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Resilience and Military Psychiatry 27

with a brief discussion of treatment strategies if soldiers are evacuated for
psychiatric reasons. The overall topic of military psychiatry is a large one,

and many topics are covered in more detail elsewhere (Jones, 1995; Jones &
Fong, 1994; Ritchie & Owens, 2004).

A Brief History of Combat Psychiatry

All wars produce stress reactions. The documented history of military

psychiatry dates at least as far back as World War I, when psychological
casualties were diagnosed as victims of “shell shock.” Th is diagnosis

reflected an underlying notion that behavioral changes were the direct
result of organic damage from exposure to artillery blasts. Early in World
War II, service members who demonstrated psychological or behavioral

symptoms were classified as “not yet diagnosed, nervous.” Later in World
War II, such symptoms were attributed instead to “battle fatigue.” Th is term
was helpful in that it suggested the potential for recovery by rest and replen-
ishment. However, few psychological casualties who were evacuated out of
theater were able to return to the combat environment. Neither hospital
treatment (during World War I) nor psychoanalysis (during World War II)

relieved the symptoms commonly suffered by psychological casualties
of war. In contrast, when service members were treated for psychological
or behavioral symptoms in theater (at “forward” locations) with brief
supportive therapy and the expectation of return to duty, most (60–80%)
were able to continue performing their duties as service members in combat
(Jones, 1995; Shepard, 2001).
During the early months of the Korean War (July–September 1950),
American military psychological casualties occurred at a rate of 250 per
1000, principally within the U.S. Army and Marine Corps. Th ese numbers
overwhelmed resources that had been assigned to manage psychological
casualties at forward locations. Casualties were thus evacuated to Japan or
the United States, and very few returned to duty. When the principles of
early and far-forward treatment were eventually reinstituted in October
1950, as many as 80% of neuropsychiatry casualties were again able to
return to duty after early intervention and treatment in theater (Glass, 1973;

Ritchie, 2002).

Thus it is by direct experience that the U.S. military has come to rec-
ognize the value of simple and immediate psychological intervention on

the battlefield. Basic principles for the early management of psychological

casualties would later be codified as “proximity, immediacy, expectancy,
and simplicity” (PIES), which directed simple immediate treatment, without
evacuation, and with the expectation of return to duty (Artiss, 1963; Glass,
1973; Salmon, 1929).

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