Shattered
During rap groups with antiwar Vietnam veterans in the early 1970s, I was struck by the special hostility they expressed toward “chaplains and shrinks.” They lumped the two together as ostensible healers who had betrayed them by lending spiritual or psychological authority to a “filthy enterprise.” When they experienced severe anxiety symptoms or strong moral revulsion toward the war--and it was difficult to separate one from the other--these healers, mostly a psychiatrist or his assistant, would “help” them to be strong enough to return to duty, to the almost daily atrocities. Precisely because it was such a “bad” war, Vietnam illuminates the severe, indeed insoluble, moral contradictions faced by psychiatrists in all wars.
However peace-loving, a psychiatrist becomes socialized to his military unit and, therefore, to its combat mission. (I know this from personal experience, after serving as an Air Force psychiatrist in Japan and Korea, well behind the lines, during the latter phases of the Korean War.) He must undergo a complex professional about-face from a clinical commitment to nonviolence to providing psychological support for a violent enterprise that takes precedence over any contrary individual inclination. He is even forced to question his therapeutic impulse to remove a troubled man from danger by sending him home because that decision, he learns, could result in a soldier’s lifelong sense of shame and failure.
Providing this support in a military mission can take the psychiatrist into the most grotesque moral terrain, as in the case of a Wehrmacht neuropsychiatrist who told me (when I interviewed him for my book “The Nazi Doctors”) that during World War II he’d been assigned to treat the psychological disorders of the Einsatzgruppen, the special mobile units carrying out mass face-to-face killing of Jews. Their symptoms, he said, resembled those of combat reactions (only sometimes including guilt feelings), mostly from the difficulties of their task, made worse when killing women and children. His treatment for them was mainly supportive: rest, sedation, brief stays in pleasant surroundings, and, wherever possible, return to duty.
Many have commented on such psychiatric contradictions in relation to the military, but much less has been said about how these contradictions call into question our overall legitimation of mass killing and the ambiguities in what we call healing. Ben Shephard, a British television producer and historian, sets himself the more limited but still formidable task of exploring “the psychological problems soldiers developed in the World Wars and during and after Vietnam” along with “the steps doctors took to counter them.”
He begins by making a dubious distinction between psychiatric “realists” concerned with “getting [men] fighting again quickly” and “dramatists” who (more pejoratively) were “interested in teasing out the fascinating complexities of patients’ symptoms and writing them up.” Still, he goes on to provide a valuable account of World War I psychiatric struggles, centered on the evocative but much-confused concept of “shell shock”: so named because it was believed that soldiers’ dramatic symptoms--blindness, deafness, muteness, memory loss, uncontrollable vomiting, and severe tremors or “shakes”--stemmed from exploding enemy artillery shells. Late-Victorian psychiatry would at times join with old-school military thought in accusations of “cowardice,” but no one could ignore the enormous drain on British manpower created by what came to be called “nervous disorders of war.” In exploring why men broke down, Shephard rightly emphasizes problems of leadership and of the quality of troops but pays insufficient attention to the soldiers’ increasing sense of the deadly absurdity of the mass slaughter of trench warfare.
Treatment ran the gamut, from indulgent evacuation to execution for desertion. In-between approaches included simple rest and encouragement, together with persuasion (sometimes accompanied by the use of painful electric current, which seemed to combine the therapeutic and the punitive) toward returning to duty. Shephard is probably right in regarding as atypical the more leisurely psychotherapy of William Rivers, conducted in the safety of an English hospital, with its exploration of ethical questions about the war (originally celebrated by Siegfried Sassoon in his memoir, “Sherston’s Progress” and more recently by the novelist Pat Barker in her “Regeneration Trilogy”). But he underestimates the importance of Rivers’ legacy for our endlessly wrenching ethical and intellectual struggles in these areas.
Shephard extends his observations to French and German World War I psychiatrists, who tended to be even more authoritarian than their British counterparts and sometimes quite brutal in their use of electric current. They met with limited but historically important legal opposition. A French civilian psychiatrist denounced such “medical militarism” and won a moral victory in a celebrated trial in which he defended the actions of a soldier for striking his doctor who had aggressively approached him with electrodes in his hands. And in Vienna there was a postwar legal inquiry into similar treatment with electric currents. (Sigmund Freud, called as an expert witness, was stunningly uncritical of the use of these methods by the prominent psychiatrist Julius Wagner-Jauregg, whom Freud apparently wished to placate for reasons having to do with Viennese medical politics.)
