Psychiatry and the War
by BRIG. GEN. WILLIAM C. MENNINGER, USA
MILITARY psychiatry differs from civilian psychiatry in that the Army must be totally responsible for a man — not only for his food and clothing, but especially for his ability to participate in his particular mission. Consequently, when a man did not fulfill his function, the Army had to find the cause and, if possible, remedy it. In many instances the cause lay in his personality and in his emotional difficulties. Since there is a human tendency to retreat into illness under stress, it was not surprising to find that many men became ill when they were unable to meet the demands of the new life.
Military psychiatry differs also in quality from civilian psychiatry. In the Army much more effort and time are invested in a preventive psychiatryan attempt to keep men healthy and to seek out causes for poor morale. Until comparatively recently, the majority of civilian psychiatric patients had to be brought to the psychiatrist by relatives, usually after a long period of “putting up with” the patient. Fortunately, this trend has changed in the last few years, and many intelligent individuals seek psychiatric help on their own initiative.
In the Army, psychiatric patients were discovered more quickly than they can be in civilian life. Men lived in such close contact that there were many observers of every man — his bunkmate, his sergeant, the dispensary surgeon, the flight surgeon, a general medical officer. When one of these noticed unusual attitudes or behavior, the soldier was often referred to the psychiatrist. Whether because of nostalgia, palpitation of the heart, disobedience, or “the shakes,” a considerable number found themselves referred to the mental hygiene consultation service in the training camp (between 4 and 5 per cent of all men in basic training) or to the neuropsychiatric ward of the station hospital. It has not been uneommon in any large camp for an outpatient psychiatric service to have as many as five hundred consultations in a month. These consultations seldom lasted less than half an hour. About 5 per cent of the men seen were sent to the hospital. Their symptoms, in many cases, certainly would not have been a matter of concern to relatives in civilian life.
This ratio of consultation, higher than in civilian life, is directly related to the structure of the Army, which requires every man to be it follower and many to be leaders; when he fails in either of these roles, he may become a “case.” Certainly the enlisted man was in no position to choose a different leader; usually he could not change his job. When a leader failed in his responsibility, his methods may have increased the possibility of maladjustment among his men. When a follower failed to accept his role, his behavior was likely to increase the maladjustment of others in his unit.
In military life the emphasis is on group welfare rather than on the welfare of the individual. In civilian life, however, the physician’s interest is primarily centered on his patient and on improving the environmental situation for the benefit of his patient. Except for court and legal psychiatry, it is rarely necessary to give special consideration to the results of a man’s behavior on the total social situation. In the Army, the psychiatric management of one soldier might vitally affect the morale of his group. For example, if he was a “goldbrick” and obtained a medical discharge on psychiatric grounds, or if he was a seriously maladjusted psychopath and was permitted to hide behind the skirts of psychiatry, the morale of his unit suffered. The Medical Department was not authorized to discharge a man who may have jumped ship or forged checks or gone AWOL, but it did its best to help such maladjusted persons.
Ninety-eight per cent of the doctors in the Medical Corps came from civil life. In some instances, the doctor’s own resentments and his reactions to them came to the front in his relation to his patients. Especially was this obvious when the physician had little interest in psychiatric disabilities, yet was responsible for their treatment. Such a physician was prone to call the patients names, to “tell them off,” to be tough with no recognition that he, the physician, was projecting his shortcomings onto his patient. The trained psychiatrists themselves had to wrestle far more frequently with their own emotions than was necessary in civilian life, for they too were cogs in the Army.
Where the psychiatrists came from
At the time of Pearl Harbor, the thirty-five psychiatrists of the regular Army Medical Corps, with few exceptions, were assigned to neuropsychiatric work in the Army hospitals in this country and our possessions. One of them was located in the Office of the Surgeon General for the principal purpose of reviewing the medical papers of officers being retired. The growth from these original thirty-five to approximately twenty-four hundred men practicing psychiatry was made against great odds. At the beginning of the war, the official organization of psychiatrists the American Psychiatric Association-had fewer than three thousand members, and this membership included 95 per cent of the recognized and qualified men in the field. Of these, approximately two hundred joined the Navy, and about six hundred came into the Army. The great majority of the psychiatrists who joined the Army came from state hospitals, where their work had been limited almost, if not entirely, to the care of “insane” patients; in the Army, they found that the psychotic patients constituted less than 10 per cent of their cases.
