Forward psychiatry was conceived and implemented to confront the deleterious problem of mental handicaps among soldiers during the World War 1 period, initially left unattended due to ill-informed ideas of masculinity, cowardice and the insufficiency of non-physical 'complaints' as grounds not to engage in battle. The system of forward psychiatric centres was oriented towards sustaining manpower through an accelerated restorative process, frequently at the expense of treating individuals with sufficient therapeutic care and adequate clinical treatment. Furthermore, significant publication bias prevented acknowledgment that forward centres were not much more effective than the prior system, if at all. However, the widespread implementation of this system likely played a role in somewhat mitigating the eminently negative impact of psychological disorders and trauma on military efficacy by maximising the amount of psychiatric cases who continued to contribute, in some manner, to the war effort. It did not, though, remove the substantial demands of modern combat on soldiers' psychological resources and thus operated as a superficial fix which had no effect on the number of psychiatric casualties and little success returning men to actual combat. The number of men leaving warfare due to neurological, psychological and affective disorders, as well as calamitous psychosomatic dysfunctions like railway spine, reached and remained at epidemic proportions with extreme rapidity during this extraordinarily harsh wartime. Theoretically, forward psychiatry was predicated on the presupposition that lessening the amount of time spent and distance away from the battle area, encapsulated in the PIE acronym, would increase war patients' desire to return to duty and high success rates would ensue. Due to the fabricated evidence of its utility in France as a strategic adaptation to the drastically evolving nature of warfare, the experiment was replicated by their allies, but this emulation served purely on a logistical level and did not benefit most who came in direct contact with it.

The prevalence of psychiatric casualties during World War 1 can hardly be overstated, as there were 80,000 documented instances of 'war neurosis' amongst the British armies on the western front and estimates amongst German troops of 200,000-300,000. Several beliefs concerning the importance of male soldiers having a strong character undermined psychiatric progress early in the war. Wilhelm II, the German Emperor, had announced that supremacy would go to the state with the "strongest nerves", many French doctors asserted that conflict would revitalise Frenchmen and British doctors regularly proclaimed the virtues of toughness and healthy character in soldiers as preconditions to their bravery and success. These concepts left no room for perceived cowardice and permeated war culture, feeding the assumption that psychological complaints were the result of a deficit in the quality/personality of those impacted. This sentiment generated stigma around traumatized soldiers, fuelled by the short-lived medical consensus that these men brazenly refused to fight, perhaps even faking their maladies, despite the absence of an obvious physical problem simply because they lacked the will and the nerve that healthy, respectable males possessed. But some earlier research into mental trauma in civilian psychiatry was linked to the unprecedented numbers of adverse mental reactions in soldiers by certain figures like Captain William Brown, who highlighted the detrimental loss of men due to mental pathology, and eventually scientific inquiry supplanted these attitudes. Terms like shell shock, nerve shock and war neurosis were devised in light of realisations that the existence of disorders in soldiers, characterised by symptoms not attributable to a clear physical cause, proved to be affecting significant numbers and were connected to the 'trauma phenomenon'. Medical Officers were instructed to label likely traumatised men as NYDN (Not Yet Diagnosed Nervous) but men were commonly referred to as "shell-shocked". This disintegrated the idea that mentally disturbed men were cowardly to avoid combat activity by providing medical justification for the behavior and underpinned forward psychiatry's inception.

The range of what had become agreed upon as symptoms were described as baffling, including functional physical symptoms like exhaustion, hysterical deafness and loss of speech, together with nightmares, persistent anxiety, depression, fainting and insomnia. Railway spine, manifesting as extreme rigidity of the back, became a major issue in armies. French and British scholars, notably Jean-Martin Charcot and Herbert Page, insisted that this could be caused by 'hysteria'. The idea of shell shock spread and sufferers were usually invalided to hospitals close to their homes, however this appeared to reinforce symptoms. The French army, noting the exacerbatory effect of returning the shell-shocked close to family and home on army population, set up forward neurology centres in the summer of 1915 designed to reduce the need for mentally wounded soldiers' referral to base dispensaries, boasting incredible results. By 1917, virtually each French army division had a neurological centre, with over 200 beds and 5-10 miles from the battleground. All psychological/mental cases were directed to such forward centres immediately as a means of preventing the aggravation of mental afflictions. These centres had to be 'within the sound of gunfire' (Reid, 2014). They became known as not yet diagnosed nervous (NYDN) centres, operating on three main principles: proximity as they were near the battlefront, immediacy which meant prompt referral from trenches, and expectation of recovery as throughout the brief duration of rest soldiers were inspired to assume they would be returned to service, given the acronym PIE. In response British consulting psychologist Charles Myers propelled the creation of four specialist centres at the rear of 'Army Areas' designed to treat shell shock cases. The return to duty rate purportedly rose from 50% to 90% (Myers, 1916), and Neurologist Gordon Holmes claimed at least a 60% better return-rate. The military administrations were initially hostile but forward treatment rapidly transformed into regular custom amongst the western allies. But the men who went into these centres rarely returned to duty and those who did likely capitulated to considerable bureaucratic pressure, still unrestored to a level of mental fortitude sufficient for active duty, if such a thing exists.