Among American psychiatrists in World War I, a previously undistinguished Thomas Salmon emerged as an impressive and tireless student of behavior at the front. Carefully applying what British psychiatrists had learned, he developed an influential model emphasizing the role of the division psychiatrist working close to the front. Though Salmon identified himself with the military mission and insisted that shell shock was “relatively simple and recoverable,” he had some awareness of the profound moral contradictions of his work, observing that “many a scared kid is being saved (for future demolition) by a little rest and bucking up and good advice.” Overall, Shephard’s many-sided rendition of World War I psychiatric experience is the strongest and most integrated section of “A War of Nerves.”
Shephard’s treatment of World War II is also compelling, if a bit more sprawling. We learn that Dunkirk, generally considered an extraordinary achievement in evacuating the British Expeditionary Force from France, became, when viewed by doctors from a British hospital, “a defeated and defeatist rout” with huge numbers of men in states of “total and abject neurotic collapse.” Encountering these devastated men, the young John Bowlby courageously stood up to the medical bureaucracy, insisting upon humane forms of treatment. One wonders how much those wartime experiences with extreme trauma played a part in his later landmark work on attachment, separation, and loss. Wilfred Bion also makes an appearance with his boldly provocative communal work at Northfield Hospital, which he extended brilliantly into a postwar discipline of group therapy that had considerable significance for broader social and political behavior. A particularly large figure is that of William Sargant, who drew upon civilian work done between the wars and achieved dramatic effects through the use of drugs--sodium amytal and other barbiturates, for sedation, abreaction (release of repressed memories and emotions) and deep-sleep therapy--as well as modified insulin coma and electric shock. A shadow later fell on this career, however, when Sargant engaged in unsavory professional behavior involving mind manipulation through connections with British and American intelligence services.
On the American side, Shephard gives a devastating portrait of Harry Stack Sullivan (the gifted but erratic theorist of “interpersonal relations”), who emerged as a leading Washington military manpower consultant and instituted a “when in doubt, reject” policy toward recruits. He is more sympathetic to William Menninger, less brilliant but steadier, and more practical and effective in his dealings with the military. In a hospital in North Africa, Roy Grinker and John Spiegel developed a method they called “narcosynthesis,” which combined the use of Pentothal with an induced flashback, (while in partial coma, the patient was told he was back on the front line), meant to provide not only cathartic abreaction but also an opportunity to resynthesize these experiences. Other American psychiatrists--including Frederic R. Hanson, Moses Ralph Kaufman and Herbert Spiegel--worked closer to the front lines and relied less on drugs, treating what came to be called “combat exhaustion” with rest and forms of brief psychotherapy that evoked loyalty to one’s unit and pride in returning to it.
Shephard may be a bit crass in declaring that “psychiatrists had a ‘good’ war in that they gained postwar professional status.” From my own encounters with some of them--for instance, as a junior colleague of Spiegel at Harvard in the late 1950s and of Theodore Lidz (who did important work in the South Pacific) at Yale through the ‘60s and ‘70s--I would say that the picture was much more complex. To be sure, such men did gain professional recognition and retained a sense of wartime achievement that could be indelible in its life-and-death intensity. Yet I also felt them to be haunted by their war experiences, which they found difficult to integrate into their subsequent personal and professional lives. Although Shephard refers occasionally to psychiatrists’ conflicts and disappointments, he does not recognize the extent to which they too could experience elements of “combat exhaustion” that could enter into later struggles with sadness and loss. They carried within them the residuum of the “Catch 22” nature of the psychiatrist’s military function--as expressed by an American front-line psychiatrist Shephard quotes who contrasted the traditional therapeutic aim of “making the experience of living desirable” to the patient with the military policy of extending to him “an invitation to death.”
