Medical Science Publication No. 4, Volume II
FUNCTIONS OF A PSYCHIATRIC CONSULTANT TO ADIVISION, AND TO AN ARMY*
HYAM BOLOCAN, M. D.
The major function of the Division and Army psychiatrist is the conservationof manpower by the prevention, diagnosis and treatment of psychiatric problems,whether they be manifested by combat casualty or disease in which the functionalcomponent is primary.
The Division psychiatrist is attached to the staff of the Division Surgeon,the Army psychiatrist to that of the Army Surgeon. Both act in an advisorycapacity in all matters concerned with morale as well as those psychiatric.
Because of the similarities in their duties, for the purpose of thispaper they will be considered together.
A. Prevention
No program of prevention can be properly effective without adequatestatistical records. The Division psychiatrist should keep statistics asto the number and type of psychiatric cases seen, with figures broken downto at least company and, on occasion, platoon level. The Army psychiatristin turn receives a regular copy of this report together with notationsas to reasons for unusual changes. However, statistics alone are insufficient,for only an intimate knowledge of the situation and the personalities involvedcan permit the proper recommendations to be made.
A high NP rate may reflect any of the following situations:
1. Severe and prolonged exposure of a unit to combat.
2. Assignment of a new inexperienced medical officer.
3. New troops.
4. Impending breakdown of an officer or NCO.
5. Lack of confidence in the leader.
6. Breakdown of the rotation system.
7. Rotation anxiety.
8. Use of medical channels for attempted evacuation of those with administrativeproblems.
9. Inadvertent shelling of men by friendly troops.
*Presented 30 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.
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1. Severe and Prolonged Exposure of a Unit to Combat.
One expects psychiatric casualties in any given campaign just as oneexpects surgical or medical casualties. However, just as good preventivemedicine accompanied by proper medical discipline can cut down the numberof casualties due to malaria or cold injury, for example, good preventivepsychiatry can cut down on the number of psychiatric casualties. Lavinpoints out the need for repeated orientation of command regarding the problemof rest and regular rotation of units (1). Secondly, one must rememberthat treatment and prevention are somewhat inseparable in that the unnecessaryevacuation of one man may affect the morale and fighting efficiency ofa whole platoon equally desirous of escaping a stressful situation. Thirdly,good psychiatry practiced during the pre-combat period is likely to lessenthe number of breakdowns during combat. However, a word of caution is inorder here. Experience has shown that less emphasis should be placed onthe possibility that a man seen prior to combat will break down,and more emphasis placed on the fact that he might be useful.
2. The New Medical Officer
(a) The Battalion Surgeon. The battalion surgeon is responsiblefor psychiatric first aid and the treatment of those cases which, the tacticalsituation permitting, can best be handled at his level. By maintaininggood medical discipline he is able to avert the unnecessary loss of manpowerand to prevent the use of medical channels for the evacuation of thosepatients whose cases are properly administrative problems.
The battalion surgeon, often young and only shortly out of medical school,when newly attached to a unit may have some difficulty in reconciling hiscivilian attitudes with the military setting. Trained to use extensiveand time-consuming laboratory procedures and dedicated to the idea of investigatingevery possibility, he may unnecessarily evacuate those with psychosomaticproblems. Furthermore, in the military setting where the patient is subjectto more hazardous duty than the physician himself usually faces, guiltmay be stimulated. Such guilt may become attached to the idea that thephysician is missing serious organic illness for which he will be condemned.This is particularly true of physicians newly attached to a unit who havenot yet had an opportunity to form strong ties of identification with thegroup. It is the duty of the psychiatrist to give these officers strongsupport by educating them to the fact that, in a setting where healthymen are under continuous risk of losing their lives or being seriouslywounded, one must not evacuate on the basis of possibilities alone. Forexample, new battalion surgeons frequently evacuate
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patients with notes on the E. M. T. tag for "for x-ray" or"for GI series." Such notes tend to fixate symptoms and causedissatisfaction in the soldier when the procedure is not eventually carriedout. The psychiatrist should warn the battalion surgeon against such notes.In those cases where the note has already been written, and in those caseswhere repeated visits of a soldier to the battalion aid station have causeddoubt, it is a good idea to have the man examined by an "informalboard" consisting of the psychiatrist and two other medical officersat clearing station. The findings are then imparted by note to the battalionsurgeon so that he may have strong supporting opinions in maintaining theman on duty.
Newly arrived medical officers should be given written directives describingthe routine for handling psychiatric casualties and outlining Theater orDivision policies. Close personal liaison is desirable since medical officersare personally familiar with the personalities of the various officersin their outfit and are able to help the psychiatrist pin-point moraleproblems.
