badges 1…

Posted on Tuesday 24 July 2012

In 1895, Stephen Crane published what would become the signature novel of the Civil War, The Red Badge of Courage, though he was born after the war and had no combat experience. In the novel, a young Union recruit became obsessed that he would "run" in battle, shaming himself as a coward. He made it through his first skirmish. But as he was proudly congratulating himself for his bravery afterwards, the Rebels counterattacked and he found himself fleeing in panic. He wandered alone behind enemy lines, humiliated at his cowardice, afraid someone would find him out. At some point, he encountered Union soldiers retreating and tried to find out what was happening at the front. One of the soldiers butted him in the head with his rifle to get past him. When he finally rejoined his unit, his friends assumed that his wound was from battle, an honorable wound that explained his absence. He went on to fight heroically in a subsequent battle.

Crane’s novel presaged the reality of World War I where there was an epidemic of wartime mental illness called Shell Shock by the soldiers. Initially, that formulation was picked up by military doctors who thought it resulted from concussive brain injury. Many in the high command, however, leaned towards malingering, soldiers feigning illness to escape the horrors of trench warfare and significant number of soldiers were sent to firing squads for cowardice, particularly on the eastern front. Others were treated with electroshock, a veiled ploy to return them to duty. Alarmed that the psychological casualties depleted the fighting force, the British command sent Dr. Harold Wiltshire to the front to investigate, where he made the salient observation that among the ranks of the physically wounded, psychological illness was rare, whereas very few of the "Shell Shock" victims were wounded. Further, the mentally ill reported that the onset was rarely during battle, but began later, often with some encounter with a reminder of the battlefield carnage. Wiltshire concluded that the soldiers were not physically injured. In fact, an actual physical wound protected them from psychological breakdown. Yet, in spite of his observations, there were elaborate schemes to certify disability based on whether the symptoms began during combat.

After that war, commissions on both sides rejected the Shell Shock idea – brain trauma. Sigmund Freud was involved and an active critic of the aversive electroshock treatments – pointing to the conflicts of interest between medical and military goals. He later wrote Beyond the Pleasure Principle, proposing that the wound in traumatic illness was to the mind rather than the brain. As his title suggests, he could find no evidence that the illness was motivated by personal gain, conscious or otherwise. The enduring psychological toll of that war was devastating, again echoed in the literature of the period in fiction, biography, and poetry [the British War Poets, Virginia Woolf’s Mrs. Dalloway, Robert Graves’ autobiography Good-Bye to All That, J.R.R.Tolkein’s epic Lord of the Rings, Erich Marie Remarque’s All Quiet on the Western Front, to mention a few]. From Remarque:

    This book is to be neither an accusation nor a confession, and least of all an adventure, for death is not an adventure to those who stand face to face with it. It will try simply to tell of a generation of men who, even though they may have escaped its shells, were destroyed by the war.

In the interval between wars, Abram Kardiner in New York followed a number of these patients and wrote a book about the factors that protected soldiers – adequate food, rest, supplies, staying with their unit, time limited deployments – things implemented in WWII. There was an idea that screening recruits for mental health issues would help [but it didn’t]. In that war, the army implemented a plan that was a major success – when a soldier developed mental symptoms, they were sent away from the front for a few days rest and counseling, then returned to duty. It was a remarkable success leading to the concepts of combat fatigue, early intervention, secondary prevention, and crisis intervention. The similarity to the redemption of Steven Crane’s protagonist, Henry, isn’t lost on us. While its success was laudable, there were plenty of psychological casualties from World War II who suffered in silence. I lost count of the patients I had whose fathers were forever changed by that war [for the worse].

And so it has gone in subsequent wars, we make incremental progress in protecting our soldiers, but there’s a particular kind of forgetting in between. People always seem surprised at the number of PTSD cases or the high incidence of suicide, and the debates between "real" and "feigned" illness never seem to get resolved. There is an invariable suspicion that the afflicted who weren’t in the throes of battle are malingering, or have compensationitis. Criteria for diagnosis and disability are debated over and over, and there’s resolve anew to separate treatment from compensation – though it never seems to happen. Commissions get convened and the monotonous camps of experts gather to debate – as if the inevitable mixture of the deeply afflicted and the opportunists that gather whenever benefits are involved can be resolved on some group basis by a commission, rather than by careful clinical evaluation of individual cases, one case at a time. And the search for some kind of objective markers to certify disease seems to never end. Was he in combat when he went mental? How soon did he begin to have symptoms? Is he faking? or greedy? or needy? It seems impossible to hold firm to the idea that an event or set of circumstances can leave an indelible imprint on the mind – one that might show up years later, or endure for decades – and there’s endless skepticism about diagnosis, treatment, or levels of infirmity. Former distinctions like courage, honor, bravery, and cowardice have been replaced by words like resilience, PTSD, and malingering, but the meanings are little changed.

This post is obviously a prequel to discussing the contemporary versions of  this debate…
    July 24, 2012 | 11:17 PM

    I’m looking very forward to this, Dr.

    July 25, 2012 | 3:39 AM

    wiley, you might find this article of interest which I stumbled across a few days ago while reading articles on the Priory site about Freud’s use of cocaine:

    July 25, 2012 | 1:39 PM

    Thanks for that link, Suzy. It’s fascinating and very rare to read so much written about WW I. The “savagery” of war is modern.

    I’m afraid that the treatment that a lot of U.S. soldiers need for TBI and PTSD is too specialized and labor intensive for most of those who need it to get it. The V.A. will just throw drugs at both of them. At least group therapy will be available for many of them.

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