The Repat doctors and the Medical Journal of Australia

On 3 August 1963, a letter of condemnation directed at the Repatriation Department appeared in the correspondence section of the MJA. The author, who used the pseudonym ‘Parkinson’s Disciple’, began the letter by asserting that ‘The Repatriation Department appears to be trying to prove one of Parkinson’s theories, that Government departments once created must make more and more work for themselves in order to justify their existence’.Footnote ¹⁸ The letter’s author urged the Australian Medical Association (AMA) to take a ‘critical look at repatriation medicine’, claiming that ‘too much is being spent on the “phonies”’, and presenting examples of veterans receiving pensions for either non-existent medical conditions or illnesses unconnected with their military service.Footnote ¹⁹ The letter ended by urging the Australian Federal Government to ‘insist on stricter control of allotment of entitlements, and even have the right of veto in some cases’, while noting that ‘more could and should be done’ for those with ‘genuine claims to Repatriation benefits’. The letter also attracted the attention of The Canberra Times, which published an article, also on 3 August, titled ‘Doctor Attacks Department’, summarising the thoughts of Parkinson’s Disciple.

This media attention prompted the serving Minister for Repatriation, Reginald Swartz, and the Chairman of the 6^th War Pensions Assessment Appeal Tribunal, Kevin Mooney, to write letters in response, published in the 24 August 1963 issue of the MJA. Swartz’s response was relatively balanced, undoubtedly keeping in mind continuing criticism of the Repatriation Department (hereafter Repat) by both the Returned & Services League of Australia (RSL) and the newspaper Smith’s Weekly for excessive harshness towards veterans applying for pensions.Footnote ²⁰ He pointed out that physicians themselves decided on the medical status of a veteran, and that the Repatriation System was specifically designed to ‘ensure that no legitimate claim is rejected’ and that the Repat was determined to ‘give the claimant the benefit of any doubt’.Footnote ²¹ Mooney was more direct in his letter, labelling Parkinson’s Disciple ‘inappropriate’ and ‘unkind’ and merely ‘considers he should not be called out from his warm bed to treat ex-servicemen’, claiming that if he felt he was underpaid for his work with veterans, he should write to the Repat to have his name removed from their list of approved physicians.Footnote ²²

This did not end the matter, as Parkinson’s Disciple responded more frankly on 21 September 1963 about the ‘phony cronies … absorbing far too much of the Department’s time, money and resources’, which led to a rush of letters from a range of physicians working with Australian veterans both within Repatriation hospitals and in private practice who agreed in part or in full with the original sentiments.Footnote ²³ In these letters a variety of allegations were made, from Robert S. Lawson writing that veterans were given ‘Commonwealth cars’ to see medical specialists on Saturday mornings, then ‘find their own way to the football on Saturday afternoon’; to ‘Parkinson’s Second Disciple’ labelling the Repat ‘preposterous’, asserting that they were perpetuating a ‘national scandal’ by ‘contributing large sums to keep a bunch of happy scroungers, unscrupulous rogues and inadequate specimens’.Footnote ²⁴ Also in response to Swartz and Mooney’s statements, a group of South Australian doctors wrote a letter directly to Swartz to complain about the ‘medical inanities’ within the repatriation system and request an amendment of the Repatriation Act, which was signed by more than sixty per cent of the doctors working at the one repatriation hospital.Footnote ²⁵ Although Swartz did not acknowledge their letter, the Repatriation Commission Chairman Sir Frederick Chilton wrote a ‘secret letter’ to the doctors to reject all allegations sent, which was read to them by the State Deputy Commissioner.Footnote ²⁶

The issue appeared to be resolved from the Repat’s perspective, despite a few similar letters appearing in the MJA in 1966, until the mass resignation in 1969 by most who had signed the 1963 letter. This included John Whiting, a young medical officer in the Repatriation General Hospital at Daw Park, Adelaide, who in the same year published Be In It, Mate!, his fictional account of the experiences of ‘Dr Andrews’ – presumably based on himself –within a Repatriation hospital. The foreword to Be In It, Mate! states that ‘although the characters are fictitious, this story is based on fact. The author uses this medium to expose the misuse of taxpayers’ money perpetrated by politicians, public servants and others’.Footnote ²⁷ Whiting felt that he was ‘a pawn in “a huge extravagant political hoax”’, ending his book with a detailed Appendix stating the recent events, from the MJA correspondence onwards. The controversy this created within the Repat eventually led to a series of internal investigations, culminating in the Independent Enquiry into the Repatriation System, a report led by Justice P.B. Toose, in 1975.Footnote ²⁸

Significant reforms were prompted by these events that improved the workings of the Repat, all of which fall outside the scope of this article. These have all been very well outlined by Clem Lloyd and Jacqui Rees, as well as by Stephen Garton.Footnote ²⁹ Instead, this article examines exactly how Australian doctors construed the mentally ill veteran and positioned veterans within this ‘national scandal’. The terms of this construction initially appeared within the original letter of August 1963 written by Parkinson’s Disciple: ‘There is a whisper that alcoholism is to be an accepted disability in any psychiatric case. One shudders at the consequences of this.’Footnote ³⁰ On 12 October, Parkinson’s Second Disciple wrote, in addition to the above quote, that ‘the most scandalous of all…are the so-called “due to war service psychiatric cases”’.Footnote ³¹ In Whiting’s Be In It, Mate!, the fictional Dr Andrews expressed his view of psychiatric patients by initially stating: ‘Why persist in giving it this grandiose title of ‘Psychiatric Wing’, when you know as well as we do that it’s overflowing with just plain drunks and no-hopers.’Footnote ³² Later, after learning he would be sent to ‘Malingerer’s Mansion’, Andrews responded ‘you mean they’re sending me to the Psychiatric Ward?’Footnote ³³ After beginning work on the ward, Andrews described the psychiatric cases in discussion with his father:

