Mental Health with Veterans
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Mental Health with Veterans
Introduction
Mental health problems among the veterans pose major policy problems. Every year, tens of thousands of American soldiers leave the military to join their civilian life. However, there is growing global recognition that veterans often face post-conflict dysfunctions that affect their mental and physical wellbeing. For instance, the ongoing conflict in Iraq and Afghanistan has heightened interests in the welfare and health of regular and reserve combatants on their returns from duty and their eventual transition to civilian life (Mitchell et al. 2020). The US literature that explores individuals returning from the 1991 Gulf War suggest that these people who had survived wars and joined the civilian life are more likely to be unemployed or lose their jobs. Such people also end up joining the prison system or rely on alcohol to escape their mental agony. Additionally, some soldiers often leave service prematurely, experience lost working days, and end up socially excluded.
The most commonly mentioned mental health problems that affect veterans include adjustment disorders, alcohol and substance use disorders, depressive symptoms, personality disorders, posttraumatic stress disorder, and drug misuse. In the United States, the experiences of service individuals returning unwell from the Vietnam War have often influenced the traumatology discipline for the past four decades (Iverson & Greenberg, 2009). These incidences resulted in the ultimate incorporation of the term posttraumatic stress disorder into the Diagnostic and Statistical Manual of Medical Disorders in 1980s (Vance et al., 2020). Despite historians recognizing the Vietnam War as low-intensity one for the US armed forces, the most popular congressionally mandated outcome study, the National Vietnam Veterans Readjustment Study showed that there is a lifetime prevalence of 30.9 percent and an existing 15.2% for PTSD.
Mental health professionals have for a long time reported numerous cases of psychiatric casualties among service personnel. Physicians have, for instance, identified battle hypnosis after military actions among servicemen in 1914. The large battle artilleries filled many health care institutions with many unscathed soldiers who presented with mental disturbances. Thereafter, this number increased phenomenally at a rapid pace. Thus, the concept of shell shock emerged in Europe as a metaphor to describe incurable wounds of war suffered both by populations and countries during and after WWI. British physician Myers first crafted the phrase ‘shell shock’ to provide a medical definition of a specific form of injury that was plaguing the British expeditionary forces (Vance et al., 2020). After associating the concept after what he perceived to be injury’s cause, he explained that the effects of an exploding shell might impair the senses, which include hearing, sight, smell, and taste. Along with other physicians, Myers started to acknowledge the misleading nature of the term. This shift in their view of the disease was driven by the idea that many of such cases occurred among individuals who had never been near shell explosions. As a matter of fact health professionals found that emotional disturbances alone were sufficient to cause the symptoms attributed to shell shock (Jones, 2012). Thus, its perceived symptoms became highly varied to the extent that they could incorporate almost any malady other than physical wound. The diagnosis and assessment of mental health problems among veterans has evolved significantly from the shell shock to modern evidence-based methods of treating them.
Shell Shock and Mental Health Problems among Veterans
Shell shock is a term that emerged to describe the traumatic experiences and symptoms that were observed among soldiers and veterans following World War I. The term was crafted by soldiers themselves and its symptoms took the form of fatigue, confusion, nightmares, and impaired sight and hearing. It was often diagnoses by assessing a service person’s inability to function without an obvious cause to be identified (Jones, 2012). Since many of the symptoms were largely physical, it had minimal overt semblance with the contemporary diagnostic procedures of posttraumatic stress disorder. During the WWI, a group of service men viewed the shell shock as cowardice or a form of malingering but Myers convinced the British military to take it seriously and design appropriate techniques that continue to guide contemporary treatment models. The earliest cases of the disease that Myers evaluated exhibited a wide range of perceptual abnormalities, which included loss or impaired hearing, sight, sensation, alongside other common physical symptoms, including tremor, loss of balance, headache, and fatigue (Stagner, 2014). He inferred that such problems were largely psychological rather than physical casualties, and held the view that these symptoms were overt illustrations of repressed trauma.
Like Myers, William McDougall asserted that shell shock could be treated using psychological interventions such as cognitive and affective reintegration. The shell-shocked military personnel, for instance, attempted to manage their traumatic experiences by repressing or splitting off any memory of a traumatic experience (Stagner, 2014). The symptoms are characterized by tremor or contractures, which are the outcomes of unconscious processes that are designed to maintain the dissociation. These scholars believed that patients might be treated if their memories were assessed and integrated within their consciousness, a procedure that may need many sessions.
