War in the Mind

by Eric T. Dean Jr.

REVIEWERS of historical works overuse the adjective "revisionist" to the point that it has become a cliché. In this case, however, the adjective is doubly merited. Shook Over Hell is genuinely revisionist on two fronts: it changes our understanding of psychiatric casualties in both the Vietnam War and the Civil War; and it does so not by sleight of hand, redefining terms while leaving the substance unchanged, but by solid research, sound analysis, and lucid (if at times repetitious) writing.

Eric Dean first challenges the myth of the troubled and scorned Vietnam veteran. The myth goes something like this: Sent to fight a dirty and unwinnable war, whose purpose they never understood, against an enemy they rarely saw in menacing jungles and rice paddies, amid a civilian population that hated and betrayed them, American soldiers in Vietnam turned to drugs and "fragging" and returned to a nation that scorned and spit upon them. As a consequence, many of these veterans formed a pathological subculture of unemployed addicts, criminals, and underachieving misfits who suffered from post-traumatic stress disorder and astronomical suicide rates. These experiences contrasted sharply with those of veterans of other American wars, who came home to victory parades, the GI Bill, and other kinds of preferential treatment, and who therefore readjusted quickly to civilian life with few psychiatric complications.

Dean convincingly demolishes every part of this myth. Citing numerous surveys and studies, he demonstrates that in the 1970s and 1980s Vietnam veterans had higher median incomes than their nonveteran peers and were unemployed at the same rate, had similar rates of drug use and addiction, and, in percentage terms, used more GI Bill benefits to attend college than had veterans of the Second World War. Wildly inflated estimates that 60,000, 100,000, or even 159,000 Vietnam veterans have committed suicide (six to sixteen times the rate for a comparable civilian group) are replaced by careful studies concluding that 9,000 veterans had taken their own lives by the early 1980s, at a suicide rate similar to that among civilians. As for psychiatric casualties during the war itself, twelve cases were diagnosed per thousand in Vietnam, as compared with thirty-seven per thousand in Korea and twenty-eight to 101 per thousand (depending on assignment) in the Second World War. Perhaps this is not surprising, given that fewer than 15 percent of U.S. troops in Vietnam served in combat units; the rest were in support, supply, and medical services.

But what about post-traumatic stress disorder (PTSD)? Have not Vietnam veterans suffered an extraordinarily high rate of such delayed reactions in the form of nightmares, flashbacks, survivor guilt, sleeplessness, depression, startle reactions, stuttering, loss of energy and sexual desire, and other dysfunctional behavior years after the horrors these men experienced in Vietnam? PTSD emerged as an officially recognized psychiatric syndrome in 1980, when the American Psychiatric Association listed it in the Diagnostic and Statistical Manual. PTSD represented a refinement of what had been known as shell shock in the First World War and as battle fatigue or combat stress reaction or, more generally, psychiatric casualties in the Second World War. PTSD differs from some of these in part because it focuses on the delayed trauma of combat, which may not manifest itself fully until months or years after the event.

The category "PTSD" developed from efforts to understand certain behavior patterns that occurred among Vietnam veterans. Dean makes it clear that diagnoses of PTSD gained a life of their own: once the category had been recognized, it was applied to all sorts of behaviors not previously considered exceptional. PTSD has now become a fad. Dean quotes numerous examples of this phenomenon: some professional football players are said to have "developed post-traumatic stress disorders comparable to those experienced by some Vietnam veterans"; during the agricultural depression of the 1980s mental-health workers said that "psychologically rural Iowa resembles a Vietnam veteran with post-traumatic stress disorder"; teenagers pressed to overachieve by their "hothouse style of upbringing are now suffering post-traumatic stress syndrome like Vietnam veterans." The Defense Department jumped on the bandwagon, attributing the mysterious ailments suffered by some veterans of the Gulf War to PTSD instead of to exposure to Iraqi chemicals, which may be responsible. A backlash against the PTSD fad inevitably emerged. One veteran spoke out bitterly against the "ludicrous blubbering and psychobabble" about the Vietnam veteran as a misfit and a loser. A jaded film critic assigned to write a review of yet another Vietnam movie declared, "So familiar has this story become that I have started to think of it as a brand new film genre -- the PTSD (Post-Traumatic Stress Disorder) genre."

Dean pulls no punches in his analysis of this fad as a consequence of political and social agendas advanced by Robert Jay Lifton and other anti-war psychiatrists, who used the myth of the psychologically crippled veteran to discredit the war; by right-wing patriots, who (paradoxically) used the same myth in their argument that American soldiers were frustrated by restraints from Washington that prevented them from winning a war they could have won; and by veterans' organizations, which lobbied for more government assistance "to entrench and extend their already extensive benefit package." Dean also offers caustic commentary on the quest for "acquisition of power and influence by the psychiatric profession," which has

a track record of advancing diagnostic categories that lack clear underlying unity based on scientific evidence, but that, nonetheless, have the effect of responding to popular needs and aggrandizing the power and authority of mental health professionals.

