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  Proximity — or forward treatment — and expectancy are the principles developed to overcome the paradox of evacuation syndrome. These concepts, which have proved themselves quite effective since World War I, involve (1) treatment of the psychiatric casualty as far forward on the battlefield as possible — that is, in the closest possible proximity to the battlefield, often still inside enemy artillery range — and (2) constant communication to the casualty by leadership and medical personnel of their expectancy that he will be rejoining his comrades in the front line as soon as possible. These two factors permit the psychiatric casualty to get the much-needed rest that is the only current cure for his problem, while not giving a message to still-healthy comrades that psychiatric casualty is a ticket off of the battlefield.

  Limited chemical treatments have been used in recent years to assist in the recovery process. According to Watson, "the so-called truth drugs have also been used near the front line to 'abreact'

  soldiers who are shell-shocked." Such drugs have reportedly been used with some success by the Israelis to induce psychiatric casualties to "talk through the circumstances leading to their reaction, an activity which appears to prevent their fears being 'bottled up'

  and so causing some other, long-term syndrome."

  But the use of chemicals in combat may not be quite so benign in the future. Gabriel, a retired intelligence officer and consultant to both the House and Senate Armed Services Committees, provides a chilling note on the future of the treatment and prevention of combat psychiatric casualties. He believes that the armed forces of both the West and the East are searching for a chemical answer to this problem. Gabriel warns that the perfection of a "nondepleting neurotrop" to be given to soldiers prior to battle would result in

  "armies of sociopaths."

  Gabriel concludes from his research that "one can but marvel at the inventiveness of the human psyche in its efforts to escape its surrounding horror." Similarly, we must marvel at the 50 KILLING AND COMBAT TRAUMA

  inventiveness of modern armies and nations in their efforts to ensure that they get full value from their soldiers. And we cannot help but come away with an image of war as one of the most horrifying and traumatic acts a human being can participate in. War is an environment that will psychologically debilitate 98 percent of all who participate in it for any length of time. And the 2 percent who are not driven insane by war appear to have already been insane — aggressive psychopaths — before coming to the battlefield.

  Chapter Two

  The Reign of Fear

  If I had time and anything like your ability to study war, I think I should concentrate almost entirely on the "actualities of war" —

  the effects of tiredness, hunger, fear, lack of sleep, weather. . . .

  The principles of strategy and tactics, and the logistics of war are really absurdly simple: it is the actualities that make war so complicated and so difficult, and are usually so neglected by historians.

  — Field Marshal Lord Wavell, in a letter to Liddell Hart What goes on in the mind of a soldier in combat? What are the emotional reactions and underlying processes that cause the vast majority of those who survive sustained combat to ultimately slip into insanity?

  Let us use a model as a framework for the understanding and study of psychiatric casualty causation, a metaphorical model representing and integrating the factors of fear, exhaustion, guilt and horror, hate, fortitude, and killing. Each of these factors will be examined and then integrated into the overall model to present a detailed understanding of the combat soldier's psychological and physiological state.

  T h e first of these factors is Fear.

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  Research and the Reign of Fear

  A variety of past investigators came up with an overly simplistic — yet widely accepted — explanation for psychiatric casualties when they declared that the cause of most trauma in war is the fear of death and injury. In 1946 Appel and Beebe held that the key to understanding the psychiatric problems of combat soldiers was the simple fact that the danger of being killed or maimed imposed a strain so great that it caused men to break down. And Watson, a London Times journalist who made a multiyear study of the application of psychology and psychiatry to war, concludes in his book War on the Mind that "combat stress, with its real fear of death, is quite different from other kinds of stress."

  But clinical studies that tried to demonstrate that fear of death and injury are responsible for psychiatric casualties have been consistently unsuccessful. An example of such a study is Mitchell Berkun's 1958 research into the nature of psychiatric breakdown in combat. Berkun began with a concern for "the role played by fear, that, is by a concern about possible death or injury in the response to adverse environments." In one of his experiments soldiers on board a military transport aircraft were told that their pilot would soon be forced to crash-land the plane. The men put through the controversial — and by today's standards unethical — fear-provoking situations in these Human Resources Research Office tests were then given "long psychiatric interviews before and after and again weeks later to see whether there were any hidden effects. None were found."

  The Israeli military psychologist Ben Shalit asked Israeli soldiers immediately after combat what most frightened them. The answer that he expected was "loss of life" or "injury and abandonment in the field." He was therefore surprised to discover the low emphasis on fear of bodily harm and death, and the great emphasis on "letting others down."

  Shalit conducted a similar survey of Swedish peacekeeping forces who had not had combat experience. In this instance he received the expected answer of "death and injury" as the "most frightening factor in battle. His conclusion was that combat experience decreases fear of death or injury.

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  In both the Berkun and Shalit studies we see indications that fear of death and injury is not the primary cause of psychiatric casualties on the battlefield. Indeed, Shalit found that even in the face of a society and culture that tell the soldiers that selfish fear of death and injury should be their primary concern, it is instead the fear of not being able to meet the terrible obligations of combat that weighs most heavily on the minds of combat soldiers.