Shephard considers the Korean War to be a “success story” for American military psychiatry, led at the time by Col. Albert J. Glass who, as a front-line psychiatrist in World War II, had learned well the treatment principles that came to be called PIE, “Proximity” (to the front), “Immediacy” (of initiating treatment) and “Expectancy” (of recovery and return to duty). I can attest to the general awareness then of these principles, but I wonder how successful psychiatrists were during the two chaotic retreats--the first near the beginning of the war involving relatively few American troops, but the second the routing of much larger American units who were surprised and terrified by the waves of Chinese troops crossing the Yalu River to attack them. From all reports, and from what I could observe in working with repatriated American prisoners of war as my final military assignment, GIs in combat in Korea were profoundly vulnerable to combat exhaustion, breakdown, and under extreme circumstances, loss of the will to live. This may be one reason why Shephard finds that, comparatively speaking, not much has been written about American Korean War psychiatry.
With the Vietnam War, Shephard enters more difficult terrain in which the behavior of soldiers and psychiatrists is inseparable from the overall agitation of American society. He is well aware that Vietnam was different, that it was a guerrilla war without clear objectives, had no front line, was a class war fought mainly by minorities and the poor, and that each soldier rotated alone after a one-year tour of duty. But he doesn’t grasp the extent to which GIs and psychiatrists alike came to experience it as an absurd and tainted enterprise, consisting more of direct killing of civilians and of illusory “body counts” than of military engagements with an enemy. Television at home and the presence of American popular culture among the troops in the field led to a back-and-forth process in which, for periods of time, the most popular song for the troops in Vietnam was Country Joe McDonald’s bitterly mocking antiwar classic, “I-Feel-Like-I’m-Fixin’-to-Die Rag.”
Shephard notes the enormous disparity in the writings of American psychiatrists in Vietnam. He finds that what he calls the “realist” American psychiatrists to be “completely discredited” so that “the field was left clear to the ‘dramatists”’ who were “ignorant of the hard, unglamorous lessons of the past.” But what he does not realize is that Vietnam brought about a reversal of his original criteria: The “realists” were those who described the “psychology of slaughter,” while the “dramatists” clung wishfully to the traditional mantra of Proximity, Immediacy and Expectancy. Nor does he record the extent of inner pain, moral conflict and overall confusion of psychiatrists there, as I learned from several I spoke to after their return.
But Shephard is more critically concerned with psychiatrists outside of Vietnam--notably Chaim Shatan and myself--who strongly opposed the war, and with those later active in the large Outreach Program, headed by Arthur Blank, of the Veterans’ Administration. He accuses us, together with writers on the Holocaust, of basing a universal (or as he calls it, “pure, scientific and ahistorical”) concept of post-traumatic stress disorder on these two anomalous events. In disseminating that concept, we are further criticized for “excusing” individual veterans for their participation in atrocities and of conditioning our society to do likewise.
To be sure, there have been many confusions associated with the concept of post-traumatic stress disorder--confusions having to do with varieties of trauma and of individual susceptibility to it, with faddist professional tendencies toward careless diagnoses, and with ambiguities having to do with legal responsibility and with eligibility for government-provided therapy. Having said all that, the concept of post-traumatic stress disorder has one particular advantage which, I believe, outweighs its limitations: It gives specific psychiatric recognition to direct physical, often life-threatening trauma, and to adult trauma in particular. To appreciate the importance of this, one must realize the extent to which adult trauma has been a stepchild in psychiatry. Even when clearly present, it has regularly been ignored in favor of either a focus on hereditary weakness of some kind or on psychological confusions during the early years of life. Psychiatrists have resisted the truths of extreme adult trauma, as have others, perhaps because it is more excruciating to hear about than just about anything else. Narratives I heard told by Vietnam veterans, Hiroshima survivors, and survivors of Nazi death camps were of an entirely different order from even the most painful childhood memories of patients I have treated. The same is undoubtedly true for those listening to the narratives of victims of torture.
Of course no traumatic disorder is “ahistorical” or “purely scientific.” Historical and political influences enter into its construction, as they do even in such classic psychiatric entities as hysteria and schizophrenia. But I feel that we should also look toward aspects of human commonality, which tend to be ignored in our postmodern distrust of anything smacking of generalization. Indeed, a reasonable reading of Shephard’s treatment of the two world wars suggests that there are shared human responses to direct, life-threatening trauma that in some measure transcend cultural differences and historical eras. These have to do with various manifestations of feeling (anxiety) and non-feeling (psychic numbing), with struggles over grief, loss and mourning, and with self-lacerating conflicts over surviving in the face of witnessed deaths. That is why there can be such common themes in very divergent work which Shephard rightly admires--that of Abram Kardiner between the two world wars and after (emphasizing “ego shrinkage”) and Erich Lindemann on the Coconut Grove nightclub fire disaster in Boston in 1942 (emphasizing immobilizing grief reactions and bodily symptoms)--as well as in my own findings in Hiroshima survivors of radically diminished capacity to feel, or what I came to call psychic numbing. This is far from claiming the universal applicability of any fixed definition of post-traumatic stress disorder (or anything else). But it does suggest that there are certain profound responses common to humanity--in such primal experiences as giving birth, the nurturing of children, sexual love and in struggling with death, particularly ugly death. From this perspective, Vietnam has all too much to tell us about severe adult trauma.