Within these and many other similar sentiments about mentally ill veterans in the MJA letters and Be In It Mate!, three recurrent themes appear. These are allegations of malingering; comments about degeneracy; and alcohol, drunkenness or alcoholism in connection to those pensioned for psychiatric disorders. To understand why these specific themes appeared within doctors’ representations of mentally ill veterans, it is necessary to consider historical and theoretical influences on physicians during this period. While society was becoming more informed about mental illness and more accepting of the mentally ill, physicians continued to express condescending views of the traumatised veteran. Although these views can be seen as a consequence of the historical conceptualisation of malingering, and specifically the historical role of physicians in its identification, this disdain can be seen to run deeper.Footnote ³⁵

Attitudes towards malingering in Australia

Malingering is by no means merely a historical issue. The American military psychologist Kenneth Morel wrote in 2010 that: ‘In military medicine the detection of malingering is a necessary function of mental health practitioners.’Footnote ³⁶ Recent psychological literature still addresses the issue of malingering, and a range of scientific models have been formulated to detect it.Footnote ³⁷ In addition, Goldberg highlights key similarities between political and military concerns about malingering within United States social welfare policy from the nineteenth century until today.Footnote ³⁸ The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) defines malingering as ‘the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs’.Footnote ³⁹ The approach of the American Psychological Association towards malingering since it was first included in the DSM-III in 1980 was to explain it in terms of ‘unconscious and pathological’ motive.Footnote ⁴⁰ The move towards the official pathologising of malingering can be seen to have partly originated in medical responses to malingering during the First World War.

Although malingering has been a concern of Australian military-medical personnel since the South African War, it was not until the First World War that medical officers on the battlefield were specifically instructed to detect it.Footnote ⁴¹ Early twentieth century British doctors were reluctant to engage in this new role, so they transformed malingering from a criminal to a medical diagnosis, meaning they could attribute malingering to heredity or psychological unfitness and thus allow them to ‘keep their medical hat on’.Footnote ⁴² The medicalisation of malingering also occurred within the Ottoman Army during the conflict. The creation of the ‘pathological malingerer’ similarly allowed medical officers to disregard every negative influence on the malingerer, including reasons for avoidance of military duty and criminal responsibility, and focus on medical cure.Footnote ⁴³ Parson’s concept of the ‘sick role’ assumes that the sick person must be ‘helpless and therefore in need of help’, and the role of physicians are thus to serve as a ‘court of appeal as well as a direct legitimizing agent’ in confirming the ‘sickness’ of the patient and using their specialist medical knowledge to help them get well.Footnote ⁴⁴ Detecting criminality in the form of malingering falls outside the medical role, so doctors moved towards redefining the malingerer as a patient to preserve the rules surrounding their prescribed role.

Australian medical officers on the First World War battlefield also felt ‘uneasy’ about adopting ‘judicial and political functions’ in detecting malingering, so they actively moved to reframe the malingerer, but most did so by emphasising aspects of psychological unfitness that originated from weakness and a lack of morality rather than the actual processes of the mind.Footnote ⁴⁵ Military psychiatry was not an predominant concern of the Australian military forces until the First World War, whereas Britain had established a hospital for traumatised soldiers and veterans in 1869.Footnote ⁴⁶ During the First World War, the British Royal Army Medical Corps began invaliding men with shell shock in 1914, whereas the Australian Imperial Force – despite fighting alongside British forces in many cases – only began in 1916.Footnote ⁴⁷ Australian medical officers believed that malingering was the ‘action of the morally weak’ and linked it to heredity or ‘social infirmity’.Footnote ⁴⁸ This is not to say that British military-medical authorities did not also attribute psychological disorders to the ‘will’ or that all Australian medical officers moved away from psychology and towards social issues in explaining the large numbers of traumatised men.Footnote ⁴⁹ In fact, the Victorian psychiatrist John Springthorpe actively used the teachings of Sigmund Freud in treating shell shocked Australians from the years of the conflict.Footnote ⁵⁰ When assessing reasons for ‘nervous’ or mental symptoms, Australian medical officers were merely more likely to focus on the morality and social life of a soldier.

Over the course of the First World War, British doctors were more likely to move away from conceptualising shell shock and other war-related traumatic disorders in terms of heredity, moving towards organicist or psychological explanations, or a combination of both. These more ‘sympathetic’ responses to mentally ill soldiers and veterans that separated their symptoms from their personality or lifestyle did not continue into later wars, however.Footnote ⁵¹ In the Australian context, military authorities during the Second World War remained more reluctant to engage with military psychiatry than Allied nations, despite the lessons of the First World War. In the early 1940s, William S. Dawson, Professor of Psychiatry at the University of Sydney, listed a series of ‘warning signs’ for the ‘recognition of psychopathic types’ in the military, which included specifically social characteristics such as ‘untidiness, lack of cleanliness, homesickness’ and those who were ‘indefatigable scribes and diarists’.Footnote ⁵² While American psychiatrists believed that war neurosis was predominantly caused by ‘exhaustion and fatigue’ in the 1940s, Australians attributed it to poor social relations and general weakness.Footnote ⁵³

The greater attention to personal characteristics and lifestyle in the assessment of war neurosis is reflected in the sentiments shared publicly by the Australian Repat doctors, who in the 1960s were predominantly treating veterans of the world wars and Korea. For example, a letter by ‘Parkinson’s Apostle’ published in the MJA on 30 May 1964 claimed men with psychiatric entitlements were not mentally ill, but instead ‘a group of inadequate individuals who would have broken down under the day-to-day stress of almost any walk of life’.Footnote ⁵⁴ It is possible to see these attitudes as a continuation of the construction of the traumatised soldier-malingerer that originated during the First World War. However, this was not the only influence on the opinions of Repat doctors in the 1960s towards the mentally ill veteran.

