9

US Army Psychiatry Legacies of the Vietnam War

Chapter 2

US ARMY PSYCHIATRY LEGACIES OF 

THE VIETNAM WAR

NORMAN M. CAMP, MD*

INTRODUCTION

THE INCOMPLETE HISTORY OF ARMY PSYCHIATRY IN THE VIETNAM WAR

THE WAR’S RATIONALE AND PROVOCATION

THE SCOPE OF AMERICA’S WAR IN VIETNAM

AMERICA’S TWO VIETNAM WARS: PRE-TET ‘68 AND POST-TET ‘68

The Buildup Phase (1965–1967): Lyndon Johnson’s War 

The Transition From Buildup to Drawdown (1968–1969)

The Drawdown Phase (1969–1973): Richard Nixon’s War 

POSTWAR FEATURES

Vietnam Veterans and the High Prevalence of Readjustment Problems

Survey of Veteran Army Psychiatrists Who Served in Vietnam

LINGERING QUESTIONS AND CONSIDERATIONS

The Larger Army During the War

The Soldiers Who Served in Vietnam

The Army Psychiatric Component in Vietnam

A Social Stress and “Disease” Model

Veteran Postwar Adjustment Problems

Final Considerations

SUMMARY

*Colonel, US Army (Retired); 3105-D Stony Point Road, Richmond, Virginia 23235; Clinical Professor of Psychiatry, Department of Psychiatry, Medical 

College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23298
10

Combat and Operational Behavioral Health

INTRODUCTION

The US ground war in Vietnam (1965–1972) began 

on March 8, 1965, when over 3,500 men of the 9th 

Marine Expeditionary Brigade made an unopposed 

amphibious landing on the northern coast of the 

Republic of South Vietnam. This was in response 

to intensification in the fighting between South 

Vietnam—an ally of the United States—and indigenous communist forces (Viet Cong guerrillas) and 

those from South Vietnam’s neighbor to the north, 

the Democratic Republic of Vietnam (North Vietnam). 

In early May, the first US Army troops (the 173rd 

Airborne Brigade) arrived in South Vietnam, landing 

at the mouth of the Saigon River at Vung Tau. Thus 

began an enormous military effort by the United 

States and other allies who sought to block the spread 

of communism in Southeast Asia. 

Considering the limited resources of the enemy and 

the superior military might of the United States, it was 

anticipated that the threat could be quickly contained. 

Only belatedly was it discovered that the resolve of 

the communists had been underestimated. The war 

became a drawn out, mostly “low intensity,” “irregular,” counterinsurgency/guerrilla conflict, which 

was far more challenging than expected. The United 

States and its allies had become intractably ensnared in 

Vietnam’s simultaneous and protracted social revolution, civil war, and nationalistic opposition to foreign 

domination. In time, the cost of the war far exceeded 

the tolerance of the American people (over 58,000 

Americans died and over 300,000 were wounded) 

and produced great national agony and incalculable 

cultural aftereffects. Finally, just over 2 years after the 

last US military personnel were withdrawn (March 

29, 1973) under a negotiated truce, North Vietnam 

violated the truce and overran South Vietnam, which 

surrendered on April 30, 1975. 

The war effort also assumed a central role in a 

decade of social and political upheaval in the United 

States—a nightmare that threatened its most basic 

institutions, including the US military. Through the 

second half of the war (1969–1972), an increasing proportion of US troops in Vietnam came to question their 

purpose there. They expressed, in every way except for 

collective mutiny (including psychiatric conditions), 

their inability or unwillingness to accept the risks of 

combat, acknowledge the authority of military leaders, 

or tolerate the hardships of an assignment in Vietnam. 

This all occurred in a setting where combat objectives 

were still in effect, weapons were ubiquitous, violence 

was adaptive, and illicit drugs were effectively marketed and widely used by US troops. The attitudes 

of these young replacement soldiers, most of whom 

were draftees or reluctant volunteers, were strongly 

resonant with the growing opposition to the war in the 

United States. A radicalized, liberal, “counterculture” 

youth movement emerged, along with antagonism 

toward American institutions and, especially, military 

service among younger, black Americans. Facilitative, 

but also emblematic, this dissenting subculture especially rallied around the burgeoning drug culture of 

the times. 

The severe breakdown in soldier morale and 

discipline suffered by the US Army during the drawdown years in Vietnam struck at the heart of military 

leadership. It also overlapped with the mission of 

Army psychiatry. From the outset, the organization 

of psychiatric services in Vietnam was especially 

weighted in favor of the treatment and rehabilitation 

of combat stress casualties. These did not materialize 

in the numbers envisioned, however, and instead 

an unprecedented flood of psychosocial casualties 

emerged. These consisted of disciplinary problems, 

racial disturbances, attacks on superiors, drug abuse, 

and the rising prevalence of soldiers diagnosed with 

character disorders, especially for those in noncombat units and with assignments relatively unrelated 

to combat risks.1

 Military leaders, as well as law enforcement, administrative, and medical/psychiatric 

elements, were all severely tested until the remaining 

US ground forces were withdrawn. 

Following the war, the Army Medical Department 

did not commit to developing a historical summary 

of psychiatry in Vietnam or study these problems for 

“lessons learned.” Furthermore, the Army evidently 

lost, abandoned, or destroyed documentation at the 

conclusion of hostilities that could serve as primary 

source material.2 Vietnam has been referred to as 

America’s first computerized war. Ironically, however, 

the Army apparently emerged from this experience 

with far fewer records pertaining to the provision of 

military psychiatric services than in earlier and less 

“sophisticated” times. In lieu of a more systematic 

approach, this chapter will draw upon the extant 

literature from the war to provide a composite of 

the stressors affecting soldiers sent to Vietnam. It 

will provide an overview of the emergent trends 

in psychiatric conditions and behavioral problems 

faced by Army leaders and the deployed psychiatric 

specialists and their mental health colleagues. It also 

will raise important questions that seem to linger 

despite the three-and-a-half decades since US troops 

left Vietnam—questions for which the answers may 

have considerable bearing for such troops in similar 

wars in the future. 
11

US Army Psychiatry Legacies of the Vietnam War

THE INCOMPLETE HISTORY OF ARMY PSYCHIATRY IN THE VIETNAM WAR

Spanning approximately a decade, from late 1962 

through early 1972, an estimated 135 psychiatrists 

served with the US Army in Vietnam in successive 

cohorts, typically for 1-year assignments.3

 Roughly 

one third of these psychiatrists were trained in Army 

residency programs; the other two thirds received 

their psychiatric education in civilian settings. The 

number of psychiatrists who served in Vietnam was 

considerably fewer than the more than 2,400 psychiatrists who served in World War II. However, those who 

served in Vietnam participated in a war that became 

surrounded with unparalleled social and political 

discord. The associated polarization and tensions of 

the period, especially later in the war, clearly affected 

attitudes within psychiatry and particularly challenged the role and ethics of psychiatry in support 

of the military.

A few publications summarize Army psychiatry 

experience in Vietnam. They primarily focus, however, on observations from the advisor period and 

the buildup phase of the war (1962–1969)3–6 and fail 

to draw sufficient attention to the rampant psychiatric 

and behavioral problems that subsequently developed 

there. Also misleading is the commonly published 

Army psychiatric admission rate for the Vietnam War 

of 12–16/1,000 soldiers per year,7–10 which appears 

quite favorable compared to Korea (28/1,000/y)10 and 

World War II (28–101/1,000/y).11 Utilizing a single 

outcome measure and averaging all 7 years of experience in Vietnam effectively dilutes the 4-fold increase 

in the last few years and minimizes both the breadth 

and the depth of the intersecting morale and psychiatric problems in Vietnam.

In 1975, Jones and Johnson published a preliminary overview of Army psychiatry in Vietnam when 

Johnson was serving as the psychiatric consultant to 

the Office of The Surgeon General, US Army.7

 They 

described common clinical entities and provided gross 

prevalence data, which they associated with changing 

theater circumstances and policy features of the war. 

They left greater detail and synthesis for other accounts 

that, regrettably, failed to materialize. 

Other circumstances also help explain the absence of 

a more complete Vietnam military psychiatry history. 

Until it was forced to study heroin use among soldiers 

late in the war,12–14 the Army undertook relatively 

little formal psychiatric field research in Vietnam after 

regular forces were committed in 1965. Notable exceptions are the study of physiological, psychological, 

and social correlates of stress by Major Peter Bourne, 

Medical Corps, and his colleagues from Walter Reed 

Army Institute of Research (WRAIR), conducted in 

1965 and 1966,15 and the surveys of illegal drug use in 

1967 by RA Roffman and E Sapol,16 and in 1969 by MD 

Stanton.17 Also helpful are publications regarding the 

theater drug abuse epidemic derived from investigative visits to Vietnam late in the war by senior military 

psychiatrists—Colonel Stewart L Baker Jr, Medical 

Corps,18 Colonel Harry C Holloway, Medical Corps,19

and Norman Zinberg, MD, a civilian psychiatrist.20

Anecdotal accounts published by psychiatrists 

who served in the war are also a useful source of 

information.21 Regrettably, some measure of skew is 

introduced because, of the 27 psychiatrists who served 

with the Army and who published accounts, 82% (22) 

were assigned there during the first half of the war 

(1965–1968). Also, of 46 publications from the entire 

group of 24 individuals, half appeared in the US Army 

Vietnam Medical Journal—a nonjuried publication that 

was circulated primarily in Vietnam and ceased publication in 1970. The few articles by psychiatrists who 

served during the drawdown phase of the war when 

psychiatric attrition rates were highest are primarily 

limited to descriptions of local patterns of drug abuse 

or drug treatment programs. 

Besides being generally spotty, the available 

research and historical literature specifically lacks 

validation of the field psychiatric practices and results 

in Vietnam,22 especially the adaptation of the classic 

combat psychiatry “doctrine” (informal) to the irregular, counterinsurgency war that was mostly fought in 

Vietnam and under increasingly controversial circumstances. This chapter will make additional references to 

this doctrine, but it can be summarized as the provision 

of brief, simple, mostly field treatments (eg, safety, rest, 

and physical replenishment); peer support; sedation, if 

necessary; and opportunities for emotional catharsis of 

the soldier’s traumatic events—applied as close to the 

affected soldier’s unit as practical and accompanied by 

expectations that the individual quickly recover, rejoin 

comrades, and reenter the combat situation.23,24

Similar uncertainties surround the use in theater 

of recently developed pharmacologic agents. Vietnam provided military medicine with its first set 

of physicians—especially psychiatrists—routinely 

trained in the use of neuroleptic (antipsychotic), 

anxiolytic (antianxiety), and tricyclic (antidepressant) 

medications. The discovery of these medications 

revolutionized the practice of psychiatry generally; 

they had considerable promise in the management of 

combat stress reactions (CSRs) and other conditions 

in Vietnam. Anecdotal reports indicate that they were 

commonly prescribed throughout the theater for a full 

range of symptoms related to combat stress. A limited 
12

Combat and Operational Behavioral Health

survey in 1967 confirmed their high use by Army 

physicians, including psychiatrists.25 However, there 

were no associated clinical or research studies, and, in 

the aftermath of the war, some have raised questions 

as to whether prescribing psychoactive medications 

for combat-exposed soldiers represented unethical 

medical practice by coercing participation among 

dissenting soldiers.

It is also critical to try to reconstruct the military psychiatry experience in Vietnam to consider the impact 

of the reversal in American approval of the war on the 

clinical decisions of the deployed psychiatrists. Ethical 

and moral reactions to a war and its politics can influence military psychiatrists regarding the diagnosis and 

management of their cases (eg, encourage sympathetic 

overdiagnosis and overevacuation—decisions proven 

in past wars to prolong morbidity in combat-affected 

soldiers).26

In 1982, in an attempt to fill in this missing information, WRAIR queried all veteran Army psychiatrists 

who could be located about their professional experiences in the war. Of the estimated 135 psychiatrists 

who served in Vietnam (133 were men, two were women), 115 were located. Of those, 85 (74%) responded to 

a structured questionnaire exploring patterns of psychiatric problems encountered, types and effectiveness 

of clinical approaches, and personal reactions to the 

associated professional challenges and dilemmas.2,27

Selected study findings will be summarized later in 

this chapter. 

THE WAR’S RATIONALE AND PROVOCATION

To understand how the US government could reach 

a point where it would expend American lives and 

resources to fight a counterinsurgency in Vietnam, 

one must remember that following the end of World 

War II (1945), the United States and its allies soon 

found themselves again in an epic struggle against 

the menace of totalitarianism—this time, Sovietsponsored Marxist communism (the “Cold War”). 

Relations between the two ideological camps were 

typically strained, and a catastrophic nuclear war 

seemed frighteningly possible. For example, between 

1950 and 1953, the United States waged a costly war 

in support of South Korea’s defense against a communist takeover by North Korea. Even closer to home, 

in 1961 the United States came perilously close to 

nuclear war with the former Soviet Union when it 

was discovered that the communist regime of Fidel 

Castro in Cuba had permitted the Soviet placement of 

nuclear missiles on that Caribbean island. The growing perception among Americans was that without 

vigorous opposition by the United States and its allies, 

democracy could be obliterated by a cascade of communist revolutions (the “domino theory”) throughout 

the developing nations of the world, such as those 

in Southeast Asia. Because the United States was a 

signatory of the 1954 Southeast Asia Treaty Organization (with France, the United Kingdom, Thailand, 

Pakistan, Australia, New Zealand, and the Philippines),28 South Vietnam’s struggle to defend itself 

against armed aggression from North Vietnam (in 

violation of the 1954 Geneva Agreement that brought 

an end to the First Indochina War)28 presented a compelling opportunity to draw the line with respect to 

the perceived threat. 

THE SCOPE OF AMERICA’S WAR IN VIETNAM

America’s enemies in Southeast Asia were 2-fold: 

(1) the indigenous Viet Cong guerrilla forces who operated in South Vietnam and who used harassment, 

terrorism, and sabotage as tactics to destabilize the 

government of South Vietnam, and (2) their allies—the 

regular units of North Vietnamese Army, who likewise 

sought a takeover of South Vietnam. 

The pursuit of US military objectives in Vietnam 

became a huge undertaking. The ground war spanned 

over 8 years and by the time the remaining military 

personnel were withdrawn in 1973, 3.4 million American military men and women had served in the theater (typically a single, 1-year assignment), as well as 

offshore with the US Navy and at US Air Force bases 

in Thailand and Guam. When it ended, more than 

58,000 Americans had died (over 47,000 due to enemy 

action or missing in action),29 and more than 300,000 

had been wounded. 