In light of the above, Myers, together with a team of physicians began to realize that the term shell shock was misguiding health professionals who were keen on addressing the problem. This is because many cases of the disease had been identified among people who had never been to a shell explosion, In fact, physicians found that emotional disturbances alone were sufficient to cause the symptoms attributed to shell shock and that it became so varied that it could nearly take the form of any malady other than physical wounds. From paralysis to insomnia, blindness to poor appetite and agitation, the shell shock emerged to become the blanket diagnosis and explanation for any number of abnormalities (Stagner, 2014). By 1918, the American Expeditionary Force’s Surgeon General reached a conclusion that the shell shock was no longer a useful diagnosis. As a consequence, the government ordered American doctors to cease using the term since it had become of minimal importance and used as a military slang.
The ambiguity that surrounded the meaning of shell shock went beyond the medical profession to the military world. This is especially the case for American service men that were operating on the West Front and writers, film producers, as well as medical professionals on the American home front. The flexibility that was inherent in the term’s definition enabled it to take a wholly new, and often even contradictory meaning. For instance, one of the special editions of the Journal of Contemporary History on shell shock in 2000 featured Jay Winter, who argued that the disease often seemed to be a quicksilver and shifting character. It thus became part of a language that, as Winter describes, one that reveals the vastness of varying national traditions and perceptions within the overall cultural history of the Great War. Assessing how Americans molded the disorder to fit their cultural environment exposes this vastness, thereby paving the way for the First World War US military culture. The continued discussions about war recovery efforts, and symbolisms regarding the country’s foreign policies at the end of the war and during the interwar era called for more assessment into the causes, diagnosis, and treatment modalities of the disease.
While the country did not enter WWI until 1917, the American press had closely monitored and assessed the global medical discussions regarding shell shock since it final official use in 1915. By the time the United States had ventured into the war, Americans had already designed their own conceptualization of this seemingly new consequence of war. While the British talks often emphasized on the disease’s origins and depicted it as a form of hysteria or malingering, the American depictions focused on validating the shell shock as an injury of war. The country’s psychiatrists, the American Expeditionary Force (AEF), as well as images in popular culture, represented the disease within the progressive, empirical language of healing and recovery. By 1916, empirical, reports from popular American psychiatrists and British soldiers on the front started to alter American media talks relating to the disease. Many scholars, for instance, held that soldiers’ witnessing of horrors of industrial warfare caused shell shock, a form of psychological trauma. By September 1916, a British soldier revealed to American readers how the war caused trench nerves among his colleagues. Thus, American psychiatrists who reported back to the United States from the European front also tabled a study regarding the shell shock within the context of mental trauma. To him, the war caused emotional strain on both the mentally stable and unstable service personnel.
Policymakers in America’s health care sector set the foundation for an expansive medical treatment program to respond to high cases of shell shock. While occasionally discussed, policymakers saw few links between the traumas of civil war and the war taking place in the European continent. Only a few scholarly publications existed on Civil War soldiers with mental and nervous injuries (Stagner, 2014). The official medical and surgical history of the War devoted their efforts merely on a few pages to treatment, and WWI era psychiatrists asserted that the number of service personnel were too small and neuropsychiatry too undeveloped to offer useful guidance for their own tasks. Additionally, American physicians, like their European peers, were inclined to believe that shell shock was not like traumas developed by previous wars. Countless shell bombardments, coupled with the slaughter of machine guns, and unannounced mine explosions resulted in the creation of a stress-intensive environment in which the soldiers’ bravery and skill no longer ensured their survival. These injuries of contemporary warfare needed modern insights into the treatment modalities, which were separate from the experiences of the past.