Mental illness in 1960s Australia

The decades after the Second World War saw widespread shifts in the attitude of general populations across the world towards the mentally ill. From the 1950s until the 1970s, a range of psychological, psychiatric and medical studies were carried out, many in Britain and the United States but also in other countries including India and Australia, to determine how people felt about psychiatry, mental illness and the mentally ill. Many of these were directed towards the general population, but also towards medical students, military officers and physicians. Studies directed towards students were aimed at assessing the decreasing popularity of psychiatry as an area of university study from the 1960s onwards, which occurred partly as a result of debates between advocates of the medical and social models of mental illness, to be discussed later in this article.Footnote ⁵⁵ Many of these studies used the Opinions about Mental Illness Scale (OMI) developed by Cohen and Struening, which scored respondents based on five criteria: authoritarianism; benevolence; mental hygiene ideology; social restrictiveness; and interpersonal aetiology. However, other models were also developed, such as the Custodial Mental Illness Ideology (CMI), the California F Scale and later versions of the OMI.Footnote ⁵⁶ Interestingly, most studies of the general public, military officers or physicians found a higher level than expected of benevolence or generally sympathetic views towards the mentally ill, although this changed when the suggestion was made that ‘sanity’ and mental illness existed on a continuum, meaning that anybody could become ‘insane’.Footnote ⁵⁷

The OMI scale was formulated in response to specific views towards mental illness and psychiatry emerging in the 1960s, including the move away from a medical model to a social model in the conceptualisation of mental illness. The third criterion within the scale, ‘mental hygiene ideology’, measures the extent to which a person ascribed to the medical model by asking whether a ‘mental illness is an illness like any other’.Footnote ⁵⁸ A similar Australian study was not conducted until 1979, when Robert Kirkby and Annie James used the OMI scale on a sample of 50 Australian medical practitioners. That study found that Australian doctors scored highly on benevolence and mental hygiene, reflecting their sympathy with the mentally ill and agreement with the medical model. Their scores on authoritarianism and social restrictiveness were low, meaning that they did not generally believe that ‘the mentally ill are different or inferior’ or ‘a threat to society’.Footnote ⁵⁹ However, the authors also noted that there can be a disadvantage to high scores on mental hygiene ideology, meaning that commitment to the medical model of mental illness may mean physicians will approach mental illness the same way they approach somatic illnesses, by treating the symptoms over the causes.Footnote ⁶⁰

The framing of the research questions by Kirkby and James reflects the gradual popularity of the social model of mental illness both in Australia and across the world throughout the mid-twentieth century. The work of anti-psychiatrists throughout the 1960s, which reinterpreted and questioned medical domination over the historical treatment and care of the mentally ill, influenced this model. Foucault, for example, claimed that ‘social mechanisms’ rooted in Enlightenment ideas governed the differing processes of confinement within nations since the seventeenth century, creating ‘new social norms required for social integration’ with the purpose of creating ‘a new dividing line’ between ‘the acceptable and the blameworthy’.Footnote ⁶¹ Other anti-psychiatrists such as Goffman and Szasz focussed on the social and cultural imperatives of the state in determining the conceptualisation of the insane.Footnote ⁶² During this period people from a range of social, political and intellectual groups ‘were united in their belief that psychiatry was not a legitimate medical specialty, but one devoted to protecting its authority and enforcing societal norms associated with an unjust society’.Footnote ⁶³

A central tenet of anti-psychiatry is deviance theory, which interprets illness as a type of deviant behaviour, or ‘motivated deviance which results in disturbed social relations’.Footnote ⁶⁴ Parsons asserted that a ‘sick person’ was not responsible for their own deviance, due to the four attributes mentioned above, namely, that the sick person must be excluded from ‘normal social roles’; cannot get well as a result of their own will; must want to get well; and must work with a physician to get well.Footnote ⁶⁵ Anti-psychiatrists drew upon Parsons’ conception of deviance to further define psychiatric symptoms as ‘violations of a social norm’. Thomas J. Scheff, a key anti-psychiatrist, introduced the term ‘residual deviance’ to describe ‘the diverse kinds of deviation for which our society provides no explicit label’, which can lead to the label of ‘mentally ill’.Footnote ⁶⁶ Interestingly, Scheff specifically used an example drawn from military psychiatry to illustrate that residual deviance is ‘denied’ or is transitory. He used evidence from military studies that claim combat neurosis could be self-terminated if a soldier remained with their primary military unit and only given minimal medical treatment.Footnote ⁶⁷ Findings like this align with the opinion by the Australian Repat doctors in the 1960s that the morale of soldiers and veterans was reduced by ‘condonement and pensions’, or the more encouraged they were to seek medical help, and were characteristic of military views that warned against encouraging malingering by ‘coddling’.Footnote ⁶⁸

