress commonly became ingrained and resistant to treatment when left untreated.

Immediate treatment promised to result in high recovery rates and the prevention of long-term psychiatric disability. As a consequence, military officials were receptive to the weeding out terrorism on the home front of a small but outspoken group of psychoanalytically oriented psychiatrists, including Roy G.

Grinker and William C. Menninger, who proposed to implement programs of forward psychiatry that resembled those of Salmon.

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In 1943, Grinker and John P. Spiegel introduced psychotherapeutic treatment near the front lines for the US Air Force. Many soldiers recovered; Grinker and Spiegel claimed that the stuporous become alert, the mute can talk, the deaf can hear, the paralyzed can move, and the terror-stricken psychotics become well-organized individuals.

Hanson, who was working in Tunisia and Algeria, introduced simple and straightforward treatments rest, good food, hot showers, and sedationwhich he claimed were successful in returning men to the fighting line in just a few days.

He informed all military medical officers of the principles of forward psychiatry.

  • No syndrome specific to any war could be identified;
  • It challenged psychiatrists to explore other causes, such as the stresses of warfare;
  • These proposals emphasized the importance of educating general practitioners in the principles of psychiatry, thereby integrating psychiatric approaches in primary health care settings;
  • The emergence of the diagnostic category of post-traumatic stress disorder changed that by linking long-term psychiatric disability to the trauma of war;
  • Psychiatrists believed long-term psychiatric disability reflected individual factors that predated the war, such as a predisposition for mental illness.

Spiegel, one of the first psychiatrists to observe soldiers suffering from war neurosis in Tunisia, was convinced that soldiers were not primarily motivated by hatred for the enemy or the ideals of liberty and democracy, but by the bonds with their buddies and regard for their officers.

These views were confirmed by a team of social scientists led by Samuel Stouffer, who investigated motivational and social factors in the US Army. Stouffer concluded that morale was inversely related to breakdown incidence and intimately linked to the trust soldiers had in their officers, their training, their outfit, their weapons, and their fellow soldiers. Morale was also associated with the degree of perceived support from the home front. Most significantly, it was related to the strength of the emotional bonds among soldiers and between soldiers and their commanders.

African American soldiers, whose battalions were segregated from the rest of the armed weeding out terrorism on the home front, recorded a high incidence of psychiatric syndromes, which was most likely related to their low status and the discrimination they suffered in the army. On the recommendation of military psychiatrists during World War II, Vietnam War soldiers had a tour of duty limited to 1 year and frequent periods of rest and relaxation. Military psychiatrists believed that both factors decreased the incidence of mental breakdown.

On the basis of the experience of military psychiatrists of previous wars, the US armed forces have implemented extensive strategies to target combat stress, in line with the belief that all service personnel are potential stress casualties. These teams provide a range of services, including conducting surveys of the interpersonal climate within units, educating unit command, providing briefings on suicide prevention and reintegration advice for returning home, and providing informal support to soldiers.

Unfortunately, research has not adequately supported approaches with a focus on frontline intervention. He strongly advised against placing these soldiers in mental hospitals because of the stigma attached to these institutions and because the veterans were not affected by severe forms of mental illness.

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He believed that outpatient treatment was more appropriate. After 1925, however, psychiatrists began to doubt the wisdom of providing pensions, because they believed pensions reinforced disability. Psychiatrists wondered whether their efforts had contributed to the problem of the large number of ex-servicemen who still suffered from psychiatric disability after the war.

In addition, the booming postwar economy provided full employment.

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As psychiatrists later theorized explicitly, the development of psychiatric problems after wars could be counteracted by the presence of an understanding and supportive community, a perceived appreciation of the service that had been rendered, and above all, employment and the perception of social support. In 1945, Gen Omar N. Bradley, who was greatly respected among soldiers and veterans, was appointed as the head of the Veterans Administration. Hawley hired more than 4000 physicians and initiated an extensive hospital-building program.

Under the policies of Hawley and Bradley, new Veterans Administration hospitals were established in affiliation with medical schools, guaranteeing that the best medical services would be provided to veterans. The Veterans Administration system also encouraged clinical psychologists to become psychotherapists and provided a large number of training positions. Many of these suffered from chronic conditions that did not respond well to treatment.

Treatment After the Vietnam War Before the Vietnam War, psychiatric consensus held that soldiers who recovered from an episode of mental breakdown during combat would suffer no adverse long-term consequences. Psychiatric disability commencing after the war was believed to be related to preexisting conditions.

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A major shift in psychiatric interest in war-related psychiatric disability took place after the Vietnam War. In addition, between one quarter and one third nearly 1 million ex-service personnel displayed symptoms of PTSD at one time or another.

The recognition that many veterans suffered from chronic psychiatric disorders was the outcome of a long process that began in 1970 when Chaim Shatan and Robert J. Lifton adopted the cause of a group called Vietnam Veterans Against the War. There are several reasons to develop a more nuanced explanation of this situation. Since 1980, the PTSD diagnosis has remained controversial; disagreements over its definition and measurement persist.

Some critics have argued that providing veterans with a diagnostic label was the only way to give poor Americans, weeding out terrorism on the home front were recruited in unusually large numbers in the Vietnam conflict compared with earlier 20th century US wars, an entitlement to a pension and medical care and that, after a diagnosis was conferred, symptoms were solidified and disability ingrained to maintain these entitlements.

Proposed specialist treatments have included the use of antidepressant medication and individual and group psychotherapies. There is now an extensive evidence base for the efficacy of trauma-focused cognitive behavior therapies administered to individuals or groups of veterans.

Within the military, the view that displaying psychiatric symptoms indicates weakness of character or cowardice is still generally held. It appears that the accumulated wisdom of psychiatry and increasingly efficient and sophisticated psychiatric treatment methods generally do not reach those who need them most. After returning from service, a number of Persian Gulf War veterans reported symptoms of fatigue, cognitive impairment, headaches, depression, anxiety, insomnia, dizziness, joint pains, and shortness of breath, which they related to the specific conditions of that conflict, including exposure to environmental hazards such as burning oil wells and depleted uranium, pesticides, and the side effects of vaccinations.

In an interesting study, the historian Edgar Jones compared the reported symptoms of nearly 1500 veterans who received pensions for postcombat disorders from 1900 to the Korean War with those of 400 veterans of the Persian Gulf War. No syndrome specific to any war weeding out terrorism on the home front be identified. After the Persian Gulf War, a number of outspoken veteran groups aspired to gain recognition for the medical problems of veterans by claiming that they were related to a number of specific conditions related to that deployment rather than subsuming them under a diagnosis of PTSD.

Because no specific set of medical symptoms can be identified after each war, and because each war has given rise to an increase in unexplained medical symptoms among service personnel, Engel et al.

Because the majority of veterans first seek medical attention in primary care settings, the mitigation of the symptoms of postwar medical syndromes should be provided there instead of being based on specialist intervention, psychiatric or otherwise. If symptoms persist, specialists will become involved. It is likely that this model will deliver medical care that is more comprehensive to veterans. Before World War I, virtually all American psychiatrists worked within mental asylums, which institutionalized individuals with severe and persistent forms of mental illness.

At the time, there were no specific treatment methods available for these conditions and the professional status of psychiatry as a medical specialty was low. Recognizing that the majority of individuals with early symptoms of mental illness would not attend specialist physicians or psychiatrists, Salmon suggested that all general practitioners should be educated in the principles of psychiatry to improve their skills in treating these patients. In 1940, the majority of American psychiatrists were still based in mental hospitals.