(b) The "New" Division Psychiatrist. The return toduty rate of the psychiatrist newly assigned to a Division usually followsa relatively set pattern. There is an initial period in which as he becomesless frightened by the possibility that a man may break down,and more impressed with a man's potential capabilities when forced to function,his return to duty rate gradually rises, reaching as high as 80 to 90 percent(depending on combat conditions, of course). As he remains with the Division,however, his return to duty rate begins to fall to around 40 to 60 percent.It is then that he begins to realize that his initial high return ratewas due not alone to the fact that prompt and proper treatment was beingutilized, but rather in reality represented a failure in the preventiveaspect in that far too many patients who might have been handled by theunit itself were reaching him, and that these patients often had not beensufficiently ill in the first place to warrant evacuation. Thus as he becomesbetter acquainted with his educative role in the Division, the rate falls.
3. New Troops.
Troops committed to battle before they have had a chance to form strongties of identification with the unit are more apt to break down. Furthermore,considerable time may elapse between the time of leaving Zone of Interiorand arrival at a combat zone. During this period efficiency may no longerbe at its peak and some lack of confidence in familiarity with weaponsmay have developed. If training has been accomplished on terrain differentto that over which the combat rages, troops may be frightened by the unfamiliaras well as being physically unprepared.
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In the beginning of a new campaign such axioms may be forgotten andit is the duty of the psychiatrist not only to bring them to the attentionof command but also to aid in the setting up of a program for the receptionof new troops.
4. Impending Breakdown of an Officer or NCO.
Since the leader usually represents the strong "father" ofthe unit, any signs of weakness or his impending breakdown are as threateningto the individual man as the breakdown of a parent in the family constellationwould be to the child. For this reason the psychiatrist should ever beon the alert for early history of signs of collapse in a leader so thatpossibly he may be pulled from future battle in time to prevent the breakdownof an entire unit. Personal liaison with battalion surgeons as well asquestioning of incoming casualties among the men usually reveals the desiredinformation.
5. Lack of Confidence in an Ineffectual Officer.
An incompetent officer will have an adverse effect on the mental healthof his men. For this reason his removal should be recommended. However,in these cases, in contrast to those cases in which the officer has performedwell, medical evacuation is not indicated, but rather a recommendationfor the proper administrative action.
6. Breakdown of the Rotation System.
The Korean campaign was unique in that at no time was there a definitegoal placed before the soldier in terms of just how much territory hadto be taken or even just who had to be defeated before the war could beconsidered concluded. No man in the line knew for certain whether the YaluRiver, the 38th Parallel or some other line was his eventual goal. Thislack of a concrete goal about which to build phantasies of returning homemay lead to feelings of hopelessness and despair with a tendency to giveway to forces which cause breakdown and present an honorable way out. Theestablishment of a rotation policy helped offset this difficulty by givingthe man a personally meaningful goal, something marked by a given pointin time, a device apparently which makes more easy the bearing of anxiety.
However, this policy in turn gave rise to problems all of which werethe direct concern of the military psychiatrist. Anything which tendedto interfere with or prolong the date of rotation led to increased anxietyin the man involved. In one case an overzealous regimental commander heldup rotation time of the men in his anxiety to maintain a certain strength.This was promptly reflected by an increase in psychiatric casualties. Areport by the Division psychiatrist involved helped remedy the situation.
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7. Rotation Anxiety.
Sometimes the anxiety engendered by approaching rotation is so overwhelmingas to cause a previously excellent soldier to break down. Unconsciously,reaching the desired goal sometimes stimulates guilt that friends willbe left behind to face further danger and hardships. An unconscious fearof punishment for aggressive wishes is often projected onto fate with consciousfear of impending disaster. These patients represent difficult treatmentproblems. They respond quickly to rest but have an immediate recurrenceof symptoms if sent back for the final days of their tour of duty. Becauserotation sometimes depends not only on spending a certain length of timeon duty, but also upon the quota assigned to the unit, there is often anunconscious wish on the part of the unit to have the man medically evacuatedso that someone else may become eligible. However, this is somewhat unfairto the man involved. A partial solution lies in pulling men back to lesshazardous jobs near their rotation time, but there are only so many openingsin a given unit. No simple solution presents itself, so that personal communicationwith the man's officer is usually desirable in order that the most practicalsolution may be arrived at.
