Featured article: Shell shock by Paul Jenkins

100 years on the experience of shell shock still has something to

tell us about how we respond to mental distress

paul-nash-the-menin-roadIn the autumn of 1914 the British army, began to see a worrying flood of psychological casualties in the wake of the new horrors of trench warfare in Northern France and Flanders. 100 years after the coining of the term “shell shock”, the image of soldiers reduced to shivering and hysterical wrecks remains one of the most haunting aspects of the Great War. Furthermore, many of the lessons of the mass psychological distress generated by the War and the efforts to deal with it are still highly relevant to our understanding of and response to mental illness today.

No doubt the First World War was not the first conflict to generate psychological casualties. Sophocles describes the Greek hero Ajax, descending into psychosis at the siege of Troy. The Americans were aware during the Civil War of those whose nerves had been shot to pieces by the strain of battle. It was the scale of the First World War, however, both in terms of the number of combatants, the brutality of the armaments and the size and relative sophistication of the medical apparatus put in place to manage casualties of all kinds which made it such a dominant issue in this conflict.

It is hard to put a precise level on the numbers affected. In part this is because there were deliberate attempts at times in the war to manipulate the diagnosis to better manage the military implications. Some numbers, however, illustrate the scale. 24,000 British soldiers sent back to England in the year to April 1916, 110,000 German soldiers passing through field hospitals with mental health problems in the first year of the War.

In terms of longer impact 120,000 individuals in Britain had by 1939 been awarded a pension on the ground of a primary psychiatric disability, 15% of all pensions awarded for disability. This is probably an underestimate of the scale of the problem given the enormous efforts of the authorities in many cases to avoid their responsibilities for psychological casualties. 44,000 more received pensions for “Soldiers’ Heart” or “Effort Syndrome”, medically unexplained symptoms with a fundamentally psychological origin.

It was rapidly recognised that the term “shell shock”, despite the evocative image it conveys, was a misnomer. Only a small minority of casualties were a direct and immediate impact of being caught under fire. For some the trauma of seeing colleagues and friends killed was the trigger.   Many were the victims of acute exhaustion. For some the strain of the war reawakened pre-existing mental health symptoms. Shell shock affected all classes with 1 in 6 psychiatric casualties being officers.

Shell shock made issues around mental health and psychological distress visible in a society which had been used to keeping them firmly out of view in the country’s asylums and private hospitals. It challenged the predominant orthodoxy which equated mental illness with an underlying genetic weakness or mental deficiency and removed a level of the deep stigma which surrounded mental health issues. Amongst the horrors of full scale industrial warfare, experienced at first hand by so many, it was clear that anyone under sufficient strain could crack. Such a view of the universality of the risk of mental distress remains a powerful route to changing attitudes towards mental illness.

Like other mental health problems individuals could show individual and collective resilience. Well led units tended to have lower levels of psychological casualties than those with poor morale. Good officers could spot men who were on the brink of a breakdown and ensure they were taken out of the front line.

Verdun French deadThe scale and horror of shell shock demanded action to address the problem. By 1918 20 specialist hospitals for the longer term victims of shell shock had been established and a series of forward treatment centres had been established. A number of humane and impressive practitioners emerged such as Charles Myers (credited with bring the term shell shock into the official medical canon), Ronald Rows the Medical Superintendent of Maghull Hospital and William Rivers, remembered for his treatment at Craiglockhart Hospital of Siegfried Sassoon.

But harsher and more brutal voices also abounded. However beyond the power of the individual to control, shellshock still represented a desire to escape the horrors of the battlefield. Some Generals and doctors were quick to push back the boundary between genuine medical symptoms and malingering. At Passchendaele in 1917 it was decided that doctors alone could not determine a diagnosis of shell shock. Others were quick to promote dramatic therapies based on the use of electric shocks or “forcible persuasion”.   In Germany psychiatrists, maligned amongst soldier activists, became targets of the brief November Revolution in 1918 on account of the brutality of their methods. Finally during the First World War the British army executed 307 of its own soldiers for cowardice and other military offences. Until the end of the War there was no systematic approach to assessing the medical condition of the accused. Some of those shot were psychological casualties.

Some of the saddest stories surrounding shell shock come from after the War. While many recovered sufficiently to return to normal civilian life others lived on with dreadful and debilitating symptoms. Some disappeared into the county asylums as specialist provision was discontinued, perhaps, if they were lucky, preserving some small badges of status in terms of wearing suits rather the uniforms worn by the other patients. Some were able to work, others not, often fighting an ongoing battle with the Ministry of Pensions, then as now producing all the tricks of the bureaucratic trade to limit its obligations. This was not “a land fit for heroes.”

So 100 years ago the phenomenon of shell shock brought mental health to the front of public attention and for a while captured a sense of genuine sympathy and support for those affected. It helped cast a spot light on the totally inadequate state of provision for people with mental illness and encouraged the development of new more humane forms of treatment based on talking therapies. My own organisation, the Tavistock Clinic, was born in 1920 out of the belief of some of those who had been involved in the treatment of shell shock that better care could be provided in the community.

A lot of that sense of optimism faded as the immediate experiences of the war were forgotten and as the pressure of another age of austerity beat down on any attempt to provide a more generous and effective system of provision. In 2014 we live in another age where mental health problems are again coming to the fore and where more generous and less stigmatising attitudes towards those affected are developing. Let’s make sure we take full note of the experience of those heroes who, 100 years ago, bore the scars of battle in their minds.

In his working life Paul Jenkins is Chief Executive of the Tavistock and Portman NHS Foundation Trust.

You can find his blog at http://ybrumro.wordpress.com/

You can follow Paul on Twitter @PaulJThinks


One thought on “Featured article: Shell shock by Paul Jenkins

  1. Thanks Paul. I think the lessons of WW1 are still just as important today as they were in 1914-18.

    Thanks for sharing.

    Lest we forget!.

    Stuart (Ed)

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