The majority of those who were sent to Vietnam 

served in the Army (60%–80%), thus the majority of 

the casualties also were from the ranks of the Army 

(over 30,000 killed in action [KIA] and over 200,000 

wounded in action [WIA]). Roughly 20% of troops 

actually served in first echelon combat arms, and the 

remainder served in combat support and service support roles. For the most part, Reserve and National 

Guard units were not called up, and the US military, 

especially the Army, resorted to increased conscription 

rates to meet its needs. Although only 25% of the total 

American forces deployed were technically draftees 

(vs 66% in World War II), many more were “draftmotivated” (ie, they enlisted in anticipation of being 
13

US Army Psychiatry Legacies of the Vietnam War

drafted because enlisting improved their chances of 

obtaining a noncombat assignment30(p32)). The average 

age of the Vietnam War soldier was younger (19 years 

old) than those who served in World War II (26 years 

old). They were also better educated than their fathers’ 

generation of soldiers. 

The war in Vietnam is classified as a “limited conventional war” because there were units larger than 

4,000 soldiers operating in the field. However, it became mostly a counterinsurgency war. The war in Vietnam is also referred to as “low intensity” because of the 

low ratio of KIA and WIA to the numbers of personnel 

deployed compared to previous American wars. For 

example, a comparison of the peak years of US Army 

WIA rates during Vietnam (1968 = 120/1,000 troops) 

and Korea (1950 = 460/1,000 troops) suggests a lower 

combat intensity in Vietnam.31 This can be misleading 

because of the smaller proportion of combat personnel compared to those in combat support and service 

support positions in Vietnam (a “tooth-to-tail” ratio 

of 1:5) and the availability of improved medical care. 

According to Ronald Spector, a military historian, 

Men in “maneuver battalions,” the units that actually did the fighting, continued to run about the same 

chance of death or injury as their older relatives who 

had fought in Korea or in the Pacific [in World War 

II]. Indeed, during the first half of 1968, the overall

[author’s italics] Vietnam casualty rate exceeded the 

overall rate for all theatres in World War II, while the 

casualty rates for Army and Marine maneuver battalions were more than four times as high.30(p55)

The data accumulated on the types of wounds sustained in Vietnam are also revealing of the nature of 

combat there. Many more American casualties were 

caused by small arms fire or by booby traps and mines 

than in previous wars, and many fewer were caused by 

artillery and other explosive projectile fragments. 

 At home, an estimated quarter of a million Americans lost an immediate family member to the war. 

South Vietnam’s military casualties numbered 220,357, 

with almost a half million becoming wounded. The 

United States spent $189 billion prosecuting the war 

and supporting the South Vietnamese government. In 

one 12-month period alone—mid-1968 through mid1969, the peak year of US combat activities—America 

and its allies had over 1.5 million military personnel 

deployed (543,000 Americans, 819,200 South Vietnamese, and 231,100 from South Korea, Australia, New 

Zealand, Thailand, and the Philippines combined); 

US forces staged 1,100 ground attacks of battalion size 

or larger (compared to only 126 by the communist 

forces); and there were 400,000 American air attacks 

that dropped 1.2 million tons of bombs, costing $14 

billion.32

AMERICA’S TWO VIETNAM WARS: PRE-TET ’68 AND POST-TET ’68

The American story of the ground war in Vietnam 

should be considered as two Vietnam War stories—

starkly different, sequential stories that pivot on the 

events occurring in 1968. Taken together, these two 

stories portray a dramatic reversal of fortune for 

the United States, a reversal that powerfully shaped 

American culture. 

The Buildup Phase (1965–1967): Lyndon Johnson’s 

War 

Lyndon Johnson was sworn into his first full term 

as President in January 1965, riding the crest of a 

national political consensus and overall prosperity. It 

was only, in the words of Newsweek, that “[n]agging 

little war in Vietnam,”33(p58) that cast a shadow on his 

ambition to create a “Great Society” of social reforms 

as his legacy. Nonetheless, the administration was 

determined to pursue those political agendas as well 

as ensure that South Vietnam did not fall into the communist sphere. 

Preceded by over 10 years of US financial assistance 

and military advisors, US military presence expanded 

rapidly in South Vietnam after the Marine landing 

in 1965. By June 1966, American troops numbered 

285,000, and another 100,000 would be pouring in by 

the end of the year. The number of inductions into the 

US military in 1966 alone was almost 320,000 men, a 

250% increase over the previous year.30

The US Army, Marine Corps, and, in the Mekong 

River Delta, Navy units committed in South Vietnam 

typically found themselves operating in a rugged, 

tropical environment with formidable impediments 

to movement over the ground, extraordinary heat and 

humidity, and monsoonal rains for months at a time. 

Furthermore, combat operations conducted 10,000 

miles from the United States required a very long 

logistical network. These troops also operated among 

an indigenous population of an exotic, Asian culture 

who spoke an exceptionally difficult language for 

Americans to learn. The local Vietnamese appeared to 

tolerate the presence of US troops, but it was common 

for them to be ambivalent about the government of 

South Vietnam and to harbor Viet Cong guerrillas. The 

relationships between US forces and the South Vietnamese were generally strained; US troops regarded 
14

Combat and Operational Behavioral Health

them warily at best.34 US combat units sponsored public relations programs designed to “win the hearts and 

minds” (ie, recruit the loyalty of villagers by providing 

for their welfare and security), but these brought only 

qualified success. 

The combat strategy employed by the US Army 

in the buildup phase in Vietnam was one of attrition 

(body counts and kill ratios),35 primarily through 

search-and-destroy missions initiated from welldefended enclaves. Guerrilla and terrorist operations 

by Viet Cong forces and periodic attacks by North 

Vietnamese regular units were the principle tactics 

of the communist forces. As a consequence, military 

engagements more often involved clashes between 

highly mobile, small tactical units as opposed to battles 

between major military formations. Furthermore, US 

successes were limited because the Viet Cong guerrillas were elusive, dictated the tempo of the fighting, 

and too often were content to snipe, set booby traps, 

and stage ambushes. Their hit-and-run tactics allowed 

them to fade safely into the jungle or into the local 

populace if the fight turned against them—tactics 

ingrained in their culture from centuries of guerrilla warfare against foreign invaders. US forces were 

more likely to find themselves in conventional war 

engagements against regular North Vietnamese divisions in the northern provinces. However, even these 

main force units more often than not staged combat 

initiatives from behind the safety of the 17th parallel 

demilitarized zone that separated North Vietnam from 

South Vietnam, thereby eluding pursuit by US units 

and their allies. Consequently, most combat activity for 

US forces involved brief encounters between isolated, 

small units—a war of no fronts. A Joint Chiefs of Staff 

study reported that of all the US patrols conducted in 

1967 and 1968, less than 1% resulted in contact with 

the enemy.35 Still, when there was contact, the fighting 

was as bloody and intense as any that had occurred 

during World War II. US forces did periodically stage 

larger scale operations during this phase of the war, 

and some elements of these engagements exacted 

heavy tolls on the enemy. 

The US military in the late 1960s enjoyed remarkable technological advantages in Vietnam. Weaponry 

was a prime example. Whether carried with them 

into the field, or employed as tactical support from air 

strikes or artillery, field commanders could bring to 

bear formidable firepower on the enemy. If the enemy 

began to outnumber an allied force in an engagement, 

close support from the air or from artillery quickly reversed the equation. Another element of US technical 

superiority in Vietnam was that of air mobility—the 

ubiquitous helicopter. This was unprecedented in US 

warfare and allowed reconnaissance and ordnance 

delivery from the air, heliborne movement of troops for 

tactical advantage, timely evacuation of the wounded, 

and frequent resupply. In fact, the first full US Army 

combat division to be sent to Vietnam was the 1st 

Cavalry Division (Airmobile).

US Army Medical and Psychiatric Support

A third element in the Vietnam theater that greatly 

enhanced life for the US combat soldier in Vietnam was 

the outstanding medical support available. From the 

outset of the war, the US military made every effort to 

ensure that troops received timely, sophisticated medical attention, including psychiatric care, despite the 

hostile physical environment and Vietnam’s geographical remoteness. The build up of Army medical units 

was completed in 1968 when 11 evacuation, 5 field, and 

7 surgical hospitals were in place. These facilities, plus 

the 6th Convalescent Center in Cam Ranh Bay, brought 

the total bed capacity in South Vietnam to 5,283.31 Most 

importantly, the new helicopter ambulance capability 

also permitted rapid evacuation of the wounded to 

the most appropriate level of medical care. As far as 

physical casualties, these efforts achieved remarkable 

success throughout the war. Comparing the ratio of 

KIA to WIA across wars attests to the superiority of 

medical care provided in Vietnam (World War II, 1:3.1; 

Korea, 1:4.1; and Vietnam, 1:5.6).31

The Organization and Preparation of Army Psychiatrists for Vietnam 

Once the mobilization was under way in 1965, 

Army psychiatrists and allied mental health personnel were rapidly assigned and widely distributed 

throughout the theater. This peaked during the 4 fullstrength years (1967–1970) when approximately 23 

Army psychiatrist positions per year were available. 

In planning to fight in Vietnam, the Army Medical 

Department assumed that the greatest psychological 

threat to the force would be the “breaking point” of 

soldiers exposed to sustained enemy fire (eg, “combat 

exhaustion”—now labeled “combat stress reaction”). 

In anticipating large numbers of these casualties, 

they not only promulgated the treatment philosophy 

developed and refined in World War II and Korea 

(doctrine described earlier),8 they also established 

policies and organizational structures36 borrowed from 

those earlier engagements—a system that weighted 

the psychiatric assets in favor of combat units, even 

though combat-exposed troops would represent less 

than 20% of the Army deployed in South Vietnam.30

Military planners were not only confident that this 

system would promote the conservation of military 
15

US Army Psychiatry Legacies of the Vietnam War

strength, they also believed that it would reduce 

morbidity in affected soldiers. This system centered 

upon assignment of psychiatrists to either a combat 

unit, typically as a division psychiatrist, or to a combat 

service support medical unit, typically a hospital (or 

specialized psychiatric detachment). 

Assignment as a Division Psychiatrist. Throughout the war only the combat divisions (composed of 

15,000–20,000 soldiers), that is, their medical battalions, 

had their own, directly assigned (eg, “organic”) psychiatrists (along with allied mental health personnel). 

The rationale was to embed mental health personnel 

within combat units to provide psychiatric treatment 

capability as far forward as could practically be accomplished.7

 It also permitted the psychiatrist to serve as a 

staff officer of the command of the division and thereby 

provide timely advice on matters affecting morale and 

mental health (eg, “command consultation”).

Assignment as a Hospital Psychiatrist. Alternatively, psychiatrists (along with allied mental health 

personnel) were assigned to Army-level hospitals or to 

the two specialized medical/psychiatric detachments 

(98th and 935th) in Vietnam. They functioned more 

often in a clinical role, and their command authority 

was from higher levels of Army medical command in 

Vietnam (ultimately the US Army Medical Command, 

Vietnam, or USAMEDCOMV, as it came to be called). 

The first priority for these psychiatric elements was 

to provide inpatient treatment for referrals from the 

combat divisions or other primary care facilities. In 

the case of the specialized psychiatric detachments 

(“KO teams” [the “KO” arbitrarily indicated that 

these were hospital augmentation detachments]), 

they offered more extended hospitalized care (up to 

30 days) as well as serving as staging centers for outof-country evacuations for soldiers needing additional 

care. The mission for hospital psychiatrists and their 

mental health colleagues also included the provision 

of outpatient care (eg, the Mental Health Consultation 

Service) for the soldiers from nondivisional (primarily noncombat) units on a regional basis. However, 

because these mental health assets were not part of 

the command structure of these units, mental health 

“command consultation” was far less predictable than 

would be the case in the combat divisions. 

One psychiatrist slot was allocated to each of the 

seven full combat divisions deployed in Vietnam, as 

well as one each to the evacuation and field hospitals. 

These were filled depending on anticipated need and 

psychiatrist availability. In addition, throughout most 

of the war, the two Army neuropsychiatric specialty 

centers were operational and each was to be staffed 

with three psychiatrists. Furthermore, each year of 

the war a senior psychiatrist was to serve in a staff 

position with US Army Vietnam Headquarters as the 

Neuropsychiatric Consultant to the Commanding 

General, United States Army Republic of Vietnam 

(CG/USARV) Surgeon. The central task of the Consultant was to direct the coordination of psychiatric 

facilities and program planning, which required extensive travel throughout Vietnam to visit psychiatrists 

and programs, to provide clinical leadership, and to 

serve as consultant to senior military leaders about 

psychiatric issues. 

The training and indoctrination provided for physicians, including psychiatrists, who would be assigned 

in Vietnam also centered on the limits of soldiers in 

combat, the causes of breakdown under sustained fire 

(social, physical, and emotional), and the prevention 

or management of large numbers of combat-generated 

psychiatric casualties as were encountered in the wars 

preceding Vietnam. This was the case in the Army’s 

two psychiatric residency-training programs (Walter 

Reed General Hospital, Washington, DC, and Letterman General Hospital, San Francisco, California) 

where the principles of prevention and treatment of 

combat breakdown were emphasized in the curricula. 

It was also the case regarding newly commissioned, 

civilian-trained psychiatrists who would be assigned 

in Vietnam. They received their primary orientation to 

military psychiatry at the Army’s Medical Field Service 

School, which was located at Fort Sam Houston in San 

Antonio, Texas. This preparation included only a few 

hours of didactic instruction in military psychiatry, 

and this was primarily regarding the pathogenesis, 

symptoms, and management of combat exhaustion37

and the organization of psychiatric services within the 

combat division.38

The Relative Infrequency of Classic Combat Exhaustion Casualties in Vietnam

In time it became evident that the large numbers of 

combat exhaustion casualties that were predicted and 

planned for in Vietnam never materialized. The only 

overview of the psychiatric problems in the Vietnam 

War, published by Jones and Johnson, did not report 

theater-wide incidence statistics for combat exhaustion 

specifically,7

 although they were apparently collected 

by USAMEDCOMV.9 Although these authors attested 

to the fact that the incidence throughout the war was 

“extremely low,”7(p53) Jones and Johnson added some 

confusion by referring to all hospitalized psychiatric 

patients in Vietnam as “combat psychiatric casualties.” 