We found that the psychiatric sections of Army hospitals were caring for about 10 to 12 per cent of the total patients with the help of less than 3 per cent of the physicians. Obviously such increasing psychiatric service called for additional help. We were given sometimes surgeons, often pediatricians, most often young physicians just out of their civilian hospital internships. A special training school for 30 men each month was started in January, 1943. In 1944 this was expanded into a three-month course for 100 officers, and supplemented by a similar curriculum given by the faculties of New York University and Columbia University, Nearly 1400 medical officers, three fifths of the physicians practicing psychiatry in the Army, have been so trained.
The opportunity to specialize on any specific treatment was not possible, because of the demand for psychiatric services in so many different types of activities. Psychiatrists were early placed in induction stations; they conducted outpatient clinics in basic training camps; they functioned in replacement centers overseas and in redistribution centers in this country; they served in disciplinary barracks and rehabilitation centers — the correctional installations of the Army; they served on every hospital ship and transport carrying neuropsychiatric patients; they were included in every Army and each division of that Army; they are today in every separation center — where men leave the Army. Perhaps 60 per cent conducted the treatment in hospitals — evacuation, convalescent, station, regional, and general.
The shortage of psychiatrists was somewhat compensated for in 1944 when clinical psychologists — Ph.D.’s and M.A.’s — were placed in every general and convalescent hospital, in every outpatient clinic in the basic training camp, and in every correctional institution. An equally great contribution was made by the psychiatric social workers who were assigned to practically every installation where a psychiatrist was working. The actual number of graduate psychiatric social workers was small, and unfortunately they were never given commissions. Some of the social work was performed by members of the Women’s Army Corps, many of whom had never had special training.
One of the most progressive steps taken by the Medical Department in this war was the development of a consultant system. Soon after Pearl Harbor the Surgeon General appointed experienced specialists from civilian life, including twenty-five consultants in neuropsychiatry, to establish the professional divisions of Medicine, Surgery, and Neuropsychiatry. Thus there were consultants for each theater surgeon, each Army surgeon, and each surgeon in the nine Service Commands in the United States. As a result of those appointments the consultant system inaugurated and enforced a standard of professional work which was higher on the average than one would find in civilian institutions.
But the job of psychiatric treatment could never have been accomplished with this personnel, even with the consultant system and with nurses specially trained for psychiatric work, had not a final step been taken—namely, the concentration of patients. In 1943, twenty-two general hospitals were designated as psychiatric centers for a concentration of those patients requiring intensive care. Twelve convalescent hospitals were functioning late in 1944, with sections in which the milder types of mental illness called “psychoneuroses” were treated. On the first of September, 1945, there were 37,000 neuropsychiatric patients under treatment in this country, approximately 50 per cent of whom were in these convalescent hospitals.
Induction
As each man came into the induction center, he was given a series of examinations, the last of which was made by a psychiatrist. It is difficult to evaluate the effectiveness of these sketchy neuropsychiatric examinations. The total result was good, for certainly the examination kept out of the Army many men who would have been failures; on the other hand, it probably also kept out some who would have been successful lighting soldiers and who were greatly needed.
In the space of from one to five minutes the physician was supposed to do some sort of crystal gazing to determine whether an inductee, strange to him, might fit into an unknown job under unknown leadership with unknown motivation toward doing that job. The psychiatric examination was misunderstood from the first, not only by the medical profession, but by the civilians and by Army personnel. No psychiatrist, no matter how great his ability and experience, could look at a man, chat with him briefly, and adequately evaluate the functioning of his personality under great stress. At best he could be expected only to pick out the gross misfits.
Out of 4,650,000 men rejected for all causes, 1,825,000 — 39 per cent — were rejected for some type of personality disorder. What do these figures mean? From the Army’s point of view the only meaning was that these men were not thought able to withstand the greatest stress. As the war continued and manpower needs became more acute, modifications were made in the neuropsychiatric standards so that men with “mild psychoneuroses“ and “transitory psychoneuroses"were inducted. Experience showed that individuals in this category often made good soldiers.
