Waking up to shell shock: psychiatry in the US military during World War II

Review Endeavour Vol.30 No.4
Waking up to shell shock: psychiatry in
the US military during World War II
Hans Pols
Unit for History and Philosophy of Science, Carslaw F07, University of Sydney, Sydney, NSW, Australia
During World War I, military officers encountered a new
and puzzling phenomenon: soldiers emerged from the
trenches stuttering, crying, trembling and at times were
even paralysed and blind. Those in charge were convinced
these soldiers were cowards or malingerers who
deserved stern discipline or to be court-martialled. A
number of physicians, by contrast, initially assumed that
these alarming symptoms resulted from close exposure
to explosions and called it shell shock. Later, they realized
that it was a psychological reaction and came up
with psychotherapeutic treatments. But it was only in
World War II that military psychiatrists, particularly
those in the USA, began to implement treatment methods
for this phenomenon in a systematic way. Their
thinking and the treatments they devised had significant
consequences for the future of American psychiatry,
which in turn influenced the development of psychiatry
and military psychiatry world-wide.
The realities of battle
During the faltering Tunisian campaign of early 1943, a 20-
year-old American sergeant and his platoon unexpectedly
found themselves under severe shell-fire. The sergeant had
already been involved in six major engagements, during
which he had held up well. This time, things turned out
differently. In a short time, almost all of his men were
wiped out by German machine gun fire. The sergeant tried
to get back to the American line, but was caught in friendly
fire. He lay flat on the ground and managed to escape
almost certain death by flinging two dead bodies, one of a
German soldier and one of a member of his own company,
over himself. As the two psychiatrists who later treated
this man for persistent anxiety described it in their book
War Neurosis, his situation was absolutely terrifying:
He lay there for a long time, trembling and
terror-stricken, until finally an artillery shell
exploded very close by and blew the two bodies off
the patient, ripping off his shirt at the same time.
The two dead soldiers had actually saved his life. His
mind at that point went blank. He wandered
about, and was picked up by some men from his
company...When he entered one of the forward hospitals
he had acute anxiety, persistent tremor, great
restlessness, loss of appetite, and insomnia with
battle dreams [1].
Corresponding author: Pols, H. (hpols@science.usyd.edu.au).
Available online 13 November 2006.
This sergeant had already been exposed to front-line
conditions on several occasions before he ended up in this
gruesome situation. However, on that occasion his mind
snapped and he was no longer able to function.
War can maim the minds of soldiers in dramatic and
unexpected ways. Witnessing fellow soldiers being killed or
mutilated, experiencing continuous threats to one’s life or
killing other soldiers and/or civilians would affect many, if
not most people. Soldiers have displayed a variety of
symptoms in the event of such psychological scarring,
including paralysis, mutism, deafness, blindness, anxiety
attacks, insomnia, confusion, amnesia, hallucinations, dizziness,
confusion states, nightmares, functional heart problems,
vomiting and intestinal disorders. Military
psychiatrists developed expertise in treating the symptoms
of shell shock during World War I, but it was in
World War II that psychotherapeutic interventions were
applied on a large scale. Since then, psychiatrists have
been involved in all the major military conflicts waged by
the Western world.
Screening and selection
The USA became involved in World War II after the attack
on Pearl Harbour on 7 December 1941. Before that date,
several psychiatrists had been discussing how they could
contribute to the war effort. They were convinced that
screening enlisted men for mental-health problems as part
of their medical checks to enter the service could weed out
not only individuals with mental illness, but also those who
were most likely to break down under the stresses of battle.
In December 1940, the psychoanalytic psychiatrist Harry
Stack Sullivan was appointed by the Selective Service
system to organize psychiatric selection for volunteers
and inductees. This, he argued, should screen out both
obvious cases of severe and persistent mental illness as
well as those individuals who had shown signs of maladjustment.
William C. Porter, a leading military psychiatrist,
stated at the time: ‘Any individual who, although not
deficient in intelligence, nevertheless has shown an inability
to adapt himself in an adult, socially-acceptable manner
to the demands of ordinary life should be regarded as a
psychopathic personality of the inadequate type and
should not be chosen for military training’ [2]. Individuals
who did not do well during peace-time could not be
expected to do well in the often stressful conditions of life
in the Armed Forces. The screening program aimed to ‘sort
into the army only that part of the population of appropriate
age who will not be broken down by any strains and
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Review Endeavour Vol.30 No.4 145
stresses they are apt to encounter’ [3]. Because screening
and selection promised to create an Army consisting of the
very best of American men, military officials heartily
approved of Sullivan’s initiatives. Up until 1944, the medical
screening program excluded 12%, or almost two million,
of the fifteen million men examined – around six times
the number excluded during World War I [4]. Of all the
men rejected for medical reasons, 37% were turned away
on neuro-psychiatric grounds [5].