Deviance theory was also influential in Australian circles in the 1970s, although it received only a fraction of the public attention that it enjoyed in the United States and Europe, and those who considered it appeared to tend towards ‘social psychiatry’, which combined elements of deviance theory and the medical model of mental illness.Footnote ⁶⁹ In 1975, Erica M. Bates from the Department of Health Administration at the University of New South Wales surveyed a random sample of 1000 people in Sydney, as well as psychiatric professionals, clergymen, university students, nurses and business managers, to determine their alignment with the medical or social/sociological models of mental illness. Although she found that most respondents in the sample accepted the medical model, Bates concluded that the ‘medical-socio-educational model’ was more effective. Her support for the social model of mental illness was apparent throughout the article, which was seemingly based on the premise that ‘there is some danger in allowing the status and power of medicine to assume control over such a large number of deviant people’.Footnote ⁷⁰ Bates continuously emphasised her agreement with the social model of mental illness throughout the article, also writing: ‘At present, the definition of deviance tends to be tailored so that the medical profession becomes the main arbiter in what probably should be a general social problem.’Footnote ⁷¹

Such ideas were used to criticise traditional psychiatry. This was not a new phenomenon, as it had experienced disapproval from patients, the media and the medical profession as a whole since the nineteenth century. From the First World War, however, the increased popularity of psychoanalysis, which reached its height in the 1940s and 1950s, contributed to the move away from biological conceptions of mental illness and towards psychoanalytic or psychodynamic views.Footnote ⁷² The treatment of psychiatric illness by specialists without specific medical training increased the vulnerability of psychiatry to attacks by supporters of anti-psychiatry, as well as the medical profession as a whole, from the 1960s.Footnote ⁷³ Rabkin wrote in 1972 that mental health professionals were increasingly acknowledging that ‘mental illness can be understood as an exaggeration of particular behaviours common to all men, brought about by stressful life conditions and resulting in impairment of the ability to cope with social expectations and standards’.Footnote ⁷⁴ The medical model that viewed psychiatric symptoms as a sign of physical illness, which had existed since the late nineteenth century, was first challenged by the psychoanalytical view of mental illness as a defence against internal processes. Following this, the popularity of psychoanalytic or psychodynamic explanations for psychiatric symptoms over biological psychiatry from the Second World War shifted again in the 1960s, due to increasing disillusionment with psychoanalysis, to ‘defining symptoms as a way of dealing with external events or other people’.Footnote ⁷⁵

The attacks in the 1960s influenced by the ideas of anti-psychiatrists therefore assumed a new character that was also shaped by changing thinking about appropriate sites for treatment of the mentally ill and technological advancements that introduced new drug therapies.Footnote ⁷⁶ The experiences of the Second World War had revealed that community treatment of the mentally ill was more effective than institutional treatment.Footnote ⁷⁷ This – combined with the influence of psychoanalytic ideas based on patients’ social lives and new available drug treatments – increased the viability of ‘social psychiatry’, or allowing the formerly institutionalised to live their lives in the wider community. Dain connected the shifts in the approach towards the mentally ill during this period with the broader international protest movement emerging in the 1960s, which had as its general aim the liberation of oppressed groups. He wrote that the increased popularity of community mental health initiatives in the United States as well as the ideas of anti-psychiatrists appealed to disability activists and others who viewed institutions as an instrument of subjugation and control.Footnote ⁷⁸ Similarly, Crossley wrote that the popularity of anti-psychiatry in Britain was partly furthered by the 1960s emerging counterculture, pointing out that that British disability activist journals including Asylums and PROMPT (Protection of the Rights of Mental Patients in Therapy) frequently spoke positively about the writings of anti-psychiatrists.Footnote ⁷⁹

Such ideas were also influential in Australian medical, intellectual and activist circles. Until the 1960s Australian society held predominantly unsympathetic views towards the mentally ill and was sceptical of psychiatry and psychiatrists.Footnote ⁸⁰ Psychiatry itself was languishing, remaining seemingly attached to the continuation of the mental hospital and medical model of mental illness while experiencing challenges by progressives who espoused social psychiatry or anti-psychiatry, as well as the rights of the mentally ill.Footnote ⁸¹ The general pattern of deinstitutionalisation in line with the social psychiatry model began in Australia in the 1960s. Between 1965 and 1975, the number of beds in Australian mental hospitals declined from 12 400 to 7400.Footnote ⁸² In Australia, like elsewhere, the shift to community mental health was appealing to social activists, who increasingly spoke out against Australia’s health care system.Footnote ⁸³ From a political perspective, this was seen as a financially appealing way to treat the mentally ill. However, Dunlop and Pols believe that the release of patients from Australia’s mental hospitals occurred prematurely, before adequate community facilities were established to support the mentally ill outside the institution.Footnote ⁸⁴

Social psychiatry was the subject of a number of MJA articles from the 1950s to 1980s, mostly significantly in a 26 November 1966 article by E. Cunningham Dax titled ‘Psychiatry and Society’, which laid out his justification and plan for the rise of social psychiatry in Australia. Dax’s position as Chairman of the Mental Hygiene Authority of Victoria and support for social psychiatry, outlined in his 1961 key work Asylum to Community, meant that he played a prominent role in the shift from institutional to community psychiatry not only in Victoria, but also nationally.Footnote ⁸⁵ He focused on possible family or social issues such as overindulgence of children, or housing, loneliness and poverty affecting the aged that caused patients to develop psychiatric symptoms, writing that ‘many social agencies and institutions will be actively involved with mental well-being’.Footnote ⁸⁶ His support for social psychiatry was clear: ‘It would be unfortunate if, with the drugs at our disposal and the social services being developed, we tended too readily, or even officiously, to interfere in the normal adjustment to life’s everyday crises.’Footnote ⁸⁷ Despite the slow development of community mental health initiatives, the introduction of Medibank and the Community Health Program by the Whitlam government in 1973 meant that over 700 community health projects had received federal funding by 1976.Footnote ⁸⁸