Roughly, between 2 and 5 per cent of the draftees were rejected for psychiatric causes in World War I. In World War II around 14 per cent of all men coming up for examination were rejected for neuropsychiatric reasons. Despite these differences, the incidence of mental illness among the troops was probably higher in the second than in the first war. There is no one reason for this apparent discrepancy, although one can point out several extremely significant factors.
What contributed to mental illness?
One important difference was related to the motivation of the average soldier. World War I was fought “to make the world safe for democracy.” In World War II no such simplified objective emerged, and the average soldier was none too clear as to why he was fighting, despite the Army’s efforts to indoctrinate him. In World War I the band and the populace saw “ their boys” off on the train. In World War II the men reported individually to the induction center, with the public apparently indifferent to their going. The average inductee regarded his induction with a certain degree of fatalism—certainly with no enthusiasm. It was largely left to the Army to provide him with the conviction that the war was important, that his job was essential, and that he must be willing to sacrifice perhaps even his life to accomplish the Army’s mission. The absence of motivation is believed to have contributed significantly to the high incidence of psychiatric casualties.
A second factor in the increase of mental illness in World War II, despite the improved induction screening, was the type of warfare. World War I was a static war, largely fought in trenches, from which there was periodic relief for combat soldiers. It was localized in a relatively small area and, at least for American soldiers, was of comparatively short duration. World War II was a mobile war fought with the tremendously increased power of its instruments of death. It was fought in every climate, over every sort of terrain. Bombing, more powerful artillery, tanks, flame-throwers, rockets, suicidal attacks, and other devices intensified the strains of war a hundredfold. In addition, there were long periods of isolation, prolonged tours of duty, and recurring exposures to such diseases as malaria, plague, cholera. All these increased the psychological stress.
A third factor in the high incidence of mental illness was the greater knowledge of personality disorders. Psychiatrists, with the experience of the last twenty-five years, identified personality maladjustment sooner and more effectively than in 1917.
Types of neuropsychiatric casualties
In spite of the screening process at induction centers, numerous psychiatric casualties were sustained both by the troops in this country and by those sent overseas. Statistics tell the story: 314,500 men were discharged for neuropsychiatric causes up to July 1, 1945. This figure constituted 43 per cent of all men discharged for medical reasons; to it must be added 130,000 additional men discharged because of personality defects which made them incapable of fitting into the Army. The largest single category of evacuees from the Pacific consisted of neuropsychiatric cases.
Surprisingly enough, the war, with perhaps one exception, — that of “combat exhaustion,” —has not produced any new types of mental illness, any new clinical syndromes (particular group of symptoms). On the other hand, the frequent occurrence of some illnesses justifies a description of the more common reactions. There is no essential difference between the clinical picture of a soldier who broke down in Camp Shelby and one who — without battle experience — broke down in Algiers. The reaction was determined very largely by the individual’s personality structure.
One type of illness was called “simple adult maladjustment” for lack of a better descriptive term. It was widely used to refer to the milder reactions of a normal personality to an abnormal situation. In the enlisted man’s language it was most aptly described as being “browned off.” Soldiers subjected to isolation, monotony, uncertainty, tropical heat, lonesomeness, for an indeterminate period, might be expected to develop “simple adult maladjustment.” Sometimes the picture was associated with poor leadership, alleged unfair treatment, broken promises. Sometimes the fates combined to develop in the soldier a morbid resentment, a hostility which was expressed toward everyone and everything in his environment.
By far the most common mental illness was some form of neurosis. It is a true mental illness which is almost always related to earlier forgotten experiences, and it usually occurs in those who present evidence of periodic or constant minor maladjustmet in their previous life history. Under special stress, anxiety emerges with varied symptoms. Some men develop fear, others vague, ill-defined tenseness and apprehension; some become obsessive or compulsive; still others reflect this anxiety through physical symptoms localized in the stomach or heart, lower back or head. Such people are suffering from a neurosis, but they are not and will not become “insane.”
Through perhaps unfortunate publicity the diagnostic term “psychoneurosis” (“neurosis” and “psychoneurosis” are used interchangeably) came into some ill-repute. Even by many intelligent persons, the prefix “psych”on any word was interpreted to mean psychotic—“insane.” Every psychiatrist has patients who can and do recover from a neurosis by making only minor changes in their environment or by quickly gaining an understanding of their conflicts and adjusting to them. Others may need prolonged treatment, but they too, in a majority of instances, can become well.
