APPENDIX E
Neuropsychiatric Problem in the Army
An analysis of the extent of the neuropsychiatric problem in the Army and the recommended policy, plans, and procedures for diagnosis and treatment of military per?sonnel with psychoneuroses are presented in the memorandums which follow:
MEMORANDUM FOR: Gen. Kirk through Gen. Hillman
15 JUNE 1944
SUBJECT: Extent of Neuropsychiatric Problems in the Army
I. INDUCTION
a. Rejection rate.-The neuropsychiatric rate is higher than any other cause of rejection. During 1942 and 1943, 1,250,000 men (about 12 percent examined) were rejected because of mental and emotional abnormalities. This is equivalent to 104 divisions! During the last 6 months of 1943, 20 percent of the men examined were rejected for neuropsychiatric reasons.
(1) Possible causes (in addition to the recognized high incidence of neuropsychiatric disorders in civilian life):
(a) Attitude of the public toward war and Army service.
(b) Lack of motivation in selectees; i.e., the security of their home, friends, and job far outweighs their belief in their importance for and their need by the Armed Forces.
b. Neuropsychiatric examinations at induction centers are not satisfactory because of:
(1) Necessary speed and the consequent brevity of the examination.
(2) Insufficient historical data are available. Selective Service System Circular No. 4, dated 18 October 1943, recently inaugurated, is increasingly helpful as it becomes more widely used. The forms need review and probable modification.
(3) There is an inadequate number of neuropsychiatrists and too often these are mediocre in quality. The induction board examination is often regarded as having a low priority in the assignment of physicians.
(4) Clinical psychologists and psychiatric social workers, both of whom are probably available, could be of great help to the neuropsychiatrist but are not included in the table or organization.
(5) A directive recently issued will improve the situation by modifying the methods of examination and eliminating the necessity to formulate the diagnostic entity to label each rejectee.
c. Desirability for consideration of neuropsychiatric rejectees:
(1) The cause of rejection should be tactfully and adequately explained, although too often this is not done.
(2) Labeling a man with a psychiatric diagnosis stigmatizes him and often may affect subsequent employment.
(3) At present there are almost no organized educational efforts directed toward communities regarding the understanding of this class of rejectees.
II. INCIDENCE OF NEUROPSYCHIATRIC DISORDERS AND DISCHARGE RATES
a. Admission rate.-The admission rate to our hospitals in continental United States for neuropsychiatric cases in 1943 amounted to 140,977-the equivalent of 12 divisions. This rate does not include any neuropsychiatric cases occurring in oversea
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theaters or the large group of psychosomatic problems and cases labeled 'exhaustion' and 'operational fatigue.' As of 1 May 1944 there were 15,700 neuropsychiatric patients in the Zone of Interior Army hospitals, one-third of whom were in locked wards.
b. Incidence rates.-The incidence of severe neuropsychiatric problems is reflected in the admission and discharge rates. The total neuropsychiatric CDD discharges from July to December 1943 were 96,178, which amounted to 8 divisions. The total neuropsychiatric CDD cases, plus Section VIII discharges, from July through December were 132,959, or the equivalent of 11 divisions. Approximately one-third of the patients evacuated during November and December 1943 from oversea theaters were neuropsychiatric cases. Apart from all these figures, one must consider the large number of patients seen in the outpatient departments of hospitals and never admitted to the hospitals and consequently not discharged. To these must be added the same group of patients seen by the division and replacement training center neuropsychiatrists. The large number of 'battle exhaustion' and 'operational fatigue' patients are not included in any available figures. A fairly large percentage of patients on orthopedic, gastrointestinal, and cardiovascular wards are primarily neuropsychiatric cases. Every severe traumatic patient, such as the amputee, has important psychiatric aspects.
c. Causes.-There are many contributing and interrelated causes. The following specific influences in the production of these high rates are worthy of consideration for possible corrective measures.
(1) Failure of command function in providing good leadership. There is abundant evidence to indicate that where there is good leadership, neuropsychiatric casualty rates (including combat) are lower. With poor leadership the rates are higher.
(2) Lack of motivation. Efforts to date have failed to educate large masses of men as to why we fight.
(3) Misassignment in jobs, as well as in location. (Even the medical recommendation that the man be kept in the Zone of Interior is often ignored.)
(4) No available assignment; i.e., men who are good only for labor, and with no labor units in existence, they are given assignments beyond their capacity.
(5) Evidence suggests that training methods may provoke psychoneurotic responses.
