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Some of the RAF pilots who attacked Iraq in the opening days of the
Gulf War were very honest about their fears. One admitted that on the first
day he felt fear of failure and fear of dying. Another said that the first
sortie was the easiest because he had less idea what he was going to face.
In the midst of all the talk of doing a job that has to be done, this honesty
shows how attitudes are changing. Even the military do not feel the need
to be that macho about combat. And, paradoxically, what may look like an
admission of weakness may be of great psychological value_especially in
warding off an old enemy of soldiers, shell shock.

As the Gulf War has now turned into a land war, infantry and tanks fought
on. The men on both sides are likely to be susceptible to shell shock, particularly
given the sheer scale of the bombs and weapons being used.

Shell shock was not recognised as a hazard on the battlefield till 1914
when a monograph was written about it during the Bulgarian campaign which
predated the First World War. An army inquiry into shell shock which began
work in 1919 argued that war in 1914 was substantially different from previous
wars. Soldiers spent longer than ever before under bombardment in the trenches_something
that we may well see in the Gulf. Secondly, they were exposed to tremendous
new artillery and to being bombed from the air. The many military doctors
who gave evidence to the inquiry included a number who described themselves
as ‘ neurologists to their battalion’. They included some distinguished
scientists such as the neurologist Henry Head and Edward Mapother, one of
the leading lights of the Maudsley Hospital in London. They admitted that
never before had there been such a psychological interest in war and its
effects. That interest owed a great deal to the rise of psychoanalysis.
Psychoanalysts such as William Rivers, who served in France, argued that
the terrors of battle were such that soldiers repressed their fears. They
could not admit them. It was not surprising that they developed hysteria,
paralysis and shell shock. One very curious symptom was that men lost the
power of speech. They became mute, deaf and stuttered a great deal. Rivers
argued that soldiers knew, both consciously and unconsciously, that they
stood to gain a great deal from being declared sick. They might be sent
back home. Rivers told the inquiry: ‘The things the men were trying to put
out of their minds were far too powerful.’ The inquiry remains one of the
most extensive studies of shell shock and is very relevant today.

Lord Moran, who eventually became Churchill’s doctor, served with the
First Battalion of the Royal Fusiliers from 1914 to 1917. The first case
of shell shock he saw was a certain Sergeant Turner who was brought to him.
Turner seemed to have no physical injuries. He had not been hit, but a bomb
had exploded near him. Turner was unable to speak. He was trembling, although,
Moran added, ‘he was trying to keep his limbs still. He appeared dazed by
what he had been through and by this end to everything.’ Moran came to the
jaunty, slightly moralistic diagnosis that: ‘it was plain to me the game
was up and he was done. When this sort of thing happens to a good fellow
it is final.’

Some of those who testified before the Army Commission did not believe
in shell shock. One brigadier referred to it as ‘a disgrace’. Many other
doctors were more compassionate but did not like the term shell shock. For
instance, one clinician, Bernard Hart, said people believed that shell shock
involved ‘some mysterious change in the nervous system’. He preferred to
speak of emotional shock and ‘ commotional disturbance’. The commotion was
due to bombs or shells exploding. At the centre of much of the debate was
whether the men were malingering.

Turner was a ‘good fellow’ and, therefore, not a malingerer. Moran,
like most British doctors of the time, believed at first that malingering
was widespread. At the start, Moran believed you could divide men neatly
into three categories_the brave, those who disliked it but did their duty,
and cowards. He sometimes sneered that the latter were ‘misshapen creatures
from the towns’.

In time and under fire, Moran realised his initial psychology had been
too crude. He was most sympathetic to heroes who suddenly crumbled. One
fearless sergeant who got the Distinguished Conduct Medal at the Somme started
to stare at incoming ‘minnies’. These were little bombs which usually made
a big crater. ‘They were lobbed from the German trench: you could see them
coming; it was like waiting for a high catch in the field.’ This sergeant’s
eyes were glued to them. Moran saw this as the first sign of a dangerous
change, even loss, of personality. Squadron Leader Fuller, neurologist to
the Royal Flying Corps, argued that soldiers were often at risk when fear
wore off ‘and was replaced by a type of callousness which sometimes increased
until a man took very little trouble to protect himself’. That callousness
made the men vulnerable to breakdown.