Few people recognize that many superior individuals are highly neurotic and that some of them adjust very well as contributing members of society. Army personnel, as well as civilians, too often interpreted this diagnosis as meaning a non-effective individual who could not be salvaged. The result of this misconception was the abuse of medical channels for the quick disposal of men by giving patients this label as a convenient method of getting them out of the Army. They might have been non-effective for many reasons — because of attitude, ineptness, inadaptability, lack of physical stamina. But with patience many of them might have been salvaged. Later this practice was stopped by using administrative discharges for those without physical stamina, while many men with psychoneurosis were salvaged for further duty.
Outside the Army a certain number of employers and even some government agencies would not employ a man if they knew that he had been discharged with a psychoneurotic diagnosis. There was never any logical basis for such a refusal except the employer’s lack of understanding, for in most instances, the veteran was perfectly capable of making a civilian adjustment. In an attempt to alleviate this situation, the Army changed its policy in February, 1945, and no longer permitted the recording of the term “psychoneurosis” on the man’s individual medical record. Instead, the medical officer was required to specify any one of the eight recognized types of neurotic reaction: anxiety reactions, disassociated reactions, phobic reactions, conversion reactions, obsessive-compulsive reactions, somatization reactions, hypochondrial reactions, and mixed reactions.
Frequently individuals were encountered whose characters or personalities were definitely warped. Often they were very intelligent but were never able to profit by their mistakes or even by punishment. They were not able to maintain a lasting loyally to any person or group or code. Such persons are not to be confused with the calculating criminal, but all too frequently they were on the verge of criminal conduct and at times became involved in it. There was a curious disharmony between their intelligence and their apparent inability to control their behavior. Only occasionally are such persons brought to a psychiatrist in civilian life, and then usually because their families grow weary of their misbehavior or their broken promises. They were extremely difficult to detect in the superficial examination at induction. The majority of the 130,000 men discharged administratively fell in this group. They were not “sick.” They were misfits before their entrance into the Army and continued to be misfits after they were taken in.
Until World War I, psychiatry’s major interest and concern lay in the group of illnesses known as psychoses — insanities. By 1941, however, perhaps 20 to 30 per cent of the American psychiatrists carried on a practice in which they rarely saw a psychotic person. In the Army less than 10 per cent of the patients were in this category. At the beginning of the war such patients were usually promptly transferred either to state hospitals or to Veterans Facilities. Later, because of increased treatment efficiency in Army hospitals, at least five out of six of these patients were sufficiently recovered to return home. They were in an age group which is favorable to treatment. Because these patients were discovered in the Army early in the progress of the illness, treatment proved much more effective than in the case of a cross-section of patients with comparable illnesses in civilian life. The high percentage of recoveries among the psychotics is one of the major achievements of Army psychiatry.
“Combat exhaustion”
As I suggested earlier, perhaps there is one new mental illness which has come out of the war. It has been variously termed “combat exhaustion,” “combat fatigue,” or “operational fatigue.” The official Army diagnosis is “combat exhaustion,” but no term is entirely adequate. The symptoms varied widely but always were related to the stress of combat. The reactions of the fighter pilot differed somewhat from those of the infantry soldier. In all cases great stress had acted upon what was presumably a normal personality.
In its most severe form, combat exhaustion manifested itself in what was termed a “pseudopsychosis,” an apparently complete disorganization of the conscious personality. The individual might act entirely irrationally; he might freeze at his post; he might run wildly about, even toward the enemy lines. He might display an excessive emotional reaction with tears or great agitation. Often he might have “the shakes” — a gross body tremor. He might be so sensitive to noise that he would attempt to dig a foxhole or run for shelter with any noisy stimulus.
With appropriate treat ment the combat exhaustion case often cleared up in a short time. Probably the most amazing salvage rates in the entire war occurred in this group. The experience in the First, Third, Fifth, and Seventh Armies all indicated that approximately 60 per cent of such casualties could be returned to duty in the Army area within two to ten days of treatment — over half of them to actual combat — and that another 30 per cent could be returned for non-combat, duty in the zone ot communications in the theater. Only the 10 per cent remaining had to be evacuated to the United States. The frequency of these cases is best indicated by the established ratio of approximately one neuropsychiatric casualty to every five wounded men. The proportion sometimes ran as high as one in three; in a few instances, under superb leadership, it was only one in ten.