(6) Individualism of our culture has developed an intolerance to the regimentation and discipline essential to the Army.
(7) With the combination of inadequate motivation and misassignment, the neurotic symptomatology becomes, in some instances, a sought-after vehicle for exit from the Army. Thus, psychoneurosis may become not only acceptable to such men but even attractive. The solution is not in stopping all discharges (which would only clutter our efforts with noneffectives) but in correcting causes.
(8) The high frequency of psychoneurotic adjustment in civilian life is recognized but it is not recognized that adjustment for the neurotic within the Army is far more difficult than in civilian life. The soldier is either on duty or, of necessity, a casualty under medical care. The neurotic civilian can so modify his life that he may work and does not become a medical problem.
(9) Need for simpler administrative discharge for mental deficiency, inaptitude, and defects existing prior to induction.
(10) There must be fundamental recognition that the Army, and particularly the Medical Department, cannot cure severe psychoneurotic patients within the structure of the Army. At most we can slightly modify them but their effectiveness will depend upon our ability to utilize men of limited capacity. On the other hand, the majority of severe 'battle' reactions can be readjusted if treated early and adequately.
III. TREATMENT AND REHABILITATION EFFORTS.
a. Attitude and policy toward psychoneurotic (and psychotic) patients:
(1) Prompt disposition of unsalvageable men is clearly the sound course but
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the Army's position as to this has varied from one extreme to the other. War Department Circular No. 161, dated 25 April 1944, caused the discharge of thousands of usable men. On the other hand, War Department Circular No. 293, dated 11 November 1943, has resulted in such pressure on commanding officers that there is evidence that an increas?ingly large number of ineffectual men are being retained, although undoubtedly this circular has been the cause of retaining many usable men who would otherwise have been discharged. Unsalvageable personnel improperly retained because of misinterpretation of this circular or pressure resulting from it have in turn added greatly to the problem of adequate and appropriate job assignment.
(2) Until recently treatment of neuropsychiatric cases has been of secondary consideration because of the attitude that all such cases should be discharged as rapidly as possible. More recently, because of the need to salvage men, the Medical Department is placing much more importance upon treatment (TB MED 28, dated 1 April 1944).
(3) Individuals classified as having a constitutional psychopathic state have generally been discharged without effort at treatment. These make up a considerable portion of the Section VIII cases and discharges for this cause in the last 6 months of 1943 equaled the strength of 3 divisions. While this group has a smaller percentage of salvageability than the neuropsychiatric group previously mentioned, no serious effort whatever has been made at salvage. In view of the shortage of manpower and because certain of this group can certainly be salvaged with proper treatment, it would seem that some test effort, at least, should be made along these lines.
b. Personnel: Medical.-To even meet the requirements as set forth by tables of organization for hospital units, approximately 500 neuropsychiatrists will be needed within the next 8 months. To meet this need, 140 recently graduated medical students are being given a 3 months' course in neurology and psychiatry, to be completed about 8 July 1944. It is not expected that more than 25 additional civilian neuropsychiatrists will be entering the Army during this period. At least one additional course, and preferably two courses, should be projected for the coming year.
Nonmedical.-Psychologists are now slowly being made available through The Adjutant General's Office, to be commissioned in that department and assigned as assistants to the neuropsychiatrists in hospitals and consultation services in replacement training centers. They have tentatively been included in the table of organization for overseas general hospitals and all hospitals of over one thousand beds in the Zone of Interior. It is estimated that between 250 and 300 such men will be necessary, although at present there are only about 75 available.
Psychiatric social workers can be of major help to the neuropsychiatrist at induction centers and replacement training centers and in hospitals, and will be of much use in the neuropsychiatric section of the reconditioning unit. Probably hundreds of these are in the Army. However, the Neuropsychiatry Division knows the names of only 325, and these names are located through the records of a civilian agency. Of these only about 60 are at present in clinical work, and there seems to be no simple machinery by which the others can be promptly freed from their present assignments to do this work for which they are specially qualified. The numbers of such trained persons required are so nominal that their loss could not noticeably interfere with the other work of the Army, whereas their special training is badly needed to meet the acute psychiatric problem which the Army faces.
c. Methods.-Treatment, preventive or reconstructive or both, is being carried out with varying degrees of success by the following agencies:
(1) Hospitals. TB MED 28, dated 1 April 1944, will improve the methods but psychoneurotic patients should, as a general policy, be removed from hospital wards and placed in special facilities annexed to hospitals as a part of reconditioning units. A directive to accomplish this is now in press.