The influence of psychoanalysis was evident in some small pieces of
research that were done at the front. Soldiers were asked not just about
their sleeping patterns but about their dreams. It was found that there
was a significant increase in nightmares and broken sleep just before soldiers
went back into the front line. There was also fear of poison gas. One study
showed that 40 per cent of those who said they had been gassed had indeed
been so. The rest suffered from ‘anxiety neurosis due to fear of gas’. There
was not, then, quick and reliable information about what was in the shells.

All the doctors who gave evidence argued that fear was a major cause
of shell shock. The most moving evidence came from an anonymous witness
who was referred to as ‘gallant’ but dared not reveal his identity. He admitted:
‘I was always consumed with fear and it was difficult to conceal that fear.
. . It is the repression of fear, the repression of the emotion of being
afraid that leads to it.’ Squadron Leader Fuller agreed: ‘Shell shock is
born of fear. Its grandparents are self preservation and fear of being found
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Thousands of men deserted during the 1914 war. Many of those who were
caught pleaded at their court martials that they had suffered from shell
shock. Those found guilty of desertion and cowardice could be sentenced
to death. Witnesses to the army’s inquiry were often pressed as to whether
shell shock was an excuse_used either to be evacuated from the front or
to avoid the firing squad. Rivers said he found it difficult and distasteful’
to give evidence in such court martials.

By the end of the war, Mapother concluded that in most cases shell shock
was real, and his expert evidence undoubtedly saved the lives of some soldiers
who were court-martialled. Estimates of the number of malingerers who pleaded
fake shell shocks varied from 5 per cent to 20 per cent. During the First
World War, 386 British soldiers were executed for cowardice: in the Second
World War, only 4 were, partly because the forces had learnt the psychological
and psychiatric lessons.

German and Austrian doctors were remarkably brutal in their treatment
of shell-shock victims because they did not want to condone malingering.
They decided that the best way to treat war neurosis was by electrical treatment.
This was well before the invention of electroconvulsive therapy, or ECT,
which was first used in Italy in 1938. Those who complained of shell shock
were given electric shocks. These shocks were given either to the head or
to the arms. Sometimes this treatment was dispensed at the front, at other
times in hospitals far away. Wagner Jauregg, who was professor of psychiatry
at the University of Vienna and technically Freud’s academic boss, admitted
that he had used such measures which had been ‘harsh enough’. But it seemed
clear to him that the shell-shocked soldiers were malingerers.

In 1920, a medical commission in Vienna examined the controversy. Freud
wrote a paper for the commission. He argued that psychoanalysis helped to
explain some of the hysterical and withdrawn behaviour of soldiers. Freud
added: ‘Something then happened which never should have: the strength of
the currents as well as the severity of the treatment otherwise, were increased
to an unbearable point in order to deprive war neurotics of the advantage
they gained from their illness.’ Freud said that all doctors knew that there
had been cases of death during the electrical treatment. Some soldiers had
been driven to suicide over it. It was an unpopular view.

The British army’s inquiry also considered the question of what could
be done to help soldiers. It concluded that soldiers needed proper sleep
and the best conditions that could be managed during battles. It recommended
better interviewing of recruits to weed out the emotionally damaged. But
there were also some stranger treatments. The most exotic was ‘the controlled
use of rum’. A number of British doctors experimented with what would now
be known as relaxation therapy. Soldiers were brought back to field hospitals
and given massage treatment. The French were apparently very successful
with this technique.

Shell shock did not clear up, however. After the First World War, there
were thousands of depressed, lifeless ex-servicemen all over Europe. Similar
reactions were seen after the Second World War, and the wars in Korea, Vietnam
and the Falklands.

In the 1920s, faced with many such patients, a few psychiatrists began
to examine psychological methods of dealing with shell-shocked victims.
One psychiatrist who became interested was Millais Culpin. Culpin argued
that if repression of fear was the basic problem, soldiers had to remember
and deal with the roots of their fear. It was a neurosis and they had to
recall the repressed fear. Culpin developed a technique in which soldiers
were given an injection of sodium amytal. Sodium amytal is meant to disinhibit
the nervous system. Soldiers were then taken through their experiences.

Very similar techniques were used with some success in the Second World
War. One retired psychiatrist, Stephen MacKeith, described how he had used
sodium amytal in treating a sailor who had been badly traumatised in a landing
on the French coast. He could not remember what had taken place yet he was
psychologically paralysed. MacKeith gave the man sodium amytal. Then, he
made him tell, step by step, everything he could remember. Slowly, the full
story of how he had been attacked and witnessed many atrocities came out.
After the war, the British set up a few experimental units at Northfield
and Mill Hill in London, where groups of ex-servicemen went through similar
treatments.