Perhaps the most unfortunate connotation of the term “combat exhaustion,” and of the other expressions for the same condition, has been the suggestion that fatigue was the incapacitating factor. It has been variously estimated on expert authority that fatigue is in itself the major factor in from 3 to 5 per cent of these casualties. (Research was badly needed to determine its actual role. Perhaps it might have been measured by blood chemistry studies and muscle metabolism investigations made on a large scale at the front lines. Such a study had been outlined for the Mediterranean Theater but the war ended before it could be undertaken.) There is no doubt, however, that the chief factor in most instances was the psychological trauma. Physical fatigue combined with psychological stress resulted in a type of illness in which psychopathology was the important feature.
A word about shell shock. This misnomer from the last war was based on the assumption that the concussion of an exploding shell in some way physically affected the nervous system— a theory that was entirely debunked even during the 1917-1918 conflict. It is difficult to determine the physical and physiological effect of concussion on the nervous system. There is a group of combat neuropsychiatric cases in this war — perhaps less than 5 per cent of the total — which have been termed “ blast injuries.” Even with the aid of the electroencephalograph, a machine which measures brain waves, there are many cases in which no positive diagnosis of “ blast injuries” can be made. Furthermore, even in blast-injury cases, the psychological element is often the incapacitating factor.
The results procured by the Army and division psychiatrists were outstanding. They were accomplished against great odds, the chief of which was the failure to plan for treatment in forward areas. When the American troops first began combat in North Africa, psychiatric casualties were conveyed back to the general hospitals in the rear. The transfer required from one to five days, depending on the transportation, and in that time the symptoms became fixed and the cases much more difficult to treat. When a man has been so far removed from the front area, it takes a big boost to get him back to his unit again. Thus less than 10 per cent of all psychiatric cases that developed in forward areas were salvaged for duty. Through the combined ingenuity of the theater surgeons, psychiatric consultants, and division psychiatrists, improvised treatment facilities were moved forward. Eventually a system was evolved whereby the casualty was treated in the clearing station with the division psychiatrist supervising the work, usually within five miles of the front line.
Those soldiers whom the psychiatrist could not salvage in forty-eight hours (he did salvage from 30 to 40 per cent) were referred on to an improvised unit termed the “exhaustion center,” where over a period of from five to eight days an additional 20 per cent were salvaged. The system was the more phenomenal because the entire program was worked out after the lighting had begun — in fact while it was in progress. The initial plan, developed largely by Hanson in the Fifth Army, became the pattern later used by the First, Third, Seventh, and Ninth Armies.
How genuine were the cases?
In light of the considerable numbers of neuropsychiatric casualties, psychiatrists are occasionally asked whether or not these cases were genuine. The answer is that they were. The psychiatric casualties in the Army could roughly be divided into two large groups: those soldiers who had previously made a good adjustment in their civilian lives but broke down in the Army because of the emotional stress of the new life; and those who at best had never maintained more than a marginal mental health when they were civilians.
In peacetime the men in this second group were not sick and the majority never went to a doctor. But they may have been excessively dependent, overseclusive; they may have had periodic stomach disturbances or other recurring physical complaints; they may have shown varying degrees of emotional instability or had difficulty in getting along with people; they perhaps shifted jobs frequently. Many of these men wanted to go into the Army and they tried hard; but basic training, even life in camps, was sufficient to throw the balance of equilibrium toward mental ill-health, with latent symptoms expressing themselves or existing mild symptoms being aggravated. The Army psychiatrists had to differentiate between these two groups, indicating those whose illness developed in line of duty and those in whom it had existed before they came into the Army.
Another differentiation difficult to make was that between those individuals who were truly sick with a neurosis or psychosis and those who presented lifelong character defects or problems of faulty attitude. Many of the men passed by induction boards had always been misfits as civilians and could not possibly fit into the Army. There was the occasional soldier whose attitude was faulty — he didn’t want to be in the Army and manifested his aversion by passivity or active hostility; there were many who very early felt that they had done their share and quite deliberately “would buck for a discharge.”