Shephard is right to raise the important question of Vietnam veterans’ responsibility for their actions, and there has been much confusion on this subject. He fails to appreciate the intense moral focus of work with Vietnam veterans by people like Sarah Haley, the author of the widely read article, “When the Patient Reports Atrocities,” and unfairly accuses her of simply accepting those atrocities. Actually, her work and that of others opened up space for a moral exploration of what was usually unmentionable. In rap groups in which I participated, veterans themselves stressed their individual responsibility for what they did, while demanding that American society in some degree share (not take over from them) that responsibility. In seeking understanding of their and others’ behavior, we discussed the idea of an “atrocity-producing situation,” a structural and psychological context created by the corruptions of the Vietnam War that could lead to atrocities on the part of almost anyone. That discussion always included assertions of individual responsibility for what one did.
In a project as vast as the Veterans’ Administration Outreach Program, there were undoubtedly times when this sense of combined responsibility was unclear. But the spirit of that enterprise was in no way to condone atrocities but rather to help veterans confront their behavior and in that way extricate themselves from the two roles Albert Camus warned against, those of victim and executioner.
Post-traumatic stress disorder, as a clinical syndrome, can have the undesirable effect of overly medicalizing behavior. That is one reason for emphasizing more generally the psychology of the survivor, a model which has a number of advantages: It makes no assumption about a disorder. It suggests the life-threatening dimension (the issue of death is too often ignored in approaches to adult trauma). And it tends to take one directly to moral questions about the event, about one’s own behavior, and above all, about the survivor’s inevitable quest for meaning in the aftermath of death and destruction.
In their quest for meaning, antiwar Vietnam veterans drew mainly upon their own direct experience, but also upon the ideas of the antiwar movement. Veterans who endorsed the war found meaning in the official American position of combating communism but often felt the need to minimize the killing of civilians and to emphasize the atrocities of the enemy. And there was a vast in-between group which took no public stand on the war but had trouble finding meaning or justification in an enterprise that felt dirty and wrong.
Shephard is uneasy with the term “massive psychic trauma” used to describe exposure to vast levels of killing and dying. But I have found striking parallels in survivors of Hiroshima and of Nazi death camps, different as these events were, and psychological resemblances in both to smaller but devastating experiences of individual loss or abuse. More than that, the reverberations of massive 20th century trauma--the genocides, atomic bombings and fear of future nuclear holocaust--all these inevitably enter into what Shephard refers to as our “consciousness of trauma.” This is not an orderly process, but given our vulnerable human psyches and the 20th century revolution in mass communication, it would be naive to assume that these events do not converge in our minds and affect the way we perceive and interpret our world. To say that these holocausts must influence our approach to trauma is not simply to invoke a questionable “big idea” (as Shephard puts it), but rather to recognize the extent to which we are all creatures of our history.
“A War of Nerves” ends strangely and revealingly. Shephard quotes from a 1943 British short story describing the behavior of the crew of a North Sea trawler after retrieving from the water large numbers of bodies and pieces of bodies from the crew of another trawler that had struck a mine. The narrator, seeing the crew upset, gets them to burst into song, not spirituals but hearty, joyous song--followed by a stiff rum drink and a peaceful sleep that night. There may be something to be said for Shephard’s appeal to human resilience and to the kind of old-fashioned stoicism cultivated in various groups. His implication is that such stoicism is superior to anything suggested by the soldiers or psychiatrists he has so extensively chronicled. But so inadequate is that anecdote for the mass slaughters we have experienced in the 20th and 21st centuries that, inadvertently, it makes the opposite point. We require further, deeper, more rigorous explorations of the extreme forms of trauma in our time if we are in some measure to overcome them and to combat the forces that create them.