Small Wars Journal

The Historical Origins of Mental Health Disease Centric Treatment Modalities

Sat, 09/10/2022 - 12:14pm


The Historical Origins of Mental Health Disease Centric Treatment Modalities

by Thomas J. Trent

               The National Institute of Mental Health and the Veterans Administration were both founded in the wake of World War II. Their emphasis on mental illness resulted in the pervasive adoption and usage of a reactive disease model of mental health (Seligman & Csikszentmihalyi, 2000). Disease models are intrinsically reactive and result in diagnoses aligned with the Diagnostic and Statistical Manual of Mental Disorders (DSM), reflected best practices, and were perpetuated in respected scholarly sources (Luthans & Youssef-Morgan, 2017). As a result, historical psychopathological treatment modalities negatively affect the Army's ability to fight and win the nation's wars due to increased abnormal mental health diagnoses and decreased psychological capital.


The Origins of Disease Model Treatment Modalities

The junior officers of World War I became the senior officers of World War 2 who led the allied response against the Axis powers. Generals Eisenhower, Marshal, Patton, and McArthur were all World War I veterans, and their subjective construal of mental illness likewise resulted from their interpretations of their experiences during World War I (Lovelace, 2019). Subsequently, they influenced Army policy and mental health treatment practices during Patton's exposure to shell shock victims during World War I informed his understanding of mental illness and its effects on the battlefield (Lovelace, 2019). According to Lovelace (2019), Patton interpreted mental illness as total and complete physical incapacitation due to these experiences. Consequently, General Patton's experiences would result in the effective denigration and physical abuse of Soldiers whose symptoms left them less than physically incapacitated.

Shell Shock (World War I)

            British psychiatrists discovered a perplexing condition called shell shock during World War I. Stuttering, sobbing, shaking, paralysis, stupor, mutism, deafness, blindness, anxiety attacks, sleeplessness, disorientation, forgetfulness, hallucinations, nightmares, heart difficulties, vomiting, and intestinal diseases were among the somatogenic, and psychogenic symptoms reported (Pols & Oak, 2007). According to Pols and Oak (2007), military physicians attributed the symptoms to neurological causes, while military officers described the afflicted Soldiers as malingerers or cowards. Subsequently, British physicians Charles S. Myers and W.H.R. Rivers did not believe in their colleagues' biological (i.e., neurological) origins; they believed the origins of shell shock were psychological and suggested psychotherapeutic interventions (Pols & Oak, 2007). Their studies attracted the interest of Dr. Thomas W. Salmon, an American military psychiatrist, whom they influenced by their work.

            Dr. Salmon shared the views of Myers and Rivers; he believed war neurosis (i.e., shell shock) was a psychological reaction as opposed to a biological disposition to mental illness (Pols & Oak, 2007). According to Pols and Oak (2007), Salmon believed that Soldiers developed combat neurosis as an unconscious means of evading an intolerable circumstance in which self-preservation instincts were at odds with duty obligations. Instead of being an indication of mental disease, shell shock was a natural response to the traumas of war (Pols & Oak, 2007). Subsequently, Salmon developed a three-tiered approach that focused on treating war neurosis.

According to Pols and Oak (2007), Salmon's three-tiered approach consisted of aid stations located a few miles behind the front lines. Soldiers were allowed to rest, given sedation, and provided adequate food. Doctors used optimistic persuasion and suggestion to reassure their patients that their reactions were normal and would pass within a few days. Salmon's second tier consisted of base hospitals 5-15 miles to the rear of the front lines; Soldiers received treatment for up to three weeks in these locations. The third and final tier (prior to repatriation) utilized the resources at Base Hospital 117, where Soldiers received treatment for up to six months; Salmon was personally involved with the treatment at Base Hospital 117 (Pols & Oak, 2007). According to Pols and Oak (2007), 65 percent of Soldiers treated at tier one locations returned to the fighting lines within 4-5 days. Despite the success, military leaders did not utilize Salmon's approach during the first years of World War II.

Screening (World War II)

            Salmon's treatment modality resulted in 65 percent of Soldiers returning to their units (Pols & Oak, 2007). However, despite Salmon's success, the military decided upon entry screening methodologies instead of treating soldiers engaged in combat operations. According to Pols and Oak (2007), officials believed screening versus treatment would eradicate biological psychiatric disorders due to combat exposure and decrease battlefield attrition. However, due to the Army's broad characterization of psychiatric disorders, attrition rates rose to perturbingly high levels (Pols & Oak, 2007). As a result, during the early years of World War II, the Army reverted to historical disease model screening and treatment plans.

Psychopathological Diagnosis

The Army's attempt to eradicate neuropsychiatric conditions from the formations was ill-conceived and did not produce the desired results. During the Tunisian campaigns, approximately 34 percent of Soldiers were diagnosed with neuropsychiatric disorders (Pols & Oak, 2007). Inflexible, broad definitions adopted by the Army were reactive versus proactive and reflected the cognitive biases of senior military officials. As a result, senior military officials were receptive to the ideas of Drs. Roy G. Grinker and William C. Menninger; their treatment approaches resembled Salmon's approaches during World War I. Almost 60 years later, similar scenarios prompted Army Chief of Staff General George Casey to reinvent the Army's proactive measures with assistance from Army Brigadier General (Dr) Rhonda Cornum (Casey, 2011).