Malingering was rare, however, if we adhere to the definition that it is an act or behavior in an otherwise normal individual for the purpose of evading military duty. That some men capitalized on symptoms by exaggerating them or by endlessly complaining about them is certainly true. But one should recognize that evading or delaying a disagreeable or difficult job is a universal human technique. The total number of men who were out of line and failed to do their part was very small. On the whole, America has every right to be proud of the performance of the men in the service. It is only the oldster or the misinformed person who assumes that there is any deterioration of American youth.
Treatment
No distinctly new methods of psychiatric treatment were created during the recent war although three were developed far beyond their pre-war usage: psychotherapy under sedation, group psychotherapy, and the treatment program in convalescent hospitals.
There are many types of treatment for mental illness, but fundamental and basic to all of them is the procedure called psychotherapy. Oversimplified, it is the management by the physician, who presumably knows the anatomy and psychology of the psyche, of a psychological conflict in his patient.
The management of the conflict might be likened to the treatment of a boil. The physician has to know how deep the boil is, its particular nature, when and how it should be lanced, and whether lancing is a good idea. In the same way psychotherapy (treatment of the psyche) sometimes is suppressive to avoid the lancing; the psychiatrist recognizes that a conflict should not be opened up and the patient should be helped by reassurance, encouragement, and introduction to new interests. On the other hand, sometimes psychotherapy is best directed towards allowing the patient to see the nature of his conflict and the steps he must take for his relief. Ideally psychotherapy should aid the patient in gaining an understanding of himself, why he is sick, how he became sick, and how he can best modify his life to regain and retain his health.
This treatment is ordinarily a slow, painstaking process, and the handful of psychiatrists in the Army could not devote the required time to each patient. Furthermore, the imperative need for manpower demanded speed in whatever treatment procedures were to be used. Both psychotherapy under sedation and group psychotherapy were expedients developed to meet the situation.
Psychotherapy under sedation — variously termed narcosynthesis, narcoanalysis, abreaction, and hypnoanalysis — was used initially almost entirely for combat soldiers and flyers. Subsequently, it was used more widely and proved itself of tremendous value in competent hands because it was simple, produced results quickly, and had no serious complications. It was effective probably because a great majority of combat soldiers, even though they became quite ill, were essentially normal personalities prior to their combat experience.
Man’s psychological apparatus operates in such a way as to exclude from his conscious recognition certain painful and unpleasant memories. But even though the memories are repressed from consciousness, the emotional charge attached to them remains and gives rise to feelings of anxiety. There was the infantry soldier who went through hours, days, weeks of hell, with death strewn around him and always in constant, terrific fear for his own life; then finally his buddy was killed next to him, and in the soldier’s language “he blew his top.” There had been some evidence of his tension even before the final straw —• jumpiness, increased irritability, difficulty with sleeping, loss of appetite. He had run a continuous, rapidly changing gauntlet of traumatic emotional blows. When the final event occurred he “blacked out.” He became amnesic and was literally engulfed and paralyzed by his own emotion. When he was evacuated, the amnesia continued. He received psychotherapy under sedation.
In this treatment the patient is given an intravenous dose of a sedative drug — amytal or pentothal. Some psychiatrists have very effectively used hypnosis with no drugs. In a few instances ether was used, and nitrous oxide was tried. In a semi-stupor the patient is encouraged to talk, to relive the emotionally traumatic experiences he could not talk about, and often not even recall. He is given “free and adequate drainage” for this emotional tension. With the help of the psychiatrist, he can reconstruct the memory of the events that have been blocked from his mind. Then he is able again to retain and to integrate these memories into his waking state and into his current situation — one of safety and security in the hospital. If he takes this step successfully, the physician next helps him to gain insight into those factors of his experience which have contributed to his illness. The procedure is not automatic and only a skillful psychotherapist is likely to be successful.
The use of psychotherapy under sedation has been carried far beyond the uses indicated by our previous understanding of its possibilities, through the brilliant work of Grinker, Speigel, Drayer, Ludwig, Gaskill, Needles, Lemkau, and a host of other American military psychiatrists in overseas theaters. The experience of Kaufman, Beaton, Markey, and others in the use of hypnosis on Okinawa accomplished the same aim. Thousands of patients were given psychotherapy under sedation and from these cases we have learned much about psychodynamics (emotional tension and its release) and also the indications for and against this method. The application of the principles and methods so developed should be of tremendous significance to the practice of civilian psychiatry, both in exploration and in ventilation of unconscious emotional conflicts, in certain types of psychiatric illness.