They also acknowledged that disagreements as to 

diagnostic criteria produced major problems in collecting and comparing incidence statistics for combat 

exhaustion in Vietnam, or even between wars. Boman, 
16

Combat and Operational Behavioral Health

an Australian psychiatrist, provided corroboration in 

his postwar analysis of military psychiatry practices in 

Vietnam. He illustrated significant diagnostic confusion in the literature, and he posited that US military 

psychiatrists systematically, if inadvertently, mislabeled combat-generated psychological problems as 

character disorders, resulting in inappropriate administrative or disciplinary dispositions as well as spuriously lowering apparent incidence rates.39 Finally, the 

only official summary of US Army medical experience 

in Vietnam (covering the war up through May 1970, 

two thirds into the war), which was authored by Major General Spurgeon Neel, does not mention combat 

exhaustion or any other forms of combat-generated 

psycholopathology.31

Also hampering the collection of data regarding 

combat exhaustion casualties in Vietnam was the fact 

that, by definition, it is a reversible, stress-generated, 

psychosomatic regression that, when treated early and 

effectively, typically remits within a couple of days. As 

a consequence, many cases would have been treated 

at lower echelons of medical care and thus not be included in hospitalization rates.40,41

Approximations of CSR incidence measures in 

Vietnam came in the form of comparisons of the 

number of hospitalized CSR cases with those for other 

psychiatric conditions. The overview by Colbach and 

Parrish of US Army mental health activities in Vietnam 

through the first two thirds of the war reported 7% 

of all psychiatric admissions were diagnosed as CSR, 

but unfortunately they did not include data sources.6

A smaller window, but one with more specific data, 

is provided by Major Peter Bourne, Medical Corps, 

Chief, Neuropsychiatry, WRAIR Medical Research 

Team in Vietnam (1965–1966). While comparing US 

Army psychiatric hospitalization rates in Vietnam 

with those of the Army of the Republic of Vietnam 

during the first 6 months of 1966, Bourne found 6% 

of US Army psychiatric admissions were diagnosed 

as combat exhaustion.9

 Captain HSR Byrdy, Medical 

Corps, division psychiatrist (1965–1966) with the 1st 

Cavalry Division (Airmobile) reported a true CSR rate 

for his division of 1.6/1,000 troops per year; however, 

he also comments, “What gets referred [to the division 

psychiatrist] depends on the tactical situation of the 

unit [and] one is hard-pressed to know what a real 

incidence is.”41(p50) Still, these figures are consistent 

with an unusually low incidence, at least for the first 

half to two thirds of the war. In addition, in a postwar 

survey of psychiatrists who served with the Army in 

Vietnam, 32% reported that they had only rare exposure to combat-induced psychiatric casualties.27

All this is not to say that the specialized treatment 

of combat exhaustion was not an important challenge in Vietnam; just that it was never at the level 

(numbers) that had been anticipated, and that in time 

it was greatly overshadowed by other unanticipated 

psychiatric conditions and behavior problems.

Morale in the Buildup Phase: Consensus at Home 

and Esprit in Vietnam

During the war’s first 3 years, opposition at home 

was only gradually building, whereas draft call-ups 

quickly gathered momentum to meet the huge personnel needs in Southeast Asia. Because reserve units and 

the National Guard were, for all practical purposes, 

exempted from deployment in Vietnam throughout 

the war, the ground forces were composed of a mix 

of career soldiers, draftees, and volunteers (including many draft-motivated volunteers). Although the 

combat could at times be very intense during these 

initial years, and the cities and countryside were not 

secure, morale and sense of purpose remained high 

among the troops fighting in Vietnam. Furthermore, 

attrition due to psychiatric or behavioral problems was 

exceptionally low compared to previous conflicts. This 

was somewhat surprising considering the psychologically depleting nature of the remote, exotic, hostile, 

tropical setting and the enemy’s guerrilla tactics and 

resolute tenacity.42

Throughout the war, soldiers fighting in Vietnam 

encountered certain novel features that distinguished 

the theater from those of previous wars and invariably 

affected morale. For example, the battlefield ecology 

was powerfully affected by the helicopter mobility of 

US ground forces; the enemy’s elusiveness but lack 

of a capacity to deliver sustained, precision-guided 

indirect fire (as with artillery and combat aircraft); and, 

especially, the overall US strategy of fighting a war of 

attrition as opposed to one for territorial control. The 

psychosocial complexion of the “rear” was unique. 

US troops typically staged combat activities from geographically isolated, fixed, relatively secure enclaves 

that were easily resupplied by helicopter. The high 

ratio of combat support and service support troops 

to combat troops (5:1) was also unusual compared to 

earlier wars. 

Efforts to understand soldier stress and resilience in 

Vietnam also have to take into account the influence 

of the draft (stress inducing) as well as the effect of 

the military’s replacement policy of individualized, 

1-year tours. The 1-year tour was intended to be stress 

reducing because these soldiers would perceive their 

obligation and risk as limited.9,31 However, over time 

the resultant churning and ultimate depletion of experienced military personnel in the theater (including 

officers and noncommissioned officers [NCOs]) also 
17

US Army Psychiatry Legacies of the Vietnam War

had a hugely negative effect on commitment and cohesion, and consequently morale.29,30

Still, according to General Westmoreland, Commander, US Military Assistance Command, Vietnam 

(COMUSMACV), the troops operating in Vietnam during the buildup years were “the toughest, best trained, 

most dedicated American servicemen in history.”43(p34)

More specific to the Army in Vietnam, Retired Brigadier General SLA Marshall, combat veteran of World 

War I and front-line observer in World War II and 

Korea, commented after his extended visit in 1966: 

My overall estimate was that the morale of the troops 

and the level of discipline of the Army were higher 

than I had ever known them in any of our wars. 

There was no lack of will to fight and the average soldier withstood the stress of engagement better than 

ever before.43(p34)

The observations and interpretations by military 

sociologist Charles Moskos from his time in Vietnam 

as a war correspondent between 1965 and 1967 are 

especially useful in understanding the morale, stress, 

and psychosocial adaptations of the soldiers serving 

in those initial years. Moskos reported high morale 

and combat motivation despite the rigors of the counterinsurgency warfare and the extremely inhospitable 

setting. He believed this arose out of the linkage between the soldiers’ individual self-concern (heightened 

because of the 1-year, individual rotation system) and 

devotion to the other soldiers in the immediate combat 

group (eg, instrumental interdependencies motivated 

by the functional goal of survival). He also observed 

their shared belief in an exaggerated masculine ethic 

as well as a “latent ideology” of devotion to US ideals, which stemmed from their conviction regarding 

the supremacy of the US way of life. Furthermore, 

the soldiers he studied were notably apolitical and 

antagonistic toward peace demonstrators (“privileged 

anarchists”) at home.44

Psychiatric investigator Bourne’s comments from 

his year in Vietnam are also illuminating. He reported 

that soldiers in these early years maintained a positive 

motivation in part through what he labeled “combat 

provincialism.” 

They are not only unconcerned about the political 

and strategic aspects of the war; they are also disinterested in the outcome of any battle that is not in 

their own immediate vicinity. . . . [The soldier] retains 

certain deep allegiances and beliefs in an . . . amorphous positive entity, “Americanism,” which allow 

him to justify his being sent to Vietnam.9(p44)

Bourne especially credited the fixed, 1-year tour for 

soldiers for the continued high morale, but he also 

expressed concern for its consequent disturbance to 

the “solidarity of the small unit”—the traditional stress 

protection system for combat soldiers.

Buildup Phase Psychiatric Overview

Correlating with the observations of high esprit 

and commitment, troop attrition due to psychiatric or 

behavioral dysfunction was exceptionally low as well 

during those first few years. The proportion of medevacs out of Vietnam for psychiatric reasons (3%–4%) 

compared quite favorably with that for the Korean 

conflict (6%) and for World War II (23%).23 Rates for deviant behaviors for the same period were also low (eg, 

the annual stockade confinement rate was 1.15/1,000, 

compared to the expected overseas rate of 2.2).4 Some 

senior Army psychiatric observers attributed this to 

an array of operational and preventive factors that 

appeared to protect the soldiers from psychiatric and 

behavioral difficulties: (a) technological superiority 

and the professionalism of the troops; (b) fixed, 1-year 

assignments; (c) high-quality leadership; and (d) adequate supplies, equipment, and support—especially 

medical support.7,23,45,46 Others also credited the application of the aforementioned doctrine of combat 

psychiatry.47,48

Although alcohol use and abuse was predictably 

a common stress outlet for these soldiers,7 military 

leaders and the psychiatric contingent were primarily concerned with the use of illegal drugs by troops, 

especially the locally grown marijuana, which was 

readily available and highly potent. In their survey 

regarding drug use patterns of 584 lower ranking 

enlisted soldiers departing Vietnam in 1967, Roffman 

and Sapol reported that of the 32% who acknowledged 

ever smoking marijuana, 61% began in Vietnam and 

one quarter were considered heavy users (greater 

than 20 times during their 1-year tour in Vietnam). 

The authors concluded that the extent of marijuana 

use in Vietnam was very similar to that among civilian peers.16 Furthermore, in the opinion of Bourne, 

marijuana use created almost no psychiatric problems.9

Use of opiates was also reported in Vietnam, but it was 

not as pure as that sold after 1970 and was not used by 

soldiers in sufficient numbers to constitute a serious 

problem for command.17

One psychological phenomenon that did attract a 

fair amount of attention from military psychiatrists 

was the phasic nature of moods and attitudes affecting soldiers during the course of their 12-month tour 

of duty in Vietnam: (a) “immersion shock” and fearfulness; (b) then mastery and reduced preoccupation 

with home, but with some depression, resignation, 
18

Combat and Operational Behavioral Health

and flight into a “hedonistic psuedocommunity”; 

(c) followed by growing combat apprehension and 

a “short-timers syndrome.”7,49,50 The latter refers to a 

low-grade form of disability often exhibited in combat 

soldiers who were within 4 to 6 weeks of their date of 

expected return from overseas (DEROS). Symptoms 

consisted of reduced combat tolerance and efficiency; 

increasing fear about being killed or wounded; and 

sullen, irritable, or withdrawn behavior. This had also 

been noted among troops serving in the Korean War 

after fixed, individualized tours were first introduced 

there in mid-1951.51

Overall, the incidence of psychiatric and behavioral difficulties among the deployed Army troops 

in Vietnam in these initial years was held to levels no 

greater than if they were still stateside. Satisfaction 

was expressed that adequate psychiatric resources had 

been deployed from the start in contrast to previous 

wars.3,8 To that effect, Bourne confidently, if prematurely, declared the end of the military-medical problem of combat psychiatric casualties: “The Vietnam 

experience has shown that we have now successfully 

identified most of the major correlates of psychiatric 

attrition in the combat zone.”47(p487)

Buildup Phase Psychiatrist Reports

The morale and confidence of the deployed Army 

psychiatrists during these early years also appeared to 

be high. This is suggested both in the large numbers 

who were inspired to publish professional accounts 

and the role satisfaction that these reports reveal. 

Taken together, these psychiatrists reflect optimism 

and tout the effectiveness of the traditional doctrine of 

combat psychiatry in Vietnam, the utilization of newly 

developed pharmacologic agents (anxiolytics and 

neuroleptics), and the extension of principles of social 

psychiatry to military leaders (command consultation). 

Simply scanning selected titles provides an impression 

as to the predominant psychiatric challenges faced 

through these early years in the war (Exhibit 2-1).

More specific to the growing antiwar sentiment in 

the United States, two Army psychiatrists who served 

in the buildup phase and published accounts, Captain 

AS Blank Jr and Captain HS Bloch, commented specifically that they did not believe the growing opposition 

to the war was significantly affecting their patients. 

Blank, who served early in this phase (1965–1966), 

commented, 

Do the ambiguities of the war seem to be a problem 

for the soldiers? The answer is very simply, “No.” I 

did not see a single patient in whom I felt that any 

kind of conflict about the war on any level was primary in precipitating his visits to me.41(p58)

Bloch, who served 2 years later (1967–1968) in the 

same area as Blank, asserted that in his experience, 

soldiers who struggled with concerns regarding the 

morality of the conflict typically were driven by preVietnam psychological conflicts.40 Nonetheless, considering what followed, it is apparent that time was 

running out on positive morale in Vietnam. 

The Transition From Buildup to Drawdown 

(1968–1969)

1968 Surprise “Tet” Offensives and Perceptions of a 

Lost War

The year 1968 was the bloodiest year in Vietnam 

for US forces (16,592 KIA), and events both at home 

and in Southeast Asia served as the tipping point in 

US sentiment for pursuing military objectives there. 

During the month of May alone, 2,000 Americans 

were killed—the highest monthly death toll of the 

war.52 June 13th marked the day that Americans had 

been fighting in Vietnam longer than any prior war. 

However, the greatest negative effect arose from the 

enemy’s “Tet” offensives. 

On the morning of January 31st, communist guerillas broke the Tet (or Lunar New Year) truce and 

launched coordinated attacks on cities and towns 

throughout South Vietnam. Although they were 

ultimately extremely costly to the communist forces 

and achieved little militarily, their political yield was 

enormous. Many held the US media accountable for 

misinterpreting these events as signaling a US defeat 

and provoking a reversal in public and political support for war.53 Nonetheless, these attacks, as well as 

the month-long, bloody battle to retake Hue and the 

prolonged siege of the Marine base of Khe Sanh, created the indelible perception in the United States that 

the war could not be won. The enemy appeared to defy 

the Johnson administration’s assurances of imminent 

defeat, and nowhere in the country seemed secure 

despite great expenditures of lives and money. As a 

consequence, calls for the war to end became urgent 

and trumped most other considerations. 

On March 31, 1968, President Johnson announced 

that he would halt the bombing over North Vietnam 

as a prelude to peace negotiations. He also declared 

that he would not seek reelection in service of that end. 

Ten days later he announced that General Creighton 

Abrams would relieve General William Westmoreland, the original commander, United States Military 

Assistance Command, Vietnam (USMACV). Still, it 

wasn’t until a year later, mid-1969, that the first Army 

units pulled out of South Vietnam. America had begun to disengage, yet the fighting continued amid 

tortuous peace negotiations, continued assignment 
19

US Army Psychiatry Legacies of the Vietnam War

EXHIBIT 2-1

SELECTED PUBLICATIONS BY BUILDUP-PHASE ARMY PSYCHIATRISTS (INCLUDING 

RESEARCH REPORTS)

Year in 

Vietnam

No. Who Published 

Articles/Total No. Deployed Army Psychiatrists (as a percentage)* Publications

1965 1/7 (14.2%) Huffman RE. Which soldiers break down: a survey of 610 psychiatric patients in Vietnam. Bull Menninger Clin. 1970;34:343–351.

Bourne PG. Urinary 17-OHCS levels in two combat situations. In: Bourne 

PG, ed. The Psychology and Physiology of Stress: With Reference To Special 

Studies of the Viet Nam War. New York, NY: Academic Press; 1969: 95–116. 