Such centres tended to have a negative impact on morale, as returned men would experience a return of symptoms shortly after release back to the front. They would frequently die from diseases likely to be psychosomatic, eg. fatigue as a result of depression and eventual degeneration from heavy physical burden. They were reported by many to be more likely to make poor, perhaps fatal, decisions, putting themselves at risk and displaying a lack of alertness to danger and threat, as well as low energy and motivation. Many of those treated under the PIE scheme were put in less demanding military situations, such as divisions designed to maintain ammunition supplies, where they would sometimes experience ridicule and/or guilt and feel worthless. Nevertheless, forward psychiatry was attractive to leaders because, purportedly, the farther a serviceman was relocated from the trenches, the less plausible his return, and the reports of its comparable success were widely known. Up until July 1917, for instance, 'of the 7301 service patients discharged from Maghull Red Cross Hospital near Liverpool, only 153 returned to military duty' whereas over 65% were extricated from the forces (Wessley, 2014). In NYDN centres, 'Soldiers were fed, allowed to rest, and then put on a programme of graduated exercise, culminating in route marches'. There was a belief that the psychoanalytic investigation of traumatic encounters could obstruct spontaneous healing processes, and so the short periods of vacation from battle were absent such methods in favour of non-medical restorative processes. Psychological therapy was almost entirely rejected in NYDN centres. The hebdomadal reviews of shellshock returns by authorities, Carmalt Jones recalled, created "vicious competition'' between the numerous NYDN centres and between "rival methods of treatment for the return of patients to their units". The monitoring process caused loudly promulgated but exaggerated return-to-duty rates, many centres alleging that 80–90% of admissions were re-established in conflict, and current historians are wary of the invalidity these primary statistics. 'A retrospective analysis of admission and discharge records for a PIE unit showed that only 17% of patients returned directly to their units' (Wessley, 2014) whilst others either went home or occupied military divisions not for warfare. Due to accusations that it encouraged invalidity and was overseen by undetermined staff, PIE and forward psychiatry was dropped from military protocol during the interwar period.

It is clear that the approach was by no means particularly desirable for psychiatric casualties, who often ended up re-traumatised back on the battlefield, or belittled and stigmatised as a consequence of views regarding the importance of national pride and the concept that 'a young man should be on the front line' and thus left to feel a sense of unworthiness, guilt and shame. They would encounter this sentiment quite intensely whilst receiving treatment and afterwards should they have returned home or even occupied less demanding duties. The same ideas that prevented the inception of effective psychiatric systems early on also contributed to ensuring PTSD victims were not treated with adequate care and dignity and forward neurology or NYDN centres seemed only to reinforce or manifest scientifically bogus concepts, such as that masculinity was synonymous with men's reliability as highly resilient and able to cope with the struggles of war, and that not doing so indicated weakness. The PIE approach may have somewhat improved the odds of patients maintaining their utility in some capacity, however this was likely more the result of pressure, attitudes and shame than a legitimate medical recovery. It is also due to the fact that proximity to the battlefield reduced a sense of hope of returning to loved ones, the main logistical flaw of sending troops back to hospitals near their homes, but this conceivably would have dampened their spirit and contributed to their difficulty returning to their former military identities. Overall, forward psychiatry that operates on the PIE principles is an inadvisable war strategy.

Source Analysis

Psychiatric battle casualties: An intra- and interwar comparison

Article in The British Journal of Psychiatry from ResearchGate · April 2001

Edgar Jones and Simon Wessely

This was an excellent secondary source of professionally investigated, cited and collated information about psychiatric casualties in modern warfare. It is written and researched scientifically and in great detail for the purpose of a British scientific journal. It focuses on the psychiatric significance of such wars as the Boer War and World War 1 and historically examines the specific cross-national causes and indicators of psychiatric developments that emerged from the demands of modern warfare and the relationship between war, psychiatric knowledge and psychiatric enlightenment. It provided valuable, detailed information on the reasons for the implementation of forward psychiatry. This allowed me a greater depth of understanding of the important role forward psychiatry played in, and how it was shaped by, WW1. It also provides a depth of understanding of the way different figures, such as Charles Myers, influenced forward psychiatry's introduction.

War Psychiatry

Essay with 6 sections on the website International Encyclopedia of World War 1 · 08 October 2014

Fiona Reid

This was a highly comprehensive essay providing case studies of shell shock during WW1 along with the broader historical context of the treatment of soldier's from a psychiatric perspective. It outlined both the historical identification of shell shock, the various neologisms and concepts that ensued, and the subsequent use of forward psychiatry as a means of addressing this (and the PIE method). It had an entire section dedicated to the premises upon which forward psychiatry and NYDN centres were based, along with relevant statistics, information and quotes. It provided a logical, chronologically ordered account of events leading to the widespread use of the system.

Bibliography

Reid, F. (2014). War Psychiatry | International Encyclopedia of the First World War (WW1). [online] Encyclopedia.1914-1918-online.net. Available at: https://encyclopedia.1914-1918-online.net/article/war_psychiatry [Last accessed 12 Sep. 2019].

Wessley, S. and Jones, E. (2001). Psychiatric Battle Casualties: An Intra and Interwar Comparison. [online] Available at: https://www.researchgate.net/publication/12101757_Psychiatric_battle_casualties_An_intra-_and_interwar_comparison [Last accessed 12 Sep. 2019].

Jones, E. and Wessely, S. (2013). Battle for the mind: World War 1 and the birth of military psychiatry. [online] The Lancet. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61260-5/fulltext [Last accessed 12 Sep. 2019].