The second major development of psychiatric trentment in the Army was the increased use of group psychotherapy. It was impossible for the psychiatrist to spend much time with any particular individual. Consequently doctors treated several patients at the same time, a practice which had been tried, particularly with children, prior to the war. The technique is still not standardized, but it has proved its worth in many Army hospitals.
Ideally a group of patients with similar problems meets for an hour every day under the leadership of a psychiatrist or, in some instances, a clinical psychologist or a psychiatric social worker. The best results have been obtained when the group numbers between fifteen and twenty-five. Various principles have been evolved for its effective management. The members compare their experiences, analyze each other’s problems, and under the skillful guidance of the therapist gain insight into their own difficulties and reach constructive conclusions about themselves. In the most successful programs the therapist continues with the same group through a series of from ten to thirty discussions.
Initially there is often some degree of hostility or skepticism, but the skilled leader welds the group into a closely knit unit, of which every member feels that he is an important part. There is no prescribed outline of discussions, although most therapists have pointed them into such general subjects as group orientation, emotional symptoms, how these are converted into physical symptoms, normal physiological expressions of emotions, constructive solutions, and so on. The discussion plan is occasionally varied with what is called psychodrama, in which the patients, in coöperation with one or more members of the staff, act out an anticipated situational problem.
The hospital
At first all psychiatric patients were sent to general hospitals. There they lived in a hospital environment, lounging around in bathrobes, often with little or no daily program. There was too much opportunity for them to discuss their symptoms among themselves without guidance, and actually to regress under the influence of nursing and protective care into a kind of hospital invalidism. To get away from this situation, twelve regionally located convalescent hospitals were established for all psychiatric patients who were not actually in need of nursing care. Here a man could look after himself; he could live in barracks; be could follow a daily program of activity particularly designed to meet his emotional needs. As of July 1, 1945, approximately hall of the 37,000 Army psychiatric patients in this country were located in these hospitals.
In addition to the individual and group psychotherapy provided by the psychiatrist and his staff of associates, clinical psychologists, and psychiatric social workers, an elaborate program of activities was initiated. Every patient had a prescribed daily program which included occupation, recreation and sport, and education. The occupational activities included not only occupational therapy in its wellestablished and recognized form, but also the diversional activities provided by the Red Cross-hobbies and handicraft skills.
The educational opportunities were almost unlimited. They were planned to be pre-vocational excursions, a trial for the patient to see if he was interested in a particular subject. On this basis the hospital was equipped with elaborate shops. In some instances as many as sixty different courses were offered — music, art, commercial subjects, mechanics, machinery, automotive subjects, electric welding, basic educational courses in reading, writing, and arithmetic.
In addition to these three major developments — psychotherapy under sedation, group psychotherapy, and the treatment program in convalescent hospitals — the Army has utilized various other methods although it has not contributed new ones. It has electro-shock therapy for its more severely mentally ill, the psychotic patients. It has used the insulin shock therapy and even more extensively sub-shock dosage of insulin. Investigative work was carried on with ergotamines for combat exhaustion. Hydrotherapy was provided in every general hospital.
Prevention
One of the largest services in the Medical Corps is concerned with preventive medicine. It interests itself in every possible method of preventing disease, from immunization to mosquito control, from water purification to quarantine. Curiously enough, the field of “preventive medicine" has not included a consideration of the prevention of mental ill-health despite the disturbing figures indicating the size of this problem. As a result the psychiatrists in the Army, in addition to their responsibility for screening and treatment, had to assume the leadership in all psychiatric preventive efforts. From the beginning it was believed that the state of mental health was very largely the charge of the commanding officers of troops. The leader is in a position to make or break his followers, particularly in the organization of our Army. A man’s assignment —or his misassignment -was of vital importance to his mental health, as were the training methods, the living conditions, and the possibilities for recreation. Because of the importance of these factors, a series of six lectures on mental hygiene was published under the title “Personnel Adjustment” — this term being used to forestall prejudice. Orders were issued that this course should be given to all officers. It was an attempt to enlighten the line officers in the matter of mental health and their responsibility for it.