Research report. 

1966 6/16 (37.5%) Conte LR. A neuropsychiatric team in Vietnam 1966–1967: an overview. In: 

Parker RS, ed. The Emotional Stress of War, Violence, and Peace. Pittsburgh, 

Penn: Stanwix House; 1972: 163–168.

Johnson AW. Psychiatric treatment in the combat situation. US Army Vietnam 

Med Bull. 1967;January/February:38–45. 

Jones FD. Experiences of a division psychiatrist in Vietnam. Mil Med. 

1967;132:1003–1008.

Dowling JJ. Psychological aspects of the year in Vietnam. US Army Vietnam 

Med Bull. 1967;May/June:45–48.

Tischler GL. Patterns of psychiatric attrition and of behavior in a combat 

zone. In: Bourne PG, ed. The Psychology and Physiology of Stress: With Reference to Special Studies of the Viet Nam War. New York: Academic Press; 1969: 

19–44. 

Kenny WF. Psychiatric disorders among support personnel. US Army Vietnam Med Bull. 1967;January/February:34–37.

1967 12/22 (54.6%) Roffman RA, Sapol E. Marijuana in Vietnam: a survey of use among Army 

enlisted men in two southern corps. Int J Addict. 1970;5:1–42. Research 

report.

Anderson JR. Psychiatric support of the 3rd and 4th Corps tactical zone. US 

Army Vietnam Med Bull. 1968;January/February:37–39.

Baker WL. Division psychiatry in the 9th Infantry Division. US Army Vietnam 

Med Bull. 1967;November/December:5–9.

Bloch HS. Brief sleep treatment with chlorpromazine. Comp Psychiatry. 

1970;11:346–355.

Bostrom JA. Management of combat reactions. US Army Vietnam Med Bull. 

1967;July/August:6–8.

Casper E, Janacek J, Martinelli H. Marijuana in Vietnam. US Army Vietnam 

Med Bull. 1968;September/October:60–72.

Evans ON. Army aviation psychiatry in Vietnam. US Army Vietnam Med Bull. 

1968;May/June:54–58.

Fidaleo RA Marijuana: social and clinical observations. US Army Vietnam Med 

Bull. 1968;March/April:58–59.

Gordon EL. Division psychiatry: documents of a tour. US Army Vietnam Med 

Bull. 1968;November/December:62–69.

Motis G. Psychiatry at the battle of Dak To. US Army Vietnam Med Bull. 

1968;March/April:57.

Pettera RL, Johnson BM, Zimmer R. Psychiatric management of combat reactions with emphasis on a reaction unique to Vietnam. Mil Med. 

1969;134:673–678.

Talbott JA. The Saigon warriors during Tet. US Army Vietnam Med Bull. 

1968;March/April:60–61.

*These numbers do not count research reports, although they are listed in the Publications column.
20

Combat and Operational Behavioral Health

of replacement troops (albeit in decreasing numbers 

after mid-1969), and a progressively confrontational 

antiwar/antimilitary faction stateside. The war took on 

characteristics of a tedious, agonizing stalemate, and 

the lack of tangible measures of progress contributed 

to the widespread feelings of futility and frustration 

about the war.

Emerging Demoralization and Dissent

The contentious and protracted counterinsurgency 

war soon started to have corrosive effects on successive 

cohorts of replacements sent to fight there. Budding 

demoralization and dissent during these pivotal years 

began to reveal itself especially in racial incidents and 

widening drug use (particularly marijuana, but also 

commercially marketed stimulants and barbiturates) 

by soldiers. Law enforcement figures demonstrated 

an increase of over 260% in the number of soldiers 

involved with possession or use of marijuana during 

1968 as compared to the previous year.30 Also, excessive combat aggression (atrocities) seemed to become 

more prevalent.54–57 According to Ronald Spector, 

who served as a Marine field historian in Vietnam 

(1968–1969), 

as the war ground on through its third and fourth 

year, the prestige of performing a mission well proved 

increasingly inadequate to men who more and more 

could see no larger purpose in that mission, and no 

end to the incessant patrols, sweeps, and ambushes 

which appeared to result only in more danger, discomfort, and casualties.30(p61)

Spector also noted that the evolving stalemate in 

Vietnam came to resemble the bloody trench warfare 

of World War I, a battle in which both sides grossly 

underestimated the other.30(p314)

Journalist Donald Kirk reported from the field in 

1969 that 

[t]he attitudes of GIs [slang for “government issue”] 

did not turn seriously until Fall of 1968 when President Johnson stopped the bombing of North Vietnam and agreed to enter into peace talks . . . .The 

change in [soldier] attitudes was so sudden . . . [as 

compared to earlier] they by and large applauded the 

[antiwar] demonstrators . . . the senselessness of the 

struggle.58(p61)

Correspondent JP Sterba provides observations 

on the shifting demographics and particularly the attitudes of the soldiers who went to fight in Vietnam 

in 1969. He demonstrated how the rapidly unfolding political events in the United States caused the 

romance and idealism of the early war to be replaced 

by a “hated, dreary struggle” in which the soldier’s 

overriding preoccupation was that of self-protection: 

These were the grunts of the class of 1968—they had 

come out of that America some of their commanders had seen only from the windows of the Pentagon. 

They were the graduates of an American nightmare 

in 1968 that stemmed mostly from the war they had 

now come to fight—the year of riots and dissention, 

of assassinations and Chicago, the year America’s ulcer burst.59(p447)

Transition Phase Psychiatric Overview

The official summary of US Army medical experience in Vietnam through May 1970 made note of rising 

annual incidence rates for psychiatric conditions beginning in 1969 (from 13.3/1,000 for 1968, to 25.1/1,000 

through first quarter of 1970). It also underscored that 

this increase did not covary with the dropping rates 

for WIA, the traditional measure of combat intensity—

a correlation that had been true in previous wars.31

The principle author of this report, Major General 

Spurgeon Neel, attributed this uncharacteristic rise in 

psychiatric disorders to dissenting soldier subgroups 

who were motivated by racial, political, or drug culture 

priorities, and to the widening use of illegal drugs by 

soldiers in Vietnam. However, because this review only 

encompassed the first two thirds of the war and was 

not published until 1973, after the troops were withdrawn, it failed to illuminate the fuller, more ominous 

picture in a timely fashion. 

Published more contemporarily in 1970, the Army 

Psychiatry Consultant to the Surgeon General, Colonel 

Matthew Parrish, and the Assistant Consultant, Major 

Edward Colbach, both of whom had served in Vietnam, did broadcast their concern about the rise in the 

psychiatric casualty rate in Vietnam up through mid1970. In their opinion this was a consequence of the 

increase in racial tensions and the general decrement 

in perception of military purpose within the soldier. 

They correctly predicted that the intent to disengage 

from Vietnam would likely produce accelerating 

psychiatric problems among those newly assigned 

there.6

 However, despite this warning, there were no 

structural changes in the organization of mental health 

assets in Vietnam nor modifications in the selection, 

preparation, or deployment of mental health personnel 

sent as replacements to the theater. 

MD Stanton17 reported sizable increases in the use of 

most drugs from a survey of drug use patterns among 

soldiers entering or departing Vietnam in late 1969, 

which he compared with results from the 1967 survey 

by Roffman and Sapol. Stanton speculated, however, 

that marijuana and some other drugs might actually 
21

US Army Psychiatry Legacies of the Vietnam War

allow certain types of individuals to function under 

the stresses of a combat environment and separation 

from home. 

As far as comparisons with the US Marines fighting 

in Vietnam, Lieutenant Commander JA Renner Jr, a 

Navy psychiatrist who served in the Vietnam theater 

in 1969, noted a similar rise regarding disciplinary 

problems, including racial disturbances, attacks on 

superiors, drug abuse, and the number of men diagnosed with character disorders (“hidden casualties”). 

He expressed his concern that military psychiatrists 

were premature in touting the low rate for psychiatric 

difficulties in the war.60 (He did not publish until 1973, 

after the Marines had left Vietnam.)

Transition Phase Psychiatrist Reports

Army psychiatrists serving in these years were 

mostly not inspired to publish accounts of their professional experience in Vietnam compared to those 

who served in the buildup phase. Indeed, the titles 

suggest increasing attention to challenges surrounding 

GI drug use and other morale issues and away from 

combat-related problems. Still, dissent within the ranks 

appears not to be a subject of major concern by these 

psychiatrists (Exhibit 2-2).

The Drawdown Phase (1969–1972): Richard Nixon’s 

War 

The second half of the war took on a starkly different character from the first half. By January 1969, 

when President Nixon succeeded President Johnson, 

the United States had been at war in Vietnam for 4 

years. Nixon promised “peace with honor,” negotiations with the enemy, and a gradual withdrawal of 

troops, while confronting extreme impatience and 

often violent protest in America.61 With the change of 

command in Vietnam, the military strategy of attrition 

shifted to a defensive one that sought area security 

and “Vietnamization” of the fighting. Enemy offensive 

activity also slackened. Overall US troop strength in 

Vietnam peaked at 543,400 in mid-1969 and declined 

through the next 3 years until all combat forces were 

EXHIBIT 2-2

SELECTED PUBLICATIONS BY transition-PHASE ARMY PSYCHIATRISTS (INCLUDING 

RESEARCH REPORTS)

Year in 

Vietnam

No. Who Published 

Articles/Total No. Deployed Army Psychiatrists (as a percentage)* Publications

1968 3/22 (13.6%) Colbach EM, Crowe RR. Marijuana associated psychosis in Vietnam. Mil 

Med. 1970;135:571–573.

Colbach EM, Willson SM. The binoctal craze. US Army Vietnam Med Bull. 

1969;March/April:40–44. 

Forest DV, Bey DR, Bourne PG. The American soldier and Vietnamese 

women. Sex Behav. 1972;2:8–15.

Postel WB. Marijuana use in Vietnam: a preliminary report. US Army Vietnam 

Med Bull. 1968;September/October:56–59. 

1969 2/22 (9.1%) Bey DR. Change in command in combat: a locus of stress. Am J Psychiatry. 

1972;129:698–702.

Bey DR, Smith WE. Organizational consultant in a combat unit. Am J Psychiatry. 1970;128:401–406.

Bey DR, Zecchinelli VA. Marijuana as a coping device in Vietnam. Mil Med. 

1971;136:448–450. 

Master FD. Some clinical observations of drug abuse among GIs in Vietnam. 

J Kentucky Med Assn. 1971;69:193–195.

Stanton MD. Drug use in Vietnam. Arch Gen Psychiatry. 1972;26:279–286. 

Research report.

*These numbers do not count research reports, although they are listed in the Publications column.
22

Combat and Operational Behavioral Health

withdrawn. US operations of battalion size or larger 

slowly began to decline beginning in mid-1968.62 Still, 

despite the reduction of combat operations and the 

peace negotiations, which proceeded erratically, US 

service personnel continued to die there (15,316 from 

1969–1972). 

In 1969, the US public was horrified to learn that 

in 1968 several hundred Vietnamese civilians of the 

hamlet of My Lai had been massacred by a US Army 

unit.63 Although there had been previous reports of 

atrocities by US troops, this incident seemed to verify 

the public’s worst fears about the war being senseless 

and destructive.

“America’s war” had become prolonged, stalemated, 

and costly; the sense of national purpose and resolve 

was dropping fast. Furthermore, the abandonment of 

hopes for military victory in Vietnam had a powerfully 

negative effect on the country, the institution of the US 

Army,64–66 and especially those whose fate it would be 

to serve during the drawdown in Vietnam and who 

would be required to fight battles of disengagement 

amid pressures from home to oppose the war and the 

military.62 Simultaneously waging war and pursuing a 

peace with the enemy undermined the commitment of 

these soldiers compared to those deployed in the first 

few years of the war. This commitment was replaced 

with alienation, disaffection, and sagging morale. In 

retrospect, gradually rising rates for psychiatric conditions and behavior problems during 1968 and 1969 

signaled a brewing discontent and dissent within the 

ground forces deployed on a massive scale. 

Cultural Polarization in America and the Vietnam 

War

To fully understand the psychosocial forces affecting the soldiers sent to Vietnam, one must appreciate 

the powerful and often clashing cultural crosscurrents 

in the United States that surrounded them in the late 

1960s and early 1970s. This history must be viewed 

against the backdrop not only of the nation’s post–

World-War-II experience and subsequent Cold War 

tensions between the United States and the former 

Soviet Union, but also of the advent of television coverage of the war, the assassination of President John 

Kennedy in 1963, and the coming of age of the post–

World-War-II “baby boom” generation. 

The years surrounding the Vietnam War (1965–

1975) represented an excruciatingly volatile period in 

American life. Intense and often militant challenges to 

government institutions, especially the military and 

the war in Vietnam, were increasingly made by: (a) a 

progressively disapproving American public, (b) the 

rising civil rights and black pride movements, and (c) 

the emerging New Left and a dissenting youth counterculture (the “generation gap”). They, in turn, were opposed by an equally fervent and reactive conservative 

sector. The prolonged, costly war in Vietnam served as 

a rallying point, both pro and con, for their passions 

and ambitions. These three movements, fostered by 

an expanding drug culture, variously fed and were 

fed by a widening crisis within the military overall 

(unprecedented demoralization and alienation), and in 

Vietnam especially. As they synergistically intersected, 

they generated a groundswell of opposition to military 

service among draft-eligible men.

Public Opposition to the War and Political Activism. Over the course of the war larger and louder 

antiwar protest rallies, marches, and demonstrations 

took place in the United States, with some reaching the 

level of riots. The new television coverage of the war 

brought the costs and the political turmoil in Vietnam 

straight into the living rooms of US citizens and most 

likely accelerated the public’s perception that the war’s 

justification was questionable, despite reassurances 

from both the Johnson and Nixon administrations. 