Releasing repressions

In some cases drugs far stronger than sodium amytal were used to unblock
these repressions. The Dutch in Indonesia in the 1950s both committed and
were the victims of atrocities. The survivors were often leading half-lives.
They felt depressed, lethargic and unable years later to shake off the traumas
of the war. At the University of Leiden in the Netherlands, Jan Bastiaans,
then its professor of psychiatry, treated several such patients. One man
he told me about had seen members of his platoon decapitated in the jungle.
Sodium amytal did no good.

Eventually, Bastiaans decided to try LSD in very controlled circumstances.
He found that the LSD managed to get the patient to talk. It was the first
step in the healing process. Bastiaans was the last doctor in the Netherlands
licensed to use LSD and said that this technique aroused much hostility.
Yet it had worked-and in one instance he recorded it on film.

A book just published on the civil conflict in Afghanistan by Soviet
writers claims that the Vietnam and Afghan wars were the first in which
ex-servicemen suffered from post-traumatic stress. The writers suggest that
this was because these were unpopular wars. This is simply wrong. Every
war since the First World War has produced thousands of cases of post-traumatic
stress. It is now accepted that victims of peacetime disasters suffer acutely
from it. After the Falklands War, many ex-servicemen complained of it and
of the fact that they got poor psychiatric help. The fact that some soldiers
and pilots in the Gulf feel able to talk about their fears is a positive
sign. It will probably do something to ward off the contemporary equivalent
of shell shock. But there is no doubt that, as well as the more obvious
devastation, the Gulf War will leave considerable psychological scars on
both sides.

David Cohen is the author of Aftershock: The Political and Psychological
Consequences of Disaster, published by Paladin.

* * *

The modern psychiatrist’s war

The stress of war in the Gulf has already produced ‘a trickle’ of psychiatric
casualties, according to Brigadier Peter Abraham, the director of army psychiatry
in Britain. Abraham is not surprised. ‘There is specific training in relation
to stress management within the units,’ he says, which involves imagining
what battle will actually be like. But of course it is not possible to prepare
soliders for some of the gruesome realities of war. There are no dead or
dismembered soliders in exercises.

The organisation of psychiatric services in the Gulf is complex. At
its heart are Battleshock Recovery Units and Field Psychiatric Teams. Ideally,
the units are located fairly near the front. The FPTs include a psychiatrist,
nurses and orderlies equipped with vehicles. Their task is to assess soldiers
who are in no shape to continue fighting, to evacuate them from the immediate
battle area and to get them fit to fight again. In the field psychiatrists
have to treat men as soldiers, not patients, says Abraham.

Since the First World War, it has been clear that soldiers recover best
if they are not totally removed from the front. ‘The idea is that as much
as possible soldiers will be treated in the theatre of operations,’ Abraham
says, so they will be kept ‘as near as possible to the man’s unit location
consistent with removal from the worst effects of battle’.

Treatment for shell shock has to be quick and a matter of common sense.
Soldiers are given the chance to sleep, rest and have plenty of warm drinks,
but battle-field psychiatrists are wary of prescribing drugs. Abraham’s
plan for treatment envisages that soldiers do some work as soon as possible,
and there is not much chance of therapeutic finesse.

‘With literally hundreds of battleshock cases held in Battleshock Recovery
Units, the psychiatric teams can hardly engage in formal behaviour therapy,
much less analytical psychotherapy,’ Abraham says. But he believes in the
therapeutic value of recapitulating the battle experiences, which soldiers
can do with and for each other as part of the ‘treatment’.

The field psychiatrists should also keep an eye open for the development
of ‘evacuation syndromes’, says Abraham. These are a sort of epidemic that
sweeps through battlefields, as soldiers under stress pick up psychiatric
symptoms from one another.

Estimates suggest that perhaps half of those exhausted by battle will
recover in the first 48 hours. Those who do not recover so quickly should
be moved farther back from the front line. Abraham says that many psychological
casualties should recover at this second station.

Predicting the number of soldiers who will suffer from shell shock is
not easy, but several studies suggest some relationship between physical
injuries and the number of battleshock cases. Both reflect ‘ the intensity
of battle’.

For every 1000 men with physical wounds in Northern France in 1944,
battleshock affected 200 more men. In the Yom Kippur War of 1973 psychiatric
injuries afflicted as many as 300 for every 1000 wounded. Abraham warns
that military estimates rarely envisage a third of casualties coming from
battleshock.