The atmosphere surrounding psychiatry in the 1960s and 1970s, then, was combative. Psychiatry was under attack by anti-psychiatrists who thought their area of specialisation was repressive, particularly so within Australia, as psychiatrists appeared to cling to the medical model of mental illness and the continued espousal of institutionalisation.Footnote ⁸⁹ The growing activist movement found commonalities with the concerns of anti-psychiatrists, and a growing number of intellectuals and medical professionals supported a social model of mental illness and the Australia-wide adoption of social psychiatry.Footnote ⁹⁰ As a result, psychiatrists began to publicly seek to stake their claim on, or cement their place within, their area of medical specialisation, usually by emphasising the medical nature of mental illness and the appropriateness of medical treatments for the mentally ill.Footnote ⁹¹ Although psychiatry was a specialisation taken within a university medical degree, Australian psychiatry was ‘divorced from the mainstream of medicine’ and ‘there existed a gulf between psychiatry and medicine which meant that a move from one sphere to the other could not unreasonably be seen as the contemporary equivalent of interplanetary travel’.Footnote ⁹²

‘The sick role’

The tendency by Repat doctors to exclude most traumatised soldiers from the body of legitimate pensioners from the 1960s reflects the historical relationship between physicians, psychiatrists and the military. Although war neurosis is mentioned within their discussion of the soldier-malingerer, the terms they used to describe the traumatised veteran: ‘dead-beats, drongos, drunkards and inadequate members of society’ are notably hostile.Footnote ⁹³ Doctors negotiated their rejection of the soldier-malingerer on medical grounds, as mentioned above. They found a way to redefine the investigation of malingering from a legal process to a medical one and redefine the malingering soldier from a criminal to a sick person.Footnote ⁹⁴ They were able to do this by assigning characteristics to the malingerer that ensured they fit into the specific social classification of a ‘sick person’.Footnote ⁹⁵ The traumatised soldier-malingerer, however, was not so easily categorised. The remainder of this article will analyse, using Parson’s conception of the ‘sick role’, how traumatised veterans transgressed this role in the eyes of the Repat doctors and how this led to their identification as ‘unscrupulous rogues’.Footnote ⁹⁶

The first aspect of the ‘sick role’, according to Parsons, places the judgement about whether or not the sick person should be excluded from ‘normal social role responsibilities’ on the doctor, as ‘court of appeal as well as a direct legitimizing agent’.Footnote ⁹⁷ Ultimately, then, it is the doctor’s decision whether or not the sick person is deserving of the ‘sick role’. Parsons goes on to say that ‘this legitimation has the social function of protection against “malingering”’.Footnote ⁹⁸ In most cases, he writes, this is a ‘perfectly straightforward technological job’, but for some cases ‘knowledge, skills and resources are not adequate, with hard, competent work, to solve the problem’. He labels these ‘absolute limits of the physician’s control’, which are reliant on the state of medical knowledge at the time, as a source of frustration and strain.Footnote ⁹⁹ The doctor’s role, then, is relatively straightforward, expressed well by the Australian physician C. Gordon Harper in his contribution to the MJA correspondence in 1963: ‘The function of the healing profession is to promote the recovery and well-being of sick people.’ ^{Footnote 100} In his statement supporting a medical model of psychiatry published in the Journal of the American Medical Association in 1975, Arnold M. Ludwig, from the Department of Psychiatry at the University of Kentucky, similarly wrote:

The presence of ‘disease’, ‘natural causes’ and ‘cure’, then, seem essential for a medical professional, which points to a reason for the disdain expressed by the Repat doctors towards the traumatised veteran.

Although Australian military forces had encountered war trauma since the South African War and formally recognised it from the First World War, military authorities appeared reluctant to engage with psychiatry from the Second World War onwards, as mentioned earlier. Rather than fully engaging with psychiatry to treat traumatised soldiers and veterans, they were more likely to focus on morality and heredity in explaining symptoms.Footnote ¹⁰² Even today physicians and mental health professionals disagree about the necessary approach to war trauma and mental illness in general, despite the comprehensive nature of the Diagnostic and Statistical Manual of Mental Disorders. Footnote ¹⁰³ This means that selecting the appropriate course of treatment is not always a clear decision, and cure is not always possible. In the 1960s, the rise of psychotherapy demonstrated that mental illness could be successfully treated by nonmedical experts, which increased the ‘gulf between psychiatry and medicine’ as physicians grew increasingly sceptical of the applicability of technical medical knowledge to non-somatic conditions.Footnote ¹⁰⁴ Around this same time, sociologists were pointing out the existing uncertainty about the causes of mental illness within the body of medical knowledge.Footnote ¹⁰⁵ This appeared to confirm existing doubts from within the medical establishment about psychiatry and the applicability of medical expertise to mental illness.

