Military psychiatry and militarism.

Today, April 25th, is Anzac Day, which commemorates the disastrous landing of Australian, New Zealand and British troops on the Galipoli Peninsula, in Turkey, in 1915. It is the equivalent of Remembrance Day in the UK or Memorial Day in the US. In every town in the country, there will be services at the town War Memorial, the first one at dawn, which is when the first troops landed, and the main one later in the morning which includes a military march past. I no longer go to the ceremonies because, after about 68 years, the sense of "Don't they ever learn?" is too strong.

I went to school in Albany, West Australia, which is where the enormous fleet of troop carriers and warships assembled before leaving for the Middle East. Directly opposite our house, right on the edge of town, lived a disabled veteran of the 10th Light Horse. They were General Allenby's shock troops in Palestine and were the first troops to enter Jerusalem after the Ottoman armies were defeated, so there was a somewhat mythical air about them. I spent a lot of time with that old man as he had built a yacht and took me sailing. He never talked about the war but he had his photo in uniform, his Mauser rifle and his sword hanging from his wall. Very rarely, I was allowed to hold the rifle and pretend to fire it.

About a mile up the hill from our place, through the bush, was the Princess Royal Forts, built in 1895 to keep the Germans away (it was very effective as they never came; a bit like Fort Denison in Sydney Harbour, built in 1855 to keep the Russians away and still effective). As a member of the first wave of the baby boom, there were never enough class rooms in our schools so several times, my class was shunted off to the Forts, which was a great place to go to school. My brother and I walked barefoot to school, kicking the frost to make patterns, which wasn't fun when your feet thawed out but we did it again the next day. The Forts are now the site of the National Anzac Centre so they have largely been preserved as they were when we went to school there. All this is by way of saying that I was soaked in military mythology almost from birth.

As a trainee psychiatrist, I did my final year at what was then the Repatriation Hospital in Perth,, later Dept for Veterans' Affairs, where I saw veterans of every war this country has been involved in since 1915. Later, I had extensive contact with veterans and with serving members of the ADF until 2015. In the 1980s at DVA, the World War II veterans were reaching retiring age and many of them had to reactivate claims they had lodged years before as, without benefits, they couldn't manage. I saw many hundreds of men, and a few women, including some famous veterans, all now long deceased. When the veterans arrived for assessment for their claims, I was provided their full medical and military files dating from their first application forty or fifty years before.

Many of them had been POWs of the Japanese, and some in Europe, others were members of the 2/2 Commandos who had deployed to Timor for a year after the Japanese invaded. One of the West Australian units had deployed in the north of New Guinea in early 1945, around towns called Aitope and Wewak. The Japanese army had been cut off by the American "island-hopping" advance but they were determined not to surrender and, if they could, to kill as many of the enemy as possible. The fighting there was generally regarded as the worst in any theatre of war in WWII, worse even than Stalingrad. Forty years later, practically none of the old men had ever said a word about it.

From memory, about half of them had had claims rejected in the 1940s and early 1950s, so they never claimed again until they were forced to. When they arrived at their appointments, they were wary and defensive, expecting another rejection. They certainly didn't expect to be taken through a full psychiatric history which, as their records showed, had never happened. Normally, the "assessment" all those years before consisted of a few lines with a brief mention of symptoms, then a diagnosis, mostly "anxiety-hysteria," occasionally "malingering," and a few words on why the claim should be rejected. The most common basis for rejecting claims, even among former POWs, was that their symptoms were "constitutional." This was one of the many words psychiatrists throw around which actually have no meaning. I mentioned a modern one last week: "neurodevelopmental." Another favourite is "evidence-based," which means "We choose the evidence, thanks very much."

Constitutional means "relating to the constitution," but what is that in human terms? It meant something like "innate, coming from within," with the barely-concealed implication of "unrelated to life experiences." This was society saying to veterans "Doesn't matter what you think, whatever is going on with you now is because you have a weak constitution, and that's your fault, not ours." And by this means, the claims were rejected (when I say "society," I mean the people who made the rules, the politicians, generals, public servants, senior psychiatrists and such like, practically none of whom would have seen active military service).

However, taking a proper history showed several things. Many of the veterans, who were generally in their sixties and seventies, could put their fingers on a specific date or place when everything went wrong, even to the hour. When their service records were checked, which they had never seen, it immediately confirmed that things had indeed gone wrong because previously well-regarded troops started getting into trouble. Their records blossomed with red ink, as that is how complaints, charges and convictions were recorded. So whatever had happened to a soldier's "constitution" along the way, it had obviously reached breaking point.

This wasn't what the text books said, so I organised a survey which I could do while seeing the patients or take it off their files. It looked at five factors in their history: their assessments of their family background, their preservice adjustment (a proxy for personality), the duration of exposure to combat, the severity of that experience, and whether they had been suffering debilitating illnesses such as malaria, dysentery, infectious hepatitis etc. at the time. It included 200 World War II veterans, and fifty Vietnam veterans for comparison. All I did was classify them according to whether they had a compensable diagnosis; the actual diagnosis wasn't important (also, the DSM-III diagnosis of Post-Traumatic Stress Disorder had not been accepted by DVA, which is another story). It showed, with unimpeachable clarity, that "constitution" had nothing whatsoever to do with the onset of mental disorder in veterans.

All of the troops were volunteers; they were practically all from WA so I knew their towns and backgrounds very well, often knew their family names. I was satisfied that they were telling the truth. They were all fit and healthy when they enlisted, there was no mental disorder and the great majority of them were well-adjusted and reliable before enlisting, with no police records or drinking. There were no drugs in those days, of course. Their service records were all first class as anybody who played up was sent to a support battalion. They were practically all suffering long-term mental disorders for which they'd had no treatment or assistance, yet they'd worked and raised families. Their family background was irrelevant as was their preservice adjustment and education (most had left school by fifteen as the Depression lasted longer in rural areas). All that counted was the duration of exposure to combat and the perceived level of "stress." Debilitating diseases increased the severity of the disorder but without the combat exposure, very few were troubled.

Most of the men had never spoken of their experiences; one after the other, they sat as tears trickled down their lined faces and spoke of the horrors they had seen. One man, who hadn't seen actual combat, stands out. He was the leader of the fire unit at an air strip in New Guinea. One day, an American fighter came in with damage to its undercarriage. The fighter slewed to a halt but, just as they reached it, it burst into flames:

We could see the pilot trying to escape, we could hear him screaming and screaming but the flames were too much. When we got him out, he was frozen in position, his hands charred, his face melted. We lay him on the grass and there was smoke coming out of his eye sockets. That's what broke me, I suddenly thought, What would his mother think? I was never any good after that but they rejected my claim in '48. Can you understand, Doc? I'm not making this up.

I understood. Nobody could make that up. There were hundreds of stories, the same pointless horror, over and over.

This morning, on my ride through the hills, I stopped briefly at the highest point. There is a view of about 40km down the edge of the Great Dividing Range. It was showery and blustery, with ragged mist drifting around the forested hill tops. Just as I got there, the sun came through the clouds and lit the Ranges. And the first lines of Charles Sorley's poem suddenly came to me:

When you see millions of the mouthless dead

Across your dreams in pale battalions go...

Capt. Charles Hamilton Sorley was killed, aged twenty, at the Battle of Loos. This, his last poem, was found in his belongings after his death. Sorley had been studying in Germany when war was declared and loved the country and the people. His body was never recovered, leading to the unanswered question from a truly great singer.