Soldiers who participated in World War 1 underwent many traumatic experiences, and worked and lived in inhumane conditions. shell shock was common among, European, Asian, and American soldiers alike. For instance, European soldiers underwent fatigue, strain, and hunger (Mcleod, 2019). Although soldiers are trained to be resilient, prolonged periods of starvation coupled with poor working conditions and war are overwhelming even for the most resilient of soldiers (Mcleod, 2019). While the soldiers were working in duress, the expectations on them was high not only from their seniors but also governments that expected them to be victorious regardless of the working conditions or their traumatic experiences (Mcleod, 2019). Therefore, the working conditions and hardships experienced by the soldiers significantly contributed to shell shock. While it was clear that the poor working conditions could cause PTSD, the supervisors and commanders did not believe so. Instead, they thought that the soldiers experiencing shell shock were weak in spirit (Mcleod, 2019). However, this appears not to be the case because the condition it was common among different groups of soldiers in different places.
Rather than merely assessing the past American experiences, the US preparation highly depended upon assessment of soldiers who suffered in the European continent. Observers began assessing psychiatrists, such as Thomas Salmon’s visits to the European Front in early 1917. Their evaluations were to make suggestions to the American military that would aid in the prevention of shell shock from disabling as many troops as it had affected the British. After Salmon’s report, the AEF launched a mental health assessment programs for all recruits. Moreover, the US Army Surgeon General developed a neuropsychiatric division for establishing specific treatment centers for patients’ shock cases in Europe. Its policies on shell shock represented the country’s military’s greater understanding of the injuries. Screening exercises indicated that the development of shell shock might have been strongly linked to hereditary insanity or mental instabilities. These reports implied that the conditions of war merely aroused shell shock in those already predisposed to psychosocial illnesses. However, these decisions to develop the neuropsychiatric division and design treatment facilities recognized that genetics alone could not explain or deter shell shock. More specifically, the AEF observed that after a soldier’s exposure to the problem in the trench warfare, unlike those with hereditary insanity, those with shell shock could be treated.
From Shell Shock to PTSD
Over time the shell shock phrase was replaced with post-combat disorder or post-war disorder, which was used to describe the clusters of medically unexplained symptoms that were observed among servicemen after exposure to warring environments. These presentations were also referred to as ‘war syndromes’ (Young, 2020). However, the term was later viewed as misleading in one respect as the same symptom clusters that were observed in solders that break down during training or service in the United Kingdom and have not yet been exposed to the stress of battle (Pagel, 2021). Additionally, post-combat disorders were not the same as combat stress responses since they are characterized by somatic and neurological symptoms of chronic characteristics.
The concept of post-war disorder would later evolve into the posttraumatic stress disorder. This occurred after researchers examined the subjective responses of sufferers and defined it. To them, a condition is regarded as PTSD after a person’s response to the event involves intensive fear, helplessness, and horror. Moreover, the diagnostic criteria for PTSD requires physicians to assess whether the person has experienced an event that is outside the confines of usual human experience and that would be markedly distressing or almost everyone (Pagel, 2021). These include serious threats to life or physical integrity, serious threats or harm to children, spouses, or other close relatives and friends. Other traumatic experiences may include sudden destruction of home or community or seeing others being seriously injured or killed as a result of an accident or physical violence (Young, 2020). The DSM criteria also suggest that such a traumatic event should be persistently re-experienced in at least one of the following ways. First, there must be recurrent and intrusive distressing recollections of the event, especially among young children, repetitive plays in which themes or elements of the trauma are expressed. When it comes to veterans, patients may experience recurring distressing dreams of the events, as well as sudden acting or feelings that point to traumatic events, which continue to recur after living service. Finally, the soldiers may have frequent hallucinations, illnesses, or dissociative behaviors.
Conclusion
Soldiers who participated in the First World War, in 1914, experienced health abnormalities that they named the shell shock. The major symptoms of the disorder included impaired auditory and optic capacities, anxiety, nightmares, parasomnia, and tremors (Stone, 2018). At the time, physicians were not aware of the causes and what the disorder was. The disorder impacted their mental and emotional wellbeing. However, unlike other known conditions including anxiety, the disorder was manifested physically in that the affected soldiers could not operate with the usual competency (Stone, 2018). Initially, it was thought that the shell shock resulted from a severe concussion that significantly affected the nervous system. In the forces, it was believed that the symptoms resulted from fear. To that effect, it was believed that soldiers who were not courageous enough experienced the illness rather than their more courageous colleagues.