A similar series was composed tor all enlisted men under the title of “Personal Adjustment” to aid them in adapting themselves to Army life. Both sets of lectures were to be given by the psychiatrist in each post, camp, station, or division. Preventive psychiatry was most effectively carried out by those who conducted outpatient clinics in each of the basic training camps and in the divisions. Not only did they provide the necessary outpatient treatment for soldiers with minor maladjustments and thus preserve manpower, but it was this group, above any other medical specialists, that assumed the responsibility of advising those officers in command of troops regarding mental health. Their patients represented the failures in the training camp. The psychiatrists were in a strategic position to learn from them the factors contributing to their failure. In most camps they made a study of the AWOL rate, the company sick-call rosters, the company punishment rosters. In many instances they were able to indicate to the commanding generals that something was wrong with the leadership in a particular company, battalion, or regiment.
As a result of special studies, numerous suggestions were made to various divisions within the War Department as to methods by which mental ill-health might be prevented or reduced. Probably the most important of these were made by Major John Appel. His recommendations were circulated throughout every theater, looking toward the establishment of a specified tour of duty of a definite length for the combat infantry soldier. He also suggested that replacements should be sent in as units instead of as individuals.
In order to practice preventive psychiatry, it was necessary to keep a constant running tabulation of the statistics which would indicate the trend of mental health; consequently psychiatrists at many levels had to become statisticians. At headquarters these figures were consolidated so that one could read the telltale story of which divisions had the greatest numbers of neuropsychiatric casualties. This permitted the ferreting out of the causes for the high rate of mental illness in a particular division. Only by tabulating such figures was it possible to discern the variants in the interpretation and application of standards for selection, treatment, or discharge in various camps and posts. While such figures were significant, no one assumed that they could tell all the story, and alone they might even give an erroneous impression; therefore, it was always necessary to compare them with the personal inspection reports of the consultants in the field.
Implications for the future
What can we estimate about the future of the men who became psychiatric casualties? There must, of course, be guesswork in any answer.
To discover that 14 per cent of all men between 18 and 35 years of age who appeared for the draft were disqualified because of personality disorders was surprising. The great majority of those men were not sick; they would have had no difficulty in keeping up to their former level of adjustment. There was no basis for either them or their employers to doubt their ability to continue at their jobs. The draft examination did not change them.
But the figure does have a major social significance. When so large a segment of the presumably healthiest age group in our population presents such defects, an inquiry is imperative to determine the causes. Education, family structure, unemployment, recreation, and all the other major interests of American life should be studied in terms of their effect on the mental health of the individual. Such a survey should guide us to corrective measures, so that problems of social welfare can be more intelligently attacked in order to improve the general level of mental health.
Experience in the war has tremendously increased the usefulness of psychiatry. Its social applications were tried in the Army and proved helpful in prevention of ill-health, in influencing motivation, in guiding orientation, as an aid to training and to the rehabilitation of social offenders. Psychiatric principles were applied generally to “normal” men to keep them “normal” in a very abnormal situation.
Psychiatry made definite gains in the realm of prevention and treatment of mental ill-health. Society has an opportunity to take advantage of this experience— in industry, education, recreation, criminal and penal work, community life. If it does so, psychiatrists must expand their work far beyond their hospitals and offices. They must pass on to every physician a more adequate understanding of personality deviations, through a major revision of medical education. They must attract to their field more men and women and continue their study of human behavior and ways of enabling people to adjust more easily to life.
The great majority of veterans who were discharged because of psychiatric illness will make a good adjustment. Surveys have indicated that they can and do return to work. Some are not entirely well when they leave the Army because their total recovery is dependent upon their integration into their family, community, and work. A few will need a long convalescence. The very nature of neurotic illnesses would indicate the desirability of providing these men with treatment instead of an indefinite pension with its unconscious incentive to remain ill. They rate special consideration, sometimes special planning. The great majority will be “healed” when they return, but because a man’s broken bone is sufficiently knit to bear his weight does not mean that he is in shape immediately to play football. The same is true of the unseen wounds of the neuropsychiatric dischargee. Understanding affection in the home, social and economic security, and satisfaction in work and play are the best medicine to supplement his assets gained from his war experience — greater maturity, pride in having contributed to a vital mission, the acquisition of new skills and abilities and of lasting friendships.
Psychiatry is at another and important crossroads. Will society accept its verities? Will psychiatry and medicine make them available? The immediate future will give the answer.