IJE Advance Access originally published online on August 30, 2006
International Journal of Epidemiology 2006 35(5):1367-1368; doi:10.1093/ije/dyl181
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Book Review |
Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War, Maudsley Monographs 47. Edgar Jones and Simon Wessely, Hove: Psychology Press, £24.95, ISBN 1-84169-580-7
E-mail: d.wainwright{at}kent.ac.uk
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The key to this ambivalence lies in the fact, astutely recognized by the military if not by all psychiatrists, that mental and emotional resilience is greatly influenced by the expectations, meanings, and definitions that prevail in a given culture and social network. Cancer cells will continue to divide whatever the patient makes of them; the diagnostic categories of psychiatry—depression, anxiety, trauma—are less objective. They refer to continua, which range from the ‘normal’ ups and downs of everyday emotional life, responsibility for the management of which lies with the individual, through to extreme psychoses over which the patient has little control and, therefore, cannot be held responsible for. The problem faced by the military, psychiatry, and society as a whole, lies in specifying the point at which personal responsibility and self-management should be replaced by therapeutic intervention and the suspension of moral sanctions. Set the Plimsoll line too high and serious suffering and dysfunctional behaviour will go untreated; set it too low and the imperative to struggle against and overcome adverse experiences will be diminished, to the detriment of much more than military effectiveness.
Jones and Wessely note that the military's dilemma mirrors the Victorian debate about the deserving and undeserving poor, but it also points to a contemporary concern with the contradictions of the welfare state, namely the desire to provide services which ameliorate the suffering of the needy, and the tendency for such interventions to have unintended adverse consequences, which often outweigh the problems they were designed to resolve. The quadrupling of the number of Incapacity Benefit recipients in the early 1990s and the recent attempts to reduce their number by a combination of therapeutic and more coercive measures is just as much about the management of resilience as was the military's attempts to keep troops at the front.
The book's 10 chapters recount the unfolding of military psychiatry in broadly chronological order, from pre-1914, through both world wars, Korea, Vietnam, the Falklands, right up to the Gulf War. What emerges from this story, apart from the military's tendency to forget the hard-won lessons of the previous conflict, is the extent to which the categorization and understanding of the emotional correlates of war are shaped by prevailing cultural norms and political concerns. The lexicon alone is sufficient to reveal this, from the vaguely poetic ‘Disordered Action of the Heart’, which emerged during the Boer War, through to the modern categories of stress and trauma. A particular favourite of mine is ‘lack of moral fibre’, a phrase reeking of Brylcream and Bakelite, which has its origins in the Second World War when it was used to stigmatize air crew who had lost the will to fight. Not surprisingly, long-serving air crew were reluctant to have their exhaustion and fatigue denigrated by this label, although it is perhaps preferable to the earlier ‘lack of intestinal fortitude’. These are not simply changes in labelling; different epistemologies are at work here, locating the origins of the response to war variously in the heart, the gut, or the psyche.
A sub-text of the book is the military's love–hate relationship with psychiatry. Those who read RD Laing and Thomas Szasz in the sixties may be surprised to discover that anti-psychiatry has an earlier history in the military. Winston Churchill expressed the viewpoint in typically forthright terms:
I am sure it would be sensible to restrict as much as possible the work of these gentlemen, who are capable of doing an immense amount of harm with what may very easily degenerate into charlantry. The tightest hand should be kept over them, and they should not be allowed to quarter themselves in large numbers upon the fighting services at the public expense... There are quite enough hangers on and camp followers already. (Churchill, 1942, cited in Jones and Wessely p. 116)These themes of charlantry and the potential for harm resurface at intervals across the long history of military psychiatry, only to be swept aside when the reality of psychiatric injury necessitates a rapprochement. Refreshingly though, Jones and Wessely do not conclude their book with a fashionable call for ever greater therapeutic intervention, but with recognition that how soldiers make sense of their experiences and their subsequent mental resilience is to a large degree shaped by cultural factors such as risk aversion and the heightened sense of vulnerability that appears to pervade contemporary culture and government policy: ‘if the guiding principle remains ’better safe than sorry,‘ they conclude, ‘the consequence may be that people end up no safer and, indeed, a lot sorrier.’ (p. 221).
The publisher's blurb claims that Jones and Wessely's book ‘will be of interest to practicing military psychiatrists and those studying psychiatry, military history, war studies, or medical history’; I have none of these interests, yet the book fascinated me, as I am sure it will anyone with an interest in the management of resilience.
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