8. Use of Medical Channels for Attempted Evacuation of Those WithAdministrative Problems.
Severe character and behavior disorders are likely to cause difficultiesregardless of assignment. Such personality types often try to escape byevacuation through medical channels. Busy and harassed officers are likelyto welcome this particularly if encouraged by lax medical discipline. Thisis sometimes understandable during the heat of battle but neverthelessnot to be condoned. It is not difficult for the psychiatrist to educatethe officers concerned that such laxity in the long run is destructiveto the morale of the men as a whole. Furthermore, if he remains firm inhis attitudes the way is often paved for more prompt administrative action.The Division psychiatrist should make the required recommendation for dispositionin a written report. Accurate figures as to the number of character andbehavior disorders seen together with the number that are repeaters areessential to both Division and Army phychiatrist in urging more promptadministrative action.
9. Inadvertent Shelling by Friendly Troops.
In battle, unfortunately, incidents may occur in which troops are subjectto attack by friendly forces. The resultant number of psychiatric casualtiesis usually far larger than the number that would result from similar exposureto enemy forces. It is a striking demonstration of the fact that strongforces other than just exposure to combat play a
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role in the formation or prevention of the psychiatric combat casualty.One may assume, therefore, that the converse is true. In other words, frequentbriefing of the troops with emphasis on the fact that they are part ofa team, and of the role that supporting troops play in protecting themwill help cut down the psychiatric casualty rate.
The Division and Army psychiatrist as well as being concerned with statisticsregarding the number and type of frank psychiatric casualties are alsointerested in the following figures:
1. AWOL rate.
2. SIW.
3. Number and nature of stockade admissions.
4. Wounded and injured, with particular regard to the number of coldor heat injuries.
A high AWOL rate is usually indicative of poor morale. Glass (2)in a study of 200 each made the following observations. Absence withoutleave is not an immediate result of intense battle trauma, but is the productof cumulative days of combat. Two-thirds of the offenses were committedfrom relatively safe areas. While the offenders were almost unanimous instating that they were motivated by nervousness or fear of combat, only25 percent had requested medical evacuation shortly before the offense.These requests had been refused. He was not able to demonstrate any definitecorrelation between the psychiatric and AWOL rates. The AWOL rate, however,is strongly affected by morale factors and it is therefore the psychiatrist'sduty to study the problem and make the proper recommendations.
The same may be said of the SIW rate. However, the statement that anoverly harsh evacuation policy is likely to lead to an increase in theSIW rate is debatable. The number of threats to perpetrate SIW's amongmen returned to duty is extremely high, yet the number who do so in thisauthor's remembered experience is low. It appears that one does not stepout of one's pattern of behavior and the man with true combat exhaustionis more likely to continue until actual breakdown rather than escape bythis type of activity.
Casualty lists should also be studied for any undue number of accidentallyinjured, or an excessive number of cold or heat injuries. These may representconsciously or unconsciously self-inflicted injuries and as such may directlyreflect morale problems to be investigated. The number of stockade admissionsand types of offenses committed are studied in order to try to pin-pointunits with remedial morale problems. A large part of the Division psychiatrist'stime is consumed in interviewing men involved in pre-trial cases. His reportsmay be certified, thus not necessitating a personal appearance at the trial.Both the Division and Army psychiatrist work closely
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with the Judge Advocate's section at their respected levels, not onlyin making recommendations in the individual case but also in advising inmatters of policy.
Education. A broad educative program is essential to fosteringthe principles of preventive psychiatry. Mention has already been madeof the role of the battalion surgeon. In addition, close contact with theregimental surgeons and colleagues at clearing station permits the Divisionpsychiatrist to disseminate a better understanding of the functional elementsin all disease, as well as to prevent needless evacuation of patients withminor psychosomatic complaints under the guise of organic illness. Thismay be done at meetings or at informal "bull sessions."
Pre- and post-combat periods may permit time for briefing of line officersregarding the handling of problems. In addition, the Division psychiatristis responsible for the training of his enlisted personnel.
The Army psychiatrist has even broader responsibilities. Prepared totravel a great deal, often in conjunction with other consultants, he willconduct at various echelons formal or informal talks on current psychiatricproblems. It is his duty to see that the knowledge of regular visitingcivilian consultants is disseminated to the largest possible audience andit is he who arranges the itinerary. In addition, periodic meetings shouldbe instituted at Army installations at which programs of mutual interestmay be shared with the Judge Advocate's section as well as the MilitaryPolice, the latter being interested in such problems as drug addictionand motivation for criminal behavior.
