From Library Journal
Shephard's ambitious study, bolstered by an impressive array of sources diaries, medical case studies, patient interviews, official publications, and physician reports chronicles military psychiatry in the 20th century. It begins at the chronological intersection of modern warfare and psychological medicine during the Great War and examines this troubled marriage through the periods of shell-shock (World War I), combat fatigue (World War II), and post-traumatic stress disorder (Vietnam, Falkland campaign, and the Gulf War). Shephard melds contemporary literary, military, and medical documentation by offering a panorama of war neuroses with conflicting schools of treatment. He suggests qualified answers as to why combatants react differently to stress and discusses the appropriate roles and investments of the military, government, and society in the rehabilitation of those psychologically crippled by war. The author, a former producer of "The World at War" series, concludes that perhaps "military psychiatry is often done best not by psychiatrists but by doctors, officers, or soldiers who understand the principles of group psychology and use the defenses in culture to help people through traumatic situations." This fine study should appeal to all readers. Recommended for psychology, psychiatry, and medical history collections, as well as for large public and academic libraries. John Carver Edwards, Univ. of Georgia Lib., Athens
Copyright 2001 Reed Business Information, Inc.
--This text refers to an out of print or unavailable edition of this title.
From The New England Journal of Medicine
I knew from the quality of the writing and scholarship in the initial chapters of this book that it would be a pleasure to read, but I also realized it would be a challenge to review the book because of its scope and detail and the controversy the author provokes. Shephard begins, ``There is a compelling reason to take a much wider look at what has happened in the past: we are making a mess of this problem today and need to learn the lesson that, in treating the aftermath of war, good intentions are not enough.'' Shephard is a British writer who has produced historical and scientific documentaries for the BBC, including parts of the excellent series The World at War. Here he vividly presents the attempts of psychiatrists, neurologists, and psychologists who helped the military and civilian society treat or prevent the psychological breakdown of service members exposed to the horrors of war. The book focuses on Britain and America in World Wars I and II, then skips to a cursory look at America's Vietnam War and its fallout up to the 1990s (with only a brief commentary on Korea). Shephard briefly covers the Falklands campaign and the Gulf War with its persistent ``syndromes.'' French and German problems and practices in the world wars provide short but informative contrasts.
Shephard conveys the grim realities of war in striking vignettes of service members and patients. He captures concisely the personae of the shapers and movers of military psychiatry, including the few, such as Dr. William Rivers of World War I fame, who are known to general readers through literature or films. The book provides a fascinating account of the interplay of competing ambitions, clinical styles and interests, personal and institutional prejudices, and public opinion. Shephard succeeds in linking the ``undoubted successes and numerous disasters'' of military psychiatry with wider societal expectations and military and medical practices as they changed during the 20th century.
One disaster was the U.S. screening program in the initial years of World War II. Shephard's account left me simultaneously laughing and appalled, and I remembered the sad patient I had seen as a resident in 1968 whose thick chart for ``inadequate personality disorder'' began when he was rejected for military service because he was unable to urinate if others were watching. Alas, Shephard does not cite later observations and studies indicating that soldiers with substantial psychopathology could function well and even heroically in units with good leadership and comradeship. One provocative theme is the cultural shift from the traditionally Victorian masculine virtues of courage and self-denial of emotional expression in the service of duty (what used to be meant by ``showing nerve'') to the traditionally female virtues of free emotional expression and the giving and seeking of sympathy and care (which could lead to a pathologic ``case of nerves'' or ``nervous breakdown''). This theme culminates in the chapters, ``From Post-Vietnam Syndrome to PTSD'' and ``The Culture of Trauma,'' which will arouse anger in some readers and will reinforce the blind prejudice of others but should be read carefully and thoughtfully by all.
Shephard acknowledges the real suffering of many veterans and the honorable intentions of those who created the diagnostic label and criteria for post-traumatic stress disorder and championed treatment and compensation programs for it. His sharp critique is founded on experience during and after the world wars. We have seen similar syndromes before, made similar mistakes, and have sometimes done better. We should also determine why many of the veterans with the worst histories of exposure do well without treatment.
Shephard disproves many persistent myths that I hope will be dispelled by widespread reading of his book. He presents hard-learned lessons that are in perpetual danger of being forgotten. Shephard illuminates the struggles of the ``tough realist'' clinicians, in whose path I respectfully follow. In World War I and then starting from scratch again in World War II, the realists worked increasingly close to the battle, trying different but simple techniques to return many overstressed soldiers to duty in a period of hours to days. Those soldiers would have become psychologically disabled if they had been evacuated. The best realist clinicians educated unit leaders, general medical personnel, and chaplains to reduce the psychological and physiologic causes of stress-induced breakdown and to restore many stressed soldiers in their units, not in medical cots. I wish Shephard had included more historical details of that endeavor.
The focus of 21st-century combat and operational behavioral health (``stress control'') is on primary and early secondary prevention at the unit and community levels. The same should be true of civilian programs of community mental health and management of psychological trauma, which grew out of the military experience. Better preventive interventions can greatly reduce the need for tertiary treatment of chronic cases far to the rear of combat or after the war. Shephard describes the many approaches to tertiary treatment masterfully, as he does numerous other topics of public interest.
I hope the public response to A War of Nerves will encourage Shephard to finish writing the saga of post-World War II military psychiatry (behavioral health). I know he can find more gold by panning deeper in streams he has just skimmed in this book, by exploring the well-studied Israeli experience, and by addressing the special problems of ``peace-keeping'' missions. Shephard's account of the first half of the saga is a masterpiece, but the second half remains to be told.
James W. Stokes, M.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
--This text refers to an out of print or unavailable edition of this title.
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