Psychiatric Casualties in War - Lieutenant Colonel Dave Grossman, Author

"Psychological Effects of Combat"

Psychiatric Casualties in War

Richard Gabriel has noted that: "Nations customarily measure the 'costs of war' in dollars, lost production, or the number of soldiers killed or wounded." But, "rarely do military establishments attempt to measure the costs of war in terms of individual suffering. Psychiatric breakdown remains one of the most costly items of war when expressed in human terms." Indeed, for the combatants in every major war fought in this century, there has been a greater probability of becoming a psychiatric casualty than of being killed by enemy fire.

A psychiatric casualty is a combatant who is no longer able to participate in combat due to mental (as opposed to physical) debilitation. Psychiatric casualties seldom represent a permanent debilitation, and with proper care they can be rotated back into the line. (However, Israeli research has demonstrated that, after combat, psychiatric casualties are strongly predisposed toward the more long-term and more permanently debilitating manifestation of Post-Traumatic Stress Disorder.)

The actual casualty can manifest itself in many ways, ranging from affective disorders to somatoform disorders, but the treatment for the many manifestations of combat stress involves simply removing the soldier from the combat environment. But the problem is that the military does not want to simply return the psychiatric casualties to normal life, it wants to return them to combat. And these casualties are understandably reluctant to do so.

The evacuation syndrome is the paradox of combat psychiatry. A nation must care for its psychiatric casualties, since they are of no value on the battlefield (indeed, their presence in combat can have a negative impact on the morale of other combatants) and they can still be used again as valuable seasoned replacements once they have recovered from combat stress. But if combatants begin to realize that insane combatants are being evacuated, the number of psychiatric casualties will increase dramatically.

Continued proximity to the battlefield (through forward treatment, usually within enemy artillery range) combined with an "expectancy" of rapid return to combat, are the principles developed to overcome the paradox of the evacuation syndrome. These principles of proximity and expectancy have proven themselves quite effective since World War I. They permit the psychiatric casualty to get the rest that is the only current cure for his problem, while not giving a message to still healthy comrades that insanity is a ticket away from the madness of the battlefield.

But even with the careful application of the principles of proximity and expectancy the incidence of psychiatric casualties is still enormous. During World War II, 504,000 men were lost from America's combat forces due to psychiatric collapse--enough to man 50 divisions. The United States suffered this loss despite efforts to weed out those mentally and emotionally unfit for combat by classifying more than 800,000 men 4-F (unfit for military service) due to psychiatric reasons. At one point in World War II, psychiatric casualties were being discharged from the U.S. Army faster than new recruits were being drafted in.

Swank and Marchand's World War II study of US Army combatants on the beaches of Normandy found that after 60 days of continuous combat, 98% of the surviving soldiers had become psychiatric casualties. And the remaining 2% were identified as "aggressive psychopathic personalities." Thus it is not too far from the mark to observe that there is something about continuous, inescapable combat which will drive 98% of all men insane, and the other 2% were crazy when they got there. Figure 1 presents a schematic representation of the effects of continuous combat.

Variation of combat efficiency over 60 days in combat

It must be understood that the kind of continuous, protracted combat that produces such high psychiatric casualty rates is largely a product of 20th-century warfare. The Battle of Waterloo lasted only a day. Gettysburg lasted only three days--and they took the nights off. It was only in World War I that armies began to experience months of 24-hour combat and vast numbers of psychiatric casualties were first observed.

The democratic nations of this century have been better than most at admitting and dealing with their combat psychiatric casualties. Information from non-Western sources is extremely limited, but we now know that America's World War II experience is representative of the universal cost of modern, protracted warfare. Armies around the world have experienced similar mass psychiatric casualties, but many have simply driven these casualties into battle at bayonet point, shooting those who refused or were unable to continue. Japanese units in World War II employed a unique set of powerful cultural and group processes to delay psychiatric breakdown, but they only succeeded in temporarily delaying the cost of combat, a cost that eventually manifested itself in mass suicide. Ultimately the toll of modern combat is truly fearful, and no nation or culture has been able to escape it.

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