The steadily growing public disapproval of the 

war in Vietnam can be traced through a series of nationwide Gallup opinion polls conducted during the 

war years in which respondents were asked: “In view 

of the developments since we entered the fighting in 

Vietnam, do you think the US made a mistake sending troops to fight in Vietnam?” In 1965, only 25% 

thought US military involvement was a mistake (vs 

60% who said “No”), but by 1971 these factions had 

almost completely reversed (60% saying “yes,” it was 

a mistake, and only 30% disagreeing).67

Following the insertion of ground troops in March 

1965, the growing personnel requirements in Vietnam 

resulted in dramatically accelerated draft calls. For 

example, total inductions in 1965 were about 120,000; 

those for 1966 and 1967 were two-and-a-half times 

the 1965 figure. As opposition to the war mounted, 

the draft became the epicenter of the antiwar protest 

until the military switched to an all-volunteer force in 

1973.30 With each passing year, as the need for more 

troops became evident, additional criteria for draft 

exemption were removed to increase the pool of eligible draftees. In 1968, in an effort to blunt the public’s 

growing concern for unevenness and inconsistency in 

the Selective Service System, the draft was modified 

to a lottery system, based on birthdays. On December 

1, 1969, the first drawing was held. Men then knew 

the likelihood of being drafted based on where their 

birthdays fell; however, for those selected and sent to 

Vietnam under this new, random system, their sense 

of injustice was compounded.68 Ultimately 4 million 

young men were exempted by high lottery numbers; 
23

US Army Psychiatry Legacies of the Vietnam War

more than 200,000 young men were accused of draft 

offenses.68

The Counterculture and Youth/Student Opposition to the Vietnam War. Opposition to US involvement in Vietnam began slowly in 1964 on various college campuses as part of a more general rising spirit of 

student activism. In addition to various liberal causes, 

“free speech,” “free love,” “peace,” and “do your 

own thing” were also popular. The means employed 

to indicate opposition included political advocacy, 

civil disobedience, “sit-ins,” “teach-ins,” and generally 

nonviolent resistance to the status quo. 

A succession of tremendous shocks ushered in a 

more fervent antiestablishment spirit: the assassination of President Kennedy in the autumn of 1963; 

the first ghetto uprisings in the summer of 1964; the 

escalation of the war in Vietnam beginning in 1965 

and the impact of the draft; the 1968 assassinations 

of presidential candidate Robert Kennedy and civil 

rights leader Reverend Martin Luther King; and, also 

in 1968, the enemy’s surprise Tet offensives and other 

seeming military setbacks in Vietnam. The result was 

widespread impatience with the prospects for orderly 

change through more peaceful, passive means, and 

deep cynicism and mistrust of American institutions 

and “anyone over 30.” The “Woodstock generation,” 

named after the huge rock festival held in upstate New 

York in August 1969, and it’s “summer of peace and 

love” were quickly fading memories as the movement 

took on a more radical perspective and accepted a more 

open, and at times violent, revolutionary approach.

As one measure, surveys of student attitudes in 

1969 revealed that although only 2% of college youth 

were highly visible activists, roughly 40% of their 

peers held similar views (“protest prone”), signifying 

a true generation gap. Among this larger group, approximately half endorsed the belief that the United 

States was a sick society and acknowledged a loss of 

faith in democratic institutions. Two thirds endorsed 

civil disobedience to promote their causes, especially 

antiwar protests and draft resistance.69

Emergent Black Pride Movement and Racial 

Tensions. In 1948, President Harry Truman put forth 

an executive order directing the nation’s military 

services to eliminate all vestiges of racial segregation. 

Since then, many positive gains made in the status of 

black Americans can be directly attributed to the men 

and women who served in the military. However, 

the burgeoning civil rights movement in the 1960s 

heightened black soldiers’ awareness of disparities 

(with accusations of discrimination) in positions and 

roles for blacks in the military, especially among the 

younger soldiers and particularly regarding combat 

exposure and risk.62,70

For instance, during the initial years in Vietnam, 

questions were raised as to whether blacks represented 

an unfair proportion of the combat casualties. In fact, 

for the period 1965 to 1966 in each of the deployed 

combat divisions, the proportion of deaths of AfricanAmericans exceeded the proportion of African-American soldiers in the division. However, closer analysis 

revealed that, overall, blacks did not serve in Vietnam 

out of proportion to their numbers in the general 

population; and rather than racially-driven policies, 

various other social and cultural factors (eg, levels of 

education and socioeconomic status) served to select 

African-Americans for greater risk in Vietnam.30 Still, 

beginning in 1967, the military began to reduce the 

numbers of black soldiers assigned to infantry, armor, 

and cavalry units in Vietnam, and by mid-1969 the percentage of black casualties was close to the percentage 

of blacks serving in Vietnam.70

Racial tensions in America became explosive following the assassination of Reverend Martin Luther 

King in April 1968. Racial protests and riots erupted 

at numerous US military installations worldwide, 

including in Vietnam. The most notorious in Vietnam 

was in August 1968, when black confinees seized the 

Long Binh stockade and held it for almost a month. 

These sentiments coincided with the rapid evolution of a more radical “black power” faction, which 

advocated a black pride revolution and rejected assimilation in American culture as a central goal for 

African-Americans. Career military blacks were often 

caught between their loyalty to the military and the 

attitudes of the younger, black enlisted soldiers who 

were restive and expected solidarity from them regarding questions of discrimination. As the war wound on, 

younger blacks increasingly opposed sacrifices and 

risks in what they perceived as a racially inspired war 

(eg, against other people of color).71,72 They dismissed 

it as a “white man’s war” and asserted their intention 

to return home to take up the fight against repression 

and racism in America.73

Soldier Resistance and the “GI” Underground 

Movement. As opposition to the war mounted, public 

attitudes in the United States toward returning veterans reversed from acceptance to scorn. This left those 

who chose, or were directed, to serve in Vietnam as 

replacements conflicted as to what represented patriotic, morally justifiable behavior, as well as less certain 

regarding the inherent risks and hardships they faced 

there. Johnston and Bachman74 compared results of 

surveys of draft-eligible men conducted in spring 1969 

and again in summer 1970, regarding their plans and 

attitudes toward military service. In that short span 

of time the majority shifted from identifying with US 

political and military policies in Vietnam to feeling 
24

Combat and Operational Behavioral Health

alienated from the greater society, the government, and 

USinvolvement there.74 The roughly 4-fold Army-wide 

increase in rates for absent without leave (AWOL) and 

desertion during the period from 1964 to 1974 provides 

a measure of the growing opposition to serving over 

the course of the war.75

Organized dissent within the military did not 

emerge until 1967 and disappeared in 1973 once combat units were out of Vietnam. It apparently was slow 

in its development because its inspiration required 

the angst of returning veterans to be combined with 

draftee resistance. In time, a vicious cycle developed 

in which returning veterans publicly repudiated their 

Vietnam service record, including joining war protest 

organizations such as Vietnam Veterans Against the 

War, which in turn encouraged prospective Vietnam 

soldiers to oppose service there. In the United States 

this essentially first-term enlistee and draftee antiwar 

resistance movement was especially promulgated 

through “alternative culture” GI coffee houses, underground newspapers (estimated to exist on 300 posts 

and bases),51(p234) antiwar protest petitions, and support 

from civilian antiwar groups. 

As it turned out, most soldiers in Vietnam were not 

true antiwar protestors and, overall, the GI resistance 

movement had only limited success.76 Still, although 

the antiwar movement within the Vietnam-era military 

failed to reach revolutionary proportions for several 

reasons, especially the lack of sympathetic civilians 

in Vietnam, its emergence was unique in US history 

and some believed it accelerated withdrawal from the 

war.51 Others argued that it emboldened the enemy 

and thus dragged out the peace negotiations and prolonged the war. Nonetheless, military and government 

officials were quite concerned about its effects. 

The Spreading Drug Culture and Its Effects on 

Soldiers Sent to Vietnam. The incidence of illegal drug 

use among teens and young adults in the United States, 

especially psychedelics and marijuana, rose rapidly 

in the 1960s in tandem with the emerging dissidence 

of this group. Various studies were conducted during 

the Vietnam era comparing drug use among soldiers 

with their civilian peers. For example, a nationwide 

study of psychoactive drug use by young men at the 

close of the Vietnam War indicated that the peak of the 

drug epidemic was 1969 to 1973, and that veterans, 

regardless of where they served, showed no higher 

rates than nonveterans.77 Regarding measures among 

the military in the United States, a survey of drug use 

at a stateside military installation in 1970, 1971, and 

1972 showed the percentage of respondents reporting premilitary drug use increased as did the amount 

of use and the number of current users.78 A study of 

pattterns of drug use among 5,482 active duty enlisted 

men assigned to 56 separate Army units in the United 

States between January 1969 and April 1969 found 

one quarter of subjects acknowledged past use of 

marijuana, amphetamines, lysergic acid diethylamide 

(LSD), or heroin.79 Two years later a similar survey of 

19,948 new military inductees between January 1971 

and June 1971 found that almost one third acknowledged civilian drug use.80

Among soldiers sent to Vietnam, Sapol and Roffman 

surveyed 584 enlisted soldiers departing Vietnam in 

1967 (31.7% reported use of marijuana at least once) 

and concluded that the rates were comparable with 

those reported in published studies among university 

students.81 In a survey of soldiers entering or departing 

Vietnam 2 years later, Stanton found a sizable increase 

in the reported use of marijuana among those leaving 

Vietnam (28.9% vs 50.1% respectively compared to 

the 1967 survey). Most of this was accounted for by 

the increase reported by soldiers entering Vietnam. 

However, Stanton did find a shift toward heavier 

use among his sample of departing enlisted soldiers 

(29.6% compared to the 7.4% from the earlier study). 

Nonetheless, his impression was that the rise in casual 

marijuana use in Vietnam mostly mirrored rising use 

patterns among civilian peers.82

Regarding heroin use, a 1972 heroin use survey 

comparing 1,007 noncombat Army soldiers in Vietnam 

simultaneously with 856 counterparts assigned to a 

stateside post found that 13.5% of Vietnam soldiers 

and 14.5% of those stateside reported previous use 

of heroin. The authors compared their findings with 

published surveys, concluding that a heroin epidemic 

occurred in Vietnam earlier in the 1970s, but that any 

conclusion that “such an epidemic ‘[w]as unique’ . . . 

and ‘infected’ many average US soldiers appears inaccurate and misleading.”83 Taken together, these studies strongly verify that younger enlisted soldiers, not 

surprisingly, brought into the service and into Vietnam 

their drug use habits from civilian life. 

Disputes About the Ethics of Combat Psychiatry

The shifting social and political zeitgeist in the latter 

half of the war—particularly the accelerating antiwar 

and antimilitary sentiment—began to affect psychiatrists and psychiatry, and provoked concerns about 

cooperating with the military. Debates—typically quite 

passionate—that questioned the ethics of psychiatrists 

who performed draft evaluations84–88 or served with 

the military, especially in Vietnam39,89–93 appeared in the 

professional literature beginning in 1970. Denunciation 

of military psychiatry came both from psychiatrists 

and other physicians who had served in Vietnam, as 

well as from those who had not.26
25

US Army Psychiatry Legacies of the Vietnam War

Mental health organizations also sought to take 

official positions on the war. Even if not specifically 

questioning the ethics of their colleagues in uniform, 

they nevertheless questioned the morality of the US 

military and government. In March 1971, 67% of members responding to a poll of the American Psychiatric 

Association voted that the United States should terminate all military activity in Vietnam.94 In July 1972, 

the American Psychological Association joined seven 

other mental health associations in attacking the US 

role in the war. Their public statement included, “we 

find it morally repugnant for any government to exact such heavy costs in human suffering for the sake 

of abstract conceptions of national pride or honor.”95

Defense of professional support for the US forces was 

published by several psychiatrists, most of whom had 

served in Vietnam.5,6,96–99

Mounting Biopsychosocial Stressors in the Combat 

Theater Ecology

In the second half of the war, even though more 

troops were leaving than were sent as replacements, 

hostilities and dangers continued. The successive cohorts of replacement soldiers in Vietnam were deeply 

affected by the moral crisis at home, which included 

increasingly radical US politics, especially regarding the war, and a rapidly expanding drug culture. 

Furthermore, the annualized troop rotation schedules, rapid and wholesale transportation of soldiers 

and media representatives, and modern technology 

all promoted the accelerated infusion of a growing 

antiwar, antimilitary sentiment into the ranks of the 

military there. Unrelenting public opposition to the 

war may have accelerated the US pullout, but the 

process demoralized those who were sent there during 

the drawdown years. Understandably, many soldiers 

interpreted antiwar sentiment as criticism of them 

personally—not the war more generally. The uncertain 

combat results in the theater and vacillating—at times 

contradictory—government policies and military 

strategies regarding prosecuting the war and pursuing 

the peace were also demoralizing. 

This demoralization and alienation of soldiers in 

the Vietnam theater often took the form of psychiatric 

and behavioral problems, especially drug abuse, racial 

incidents, and misconduct, and presented problems 

for the Army and Army psychiatrists on an unprecedented scale. These were even more of a problem 

among soldiers in the “rear,” but even within combat 

units, troops covertly, and at times overtly, challenged 

authority (eg, combat refusal incidents, “search and 

avoid” missions, excess combat aggression). Matters 

became even more serious after a Vietnamese-based 

heroin market began to flourish in the spring of 1970 

and large numbers of US soldiers became users. It took 

9 months to institute an effective urine drug screening 

system that would permit the military to comprehend 

and react to this insidious and widespread problem 

of self-inflicted soldier dissent and disability. Equally 

disturbing to the Army in Vietnam were the incidents 

of soldiers attacking their superiors, typically with 

explosives (“fragging”—named after the fragmentation grenade). Like the widening use of heroin by 

soldiers, such attacks became increasingly common in 

the drawdown phase of the war.62,100 Although there 

are no official figures, data presented by Gabriel and 

Savage identified a total of 1,016 incidents (for all 

branches) for the years 1969 through 1972 (eg, “actual 

assaults” combined with incidents where “intent to 

kill, do bodily harm, or to intimidate” was suspected).65

Whereas assassination of officers and NCOs had been 

seen in earlier wars to a limited degree, typically under 

combat circumstances, the Vietnam theater is distinct 

in that not only was the prevalence of such incidents 

exceptionally high, but these attacks occurred more 

often in rear areas with the tacit approval of peers.101

Thus, despite the reduction in combat levels, Army 

leadership and the medical/psychiatric contingent in 

Vietnam became increasingly consumed with problems associated with the wholesale demoralization 

and alienation of soldiers—symptoms of a seriously 

compromised Army that were competing for attention 

with the challenge of preparing the South Vietnamese 

military to take over from the United States and its allies. Furthermore, by now the deployed psychiatrists 

were surrounded by a professional literature that was 

mostly critical of the military psychiatric structures and 

doctrine that were applied in Vietnam.26

An especially thorough historical series on the Vietnam War by the Boston Publishing Company included 

vivid descriptions of the various expressions of the 

contempt for the war and the South Vietnamese shared 

by US military forces in the last years of the war:

The daily round of random death and incapacitation from mines and booby traps, combined with 

short-timers fever and skepticism about the worth 

of “search and clear” steadily lowered American 

morale.62(p97)

The authors give ample witness to the pervasive 

demoralization in the theater and the brittle nature 

of race relations, primarily within noncombat units. 