At the time, US Army policy dictated that any soldier
diagnosed with mental illness during combat should be
removed from the battlefield to receive treatment in a
mental hospital at home. The psychiatrists who formulated
this policy were employed by mental hospitals and
were experienced in dealing with severe and persistent
forms of mental illness. According to them, individuals who
broke down had a predisposition to mental illness, which,
for some reason, had escaped detection during screening.
Although they assumed that the stresses of warfare
encouraged these conditions to come to the surface, they
were ultimately not their cause. The conditions of battle
merely revealed what would most likely have remained
hidden during peace-time. Roy Halloran, the medical
superintendent of a mental hospital in Massachusetts
and psychiatric advisor to the US Army, expressed the
following perspective on the nature of war:
The Army can well be called the proving ground of
man...Those who are relatively poorly integrated will
usually break under the stresses of the training
period and can be eliminated, while those who are
of better mettle reach the combat areas where the
effects of fatigue, lack of food, fear, noise and the sight
of wounded and dying comrades severely test the
most stable personalities [6].
War and army life showed the true character of men.
Both military psychiatrists and army officials believed that
although the easygoing and undemanding nature of peacetime
society had enabled weaker characters to pass unnoticed
and even do well, the harsh realities of army life
would offer no such comforts. Both the screening program
and the absence of psychiatrists in the US Army at the
beginning of World War II were predicated upon the belief
that sturdy, well-adjusted soldiers of strong character
would be able to withstand the stresses of war. This
assumption turned out to be ill-founded.
Treatment near the front lines
During the first few months of their involvement in World
War II, the US Armed Forces encountered strong resistance,
both in the North African and Pacific theatres of
operation. Nevertheless, the few psychiatrists in the army
reported that the incidence of mental illness was equal to
that reported during peacetime. Neither were any new
types of mental illness observed. They concluded that
the war had nothing new for medical science to be concerned
with and that psychiatrists could go about their
business as usual. This view changed very soon. The German
resistance in North Africa was much more tenacious
than expected and the progress in the Pacific was difficult
and slow. The engagements on and around Guadalcanal
Figure 1. An American casualty from the front line fighting on Guadalcanal is
transferred to a makeshift stretcher before being taken to hospital. Image
reproduced courtesy of the Library of Congress.
(part of the Solomon Islands), which was the first major
campaign against the Japanese Imperial Forces, became a
gruelling battle of attrition (Figure 1). When the Allies
encountered strong resistance, the incidence of mental
breakdown increased rapidly. At times, up to 40% of all
soldiers incapacitated in action were diagnosed with
neuro-psychiatric symptoms [7]. The rates of nervous
breakdown (or war neurosis, battle fatigue and combat
stress, as shell shock had come to be called in World War II)
far exceeded those observed during World War I. The rates
among the US Armed Forces were particularly high, which
was very disconcerting for American military officials.
It became obvious that Sullivan’s ambitious screening
program had been a dismal failure. Not only were more
men than ever rejected for service, but also the number of
soldiers suffering from war neurosis was greater among
the American troops than in the other forces of the Allies.
Military officials became concerned because more men
were leaving the African and Pacific theatres than were
entering it. The unexpected and dramatic failure of selection
as a means of preventing psychological breakdowns
among service people during the first years of World War
II, combined with the pressing military need for manpower,
led to severe criticism of psychiatrists by the military
[8]. In 1944, screening was abolished under the order
of General George C. Marshall [9].
At that time, US Military officials responded to a small
group of outspoken psychiatrists with a psychoanalytic
orientation. They believed that treatment undertaken as
soon as possible after the onset of symptoms of war neurosis
would be most effective. Hence they proposed to treat
soldiers as close to the front line as possible. Treating war
neurosis near the battlefield also sent a clear message to
the troops that the display of symptoms did not provide an
easy way out of the war. The neurologist Roy R. Grinker,
who had been analysed by Sigmund Freud himself,
developed a form of psychotherapy with his former
resident John Spiegel in which soldiers who had broken
down were encouraged to re-experience their trauma in
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146 Review Endeavour Vol.30 No.4
They give a picture of mental strain that combines
the best of Edgar Allan Poe and Buck Rogers. One
cannot help but believe that the enemy made a careful
study of our psychology and our ways of thinking
and living and used this knowledge against us in this
campaign...They were alone on this island and their
expected relief did not come. They had no way of
knowing why it did not arrive. Soon they were sure
that none of them would get off the island – they were
expendable, doomed. Soon this helpless hopelessness
overwhelmed them and contributed no small part to
their final collapse [14].