He supervises the indoctrination and training of new incoming psychiatrists,arranging for their assignments according to training and personality.Regular visits are made to each Division and all installations with psychiatristsso that there can be a mutual exchange of ideas and an opportunity to gainfirst-hand knowledge of existing conditions. Research is to be encouragedwhenever possible.
B. Diagnosis and Treatment.
Division Facilities. Since the T/O & E lists no officialNP equipment, the Division psychiatrist utilizes the equipment of the clearingcompany. He usually makes his headquarters at the holding platoon, andis thereby available for consultation with other medical officers. However,he should insist on separate tentage for psychiatric patients since ithas been found that intermingling of psychiatric casualties with otherpatients leads to mutual contamination of symptoms. Furthermore, separationhelps foster a return-to-duty atmosphere and facilitates the soldier'sacceptance of the psychogenic nature of his complaints.
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A small wall tent is used for private interviews. There should be sufficienttentage so that, the tactical situation permitting, one hundred patientsmay be held at a time. Clearing company messing, latrine and shower facilitiesare shared. Maintenance should be carried out by the patients themselves,under the supervision of NP personnel, this being considered a form ofoccupational therapy. Although the T/O & E provides for nine NP techniciansmost Division psychiatrists worked with a staff of four to seven men. Thesehelp relieve the psychiatrist of much burdensome detail, are responsiblefor the keeping of accurate records, make pertinent observations on thepatients, and by showing a warm, sympathetic, but firm attitude play animportant role in the treatment.
Army Facilities. Army facilities are of two types, the hospitalward and the rehabilitation center. The number of beds to be made availabledepends upon the tactical situation. Army facilities are intended to handledirect admissions from Army and nearby Corps units (in some cases Corpsand Army units utilize the nearest Division facilities) as well as to takeall casualties evacuated from Division. When the Division's load is exceeded,Army units should be prepared to admit directly from the combat zone.
An attempt should be made to keep hospital admissions to a minimum andemphasis should be placed on transfer to the rehabilitation center. Here,there is little hospital atmosphere, a "return to duty" atmosphereis fostered and secondary gain eliminated.
The Army psychiatrist although not in charge of these facilities isresponsible for their supervision, seeing that official policies are carriedout.
Holding Policy. The Division psychiatrist is directly responsiblefor the diagnosis and treatment of those cases arising in Division. TheArmy psychiatrist supervises the diagnosis and treatment of cases carriedout by other psychiatrists in Army installations, as well as by the Divisionpsychiatrists.
Since the differential diagnosis and treatment of combat neuropsychiatricbreakdowns is to be discussed this afternoon, no attempt will be made tocover the subject in this paper. However, this represents, together withpreventive psychiatry, one of the major functions of the military psychiatrist.The diagnosis of those cases not directly related to combat presents thesame problems as in civilian psychiatry, although disposition will of coursediffer. Fixed character and behavior disorders are not expected to respondto brief psychotherapy at any level. Therefore, decision as to dispositionis based primarily on ability to function. In the case of aggressive characterdisturbances and antisocial personalities, psychiatric channels are notto be used as a substitute for disciplinary or administrative proceedings.
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The psychiatrist should not be frightened by labels. Patients who couldin reality only be called ambulatory schizophrenics or mental defectiveshave performed well in the right assignment. Amazing "cures"have been reported in some enuretics, and passive-dependents when forcedto do so have on occasion performed in a creditable fashion. Nor shouldthe fact that a man is a "repeater" necessarily indicate a needfor evacuation. This may merely be an acting out of his neurotic patternrather than a real breakdown.
Notes from line officers should be honored whenever possible. Becauseof the rapid change in clinical picture, casualties evacuated should beaccompanied by a note for the benefit of the next psychiatrist seeing thepatient. For the same reason the psychiatrist should attempt to see patientsas soon as possible after admission.
Follow-up studies are desirable. Close liaison should be maintainedwith G-I and the AG section so that questions of assignment may be discussed.
Other Functions. During the Korean campaign it was the Army psychiatrist'sduty to draw up plans for the exchange of psychiatric casualties of war.Division psychiatrists as well as psychiatrists working at Army level tookan active part in the exchange.
Because of the presence of foreign troops and on occasion the sharingof facilities, close liaison with foreign medical officers was desirableand sometimes was profitable not only from a professional standpoint butfrom the standpoint of personal friendships as well.
References
1. Lavin, Robert J.: Division Psychiatry. Medical Bulletinof The U. S. Army, Far East. Vol I, No. 8, page 137, July 1953.
2. Glass, Albert J., Lt. Col., MC: Supplemental Number,The Bulletin of the U. S. Army Medical Department, Vol. IX, pp. 62-63,November 1949.