The centrality of ‘cure’ to the Repat doctors is evident in both the MJA correspondence and in Be In It, Mate! The original MJA letter of August 1963 by Parkinson’s Disciple alleged that ‘The [Repatriation] Department does not consider that anything can be cured if one wore a uniform’, illustrating the belief that the Repat’s aims did not align with those of the Repat doctors – namely, treatment towards cure.Footnote ¹⁰⁶ On 5 October 1963, a letter by C. Gordon Harper of Port Macquarie was published in MJA in which he wrote: ‘Only once have I seen a repatriation patient cured of anything. In that case it happened only when it dawned on him that his domestic life was becoming endangered by his continual invalidism and ineffectiveness as a husband. Today he is completely rehabilitated.’Footnote ¹⁰⁷ Whiting also wrote in Be In It, Mate!: ‘The present system hardly encourages a man to admit improvement, let alone cure, if he thereby suffers a loss of pension. Our best medical efforts are thereby frustrated.’Footnote ¹⁰⁸ These statements demonstrate clearly the frustration described by Parsons and felt by these medical men at their inevitable failure to effect cure using their specialist medical knowledge.Footnote ¹⁰⁹ This does not appear to be an issue specific to this context, however. In his 1987 article ‘When Doctors Get Sick’, Spiro writes that ‘men and women are more than their bodies’, urging fellow physicians to reduce their focus on ‘final answers’, or cure, and that ‘talking about problems of life and practice, to find solutions which may not lie in the cell, could enlarge our perspective’.Footnote ¹¹⁰ If medical knowledge is not entirely applicable to mental illness, then Parsons’ first aspect of the ‘sick role’ cannot be met, namely, that physicians need to use their own specialist knowledge to confirm that the sick person should be excluded from ‘normal social role responsibilities’.

Parsons’ second aspect of the ‘sick role’ again relies on the medical practitioner’s expert opinion to determine that the sick person ‘cannot be expected by “pulling himself together” to get well by an act of decision or will’.Footnote ¹¹¹ As mentioned earlier, Be In It, Mate! provides a description of the typical ‘psychiatric case’:

Two themes stand out within this passage, which are also found in responses by other Repat doctors. The first is the rejection of war trauma as a genuine consequence of combat or military membership. It has long been acknowledged that military involvement can cause neurosis even in the absence of direct combat.Footnote ¹¹³ The tendency of military authorities from the Second World War onwards to discount psychiatric explanations for mental health conditions in favour of morality or personal characteristics, as well as the existing tension between psychiatry and medicine, created an atmosphere of doubt among physicians treating traumatised veterans, as mentioned above.

The second is the relationship between heredity and war trauma, which governed medical and psychiatric considerations of such conditions until after the Vietnam War. Alistair Thomson writes that the Repat files after the First World War were notable for their ‘moral judgements about family traits and mental weakness’.Footnote ¹¹⁴ Despite the increasing incidence of war neurosis in the Second World War and beyond, it was not until the publication in 1980 of DSM-III that post-traumatic stress disorder was introduced as a war-related psychiatric condition that, for the first time, was not related to heredity.Footnote ¹¹⁵ This was due largely to pressure from anti-war psychiatrists such as Robert Jay Lifton and Chaim Shatan, who treated Vietnam veterans after the war.Footnote ¹¹⁶

The belief that most ‘psychiatric cases’ are ‘drunks, bums and no-hopers’ also assumes that they are in control of their symptoms and illness. Whiting also wrote, through his young Dr Andrews: ‘It might be a good idea to stop molly-coddling this type of person, and get him standing on his own two feet, instead of encouraging him, as the Department does now, to lounge around and be a waster, by paying him bigger and bigger pensions’.Footnote ¹¹⁷ ‘Standing on his own two feet’ implies that the veteran should be able to recover from their illness using their own ‘decision or will’, in Parsons’ words.Footnote ¹¹⁸ It is evident by these statements that the Repat doctors considered ‘psychiatric cases’ to also transgress Parsons’ second aspect of the ‘sick role’.

In his 1963 MJA letter, C. Gordon Harper continued to compare the traumatised soldier-malingerer to ‘the normal patient who come to us with the expectation of something being done to get them off the sick list’, who ‘make an effort to get well, and stay well, to the best of one’s ability’.Footnote ¹¹⁹ These align with the two remaining aspects of Parsons’ ‘sick role’ theory: that the sick person must want to get well, and that they must seek ‘technically competent’ help from a physician and ‘cooperate’ with them to get well.Footnote ¹²⁰ Most Repat doctors blamed the Repatriation Department for creating an atmosphere in which former soldiers were encouraged to ‘hang on at all costs to every listed disability or complaint, with a determination which in the case of less sheltered patients would have been sufficient to effect a cure’.Footnote ¹²¹ ‘Parkinson’s Second Disciple’ mentioned that malingering veterans were ‘aided and abetted by bureaucracy’.Footnote ¹²² Whiting wrote that Repat ‘bureaucrats, aided and abetted by certain notoriety-seeking politicians and ex-servicemen’s organizations, especially the R.S.L., are actively encouraging men and women in huge droves to come in for their pickings…most politicians, for fear of losing votes, are frightened to use the scalpel’.Footnote ¹²³ In the MJA on 30 May 1964, ‘Parkinson’s Apostle’ also wrote that ‘the present attitude of condonement and pensions only fosters them in their inadequacy and provides sufficient money for an escape into alcoholism’.Footnote ¹²⁴