They also document the associated weakening of the 

military legal system. According to these authors, 

combat refusals, drug problems, and racial strife often 

proved impossible to resolve in the last years in Viet-
26

Combat and Operational Behavioral Health

nam. While punishments tended to be increasingly 

lenient, commanders openly acknowledged that rather 

than hunt the enemy or carry out a tactical mission, 

they considered their primary responsibility to be to 

return their men safely home. “It sometimes seemed 

to be little more than a ragtag band of men wearing 

bandannas, peace symbols, and floppy bush hats, with 

little or no fight left in it.”43(p16)

Similarly, Balkin’s historical review of the severe 

breakdown in morale and effectiveness of the US 

military in Southeast Asia during this phase of the 

war provided thoroughly referenced data indicating 

an unprecedented increase in rates of combat refusals, combat atrocities, heroin use, assassinations (or 

threats) of military leaders, racial conflicts, desertion 

and AWOL, and the emergence of the GI antiwar 

movement.51 It also underscored the corrosive effects 

on morale and cohesion consequent to pervasive careerism among military leaders (“ticket punching,” 

an emphasis similarly brought to bear by Gabriel and 

Savage65).

Kirk, a journalist reporting from the last years of 

the war, noted that,

[i]t is, in reality, a desultory kind of struggle, punctuated by occasional explosions and tragedy, for the 

last Americans in combat in Vietnam. It is a limbo 

between victory and defeat, a period of lull before 

the North Vietnamese again seriously challenge allied control over the coastal plain, as they did for the 

last time in the Tet, May and September offensives 

of 1968. For the average “grunt,” or infantryman, 

the war is not so much a test of strength under pressure, as it often was a few years ago, as a daily hassle 

to avoid patrols, avoid the enemy, avoid contact—

to keep out of trouble and not be the last American 

killed in Vietnam.58(p65)

More ominous is the investigative report by Linden, another journalist, about his visit in 1971. Linden 

covered much of the same ground as those mentioned 

above, but he provided case examples and other observations. These included corroboration from Captain 

Robert Landeen, an Army psychiatrist assigned to the 

101st Airborne Division. Linden dynamically depicted 

the circumstances and meanings that combined to 

produce a class war between leaders and subordinates 

in Vietnam, often with fragging as its final result. He 

described how fraggings and other threats of violence 

were commonly used as a means of controlling officers 

and NCOs: “[fragging in Vietnam became] prevalent, 

passionless, and apparently unprovoked, representing the grisly game of psychological warfare that GIs 

use.”100(p12)

Not surprisingly, the Army’s pernicious morale and 

discipline problems were mirrored on a comparable 

scale among the Marines fighting in Vietnam. The official review of US Marine activities late in the war acknowledged rampant combat atrocities, “friendly fire” 

accidents, combat refusals, racial strife, drug abuse, 

fraggings, and dissent.102 William Corson, a retired 

Marine lieutenant colonel (expert on revolution and 

counterinsurgency warfare, and a veteran of World 

War II, Korea, and Vietnam), blamed the military’s 

demobilization problems in late Vietnam (drug use, 

dissent, and racial incidents) on both America’s failure 

in Vietnam and to an “erosion of moral principle within 

the military.”103(p100) He referred to the rise in fragging 

incidents as a new service-wide form of psychological 

warfare and an aspect of institutionalized mutinous 

behaviors (along with sabotage, evasion of leadership 

responsibilities, and internecine conflict). According 

to Corson, “[a]s with fragging, the potential for a mutinous refusal to carry out an order is so widespread 

[in Vietnam] that routine actions are being avoided by 

those in charge.”103(p99)

Drawdown Phase Psychiatric Overview

Traditional Military Psychiatry Indices. The summary of Army neuropsychiatry in the Vietnam War 

provided by Jones and Johnson illustrated a dramatic 

rise in the standard indices of psychiatric attrition 

during the last few years of the war.7 As noted previously, the inpatient hospitalization rate had hovered 

around 12–14/1,000 soldiers per year through the first 

3 years of the war7–9—favorable compared to figures 

for Korea (73/1,000) and World War II (28–101/1,000).11

However, the rate started to rise in 1968, doubled by 

April 1970, and doubled again by July 1971, reaching 

an annualized rate of 40/1,000. From there it dropped 

rapidly until the remaining troops were pulled out in 

March 1973, apparently primarily because the Army 

relaxed its medevac policies (in Vietnam only) for 

drug-dependent soldiers, which ordinarily would 

have excluded them104 (Figure 2-1).

Especially dramatic is the skyrocketing out-of-country psychiatric evacuation rate, which had remained 

below 4–5/1,000 troops per year throughout the war 

until 1971. By July 1971, it had risen to 42.3, and by 

the following year, July 1972, the rate had climbed to 

129.8. In other words, at that point in the war, one out 

of every eight soldiers was being medically evacuated 

from Vietnam for psychiatric reasons (primarily for 

heroin dependency). 

As a corollary, the percentage of neuropsychiatric 

evacuations among all medevacs from Vietnam also 

accelerated. It had remained below 5% but rose to 30% 

in late 1971, and by late 1972 it was at 61%. By 1971, 
27

US Army Psychiatry Legacies of the Vietnam War

Figure 2-1. US Army Vietnam rates per 1,000 troops for battle 

deaths,1

 psychiatric hospitalization,2 and psychosis.3

1

US Army Adjutant General, Casualty Services Division 

(DAAG-PEC). Active duty Army personnel battle casualties and nonbattle deaths Vietnam, 1961–1979, Office of The 

Adjutant General counts. February 3, 1981.

2

Datel WE. A Summary of Source Data in Military Psychiatric 

Epidemiology. Alexandria, Va: Defense Documentation Center; 1976. Document ADA 021-265.

3

Jones FD, Johnson AW, Jr. Medical and psychiatric treatment 

policy and practice in Vietnam. J Social Issues; 1975;31(4):49-

65.

DEROS: date of expected return overseas

more soldiers were being evacuated from Vietnam 

for drug use than for war wounds.82 However, taken 

alone this could overstate the case for spiraling neuropsychiatric rates because the WIA rate was declining 

simultaneously.

It is of special note that the doubling rate for psychosis in 1969 and 1970 in Vietnam (see Figure 2-1) from 

its rather historically predictable 2/1,000 troops per 

year presented a paradox for Army psychiatry. Because 

it coincided with an Army-wide rise in the psychosis 

rate, it was initially explained by Jones and Johnson 

as secondary to the influence of illegal drugs in confusing the diagnosis.7

 Subsequently, Jones noted that 

the psychosis rate reverted back to its historical levels 

only in the Vietnam theater and only after the Army 

allowed drug-dependent soldiers to utilize medevac 

channels.105 He speculated that the rising rates also 

reflected the tendency for Army psychiatrists and other 

physicians in Vietnam to mislabel soldiers “who did 

not belong overseas” as psychotic (eg, insinuating the 

physicians’ intent to manipulate the system).105

Behavior Problems and Misconduct. In themselves, these traditional measures of psychiatric 

morbidity are startling. Equally disturbing, however, 

during the drawdown years in Vietnam the Army 

also saw a concomitant rise in behavioral problems 

as measured by rates for: (a) judicial and nonjudicial 

(Article 15) disciplinary actions,106 (b) noncombat 

fatalities,107 (c) combat refusals,62 (d) corruption and 

profiteering,30,51 (e) racial incidents,30,51 (f) convictions 

for the specific crime of “fragging,”108,109 and, especially, 

(g) use of illegal drugs. Army mental health personnel 

often became involved with these types of problems 

and sought to apply traditional means and models but 

with uncertain results.

Heroin Epidemic. As already suggested, the exponential increase in heroin use by lower ranking soldiers 

from 1970 on—a problem that overlaps the realms of 

psychiatry and military leadership (discipline and 

morale)—greatly confounded the psychiatric picture 

in Vietnam in the latter third of the war. Jones and 

Johnson substantiate that the rapidly rising, late-war 

psychiatric admissions/evacuations were primarily 

for narcotic use once urine drug screening technology 

became available in June 1971. This greatly increased 

military detection capability, increased the jeopardy 

for drug-using soldiers, and consequently affected 

prevalence measures. DoD statistics estimate 60% of 

soldiers in Vietnam late in the war were using marijuana, and 25% to 30% were using heroin.62 Robins’ 

follow-up study of Vietnam veterans’ drug use in 1972 

found that 44% of the general sample reported having 

tried some narcotic while in Vietnam (compared to 7% 

who acknowledged using heroin before assignment 

there).110 Even more ominous, deaths (confirmed by 

autopsy) attributed to drug abuse rose to a peak of 

15 for the month of November 1970 before starting to 

slowly recede.111

Stanton’s review of the most credible drug use 

prevalence studies conducted through the course of the 

war underscores that although the rise in drug use in 

Vietnam between 1966 and 1970 is best explained with 

the rise in pre-Vietnam use, the meteoric rise in heroin 

use beginning in 1970 is not. Instead, the rise coincides 

with the deteriorating social and political features in 

the United States and the sudden availability of very 

inexpensive, almost pure heroin in Vietnam.82 Because 

the heroin was so cheap, pure, and accessible, soldiers 

in Vietnam most commonly mixed it with tobacco and 

smoked it in ordinary-looking cigarettes. Some soldiers 

preferred to snort heroin (insufflation), and a minority 

injected it intravenously. 

Some insight into the world of the heroin-using 

soldier in Vietnam comes from the sociological studies of Ingraham.112 He interviewed opiate-positive 

40

35

30

25

20

15

10

5

0 1965 1966 1967 1968 1969 1970 1971 1972

9.42 15.6 21.6 36.3 28.4 15.7 11.7 17.1

6.98 11.8 9.8 12.7 15.4 25.2 31.3 10.4

1.58 1.83 1.78 3.63 4.35 2.43 2.2

Army battle

death rates

Army psychosis

 rate

Army psychiatric

hospitalization rate

DEROS drug

screen begins

(June 1971)

Heroin

market

begins

(spring

1970)
28

Combat and Operational Behavioral Health

soldiers recently returned from Vietnam in late 1971 

and presented findings regarding drug-use patterns.

He noted the fraternal social network described by 

his respondents (that existed within the larger but 

basically approving body of soldiers) and the various 

status distinctions that existed within this “head” society. The soldiers rationalized heroin use as a necessary 

adaptation to the unique stressors in Vietnam (not 

typically combat stress), considered their use to be 

minor because they had not injected drugs, and denied 

any need for further treatment. Most contended that 

they were able to maintain their habits without loss 

of function. The jargon of these soldiers exalted the 

enlisted “heads” and denigrated the “lifers/juicers” 

(NCOs and officers). For Ingraham, heroin use was 

not especially representative of a political ideology 

(antiwar), but instead it reinforced the appreciation 

of an extended network of associates with whom a 

member could express antimilitary sentiments accompanied with an intense sense of acceptance and 

belonging.112

The “Amnesty Program.” As noted in Neel’s report, 

Army Medical Support in Vietnam, “Growing awareness of the nature and extent of the drug problem in 

Vietnam led to a search for a flexible, non-punitive 

response.”31(p48) Ultimately, the “Amnesty Program,” 

an adaptation of Army Regulation 600-32 (Drug Rehabilitation/Amnesty Program), became US Army Vietnam 

(USARV) policy.113 This policy outlined procedures and 

conditions regarding a one-time-only “amnesty,” as 

well as stipulated the elements that should comprise 

a unit’s rehabilitation program (“for restorable drug 

abusers, when appropriate, and consistent with the 

sensitivity of the mission”). Efforts at implementation 

saw major commands hastily improvise treatment/

rehabilitation programs and facilities that utilized resources at hand and reflected a diversity of approaches 

for soldiers voluntarily seeking drug abstinence. In 

time, however, it became evident these were mostly 

failed efforts. The only variable that predicted successful heroin abstinence was the soldier nearing his 

DEROS.20,114,115 Consequently, the military was forced 

to resort to a law enforcement approach wherein units 

were subjected to unannounced urine screening. Soldiers found to have morphine breakdown products in 

their urine were quarantined in detoxification centers 

and, when medically cleared, returned as medevac patients to one of 34 Army hospitals in the United States 

for further evaluation and treatment. As of September 

21, 1971, 92,096 soldiers had been screened and 5.2% 

(4,788) had tested positive.18 However, these numbers 

must considerably underrepresent actual prevalence 

in Vietnam because soldiers preparing to leave were 

highly motivated to discontinue their heroin use in 

order not to delay their departure. 

Effects of the Heroin Problem in the Theater and 

Postdeployment. The most serious concern arising 

from the heroin problem was the effect of soldier 

drug use on military preparedness and effectiveness. 

According to Spector, few if any soldiers used drugs 

in combat, although some believed that after a battle 

it helped calm them down.30 From another approach, 

Holloway and his research colleagues concluded that 

drug abuse among US military forces represented a 

“significant threat to combat readiness.”116

On the plus side, the great apprehension of government and military leaders that the military would 

release large numbers of addicted Vietnam returnees 

onto the streets of the United States proved baseless. 

Not only did a controlled research study of withdrawal 

patterns of heroin-dependent soldiers conducted in 

Vietnam demonstrate a surprisingly mild physiological withdrawal despite high levels of heroin tolerance,12

other studies in the United States revealed that these 

soldiers generally did not return to heroin use.117 From 

Stanton’s postwar perspective, given the remission rate 

of 95% for heroin-using soldiers once they returned 

stateside and the lack of data indicating that heroin 

use degraded individual or group performance in 

Vietnam, the question can be raised as to whether 

heroin use there really was more deleterious than 

the alcohol use of previous wars.82 In support of that 

perspective, Zinberg recalled from his 1971 inspection 

visit in Vietnam a military judge telling him that 80% 

of his heroin use cases received top efficiency ratings 

from their commanding officers.20

Drawdown Phase Psychiatrist Reports

As in the tranisition phase, few Army psychiatrists 

deployed during the drawdown phase of the war 

published accounts of their experiences. Those who 

did publish wrote about the epidemic of soldier heroin 

use and implied that their efforts to respond to this 

and related problems of soldier demoralization and 

dissent through traditional psychiatric models mostly 

failed (Exhibit 2-3).