According to Cornum et al. (2011), contemporary psychologists utilized a laissez-faire approach emphasizing screening and treatments for detected psychopathological symptoms. Cornum et al. (2011) conservatively estimated the potentiality for Soldiers to develop symptoms at 150,000 or roughly 10 percent of the 1.64 million Soldiers who served in Iraq and Afghanistan. 150,000 Soldiers, 30 percent of the Army's total force, and each diagnosed case represent an increased burden on the healthcare system. According to Baiocchi (2013), 131,057 Soldiers deployed to Iraq and Afghanistan from September 2001-December 2011. Continuing to maintain treatment-focused (Casey, 2011) strategies does not align with the Army's mission to fight and win the nation's wars; treatment fails to leverage the strength resultant from the development of psychological capital (PsyCap). Furthermore, the status quo approach will likely increase the number of Soldiers diagnosed with substance abuse problems (Krasikova et al., 2015).

Psychological Capital

According to Merriam-Webster (n.d.-a), value-adding capital is an asset to individuals and organizations. Hope, efficacy, resilience, and optimism (HERO) represent a collective of abilities (Luthans & Youssef-Morgan, 2017); leaders cultivate these skills through deliberate exposure to failure, adversity, dynamic tactical and technical environments, and unfamiliar socio-psychological conditions. Leaders are not at the mercy of hurrying up and waiting for the next disaster to build the capabilities of their Soldiers. Instead, well-planned, conceived interventions produce the personality changes necessary to maximize Soldiers' performance by developing the determinants of PsyCap (Luthans & Youssef-Morgan, 2017).

According to Krasikova et al. (2015), Soldiers who evaluated themselves as having well-developed competencies before deployment were at a decreased risk of being diagnosed with substance misuse disorders (both alcohol and drug addiction) than those who described themselves as having an immature skillset. According to Meadows et al. (2018), approximately 32 percent of Soldiers report hazardous or disordered drinking. Luthans et al. (2013) opined regarding the agentic effects of the competencies to prevent alcohol and substance abuse. Likewise, Soldiers lacking the benefits of development prior to deployment are at increased risk for substance abuse. Substance abuse affects the Army's readiness and reduces its ability to project combat power. Likewise, PsyCap reduced the number of psychological health conditions post-deployment (Krasikova et al., 2015).

Krasikova et al. (2015) showed, using data from a sample of 1,889 U.S. Army troops, that those who had mature abilities before deployment were less often diagnosed with mental health disorders while on active duty. According to Seligman (2011), the Army introduced the Comprehensive Soldier Fitness (CSF) program to build Soldiers with the competencies necessary to prevent mental health disorders. CSF provided Soldiers with the knowledge, skills, and abilities to become more adaptable, increase their affective and emotional awareness, reduce catastrophizing, develop higher levels of optimism, and utilize their character strengths (Cornum et al., 2011; Krasikova et al., 2015; Seligman, 2011). The critical components of psychological capital are emotional intelligence and HERO.

Emotional Intelligence

            Emotional intelligence is a subset of social intelligence and represents the ability of the individual to monitor their affect and emotions and the affect and emotions of others (Barrett, 2017, 2020; Salovey & Mayer, 1990). According to Merriam-Webster (n.d.-b), intelligence represents an ability associated with performance expectations. Emotionally intelligent Soldiers interpret their affective state accurately to cultivate an affective, emotional response to arouse appropriate behaviors (i.e., motivation). Likewise, they also learn to effectively perceive the affective and emotional states of others to cultivate positive socio-psychological states that maximize human and organizational performance (Salovey & Mayer, 1990). The determinants of emotional intelligence are the four resources hope, efficacy, resilience, and optimism; together, they form a core higher-order construct that leverages the synergy of the abilities working in concert (Luthans & Youssef-Morgan, 2017).


            Cultivating hope requires two things: 1) forward motion and 2) the capacity to create the means (and alternative ways) to accomplish objectives (Luthans & Youssef-Morgan, 2017). Efficacy results from the conviction that momentum may be effectively harnessed and deployed along predetermined courses. The fundamental components of efficacy include successful experiences, good feedback, emotional alignment, and learning (Bandura, 1997). Resilience is the capacity to recover quickly from setbacks, difficulties, and the strain of collaborating with new people (Luthans & Youssef-Morgan, 2017). Resilience develops over time through exposure to dynamic environmental conditions and needs for sustenance hardwired into the body (Hudson & Fraley, 2015). Optimism is the capacity to see setbacks as temporary and attribute success to deliberate action; that is the epitome of optimism (Luthans & Youssef-Morgan, 2017).


Since World War I, the military and the Army have struggled with disease-focused treatment and screening programs. Unfortunately, the Army's historical affinity for such treatment modalities reduced readiness due to a failure to address the plasticity of the psychological mind versus the biological nature of the brain, the reactive nature of disease diagnoses and treatment, and the failure to harness the synergistic effects of PsyCap to reduce substance abuse. As a result, historical psychopathological treatment modalities negatively affect the Army's ability to fight and win the nation's wars due to increased psychopathological diagnosis and decreased psychological capital.



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About the Author(s)

MSG Thomas J. (TJ) Trent is currently a student in the Sergeants Major Course Class 73, Sergeants Major Academy, Fort Bliss, Texas. Over the last 20 years, he has served in various tactical, operational, and strategic positions at the Battalion, Brigade, Division, and Corps levels. Most recently, he served as the Division G3 Sergeant Major for the 32D Army Air, and Missile Defense Command forward deployed to the CENTCOM AOR. MSG Trent earned a Master’s Degree in Business Administration and is currently pursuing his Ph.D in Psychology. His research focuses on maximizing human and organizational performance to support the Army’s mission.