Figure 2. An American soldier in a psychotherapy session. Image reproduced
courtesy of the National Archives and Records Administration, Washington, DC,
USA.
psychotherapy sessions (Figure 2). The two men were
convinced that this would aid the soldier’s recovery and
return them to the fighting lines. In addition to their
description of the 20-year-old platoon sergeant caught up
in the Tunisian Campaign of 1941, they presented several
other cases of men who had fought with distinction before
an unusually traumatic encounter with death led to the
onset of similar symptoms to support their argument [10].
According to Grinker and Spiegel, and their colleagues,
breakdowns were caused by hardship, long exposure to
combat and ‘unusually harrowing events which a normal
personality cannot tolerate’ [11]. This view led to radical
changes in the theoretical perspective then dominant in
American psychiatry. Practitioners no longer assumed
that mental breakdown was caused by a predisposition.
Instead, they now saw it as a normal reaction of normal
individuals exposed to the extraordinary stresses of warfare.
According to Grinker and Spiegel, ‘it would seem to be
a more rational question to ask why the soldier does not
succumb to anxiety, rather than why he does’ [12]. Psychiatrists
acknowledged that every man had his breaking
point: it was only rational to ask when he would break
down rather than if. The newly coined term ‘stress’, which
became very popular in American medicine and culture
after World War II (mostly because of its use in military
psychiatry), was used to describe these situations [13].
Psychiatrists and sociologists
Soldiers who broke down suffered from severe and debilitating
anxiety attacks, tremors, stuttering, amnesia and
nightmares; most of them were unable to perform the most
basic functions of daily life. In the descriptions given by
Grinker and Spiegel, the heroism of the soldiers cannot be
denied. Most of them had collapsed only after prolonged
exposure to battle and had been exemplary soldiers who
had distinguished themselves with bravery and courage.
In a paper presented at the 1943 annual meeting of the
American Psychiatric Association (APA), the Marines who
had been trapped on Guadalcanal were described in these
terms:
Soldiers suffering from war neuroses were heroes, not
cowards. They were normal individuals who could no
longer handle the extraordinary stresses of warfare and
who had contributed more than their share. Surely these
soldiers deserved the best possible treatment that medical
science could provide.
Through simple and straightforward treatment techniques,
Grinker and Spiegel claimed to be able to return up to
80% of soldiers to the front lines within a week [15]. The
psychiatrists presented their treatment methods in a
rather heroic way: ‘the stuporous become alert, the mute
can talk, the deaf can hear, the paralyzed can move, and
the terror-stricken psychotics become well-organized individuals’
[16].
The heroic depiction of soldiers who had broken down
made psychiatric intervention on the battlefield acceptable
and imperative to military officials and the public back
home. However, the heroic image of soldiers suffering from
war neurosis is misleading on several counts. First, many
soldiers broke down shortly after induction or when serving
in the rear echelons. The conditions in the US Army
were often so dismal that many soldiers could not cope [17].
This was true in particular for African-American draftees,
who suffered discrimination, lack of career advancement
within the US Armed Forces and abuse in segregated units
[18]. Second, killing was never mentioned as a cause for
mental breakdown. The fact that war involved killing and
that soldiers were trained to kill effectively, did not figure
in the accounts of American psychiatrists. This was
because the heroic images of soldiers suffering from war
neurosis legitimized an extensive role for psychiatrists in
the US Armed Forces. In the opening days of World War II,
only 35 psychiatrists were involved with the military. By
the end of the war, this number had risen to nearly 1000,
just short of one third of all American psychiatrists [19].As
Edward A. Strecker noted in his presidential address to the
APA in 1944: ‘Practically every member not barred by age,
disability or ear-marked as essential for civilian psychiatry
is on active duty’ [20].