Two accounts from this period seem especially 

illuminating. Major R Ratner served with the 935th 

Medical (psychiatric) Detachment on the Long Binh 

post near Saigon (August 1970–August 1971) and later 

documented his experience there (“Drugs and Despair 

in Vietnam”), which mostly addressed the challenge of 

the heroin epidemic.118 Ratner conveyed a dark picture 

of military life in Vietnam at that time. He considered 

his caseload to be only a fraction of the estimated 30% 

of all younger, lower-ranking soldiers who used heroin 

regularly; and that they in turn only partially reflected 
29

US Army Psychiatry Legacies of the Vietnam War

EXHIBIT 2-3

SELECTED PUBLICATIONS BY DRAWDOWN-PHASE ARMY PSYCHIATRISTS (INCLUDING 

RESEARCH REPORTS)

Year in 

Vietnam

No. Who Published 

Articles/Total No. Deployed Army Psychiatrists (as a percentage)* Publications

1970 2/20 (10%) Char J. Drug abuse in Vietnam. Am J Psychiatry. 1972;129:463–465.

Ratner RA. Drugs and despair in Vietnam. U Chicago Magazine. 1972;64:15–

23. 

1971 1/13 (7.7%) Joseph BS. Lessons on heroin abuse from treating users in Vietnam. Hosp 

Community Psychiatry. 1974;25:742–744.

Holloway HC. Epidemiology of heroin dependency among soldiers in Vietnam. Mil Med. 1974;139:108–113. Research report. 

1972 0/1 (0.0%) Holloway HC, Sodetz FJ, Elsmore TF, and the members of Work Unit 102. 

Heroin dependence and withdrawal in the military heroin user in the US 

Army, Vietnam. In: Annual Progress Report, 1973. Washington, DC: Walter 

Reed Army Institute of Research; 1973: 1244–1246. Research report.

*These numbers do not count research reports, although they are listed in the Publications column.

the pervasive demoralization within the larger military 

population in Vietnam. Although alluding to likely 

individual premorbidity factors in the drug-dependent 

soldier, Ratner credited more their universal despair, 

which he attributed to a combination of societal factors 

(eg, America’s motivation for waging war in Southeast 

Asia represented a displacement of its internal “racial 

hostilities”) and an “inhumane” Army. Furthermore, 

he acknowledged the sense of clinical impotence he 

shared with his colleagues (“there seems to be no place 

for a psychiatrist to begin”) and appeared to echo the 

cynicism of his soldier-patients.118

Equally troubling is the publication of Lieutenant 

Commander HW Fisher, a Navy psychiatrist who 

served with the 1st Marine Division during the same 

year as Ratner, only far to the north near Da Nang. 

According to Fisher, of 1,000 consecutive referrals, 

he diagnosed 960 Marines as personality disorders, 

usually antisocial.119 Furthermore, although he differs 

from Ratner in attributing their military dysfunction 

to predisposition (eg, he labels them with personality 

disorder diagnoses), Fisher especially faulted their 

officers and NCOs for encouraging indiscipline. He 

felt that this occurred through vacillations in enforcing regulations and argued that these problems were 

exacerbated by expectations that psychiatry provide 

medical evacuation out of Vietnam or recommend 

administrative separation from the service in lieu of 

punishment, thus serving as encouragement of the 

deviant Marine’s rebellion.119

Taken together, the record from this phase suggests 

the morale of some of these psychiatrists suffered a 

serious decrement parallel to that of the typical soldier 

of that period. More importantly, it also indicates that 

the psychiatric contingent, like the military leadership 

in Vietnam, was wholly unprepared to contend with 

the extensive proportion of US troops who would 

in time oppose serving under the post-Tet (1968) 

circumstances through antimilitary behaviors and 

psychological disability.

POSTWAR FEATURES

Vietnam Veterans and the High Prevalence of Readjustment Problems

A comprehensive review of postdeployment adjustment and psychiatric morbidity is outside the scope 

of this chapter. However, the data indicate that many 

who served in Vietnam subsequently experienced serious and sustained readjustment problems, including 

frank posttraumatic stress disorder (PTSD). Some suggest that the prevalence of debilitating psychological 

and social problems among Vietnam veterans greatly 

exceeds that for earlier US wars. Additionally, when 
30

Combat and Operational Behavioral Health

postdeployment adjustment difficulties are included 

with psychological problems that arose in the theater, 

the psychosocial cost for the Vietnam War appears 

unprecedented.

However, estimates as to the prevalence of sustained postwar adjustment and psychiatric problems 

for Vietnam veterans seem to vary as widely as the 

political reactions to the war itself.22,120–125 Furthermore, 

comparisons of the psychosocial effect of combat 

service across US wars is especially difficult because 

measures are inconsistent. Somewhat reassuring, a 

1980 Harris Poll of Vietnam veterans commissioned by 

the then Veterans Administration found 91% reporting they were glad they had served their country, 74% 

said they enjoyed their time in the service, and nearly 

two thirds said they would go to Vietnam again, even 

knowing how the war would end.29

Nonetheless, rising professional concern for the 

psychological injury of veterans secondary to service in 

Vietnam brought about a revolutionary change in the 

taxonomy of psychiatric disorders in civilian medicine. 

In the decade that followed the war, the International 

Classification of Disease, 9th edition, Clinical Modification (ICD-9-CM),126 and the Diagnostic and Statistical 

Manual of Mental Disorders, 3rd edition (DSM-III),127

both contained the new category “Post-Traumatic 

Stress Disorder or PTSD,” which had been originally 

called “post-Vietnam syndrome.” The inclusion of 

PTSD in DSM-III reflected the political efforts of the 

Vietnam veterans who were seeking greater recognition, as well as the efforts of Americans with residual 

antiwar sentiment and psychiatrists who believed that 

DSM-II had neglected the ordeal of combat veterans.128

In that DSM-III includes combat as an etiological factor 

for PTSD, it suggests that overwhelming combat stress 

and civilian catastrophes are identical—a proposition 

that seems arguable. 

The most definitive findings regarding PTSD prevalence and incidence following the Vietnam War come 

from the government-sponsored National Vietnam 

Veterans Readjustment Study (NVVRS). At the time of 

the study (mid-1980s), approximately 30% of male and 

27% of female study participants had evidenced PTSD 

at some point since serving in Vietnam, and for many 

PTSD had become persistent and incapacitating (15% 

and 9% of study participants respectively).129

However, divergence from the emphasis in the 

original PTSD model (the traumatic event is singularly 

explanatory) has occurred. Over the years since the 

war, disputes have arisen as to the relative weight to 

give various etiologic influences (eg, predisposition 

and personality, traumatic extent of combat theater 

circumstance, and post-Vietnam experience). These 

disputes have complicated the diagnosis and treatment of PTSD and related adjustment difficulties. 

Many behavioral science observers have commented 

on the considerable potential for postwar adjustment 

difficulties to be powerfully affected by psychological 

and social dynamics that are not the direct consequence of combat zone “trauma.”39,123,130–132 According to Arthur S Blank Jr, a former Army psychiatrist 

who was assigned in Vietnam and who subsequently 

served for many years as National Director for the 

Department of Veterans Affairs Readjustment Counseling Centers, 

[s]ince 1973 I have treated, evaluated, supervised the 

treatment of, or discussed the cases of approximately 1,400 veterans of Viet Nam with PTSD and have 

yet to hear a single case where the veteran’s symptoms were not accompanied by either (1) significant 

doubts or conflicts about the worthiness of the war, 

or (2) considerable anger about perceived lack of 

support for the war by the government or the nation. 

Furthermore, although researchers have been barred 

from exploring the relationship between the occurrence of PTSD and the overwhelmingly conflicted 

nature of the war, it is the observation of almost all 

clinicians who have treated substantial numbers of 

Viet Nam veterans with PTSD that the clinical condition is almost always accompanied by a deeply 

flawed sense of purpose concerning what happened 

in Viet Nam.133

Following the cessation of hostilities in Southeast 

Asia, the ethical challenges to military psychiatry, 

which were voiced during the war, shifted to retrospectively critical conclusions regarding negative 

long-term consequences of field psychiatric practices 

in Vietnam (the aforementioned doctrine). The perspective seems to be that the implementation of these 

practices may have been in the service of collective 

goals (eg, military objectives), but in the process it 

ignored the needs of the soldier and fostered the development of PTSD.39,134–136 Offsetting opinion came 

from Blank, who noted that acute CSRs usually do 

not meet the criteria for PTSD and do not generally 

evolve into diagnosable PTSD later.137 It also came 

from Jones, who argued vigorously that postwar 

sympathies for maligned Vietnam veterans may 

have led psychiatrists without military experience 

to misunderstand the unique aspects of a soldier’s 

state when psychological defenses become overwhelmed in combat. As a consequence they fail to 

appreciate the characteristically fluid and reversible 

nature of the resultant acute stress disorder and the 

increased risk for psychiatric morbidity (including 

PTSD) if treatments do not promote symptom suppression and rapid return to military function and 

comrades.138
31

US Army Psychiatry Legacies of the Vietnam War

Survey of Veteran Army Psychiatrists Who Served 

in Vietnam

As mentioned earlier, in 1982 WRAIR queried 

veteran Army psychiatrists who served in Vietnam 

about their experiences in the war.2,27 Of the estimated 

135 who served in Vietnam, 115 were located, and of 

those, 74% (85) completed a structured questionnaire 

exploring patterns of psychiatric problems encountered, types and effectiveness of clinical approaches, 

and personal reactions to the associated professional 

challenges and dilemmas. Study respondents were 

evenly distributed over the years of deployment in 

Vietnam so that the gleaned information can be considered representative. Also, in the theater, 21% (18) 

served exclusively in combat units (roughly one third 

of the slots each year), 49% (42) served exclusively 

in combat service support medical units (eg, with 

hospitals or the psychiatric specialty teams), and 25% 

(21) spent some time assigned to each. The remaining 

four served exclusively as the theater “Neuropsychiatric Consultant” to the CG/USARV Surgeon. The 

following summarizes the most salient findings from 

the study:

• Unprecedented levels of predeployment professional training. The degree of formal psychiatric training shared by these psychiatrists was 

unprecedented in contrast to World War I and 

World War II, as was the proportion of deployed psychiatrists who received residency 

training in Army programs (one third).139

• As theater problems progressively increased, predeployment military experience among replacement 

psychiatrists decreased. Although the psychiatrists who served in Vietnam averaged little 

postprofessional training experience in the 

military, greater numbers of civilian-trained 

psychiatrists with no practical military background, as well as an increasing proportion 

of military-trained psychiatrists with no field 

experience, were sent during the second half 

of the war. In the first half of the war these two 

groups constituted only one quarter of the assigned psychiatrist strength. In the second half 

they represented three quarters. This decline 

in practical experience, which characterized 

successive groups of psychiatrists sent to 

Vietnam, was mirrored in an equally salient 

reduction in relevant background experience, 

though not rank, of the Vietnam theater Neuropsychiatric Consultant to the CG/USARV 

Surgeon.

• Psychosocial disorders progressively outweighed 

combat-generated ones. Regarding the distribution of patients by standard psychiatric diagnoses, these veteran psychiatrists reported 

over one half of their clinical efforts were 

devoted to personality disorders, adjustment 

reactions, or substance abuse syndromes. 

Furthermore, 32% (24) of the study participants reported that they had only rare 

exposure to combat-induced psychiatric 

casualties during their tours. Similarly, the 

mean percentage of clinical caseload devoted 

to “combat reactions” for all psychiatrists in 

the study was only 12.6%. These findings 

appear to validate that Vietnam was a “lowintensity” war,31 at least by the measure of 

its potential to psychologically overwhelm 

soldiers committed to combat. Furthermore, 

the burden of treating various psychosocial 

problems rose dramatically as the war passed 

the halfway mark. In comparing ratings of 

16 behavioral problems by the study participants from the first half of the war with those 

of the second half, the exponential rise in the 

heroin problem was distinguishable from the 

steady, although not insignificant, problems 

associated with the use of other drugs such 

as alcohol and marijuana. This finding held 

true when comparing psychiatrists who 

served only with combat units with those 

who served only in hospital assignments. 

Also, like the jump in problems associated 

with heroin use in the latter third of the war, 

the study psychiatrists overall reported a 

significant rise in their involvement in group 

racial conflicts and with individuals responsible for violent incidents.

• Psychoactive medications were extensively prescribed, but risks and benefits were not monitored.

The descriptive and quantitative data from 

the 48% (41) of the study psychiatrists who 

acknowledged some exposure to combat 

reaction cases indicate that they extensively 

used and highly valued these medications 

(neuroleptics and anxiolytics) in the treatment and management of soldiers suffering 

from a wide variety of combat-generated 

symptoms. (The Army psychiatrists in 

Vietnam, however, had little or no way 

to measure the subsequent effects of such 

medications on the combat effectiveness, or 

vulnerability, of solders who were returned 

to duty following such treatment, or regarding their long-term effects including postwar 

adjustment.)
32

Combat and Operational Behavioral Health

• Many Vietnam psychiatrists still felt embittered, 

especially those who served in the latter half 

of the war. A large proportion of the study 

psychiatrists emphasized, often eloquently, 

that they still felt quite strongly—typically 

negatively—about the war and their role in it. 

This was primarily the case among those who 

served in the second half of the war. These 

psychiatrists’ responses indicate that in many 

respects they felt overwhelmed when trying 

to treat soldiers (and advise commanders) 

affected by a raging drug epidemic, eruptions of racial animosities, and outbreaks of 

violence, while using staffing and policies 

instead designed to manage large numbers 

of combat-generated casualties. Compared to 

their counterparts in the first half of the war, 

these psychiatrists tended to be more vocal, 

more divided (according to training differences), and, in some cases, quite defensive. 

The psychiatrists of this latter period also 

appeared more likely to perceive inequities 

and to be critical of their preparation and 

utilization by the Army.2,27

LINGERING QUESTIONS AND CONSIDERATIONS

This review indicates that during the drawdown 

years in Vietnam (1969–1973), Army psychiatrists 

faced a different and more challenging scenario than 

that encountered by those who preceded them—one 

that suggests a dangerous erosion of Army morale 

and discipline and an associated epidemic of psychiatric conditions and misconduct. It also raises 

important questions that might have been more 

easily answered at the conclusion of hostilities if a 

thorough and systematic study of the psychiatric 

and behavioral crisis there had been conducted—

questions for which the answers may be critical 

in preparing for a similar military engagement in 

America’s future. 

Should more have been done by military and 

medical/psychiatric leaders to preserve the mental 

health, psychosocial resiliency, and, by implication, the 

combat readiness of the replacement soldiers sent to 

fight in Vietnam? Did the military leadership and the 

psychiatric component in Vietnam ignore the mounting evidence and warnings by senior medical and 

psychiatric observers6,31 and fail to adjust psychiatric 

perspectives or modify the preparation, deployment, 

and organization of psychiatric assets in order to meet 

these challenges? By way of response, the following 

considerations are offered despite the late date and 

incomplete information.

