Effects of War on Soldiers Part I: History of PTSD

I have provided psychological services to war veterans for over 40 years, having started in my work with veterans in the mid-1970s. In this time, I have learned a lot about war and its effects on those involved in direct combat as well as those involved in other activities that are typically called support activities in the war zone.

This unique opportunity to not only help veterans who are affected by their wars, but also to learn about the wars, has been something that I would not trade for anything and, as I have said on many occasions, if I had a chance to redo my life I would change many things but not my opportunity to work with war veterans.

The reason for this is simple. I am one of the few males in this world whose window of time for military duty fell during a peaceful period, between 1956 when I graduated high school and 1965 when I was already married, had a family, and was in graduate school. This was the period between the end of the Korean War and the beginning of the Vietnam War. After meeting real combat soldiers and coming to understand war through their eyes, I realized and became ever grateful for the fact that I was spared from such hardship and this gave me incentive to want to give whatever service I could to the men and women who went through the hell of war. In addition, I realized that war tends to clear people of many of the typical human foibles, such as the need to impress or to worry about the reactions of others or other insignificant things in life, as well as the various aspects of pride and self-aggrandizement. I find that war veterans are among the most genuine and honest people of this world and a pleasure to meet and work with.

So, what I have learned is this: soldiers of all wars throughout time who have engaged in direct combat and survived are always significantly affected by their wars and become changed persons. Some of the changes that soldiers undergo appeared to be universal and can be predicted, and some are different and unique to the soldier. Over the years, the effects of war on soldiers have been described in varying ways, but the one consistent factor is that it creates a powerful stress on the soldier to the extent that he becomes changed for some period of time or permanently.

In World War I, the stress reaction was labeled “shell shock” and was described as an injury to the nerves. The typical treatment was to remove the soldier from his combat position to a rear hospital where he was expected to rest up, after which he was encouraged to return to his combat duties. The general attitude at the time was that such “emotional breakdowns” were a sign of weakness and should be discouraged. Because of this, not much follow-up treatment or service was made available to combat veterans, although the British government did create disability pensions for what was called “soldier’s heart” because its symptoms were somewhat similar to the symptoms of heart disorders affected by acute anxiety. A World War I correspondent wrote the following observation of war veterans:

“Something was wrong. They put on civilian clothes again and looked to their mothers and wives very much like the young men who had gone to business in the peaceful days before August 1914. But they had not come back the same men. Something had altered in them. They were subject to sudden moods, and queer tempers, fits of profound depression alternating with a restless desire for pleasure. Many were easily moved to passion where they lost control of themselves, many were bitter in their speech, violent in opinion, frightening.”  (From Shephard, Ben. A War of Nerves: Soldiers and Psychiatrists, 1914-1994. London, Jonathan Cape, 2000.)

In World War II, the same stress reaction was labeled “battle fatigue” or “war neurosis.” Medical doctors, including psychiatrist, associated with the armed services began noticing that soldier started showing symptoms of exhaustion and chronic fatigue after six months to a year in combat and this initiated the process of implementing time defined tours of duty in the war zone. However, the general attitude in most nations engaged in the war remained the same as it was during World War I and veterans still did not get proper services or encouragement to pursue them after the war.

In a comprehensive summary in Wikipedia, titled Combat Stress Reaction, several quotes reflecting national attitudes are given. American flight surgeons treating soldiers in South Pacific jungles noted:

Many have chronic dysentery or other disease, and almost all show chronic fatigue states. . . .They appear listless, unkempt, careless, and apathetic with almost mask-like facial expression. Speech is slow, thought content is poor, they complain of chronic headaches, insomnia, memory defect, feel forgotten, worry about themselves, are afraid of new assignments, have no sense of responsibility, and are hopeless about the future. (Mae Mills Link and Hubert A. Coleman, Medical support of the Army Air Forces in World War II (1955) p 851.)

In Contemporary Studies in Combat Psychiatry, (1987), a German medical doctor’s opinion of battle fatigue was described:

… he believed that there were no important problems due to stress breakdown since it was prevented by the high quality of leadership. But, he added, that if a soldier did break down and could not continue fighting, it was a leadership problem, not one for medical personnel or psychiatrists. Breakdown (he said) usually took the form of unwillingness to fight or cowardice.