Sociologists and anthropologists also got in on the
military act. In The American Soldier, Samuel Stouffer
and his team of social scientists concluded that the incidence
of mental breakdown was inversely related to morale
[21]. It was therefore possible to prevent mental breakdown
by building up morale, Stouffer reasoned. He thought
that the degree of morale was related to the confidence
soldiers had in their training, their officers and the army as
a whole, as well as the level of support they perceived they
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Review Endeavour Vol.30 No.4 147
Figure 3. ‘If only you knew what it meant!’ An instructive cartoon from 1943 that was produced by the Office for Emergency Management, and was intended to bolster the
morale and fighting spirit of soldiers in the US Armed forces. Image reproduced courtesy of the National Archives and Records Administration, Washington, DC, USA.
were getting from the home front (Figure 3). In addition,
the nature of the bonds between soldiers was of decisive
importance [22]. Military officials eagerly implemented
measures to boost morale by showing movies with the
theme ‘why we fight’, handing out propaganda leaflets
and holding informal talks with the troops about the
purposes of the war. These talks were unsuccessful and
widely scorned by the men.
The ratio of fire
One of the most influential studies conducted during World
War II was that of US Army historian Colonel S.L.A. ‘Slam’
Marshall, who was present during several battles in the
Pacific theatre of operations. Because of his interest in the
human element of warfare, he interviewed a great number
of soldiers after major engagements [23]. The increasing
technological nature of modern war, he found, had led to a
neglect of human nature, which he considered essential to
strategic planning and success in war. Marshall’s findings
were startling: he asserted that most soldiers never fired
their weapons or, if they did, they deliberately fired over
the enemy soldiers. Only about 15% of infantry soldiers or
at most 25% of men in well-trained battalions made effective
use of their weapons. This meant that most battles
were won by the thinnest of all possible margins. If 75% or
even 85% of enlisted men were not fighting efficiently, the
extensive training of all men and the distribution of weaponry
would be highly ineffective. According to Marshall, it
should be possible to do something about this situation.
Marshall argued that the reason why so few men used
their weapons effectively was the inherent human revulsion
against killing other human beings:
It is therefore reasonable to believe that the average
and normally healthy individual...still has such an
inner and usually unrealized resistance toward
killing a fellow man that he will not of his own
volition take life if it is possible to turn away from
that responsibility...At the vital point, [the soldier]
becomes a conscientious objector, unknowing [24].
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148 Review Endeavour Vol.30 No.4
According to Marshall, the fear of killing, rather than
the fear of being killed, caused soldiers to break down. In
many ways, these conclusions were reassuring. Even after
demanding Army training and exposure to battle, most
men remained decent human beings with an ethical sense
of the invaluable nature of human life. Despite it all, they
retained a strong aversion to killing. Marshall, however,
viewed this as a problem to military efficiency that could be
solved rather than an illustration of the high-minded
nature of soldiers. He advocated that training be modified
to increase the percentage of men who would use their
weapons effectively (which he called the firing ratio).
Marshall also emphasized the importance of the human
bonds between soldiers: ‘one of the simplest truths of war is
that the thing which enables an infantry soldier to keep
going with his weapons is the near presence or the presumed
presence of a comrade’ [25]. It was both the perceived
and actual presence of comrades who could easily be
lost sight of on the battlefield, which, in Marshall’s description,
resembled a moon landscape devoid of any human
presence:
The battlefield is cold. It is the lonesomest place
which men may share together...The harshest thing
about the field is that it is empty. No people stir
about. There are little or no signs of action. Over all
there is a great quiet which seems more ominous that
the occasional tempest of fire. It is the emptiness
which chills a man’s blood and makes the apple
harden in his throat. It is the emptiness which grips
him as with a paralysis [26].
This battlefield, where no motion could be seen, no noise
could be heard and where human beings appeared entirely
absent, could test the mettle of even the hardiest of man. It
destroyed group cohesion and led to chaos, as every soldier
felt that he was on his own. This impasse was often broken
by a few courageous individuals who made proper use of
their weapons, thereby making their presence felt to the
others. These soldiers became ‘pivots of strength to the
entire line...the sustained action of these men had rallied
others around them’ [27]. It was impossible to predict who
these men were ahead of time. Marshall singled them out
for praise because it was only their concerted action that
enabled battles to move forward and wars to be won
(Figure 4). Success in battle depended on the sustained
action of these few men. If the skills of these men could be
acquired during training, future deployments could be
expected to be much more successful.
In Marshall’s perspective, superior training in the use of
weaponry would also foster group cohesion and, in combination,
could lead to superiority in battle. He recommended
changes in Army training practices to increase
the ratio of fire, apparently with a high degree of success.