The Larger Army During the War

Although the troops in Vietnam were more demonstrative, clearly the long and controversial war took a 

massive toll on the morale and mental health of the 

US Army generally.64–66,140 The troops in Vietnam were 

resonant with the restive, antiestablishment sentiments 

of their military peers outside the theater. More specific to mental health, epidemiological data provided 

by Datel regarding the larger US Army indicate that 

by mid-1973:

• the worldwide incidence of neuropsychiatric 

disease among Army personnel rose to near 

the peak level seen during the Korean War; 

• the psychosis rate for the worldwide active 

duty Army had never been higher; 

• character and behavior disorder diagnoses 

also peaked; and 

• the proportion of Army hospital beds in the 

United States occupied for all psychiatric 

causes was greater than it had ever been,25

including during the so-called “psychiatric 

disaster period”10 of World War II. 

The Soldiers Who Served in Vietnam

The reduction in combat activities and the perception of demobilization surely explains some of the rise 

in psychiatric conditions and behavioral problems 

from 1969 on. These kinds of problems were predictable based on data from World War II and Korea, 

where large numbers of soldiers were stationed far 

from home, living in confined and isolated groups, 

and serving primarily in service and support roles.141,142

Similar problems have been associated with constabulary forces and those in the process of demobilization 

in an overseas setting who resent being asked to 

sustain further sacrifices beyond the conclusion of 

hostilities.104,143 Even a dramatic increase in the use of 

narcotics by US soldiers was seen at the close of the 

Korean War, which was also attributed to service in 

the Asian theater.144 Should all of these problems be 

lumped under a concept like a collective “short-timer’s 

syndrome” (ie, impatient to complete their assignment 

and return to their stateside lives)? In the case of the 

skyrocketing evacuation rates in Vietnam for soldiers 

with opium breakdown products detected in their 

urine, Jones referred to these casualties as “evacuation syndromes” (eg, efforts by soldiers to manipulate 

the system to get relief from foreign deployment and, 
33

US Army Psychiatry Legacies of the Vietnam War

perhaps, combat risks).105

However, beyond these familiar stressors, the troops 

in the latter part of the war in Vietnam also exhibited 

intense opposition to military authority—an attitude 

that coincided with the virulent antiwar and antimilitary feelings of those at home. Should it be concluded 

that the pervasive psychiatric and behavioral problems 

in these individuals were primarily expressions of an 

embittered aggregate of soldiers who resented being 

asked to make sacrifices to salvage America’s lost 

cause there while surrounded by the moral outrage 

and blame of the US public? Some consider these 

soldier behaviors to have collectively represented a 

“macromutiny.”145 But was Vietnam so sociopolitically 

unique that the US experience there can be discounted 

as unlikely to repeat? Or does a closer look need to be 

taken at what happened there? What can it teach about 

the limitations of human nature, including among 

the civilian population at home, under these specific 

conditions of war and deployment, especially from 

the standpoint of the social psychology of military 

groups?

The Army Psychiatric Component in Vietnam

Certainly the overall record of psychiatric care 

provided through the course of the war in Vietnam 

was laudatory. But the traditional psychiatric models 

for the management and treatment of this avalanche 

of demoralization and alienation seem to have mostly 

been ineffective by the end of the war. It does appear 

that military psychiatry failed to extrapolate from 

drawdown and demobilization problems seen in earlier wars. A failure to anticipate the growing demoralization and dissent in Vietnam secondary to public 

repudiation of the war resulted in a failure to modify 

the system of mental health resources and the selection 

and preparation of replacement psychiatrists. 

A Social Stress and “Disease” Model

On the other hand, perhaps these problems were 

insoluble on any terms pertaining to clinical psychiatry. 

First, the overlap between matters bearing on morale 

and mental health ultimately became quite entangled 

as the war progressed, and yet those primarily responsible for the former (military commanders) and 

those responsible for the latter (military mental health 

personnel) did not typically maintain a running dialogue, especially in instances of divergent command 

structures, which was most usually the case. Second, 

considering the exceptionally high prevalence of 

problems that arose among previously functional 

soldiers, the pathogenesis is more suggestive of a 

social–psychiatric disorder of the collective (eg, Goffman’s pathogenic “total institution,”146 Fleming’s 

“sociosis,”131 or Rose’s “macromutiny”145), as opposed 

to one primarily centered on the individual soldier. In 

this regard, it should be noted that the psychiatric training of the times, including in the Army settings (and 

despite intents otherwise23) did not emphasize social 

pathology and interventions (including at the macro 

level) nor provide sufficient practical training. 

In other words, in that these problems were epidemic in the Vietnam theater and were not, for the 

most part, combat-related, a social stress model seems 

especially warranted because these seem to represent failures of adaptation at the group level. They 

evidently arose from complex interactions combining 

personal circumstance with powerful biological (often 

including drug-induced), psychological, and social 

stressors (in Vietnam as well as from home)—stressors 

that became progressively onerous for sequential cohorts of replacement soldiers as the war wound to its 

bitter conclusion. 

Veteran Postwar Adjustment Problems

As noted earlier, the important subject of the adjustment problems of veterans after the war is beyond the 

scope of this chapter, but it should be mentioned that 

the clash of values affecting soldiers in Vietnam also 

invariably complicated the reintegration of returning 

soldiers. For many, it may have contributed to chronic 

psychiatric conditions and serious adjustment difficulties because some symptom formation may have 

served to obtain, through the “sick role,”147 an honorable adaptation to impossibly contradictory public 

(moral) pressures (eg, “damned for going, blamed for 

losing”). Furthermore, in most cases the symptoms and 

difficulties of these veterans remained unaddressed 

because of the unavailability of the PTSD diagnosis 

prior to 1980. Following the promulgation of the PTSD 

diagnosis through the publication of DSM-III, the problems and conditions of this group of veterans began to 

be more systematically addressed by the Department 

of Veterans Affairs, which began the gradual implementation of the Vet Centers—a nationwide system of 

community-based, war veteran counseling centers133

(totaling 260 centers by 2009). More information on 

the Vet Centers is available at their Web site: http://

www.vetcenter.va.gov. 

Final Considerations

In his book, Psychiatry in a Troubled World,

148 Dr William C Menninger, the Army Surgeon General’s chief 

psychiatrist through most of World War II, described 
34

Combat and Operational Behavioral Health

military psychiatry as a “dirty job,” one in which the 

psychiatrist helps a normal individual adjust to the 

abnormal situation of combat. He was primarily referring to the moral weight inherent in expecting soldiers 

to return to combat duty and additional risks following 

the brief, simple measures associated with the classic 

combat psychiatry treatment regimen (the doctrine 

mentioned earlier). Following military psychiatry’s 

experience in Vietnam, it can surely be acknowledged 

that it is a “messy job” as well. As such, attention can 

be drawn to the multivariate social and environmental 

stressors that can also serve to corrupt soldier morale, 

commitment, and discipline, as well as mental health, 

under certain adverse combat theater circumstances, 

and psychiatry’s limited capabilities for making this 

bearable for them. 

SUMMARY

The commitment of US forces in Southeast Asia 

resulted in 7 exhausting years of combat activities. 

Ultimately, however, despite their material and 

technological inferiority, the enemy’s resolve and resilience outlasted the tolerance of the US public, and 

US involvement ended following mounting protest 

in the United States, withdrawal of US military forces 

and civilian advisors in 1973, and, finally, the defeat 

and surrender of the Saigon government to North 

Vietnam in April 1975—little more than 2 years after 

the negotiated truce in January 1973. More specific 

to military psychiatry, these remarkable events and 

circumstances—and the attendant social and political 

convulsion in America—adversely affected the mental 

health and psychological resilience of a large proportion of the military service members assigned in 

Vietnam, and the task for military psychiatrists there 

broadened and became more complex. 

Even if widely scattered, the various publications 

from psychiatrists and other professionals who served 

in Vietnam, visited the theater, or were in a position to 

review the circumstances there, do comprise a partial 

historical record. These reports and the WRAIR survey of veteran Army psychiatrists suggest a number 

of characteristics regarding the psychiatric challenge 

in Vietnam, some of which appear to be unique compared to the wars that preceded it. They also provoke 

additional important questions.

In the beginning, when US ground troops were first 

committed and throughout the buildup phase (1965–

1967), adequate psychiatric resources were deployed 

with the combat forces, and psychiatric and behavioral 

problems were manageable. Rates of psychiatric evacuations from Vietnam were exceptionally low, as were 

rates for disciplinary problems. Morale and commitment of Army troops, including psychiatrists, proved 

to be high. Of special note is that newly developed 

psychoactive medications, especially neuroleptics and 

anxiolytics, were enthusiastically used throughout the 

theater by psychiatrists and other medical officers, but 

their use and effects were never studied.

The US public’s attitude toward the war reversed 

dramatically following the enemy’s bold surprise attacks in 1968. These events heralded the withdrawal 

of US forces and demobilization from the war. Despite 

this, there continued the assignment of replacement 

soldiers (in decreasing numbers), including psychiatrists; killing and wounding of more US service members; and passionate antiwar, antimilitary sentiment 

within US society. These years also saw the beginning 

of a surge in psychiatric admissions and behavioral 

problems throughout the Army—and especially in 

Vietnam.

Over time, the reality in Vietnam proved to be far 

different than expected. The combat exhaustion casualties that were predicted never materialized and the 

replacement Army psychiatrists and allied personnel 

who served in Vietnam from 1969 on found themselves 

in a radically different war (and with a radically different Army) than was faced by those who served in previous wars (with their emphasis on psychiatric attrition 

among soldiers worn down by sustained combat) or 

those who preceded them in Vietnam. Furthermore, 

psychiatrists with appreciably less military experience, 

including those in leadership positions, were sent 

even as the problems in the theater were multiplying. 

Not only were they challenged with unprecedented 

levels of psychiatric and behavior problems, it was 

unprecedented for these rates to rise while the United 

States was reducing its military and political presence 

in South Vietnam, US forces were gradually turning 

the fighting over to the Army of the Republic of South 

Vietnam, and US casualty rates were declining.

What military psychiatry ultimately encountered 

in large numbers were young troops with severe 

demoralization, a progressive reluctance to soldier, 

antagonism—sometimes violent—toward military 

authority, and a variety of psychiatric conditions and 

behavioral disorders. Theater psychiatric hospitalization statistics indicate a 4-fold increase compared to 

the early war years. Related, and even more remarkable, was the common and casual use of heroin by a 

large proportion of US troops, although most were not 

addicted. At its worst point, one out of every eight enlisted soldiers was medically evacuated from Vietnam 

because of narcotic use.
35

US Army Psychiatry Legacies of the Vietnam War

These accelerating psychiatric conditions and behavior problems, which coincided with America’s repudiation of the war and the counterculture passions of their 

civilian peers, were certainly consequential to serving in 

the combat theater, but in most cases they had little or 

no direct connection to combat activity. It appears that 

many soldiers more or less disabled (or demobilized) 

themselves through mental disorders, drug use, and 

other symptoms and forms of misconduct. 

Regarding the response of the deployed mental 

health elements, because the rising theater and deployment demoralization and alienation-driven problems 

arose far more predictably among noncombat troops, 

the center of effort shifted to hospital-based mental 

health assets and gradually overtaxed the psychiatric 

and related medical resources. These problems mostly 

failed to yield to conventional psychiatric approaches, 

and increasingly drastic administrative and law 

enforcement measures were required. The late-war 

psychiatrists complained about being unprepared 

and may have become uncertain of their goals and 

structures. They may have also shared, to some degree, 

the demoralization and antimilitary passions of the 

soldiers with whom they served. Combat readiness 

went thankfully untested by the enemy. Nonetheless, 

it is striking that there were no structural changes in 

the organization of mental health assets in Vietnam or 

modifications in the selection, preparation, or deployment of mental health personnel sent as replacements 

to the theater. 

With the advantage of the relative objectivity offered 

by the passage of time, it can now be acknowledged 

that the models for understanding and anticipating 

casualties both from combat stress and from deployment stress are considerably more complex than was 

understood before—or even during—the Vietnam 

War. The earlier model was derived from observations of troops fighting in sustained, intense combat 

environments, and it primarily weighed combat stress 

against resiliency of the individual soldier (although 

the buffering effects of allegiance to combat buddies 

and other factors were considered to be vital). But in an 

extended, “low-intensity,” counterinsurgency conflict 

the model must be broadened to also take into account 

other critical, compounding, and often indirect influences of the combat theater. A list centered around 

“soldier variables” might include the usual ones, that 

is, (a) the nature and setting of the fighting; (b) training 

and expertise; (c) physical condition; (d) background 

and personality; (e) social circumstance (within the 

small combat unit as well as the soldier’s network of 

family and friends); (f) confidence in military leaders 

and equipment; and (g) commitment to the military 

goals. It might also, and surely not least, include the 

necessity to ensure that soldiers believe the country 

requires, as well as values, the inherent risks and sacrifices they undertake. 

Retrospective suggestions generated out of the 

Vietnam War especially include the need for the 

military to develop a multivariate concept of combat 

“theater” breakdown (as opposed to combat breakdown) that considers both the symptomatic soldier 

and the dysfunction arising in groups of soldiers, 

and to employ an epidemiological approach for 

early recognition of deteriorating psychosocial and 

psychiatric circumstances. For example, in Vietnam a 

psychiatric field research team could have been created for the sole purpose of collecting, analyzing, and 

disseminating information regarding a wide array of 

often initially innocuous indices of flagging morale 

(eg, rising malaria rates among soldiers subverting 

malaria prophylaxis as a means of avoiding service). 

This information could have then served for clinicians 

and commanders as a timely map of the psychosocial “terrain” of stressors, morale, performance, and 

symptom patterns of the troops, which would have 

permitted the development of early intervention 

measures. Such an epidemiologic approach could 

have been combined with systematic debriefing of 

returning psychiatrists to redirect some of the attention of replacement psychiatrists from a combat stress 

model toward a social stress model of psychiatric 

dysfunction. 

Other structural adaptations as the war in Vietnam lengthened might have included: (a) extending 

the tours of each of the theater Neuropsychiatry 

Consultants (as well as tours of other psychiatrists in 

leadership positions) to provide needed continuity; (b) 

increasing the level of seniority of the replacement military psychiatrists as the pool of experienced civilian 

psychiatrists unavoidably decreased; and (c) linking 

numbers of deployed psychiatrists to epidemiologically documented need, rather than to overall troop 

strength. Finally, a policy could have been established, 

presuming it met overall mobilization needs, requiring 

that each recently graduated psychiatrist serve some 

time with a stateside military unit before departing 

for Vietnam.

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