The recurring topic of degeneracy in the Repat doctors’ descriptions of the traumatised soldier-malingerer, specifically related to alcohol or alcoholism, is not an unusual response by physicians. Historical accounts of malingering, especially those in relation to mentally ill soldiers, frequently demonstrated that military-medical officers attached a class judgement onto the malingerer or patient, occasionally related to cultural factors. British authorities in the mid-nineteenth century thought both civilian and soldier malingering to be a problem restricted to the working classes or foreigners. Kanaan and Wessely attribute this to the difficulty in distinguishing illnesses using clinical or psychiatric means in comparison with the ease of categorising them according to gender or class.Footnote ¹²⁵ Before the shell shock phenomenon challenged the practice of distinguishing ‘nervous’ conditions in this way, British medical officers labelled trauma experienced by officers and rank and file soldiers differently. Officers were diagnosed with ‘neurasthenia’, a more ‘respectable’ illness that had traditionally been associated with the working man, whereas rank and file soldiers were more likely to be labelled ‘hysterics’, reflecting the perceived similarities between traumatic conditions emerging from the First World War and the late nineteenth century ‘hysteria’ diagnosis, which was traditionally seen as a ‘feminine’ disease.Footnote ¹²⁶ The behaviour of traumatised Indian soldiers in the British Army was similarly categorised by British authorities in terms of ethnic and religious background, as part of a larger effort to identify social groups within India that were considered more worthy of recruitment.Footnote ¹²⁷ Medico-cultural constructions of war trauma have thus formed an essential component of the consideration of traumatised veterans by military doctors, illustrating Rosenberg’s argument about the underlying moral character of diagnosis in which he labels ‘disease entities…indisputable social actors, real inasmuch as we have believed in them and acted individually and collectively on those beliefs’.Footnote ¹²⁸ The accounts of traumatised Australian war pensioners by the Repat doctors are notable, however, due to the recurring references to alcohol.

The Repat doctors frequently tied the ‘psychiatric case’ with the ‘drunk’ or ‘alcoholic’. This includes Parkinson’s Apostle’s words above that connect the availability of military pensions with the turn to alcoholism, as well as the original MJA letter by Parkinson’s Disciple warning that alcoholism was to be considered a pensionable condition.Footnote ¹²⁹ The relationship between alcohol and the soldier experience has a long history. The presence of alcohol on the battle front has been labelled ‘therapeutic’, as it allows soldiers to endure the emotionally difficult aspects of the war experience, and aids in forming bonds within military units.Footnote ¹³⁰ Australian soldiers in all wars have been allowed small amounts of alcohol, and the Vietnam War was notable for the presence of ‘boozers’ on the war front, which soldiers frequently visited.Footnote ¹³¹ The presence of alcoholism within forms of war neurosis has also been long acknowledged. Alcoholism was a common symptom of war neurosis after the First World War, and by 1939, 4891 veterans were receiving treatment for psychiatric conditions in Repatriation hospitals, some specifically for alcoholism.Footnote ¹³² Numerous recent studies specifically focus on the connection between trauma in war and alcohol use, in an attempt to reduce reliance by veterans.Footnote ¹³³ Despite the psychological basis for certain instances of alcoholism, the tendency of Australian military-medical authorities to frame trauma in a medico-cultural way since the First World War meant that the possibility of alcohol as a symptom of a psychiatric condition was dismissed. In line with Kanaan and Wessely’s findings mentioned above, it was easier for medical professionals in search of a definable illness and achievable cure to focus on alcoholism as a personality flaw over any pathological reasons for addiction.Footnote ¹³⁴

This tendency gave rise to negative comments about alcoholic soldiers such as those cited in this article, as well as three other notable examples from Be In It, Mate! In one section of the book Dr Andrews’ colleague Dr Bell describes the case of a 22-year-old veteran, Mr Davidson, who:

When Andrews asked whether Davidson was employed, Bell said: ‘Work! He hasn’t worked for three years – war nerves, old man. His wife is the one who goes out to work. He contributes his war pension – or what’s left of it after a week on the grog.’Footnote ¹³⁵ This passage not only connects trauma and alcoholism, it also raises Davidson’s failure to act as breadwinner in his family unit, relying on his wife to support him. Also, importantly, it mentions Davidson’s desertion from his military unit. During the First World War, the British Army initially executed ‘malingerers’ who deserted – many of whom were suffering from shell shock or another psychiatric condition – before the morality of the death penalty for such acts began to be more widely questioned.Footnote ¹³⁶ The British Army defined malingering at this time as an ‘evasion of man’s duty to the state’ and to his fellow soldiers, and desertion as its ‘most dangerous form’ was a sign of a man’s morality.Footnote ¹³⁷

In an earlier passage, Dr Andrews asked Dr Bell how many ‘real’ psychiatric cases there were in the hospital, to which Bell responded:

In the final example, Andrews responded ‘mockingly’ after a colleague, Cranford, used the word ‘drunk’ to describe Repat ‘psychiatric cases’: ‘Careful…you mustn’t use that word – drunk. You mustn’t call them alcoholics either. Only the common people are alcoholics and get drunk. A recent ruling from above says that our drunks are all nerve cases, due to the war – of course’.Footnote ¹³⁹