He was present during the Korean War and observed that
the ratio of fire had increased to 55% [28]. During the
Vietnam War, it increased to up to 95%.
Conclusion
American military psychiatrists drew three significant
lessons out of their involvement in World War II. First,
they acknowledged that it was very difficult to predict
Figure 4. ‘We’ll have to fight like hell to keep up their morale!’ Cartoon from circa
1942–1943. Image reproduced courtesy of the National Archives and Records
Administration, Washington, DC, USA.
which individuals would break down under the stresses
of warfare; they realized breakdown was less about stable
personality characteristics and more about the intensity of
combat, group cohesion and duration of deployment.
Screening for psychiatric disorders could therefore not
be expected to reduce the incidence of war neurosis [29].
Second, they realized the importance of group cohesion and
the emotional bonds between soldiers for maintaining
morale. The leading military psychiatrist Albert Glass
stated that ‘perhaps the most significant contribution of
World War II military psychiatry was recognition of the
sustaining influence of the small combat group or particular
members thereof, variously termed ‘‘group identification’’,
‘‘group cohesiveness’’, ‘‘the buddy system’’, and
‘‘leadership’’’ [30]. Stimulating group cohesion promised
to prevent the psychiatric problems of war. Third, the
psychotherapeutic treatment of battle fatigue near the
battlefield as soon as was feasible after the appearance
of symptoms resulted in a high rate of recoveries. After
World War II, American psychiatrists emphasized the
early treatment of mental disorders in community settings
over long-term care in mental hospitals. Psychoanalysis
and psychodynamic approaches dominated American
psychiatry for almost 30 years after the war [31].
At the time of World War II, the psychiatric consensus
held that soldiers who recovered from an episode of mental
breakdown during combat would suffer no adverse long-
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Review Endeavour Vol.30 No.4 149
term consequences. Psychiatric disability commencing
after the war was believed to be related to factors which
pre-dated the war [32]. Consequently, military psychiatrists
devoted relatively little attention to post-war psychiatric
syndromes. This would change after the Vietnam
War when an authoritative study claimed that up to 15% of
ex-service personnel were suffering from Post Traumatic
Stress Disorder (other studies quoted numbers of up to
40%) [33]. Some psychiatrists have claimed that the oneyear
tour of duty interfered with the formation of strong
emotional bonds between soldiers [34]. Others believed
that the political polarization during and after the Vietnam
War, when veterans were accused of being massmurders
and baby-killers, contributed to their psychological
problems. Still others blamed the success of US Army
training in increasing the ratio of fire. The lessons learned
by military psychiatrists during World War II are still
generally accepted. Today, however, the treatment of the
long-term and chronic psychiatric syndromes of war after
soldiers have returned home constitutes the most important
challenge for both civilian and military psychiatrists.
References
1 Grinker, R. and Spiegel, J.P. (1943) War Neurosis in North Africa: The
Tunisian Campaign, Josiah Macy, Jr. Foundation for the Air Surgeon,
Army Air Forces (New York, NY, USA), p. 23; this book was later
republished as Grinker, R. and Spiegel, J.P. (1945) War Neuroses,
Blakiston (Philadelphia, PA, USA)
2 Porter, W.C. (1941) The military psychiatrist at work. American
Journal of Psychiatry 95, pp. 317–323
3 Sullivan, H.S. (1942) Mental hygiene and national defense: a year of
selective-service psychiatry. Mental Hygiene 26, pp. 7–14
4 Glass, A.J. et al. (1959) Psychiatric prediction and military
effectiveness (Part I & II). US Armed Forces Medical Journal 7, pp.
1427–1443 and pp. 1575–1588, respectively; see also Ginzberg, E. et al.