Understanding shell shock was not easy when it was first noticed among the soldiers who participated in World War 1. While the symptoms of Shell Shock including anxiety and tremors were initially detected among soldiers who had directly participated in battle, they were later detected in soldiers who had not been near exploding weapons including bombs (Stone, 2018). At first, the condition suffered by the second group of soldiers was thought to be neurasthenia. Neurasthenia is a condition signified by severe nervous breakdown as a result of participation in war, but was also encompassed by shell shock (Stone, 2018). Before World War 1, similar disorders were observed among German and French soldiers in the 18th Century (Macleod, 2019). The term neurasthenia was used to describe the disorder that was symptomized by low-grade nervousness (Stone, 2018). The greatest symptom of the disorder was believed to be exhaustion because soldiers who suffered from Shell Shock were generally exhausted.
Unlike in the World War 1 where the symptoms of Shell Shock were speculated to be fear of war, there were no suspected cause of the disorder in the 19th Century. However, the main symptoms of the disorder then were singled out to be extreme fatigue, insomnia, nightmares, anorexia related depicted by physical and mental tiredness, and sensory sensitization (Stone, 2018). At the time, Shell Shock was believed to be caused by an undetectable change to the chemical structure of the nervous system. In the US, the disorder was thought to be a disease associated with the modern American lifestyle (Macleod, 2019). In particular, neurasthenia, which was held as a component of Shell Shock, was believed to be perpetrated by the fast-paced lifestyle, increased workload, and emotional repression associated with the modernity paradigm.
The pre-war diagnosis of Post-Traumatic Stress Disorder (PTSD) was arguably messy, controversial, and confusing. For instance, it was thought that the illness was connected to other underlying disorders including epilepsy rather than traumatic experiences. Among the soldiers who suffered from PTSD, then known as shell shock, laboratory tests revealed that hysteria caused by psychical abnormality was common (Macleod, 2019). According to the restricted field consciousness theory, the mind assembles information and ideas according to the specific experiences that the body is exposed to (Gyatso, 2020). In this regard, exposure to specific disturbing experiences were likely to elicit responses that were products of extreme changes that corresponded to the nature of the stimuli (Trivedi, et al. 2020). Although shell shock was associated with traumatic experiences by soldiers, it was wrongly diagnosed as fear of war, and feebleness (Stone, 2018). However, in reality, a significant number of brave soldiers suffered from shell shock. Consequently, soldiers’ health significantly deteriorated because they did not receive the right emotional and psychiatric interventions that would improve their emotional and mental wellbeing.
In 1914, a British doctor Albert Wilson, asserted that soldiers who suffered from Shell Shock would not be tended to by psychiatrists. His rationale was that the soldier patients who were crying like children and mentally disturbed would recover after receiving treatment for their physical injuries (Macleod, 2019). Moreover, the doctor argued that their brave colleagues would increase their motivation and give them courage to overcome the spirit of fear that affected their metal wellbeing. However, it became apparent that mental intervention was necessary since the symptoms shown by the soldiers did not change even after being discharged from the hospital (Macleod, 2019). Since even unwounded soldiers experienced severe hysteria, it became apparent that shell shock was caused by their experiences of seeing their colleagues hurt and killed apart from their physical injuries.
References
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Jones, E. (2012). Shell shocked. American Psychological Association, 43(6), 18.
Macleod, A. S. (2019). Shell Shock Doctors: Neuropsychiatry in the Trenches, 1914-18.
Mitchell, L. L., Frazier, P. A., & Sayer, N. A. (2020). Identity disruption and its association with
mental health among veterans with reintegration difficulty. Developmental psychology.
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Stagner, A. C. (2014). Healing the soldier, restoring the nation: representations of shell shock in
the USA during and after the First World War. Journal of Contemporary History, 49(2), 255-274.
Stone, M. (2018). Shellshock and the psychologists. In The anatomy of madness (pp. 242-271). Routledge.
Trivedi, R. B., Post, E. P., Piegari, R., Simonetti, J., Boyko, E. J., Asch, S. M., … & Maynard, C. (2020). Mortality among Veterans with major mental illnesses seen in primary care: results of a national study of Veteran deaths. Journal of general internal medicine, 35(1), 112-118. DOI: https://doi.org/10.1007/s11606-019-05307-w
Vance, M. C., & Howell, J. D. (2020, September). Shell Shock and PTSD: A Tale of Two
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