  One of the reasons that fear may have been generally accepted as the major explanation for combat stress is that it has become socially acceptable. H o w many times have we heard in movies and on television that only fools are not afraid? Such acceptance of fear is a part of modern culture. But we still tend to carefully avoid any examination of what kind of fear — fear of death, injury, failure, and so on.

  During World War II the U.S. Army intentionally built a permissive attitude toward fear, and Stouffer's landmark World War II studies of 1949 show that men w h o exhibited controlled fear were not generally poorly regarded by their peers. Indeed, during World War II, in a widely distributed pamphlet entitled Army Life, the U.S. Army told its soldiers: " Y O U ' L L BE S C A R E D . Sure you'll be scared. Before you go into batlle you'll be frightened at the uncertainty, at the thought of being killed." A statistician would call that biasing the sample.

  Research in this field has been that of blind men groping at the elephant — one grasps what he thinks is a tree, another finds a wall, and still another discovers a snake. All have a piece of the puzzle, a piece of the truth, but none is completely correct.

  There is within us the need to say what is socially acceptable, and like blind men groping at some vast beast, we tend to report that aspect of its anatomy that we already expect to find, and we reject those manifestations with which we feel uncomfortable. The supplied, accepted, comfortable name for this beast is "fear."

  And few people are comfortable when dealing with such powerful alternative explanations as guilt. Fear is a specific yet brief and fleeting emotion that lies within the individual, but guilt is often long term and can belong to the society as a whole. W h e n we are faced with hard questions and the d
ifficult task of introspection, 54 KILLING AND C O M B A T T R A U M A

  it is very easy to avoid the truth and give the socially acceptable answers that war literature, Hollywood films, and scientific literature tell us we should give.

  Fear's Place in the Soldier's D i l e m m a Fear of death and injury is not the only, or even the major, cause of psychiatric casualties in combat. That is not to say that there is not some wisdom in this common understanding of battle, but the whole truth is far more complex and horrible. This is also not to suggest that the carnage and death of battle are not horrible and that the fear of violent death and injury is not a traumatic thing. These factors by themselves, however, are not sufficient to cause the mass exodus of psychiatric casualties found on the modern battlefield.

  There are deeper underlying causes for the psychiatric casualties suffered by soldiers in combat. Resistance to overt aggressive confrontation, in addition to the fear of death and injury, is responsible for much of the trauma and stress on the battlefield. Thus, the Reign of Fear is represented as only one contributing factor in the soldier's dilemma. Fear, combined with exhaustion, hate, horror, and the irreconcilable task of balancing these with the need to kill, eventually drives the soldier so deeply into a mire of guilt and horror that he tips over the brink into that region that we call insanity. Indeed, fear may be one of the least important of these factors.

  Ending the Reign of Fear

  Nonkillers are frequently exposed to the same brutal conditions as killers, conditions that cause fear, but they do not become psychiatric casualties. In most circumstances in which nonkillers are faced with the threat of death and injury in war, the instances of psychiatric casualties are notably absent. These circumstances include civilian victims of strategic bombing attacks, civilians and prisoners of war under artillery fire and bombings, sailors on board T H E R E I G N O F FEAR

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  ship during combat, soldiers on reconnaissance missions behind enemy lines, medical personnel, and officers in combat.

  Fear and Civilian Victims of Bombing Attacks The Italian infantry officer Giulio Douhet became the world's first recognized airpower theoretician with the publication of his book Command of the Air in 1921. Douhet declared, " T h e disintegration of nations [which] in the last war was brought about by [attrition]

  will be accomplished directly by . . . aerial forces."

  Prior to World War II, psychologists and military theoreticians such as Douhet predicted that mass bombing of cities would create the same degree of psychological trauma seen on the battlefield in World War I. During World War I the probability of a soldier becoming a psychiatric casualty was greater than that of his being killed by enemy fire. As a result of this, authorities envisioned vast numbers of "gibbering lunatics" being driven from their cities by a rain of bombs. Among civilians the impact was projected to be even worse than that seen in combat. W h e n the horror of war touched women, children, and the elderly, rather than trained and carefully selected soldiers, the psychological impact was sure to be too great, and even more civilians than soldiers were expected to snap.

  This body of theory, established by D o u h e t and later echoed by many other authorities, played a key role in establishing the theoretical foundation for the German attempt to bomb Britain into submission at the beginning of World War II and the subsequent Allied attempt to do the same to Germany. This strategic bombing of population centers was motivated by quite reasonable expectations of mass psychiatric casualties resulting from the strategic bombing of civilian populations.

  But they were wrong.

  T h e carnage and destruction, and the fear of death and injury caused by the months of continuous blitz in England during World War II were as bad as anything faced by any frontline soldier.