These passages not only interconnect malingering, alcoholism and ‘war nerves’, but also suggest that veterans who drink can be compared to alcoholics in society. An examination of medical attitudes to alcoholics and alcoholism, then, could reveal more about how the Repat doctors viewed the traumatised veteran in the 1960s and 1970s. Few Australian studies specifically investigated medical views of alcohol and alcoholism; however, there is some indication that a tension existed at the time between social and medical perspectives of alcoholism. In her 1968 article ‘Heavy Drinking and its Relation to Alcoholism’, sociologist Margaret J. Sargent, perhaps unsurprisingly, focused solely on social and cultural factors that influenced Australians who drink.Footnote ¹⁴⁰ The psychiatric view, however, called for greater medicalisation of alcoholism. In 1961, H. M. Southwood, President of the Australasian Association of Psychiatrists, sought to define ‘mental health’ from a psychiatric perspective in his MJA article ‘The Psychiatrist and the Public’. He argued against attaching social or moralistic definitions to ‘mental ill-health’, including oversimplified statements relating ‘mental sickness’ with ‘delinquency, alcoholism, broken homes, twisted lives, crime, apathy, dejection, melancholy and suicide’, writing that the psychiatric view is more complex.Footnote ¹⁴¹ In his 1971 article ‘Alcoholism and Drug Dependence: Planning a New Service’, psychiatrist B. L. Hennessy discussed the importance of a medical treatment centre for alcoholics, citing both social and psychiatric factors in the development of alcoholism and labelling the lack of available psychiatric treatment ‘perturbing’.Footnote ¹⁴²

International studies prove more valuable in revealing public and medical attitudes towards alcohol and alcoholics. In 1971, American sociologists Chalfant and Kurtz analysed assessments of alcoholics by social workers in line with Parsons’ ‘sick role’, writing that more recent studies emerging from the 1950s had moved away from ‘deviance’ as an individual fault and towards definitions placed upon the ‘deviant’ by others in society. They confirmed, however, that although society was moving from a moral to medical approach towards alcoholism, individual medical practitioners still frequently blamed the alcoholic for their condition.Footnote ¹⁴³ Similarly, Abram and McCourt wrote in 1964 that despite efforts by the American Medical Association and the World Health Organisation to medicalise alcoholism, ‘At the clinical level…alcoholism continues to be viewed with the ambivalence, often expressed in feelings of derision, disgust and anger, such as were accorded other mental illnesses a generation ago’.Footnote ¹⁴⁴ Casper suggests a reason for this ambivalence in his study of ‘punch-drunk slugnuts’, or people with brain damage caused by head injuries who were categorised by doctors and the general public as ‘losers’, living on the fringes of society. The medicalisation of their condition was resisted by physicians, partly due to the difficulty in reconceptualising a long-standing social stigma, which Casper wrote ‘shows the material working power of culture, custom and conceit in shaping clinical knowledge’.Footnote ¹⁴⁵

Such feelings are illustrated by the title of some studies of the time, namely, ‘Doctors and Dirty Work’ and ‘Normal Rubbish’.Footnote ¹⁴⁶ In these studies, many doctors and other medical professionals expressed a sense of futility when discussing alcoholic patients that emerged from their inability to adequately diagnose and cure alcoholism:

If medical professionals are not able to appropriately legitimise an illness, by recognising and following a clear path to cure, Parson’s first aspect of the ‘sick role’ cannot be met, as mentioned above.Footnote ¹⁴⁸ Jeffery found that this led to frustration that was projected towards the patient: ‘Staff felt uncertain about the existence of an illness if there was no therapy that they, or anyone else, could provide to correct the state, and it would seem that this uncertainty fostered frustration which was vented as hostility towards these patients.’Footnote ¹⁴⁹ This ‘hostility’ took the form of labelling alcoholic patients as ‘rubbish’, which frequently appeared as sarcastic notes on patients’ record cards. This tendency is also supported by Braslow’s research on the treatment of neurosyphilis in the first half of the twentieth century, which found that open disdain of ‘silly’, ‘obscene’ and ‘vulgar’ patients by physicians transformed into a more respectful relationship once cure became possible through malaria fever therapy in the 1920s.Footnote ¹⁵⁰ Moreover, like the class judgements placed on malingerers or traumatised soldiers and veterans, socioeconomic class and cultural background were found by Mendelson et al. to significantly influence physician attitudes towards alcoholic patients.Footnote ¹⁵¹ Also, the more senior the position of hospital staff, the more critical they were of alcoholics and drug addicts.Footnote ¹⁵²

Similar frustration emerged when alcoholic patients failed to work at their sobriety in cooperation with the doctor. Parsons’ third and fourth aspects of the ‘sick role’ require the patient to want to get well and to cooperate with physicians to do so.Footnote ¹⁵³ Mendelson et al. observed in their 1964 study that one of the main reasons physicians found alcoholics difficult to treat is because they ‘seldom follow [their] advice’.Footnote ¹⁵⁴ One of the doctors interviewed in Jeffery’s study highlighted the importance of cooperation:

Physicians in these studies shared the opinion of Repat doctors that patients needed to take personal responsibility for their recovery and avoid becoming – in the words of ‘Parkinson’s Second Disciple’ in the MJA: ‘dead-beats, drongos, drunkards and inadequate members of society who are encouraged by the Department to seek shelter from their responsibilities in its wards’.Footnote ¹⁵⁶

In his 1979 study of ‘normal rubbish’ in hospitals, Jeffery found that if a physician did not hold the knowledge required to treat a patient, they may have been more likely to question the legitimacy of their illness, or their status as a ‘sick person’. A doctor interviewed in his study, when asked what type of patient was worth treating, said: ‘Anyone who is genuinely ill – I’m not talking about the psychiatric types I suppose, they’re genuinely ill but the thing is I don’t really understand psychiatric illness.’Footnote ¹⁵⁷ The de-medicalisation process by physicians who felt unable to work with a patient to effect a cure described by Jeffery can be directly compared to the – often furious and harsh – de-medicalisation of pensioned traumatised veterans by the Repat doctors, who were strengthened in their convictions not only by their long-term roles as detectives against malingerers, but also by the continuing ambivalence within the medical establishment and society with regard to psychiatry and psychiatrists.