From Shell Shock to PTSD: Military Health Care and Mental Health Policy

• In Event: Political History of Public and Mental Health Policy

Abstract

From shell shock on Europe’s front lines in World War I to post traumatic stress disorder in and on return home from Afghanistan and Iraq in the 21st century, military health care systems have long needed to address the psychological implications of waging war. But while difficult psychological consequences of war for service members and their families have been a constant over the last century, the contexts and methods of waging war abroad, and the political and policymaking contexts at home, have varied, leading to variation in the approaches the government has taken to identifying, diagnosing, and treating service members’ and veterans’ mental health issues.

This paper examines the U.S. government’s varying approaches to the diagnosis and treatment of military mental health issues across conflicts and time over the last century, and describes the causes and consequences of this variation. It also examines recurrent tensions over the legitimacy of the government’s role in providing health care, and the legitimacy of different approaches to the diagnosis and treatment of mental health issues. Using original archival and other executive and legislative branch primary source materials, and both qualitative and quantitative data, the paper examines how institutional actors across different substantive and temporal contexts have recognized and responded to a recurrent and intractable policy problem. Broadly, I argue that this narrative shares features of the American state’s approach to mental health that I find more generally: policymakers across institutions have consistently attempted to expand and generalize diagnostic categories and to assist more people, but have struggled to provide optimal treatment, reign in suboptimal treatment, and identify a consistent set of best treatment practices.

The paper adds to debates about health politics and policy, the American state, and the domestic consequences of foreign policy. Military health care has recently received renewed attention (Moore 2015), and the consequences of foreign war for domestic policy and the growth and transformation of the American state have long received scrutiny (Gourevitch 1978, Dudziak 2000, Katznelson and Shefter 2002, Sparrow 1996, Higgs 1987). But while debates about military mental health care have risen in public prominence, the variations in and determinants of military mental health policy remain poorly understood. Accordingly the paper also informs active policy debates about reforming military mental health care, a central concern in an era when twenty veterans commit suicide daily, service member and veteran homelessness and mental illness continue to increase, and debates about optimal approaches to the diagnosis and treatment of military mental health issues persist.

Author

• Herschel Nachlis, Dartmouth College