  Relatives and friends were mutilated and killed, but in a strange sort of way, that was not the worst of it. These civilians suffered 56

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  one indignity that most soldiers need never face. In 1942, Lord Cherwell wrote: "Investigation seems to show that having one's house demolished is most damaging to morale. People seem to mind it more than having their friends or even relatives killed."

  For the Germans it was worse. The might of the vast British Empire was brought to bear on the German population via Britain's nighttime area bombing. At the same time, the United States devoted its efforts to "precision" daylight bombing. Day and night for months, even years, the German people suffered horribly.

  During the months of firebombings and carpet bombings the German population experienced the distilled essence of the death and injury suffered in combat. They endured fear and horror on a magnitude such as few will ever live to see. This Reign of Fear and horror unleashed among civilians is exactly what most experts hold responsible for the tremendous percentages of psychiatric casualties suffered by soldiers in battle.

  And yet, incredibly, the incidence of psychiatric casualties among these individuals was very similar to that of peacetime. There were no incidents of mass psychiatric casualties. The Rand Corporation study of the psychological impact of air raids, published in 1949, found that there was only a very slight increase in the "more or less long-term" psychological disorders as compared with peacetime rates. And those that did appear seemed to "occur primarily among already predisposed persons." Indeed, bombing seemed to have served primarily to harden the hearts and empower the killing ability of those who endured it.

  When faced with the failure of their predictions, postwar psychologists and psychiatrists scrambled to find a reason for the obstinate failure of the populations of Germany and England to become mass psychiatric casualties in response to strategic bombing.

  They finally used the theory of gain through illness as a model to explain what had occurred. This held that these individuals failed to become "ill" because they simply had nothing to gain by doing so.

  The theory of gain through illness, however, fails for two reasons: soldiers in combat will become psychiatric casualties even when T H E R E I G N O F F E A R

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  they have nothing to gain by doing so — such is the nature of insanity — and second, these individuals did have much to gain by "letting slip the bonds of reality" and escaping into the country-side, or better yet escaping to the psychiatric clinics that were usually located far from the targets of strategic bombing.

  Fear and Prisoners of War as Artillery and Bombing Victims Gabriel notes that studies from both the First and Second World Wars show that prisoners of war did not suffer psychiatric reactions when they were subjected to artillery attack or aerial bombardment, but their guards did. Here we see a situation in which noncombatants (prisoners) were not traumatized by death and destruction, while the combatants (guards) with them were. T h e theory of gain through illness has been applied to explain this disparity; that is, the guards could gain by becoming psychiatric casualties and departing to the nearest psychiatric clearing station, while the prisoners had nothing to gain and nowhere to go, so they elected not to become psychiatric casualties. But this theory does not bear up under careful scrutiny.

  Soldiers w h o are surrounded and without cover will flee from battle, even when they have nothing to gain by doing so. An excellent example of this can be seen in one of Custer's cavalry units, which was cut off and surrounded by the Indians for two days before being rescued. (Yes, some of Custer's 7th Cavalry, at a different location under the command of Major R e n o , did survive the Little Big Horn. Only the ones with Custer were all killed.) According to Gabriel many of these soldiers, pretending to be ill or wounded, left their defensive positions for the medical station, even though it offered no protection. Indeed, the medical station was exposed to hostile fire and was very possibly less safe than positions on the perimeter. This example makes an important point about gain through illness: combatants will try to get out of the battle (a situation where they are required to kill) even when it puts them at risk.

  Gabriel discards the
gain-through-illness explanation in the case of prisoners of war (POWs) and guards receiving artillery fire 58

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  or bombardment. He comes much closer to a more plausible explanation when he states that the prisoners "had shifted responsibility for their survival to the guards." T h e prisoners had indeed relinquished responsibility to their guards: responsibility for survival and responsibility for killing.

  T h e prisoners were unarmed, impotent, and strangely at peace with their lot in life. They had no personal capacity or responsibility to kill, and they had no reason to believe that the incoming artillery or bombs were a personal matter. T h e guards, on the other hand, took the matter as a personal affront. They still had a capacity and a responsibility to fight, and they were faced with the irrefutable evidence that someone was intent on killing them and that they had a responsibility to do likewise. T h e psychiatric casualties among the guards — as among most other soldiers in the same circumstances — represented an accepted method of escape from the unbearable responsibility inherent in their roles as soldiers.

  Fear and Sailors in Naval Combat

  For thousands of years naval battles involved missile combat (bow and arrows, ballista, cannons, and so on) at extremely close range, followed by grappling, boarding, and vicious life-or-death, close-in battle with no way to escape. T h e history of such naval warfare — like that of ground combat — provides many examples of psychiatric casualties resulting from this kind of combat. In its emotional demands naval warfare was very much like its land-based equivalent.

  But in the twentieth century, psychiatric casualties during naval warfare have been nearly nonexistent. The great military physician Lord Moran noted the remarkable absence of psychological illness among the men he ministered to aboard ships in World War II.