Canada and Britain were more accepting of combat stress than other countries, as indicated in the quote from a Canadian historian:

“The infantry units engaged in the battle also experienced a rapid rise in the number of battle exhaustion cases with several hundred men evacuated due to the stress of combat. Regimental Medical Officers were learning that neither elaborate selection methods nor extensive training could prevent a considerable number of combat soldiers from breaking down.” (Copp, Terry “The Brigade” (Stackpole Books, 2007) p.47.)

But, the Finnish head of military medicine was not so forgiving, considering “…shell shock as a sign of weak character and lack of moral fibre. His treatment for war neurosis was simple: the patients were to be bullied and harassed until they returned to front line service.”

History clearly shows that the traumatic effects of war on soldiers were either discounted or not understood well enough to treat in any effective way. This lack of understanding and treatment continued with the Korean and post-Korean war era, and to some extent through the Vietnam and post-Vietnam war era.

Not much changed in the treatment and care of Korean War veterans because their symptoms and ailments were still viewed in the same way that the symptoms of soldiers were reviewed during World War II, and they were treated similarly. Veterans with disabling PTSD symptoms either sought out help from their local physicians and were typically treated for anxiety or depression or they kept those problems private and buried, usually with the aid of alcohol, smoking cigarettes, and continuous activities by which to avoid letting their thoughts stray to war related memories. The trauma-based symptoms of Korean War veterans were still described as battle fatigue or war neurosis, and few of these veterans sought help from their VA medical centers.

It was not until the second half of the 1970s, after the 10 year long Vietnam War was formally ended, that new attention was given to the traumatic effects of war on soldiers. It took the efforts of an anti-war group of Vietnam veterans, Vietnam Veterans Against the War, and various antiwar activists to initially name the effects of war trauma on veterans as Post-Vietnam War Syndrome. These and other Vietnam veterans who felt alienated, discounted, and misunderstood by their countrymen after returning home, refused to simply be ignored or mistreated by the government and the country. They began their own protests against poor or unsuitable treatment by the VA systems and by other governmental agencies. And, their unstoppable defiance and indignation caught the attention of our government and their agencies.

With the release of the latest issue of the Diagnostic and Statistical Manual of Mental Disorders, version III, in 1980, PTSD was finally given formal recognition as a diagnostic mental disorder category. With this new and more enhanced description of the effects of trauma on soldiers came new and more concerned and informed awareness of the soldiers problems by medical, psychiatric and psychological professionals, and subsequently a greater emphasis on and improvement of treatment methods. The VA administration responded to the pressures of Vietnam veterans by developing a parallel system of storefront psychotherapeutic clinics for war veterans that were staffed by war veterans who were trained as mental health specialists and psychologists experienced in working with veterans, and set up as places where veterans can easily go to get direct services with minimal red tape or bureaucracy. These clinics were called Vet Centers, and they became effective in attracting disenchanted Vietnam veterans to seek services in their facilities.

ASC’s first formal contract with the VA system was through the Minneapolis Vet Center to provide psychotherapeutic services to Vietnam and other war veterans.
The Minneapolis Vet Center contracted with ASC because our clinic was already providing psychological services for some of the Vietnam veteran in the Mankato area and sending many of those veterans to the Minneapolis VA Medical Center (VAMC) for additional services.

Since the development of PTSD as a diagnosis and the introduction of the Vet Centers, services to war veterans have become much more available and more credibility has been given to the seriousness of war effects on veterans. But, since about 2000, increased pressures have been placed on the VAMC’s to see more and more veterans without an equal expansion of services and with a shift in philosophy that emphasized providing all services in-house and reducing reliance on outside professional providers. This has produced the inevitable breakdowns in the system, like the waitlist problems that resulted in deaths of some veterans while they waited for services, and the falsification of statistics and outright lying by VAMC administrators.

Measures have been taken by our legislators, like Tim Walz, who are committed to improving veteran services, but problems remain in the VA system, and many veterans remain disenchanted. At this point, it looks like the best solution to the existing problem of inadequate or inferior services that are available to veterans is to create a system similar to the medicare system where veterans would have a medical card that can be used with any licensed hospital, clinic or individual provider in addition to having access to the VAMC’s.