EVEN though Dean discusses the possibility that PTSD is "a grab-bag of symptoms" rather than "a distinct psychiatric disorder," the core of this book is an application of the PTSD concept to Civil War soldiers. Part of the myth of the scorned and troubled Vietnam veteran is the implied contrast between his postwar treatment by a hostile or indifferent society and the hero's welcome given veterans of other wars. Although many studies of Civil War soldiers have appeared in recent years, they have focused mainly on the wartime experiences of these men; their postwar history has been relatively neglected. Union veterans returned home as victors, celebrated by parades and official receptions. Confederate veterans did not have this solace, but the romanticization of their heroic courage and pure devotion to a sanctified though doomed Lost Cause fulfilled the same cathartic function. Dean writes, "A reexamination of the Civil War veteran through the lens of the Vietnam experience promises new perspectives and challenges, regarding ... the assumption that Civil War veterans readjusted well after their war."

The combat experience of Civil War soldiers was more intensive and prolonged than that of American soldiers in Vietnam. The actual number of American soldiers was the same in both wars: three million. This represented nearly 10 percent of the U.S. population in 1861, as against 1.5 percent of the population in 1970. The number of American dead in the Civil War was 620,000; in Vietnam it was 58,000. In proportion to the population, the death rate was sixty-nine times as great in the Civil War as it was in Vietnam. The ratio of combat to support troops in Vietnam was one to seven; it was almost the reverse in the Civil War. Some 35 percent of Civil War soldiers were killed or wounded, as compared with 5.5 percent of U.S. soldiers in Vietnam. There was no helicopter evacuation of the wounded and no antibiotics or antiseptic medicines in the Civil War. The physical hardships endured by Civil War soldiers would have been almost inconceivable to an American in Vietnam.

In view of these facts, Dean is quite right to hypothesize a high incidence of psychiatric casualties during the Civil War and of what we now call PTSD afterward. The problem in identifying these phenomena is that Civil War medicine had no term or concept to describe them. But observations by surgeons, officers, and soldiers themselves make clear the frequency of psychiatric casualties, which were all too often officially regarded as cowardice or malingering. Nevertheless, diagnoses of "insanity," "homesickness," "melancholy," "acute mania," "dementia," "nostalgia," "irritable heart," and even "sunstroke" offer hints of an effort to identify and understand these casualties. Dean also presents evidence of a higher post-Civil War crime rate among veterans than among nonveterans, of nightmares and flashback recollections, of disorderly behavior, and of suicide (though data to compare veteran and nonveteran suicide rates do not exist).

Dean's research in Civil War letters and memoirs, postwar newspapers, and pension files was thorough and exhaustive. It has yielded more information about the mental health of Union veterans than historians had previously realized was available. (Comparable sources for Confederate veterans are much thinner or nonexistent.) The most original and important feature of this book is Dean's analysis of 291 case studies of Civil War veterans committed to the Indiana Hospital for the Insane. Most of them exhibited symptoms that would today be diagnosed as PTSD. The inquest record for one such inmate, Jason Roberts, supplied the title for this book:

Says he has been shook over hell.... Sometimes he is raving and excited, at others melancholy ... Very peculiar and excentric. flying from one Subject to another, and talking incoherently on all Subjects, ... The subject of religion and his experiences in the army being paramount in his mind ... [he] thinks all his enemies should be in hell.

The amount of effort and patience required to match these asylum inmates with their combat experiences is awe-inspiring. Yet a caveat is in order. Does Dean ask the right questions about this sample?

Is the Indiana Sample of 291 men representative of Civil War veterans in Indiana or elsewhere? Can the problems of the men in this sample be generalized to a significant proportion of the approximately 180,000 [actually 135,000] Indiana veterans or the 1.9 million Union veterans?

The answers would seem to be obvious: men committed to a hospital for the insane are by definition not representative, and their problems cannot be generalized.

Having put so many hundreds of hours of research into this sample, however, Dean wants it to bear more weight than it possibly can. He acknowledges that the regiments to which these 291 men belonged had higher than average casualties from both disease and combat, but "the most salient point about the Indiana Sample is how close to average it seems in so many other respects." He continues, "One is tempted therefore to think that the problems of the Indiana Sample could not have been atypical." This is sloppy thinking. The question is not whether these men and the units to which they belonged were representative in a variety of objective criteria -- age, occupation, ethnicity, length and theater of service, number of battles, and so forth -- but whether their psychiatric problems were typical or representative of the personalities of the more than 99 percent of Civil War veterans who were never committed to an asylum. To suggest otherwise exposes Dean to the same charge of inflating the psychiatric casualties and PTSD of Civil War veterans that he has so effectively proved against superficial students of Vietnam veterans.

The Atlantic Monthly; March 1998; War in the Mind; Volume 281, No. 3; pages 110 - 112.