(1955) The Lost Divisions, New York: Columbia University Press
5 Appel, J.W. (1945) Incidence of neuropsychiatric disorders in the
United States Army in World War II (preliminary report). American
Journal of Psychiatry 102, pp. 433–436
6 Halloran, R.D. and Farrell, M.J. (1943) The function of neuropsychiatry
in the army. American Journal of Psychiatry 100, pp. 14–20
7 For an overview of American military psychiatry during World War II
see Glass, A.J. and Bernucci, R.J., eds (1966) Neuropsychiatry in World
War II: Zone of the Interior (Vol. 1), Government Printing Office
(Washington, DC, USA); and Glass, A.J. and Bernucci, R.J. eds
(1966), Neuropsychiatry in World War II: Overseas Theaters (Vol. 2),
Government Printing Office
8 Jonas, C.H. (1946) Psychiatry has growing pains. American Journal of
Psychiatry 102, pp. 819–821
9 For a historical overview of screening in the military which draws the
same conclusion see: Jones, E. et al. (2003) Screening for vulnerability
to psychological disorders in the military: an historical survey. Journal
of Medical Screening 10, pp. 40–46
10 Grinker, R. and Spiegel, J.P. (1943)
11 Miller, M.L. (1944) Aftermath of operational fatigue in combat
aircrews. American Journal of Psychiatry 101, pp. 325–330
12 Grinker, R. and Spiegel, J.P. (1943), p. 115
13 For the origins and the popularization of the term ‘stress’ see Viner, R.
(1999) Putting stress in life: Hans Selye and the making of stress
theory. Social Studies of Science 29, pp. 391–410. Its popularity in
military psychiatry is reflected in the title of the second book of Grinker
and Spiegel: Grinker, R. and Spiegel, J.P. (1945) Man under Stress,
Blakiston
14 Smith, E.R. (1943) Neurosis resulting from combat. American Journal
of Psychiatry 100, pp. 94–95
15 Hanson, F. ed. (2005) Combat Psychiatry: Experiences in the North
African and Mediterranean Theaters of Operation, American Ground
Forces, World War II. University of Hawaii Press (Honolulu, HI, USA)
16 Grinker, R. and Spiegel, J.P. (1943), p. 82
17 Recently, historians have embarked on a reappraisal of World War II,
which has been represented as the just and glorious war fought by the
best generation. See Fussell, P. (1989) Wartime: Understanding and
Behavior in the Second World War, Oxford University Press, New York;
and Polenberg, R. (1992) The good war? A reappraisal of how World
War II affected American society. Virginia Magazine of History and
Biography 100, pp. 295–322
18 Dwyer, E. (2006) Psychiatry and race during World War II. Journal of
the History of Medicine and Allied Sciences 61, pp. 117–143
19 Menninger, W.C. (1947) Psychiatric experience in the war, 1941–1946.
American Journal of Psychiatry 103, pp. 577–586
20 Strecker, E.A. (1944) Presidential address. American Journal of
Psychiatry 101, p. 1
21 Stouffer, S.A. et al. (1949) The American Soldier: Adjustment During
Army Life (Vol. 1 – Studies in Social Psychology in World War II),
Princeton University Press (Princeton, NJ, USA); Stouffer, S.A. et al.
(1949) The American Soldier: Combat and Its Aftermath (Vol. 2 –
Studies in Social Psychology in World War II), Princeton University
Press
22 For an overview of these studies see Wessely, S. (2006) Twentiethcentury
theories on combat motivation and breakdown. Journal of
Contemporary History 41, pp. 269–286
23 It has since become known that Marshall fabricated most of his
statistics. This, however, does not detract from his enormous
influence on US Army training practices. See Spiller, R.J. (1988)
S.L.A. Marshall and the ratio of fire. RUSI Journal 133, pp. 63–71
24 Marshall, S.L.A. (1947) Men Against Fire: The Problem of Battle
Command in Future War, William Morrow and Infantry Journal
Press (Washington, DC, USA), p. 79
25 Ibid., p. 42
26 Ibid., pp. 44–45
27 Ibid., p. 61
28 Ibid., preface
29 See also Jones, E. et al. (2003)
30 Glass, A.J. (1972) Mental health programs in the armed forces. In
Child and Adolescent Psychiatry, Sociocultural and Community
Psychiatry (Caplan, G., ed.), pp. 577–586, American Handbook of
Psychiatry, New York
31 See Hale, N.G. (1995) Freud and the Americans, 1917–1985: The Rise
and Crisis of Psychoanalysis in the United States, Oxford University
Press (New York, NY, USA)
32 Wessely, S. (2006) Twentieth-century theories on combat motivation
and breakdown. Journal of Contemporary History 41, pp. 281–282
33 Kulka, R.A. et al. (1990) Trauma and the Vietnam War Generation:
Report of Findings from the National Vietnam Veterans Readjustment
Study, Brunner/Mazel (New York, NY, USA); Kulka, R.A. (1990) The
National Vietnam Veterans Readjustment Study: Tables of Findings
and Technical Appendices, Brunner/Mazel
34 Lt. Col Grossman, D. (1995) On Killing: The Psychological Cost of
Learning to Kill in War and Society, Back Bay (Boston, MA, USA)
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