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(2) The division neuropsychiatrist. Most reports indicate that very satisfactory work is being done by the sixty division neuropsychiatrists but their work should be coordinated by the appointment of a psychiatrist to each army (two have been so appointed) and arrangements should be made so that there can be a direct route of technical communication between the Neuropsychiatry Division of The Surgeon General's Office and these men. The division neuropsychiatrists also are badly in need of enlisted men as assistants but are now, as a general matter, prevented from obtaining these because there is no allotment for them under the existing table of organization of the division.
(3) The replacement training center neuropsychiatrist. Neuropsychiatrists at 30 Army Service Forces training centers are now doing an excellent job but similarly need a table of organization to include a psychiatric social worker for every two to three thousand men served by the unit.
(4) Outpatient departments. In connection with hospitals, outpatient departments are doing excellent work but would be greatly facilitated by the addition of a psychologist and an adequate number of psychiatric social workers.
(5) Neuropsychiatric sections of reconditioning units. With only a very few exceptions, these are still merely projects on paper but they offer the most hope of providing effective psychiatric treatment. The program for these is outlined in TB MED 28, dated 1 April 1944, corrected in TB MED 32, dated 15 April 1944.
(6) Retraining. Three experimental units caring for approximately 1,200 men at the Engineer Replacement Training Center, Fort Belvoir, Va., the Quartermaster Replacement Training Center, Camp Lee, Va., and the Ordnance Replacement Training Center, Aberdeen Proving Ground, Md., have been eminently successful and should be extended to all Army Service Forces training centers and selected Army Ground Forces training centers. The opportunity for job placement in the latter is much less than in the former. A weak link in the rehabilitation of neuropsychiatric patients is the lack of assurance that men will be assigned with some consideration of their choice, condition, and ability, although this is specifically directed in WD Circular No. 293, dated 11 November 1943, and reinforced by WD Circular No. 164, dated 26 April 1944. In cooperation with the Neuropsychiatry Division of The Surgeon General's Office, Dr. Walter V. Bingham of The Adjutant General's Office is drawing up an additional directive, specifying psychoneurotic patients, to aid in this direction.
d. Discharge.-The principle holds that the earlier treatment is given, the more likely it is to be successful. Once the neuropsychiatric patient crosses the discharge line, he has a fair chance of being a Government pensioner indefinitely. In the last war it is estimated that each hospitalized neuropsychiatric casualty cost us $33,000. Every discharged neuropsychiatric patient with a diagnosis of 'psychoneurosis, severe,' begins with a minimum of $50 a month pension and, literally, is paid to remain sick. In addition, he is stigmatized and in many places is refused jobs.
Discharge procedure probably needs reconsideration as applied to the neuropsychiatric case. Oversea veterans return in many instances disgruntled, disillusioned, and embittered and, if discharged, not only may remain invalids or semi-invalids but convey their attitudes of hostility to their relatives and friends. There is inadequate preparation of the men for discharge and inadequate preparation of the community and families for their acceptance. There is very limited provision for outpatients in civilian psychiatric clinics. Of an available 39,417 Veterans' Administration hospital beds for neuropsychiatric patients, 37,275 are now occupied, with a turnover of about 1,000 closed-ward cases per month. These beds, however, are presumably entirely for psychotic patients. There are essentially no outpatient facilities provided by the Veterans' Administration for neuropsychiatric cases. Although the neuropsychiatric problem in the Army is one of its chief concerns and the same holds true for the Veterans' Administration, there is no official advisory relationship between the neuropsychiatric divisions of these two organizations.
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IV. PREVENTIVE PSYCHIATRY
The major job of psychiatry in the Army, as conceived by the Neuropsychiatry Division of The Surgeon General's Office, is the psychiatry of the normal man-the preservation of his mental health. Selection and treatment are extremely important but most important are the motivation and the placement of each individual soldier. The normal living habits and attitudes of the average American civilian are antithetical to what must be demanded of him in the Army in the way of regimentation, discipline, and rigorous existence. His adjustment to the various features of the training program, to the prolonged separation from home, to the necessary isolation and often indefinite waiting, and to battle experiences produces far more severe psychological strains than any other comparable event in civilian existence. Any man may break and it is widely recognized that the majority who do break in combat could not have been screened out by any psychiatric or psychological technique.
a. Morale.-While the Morale Services Division is doing an excellent job, this job is still inadequate as evidenced by surveys and many reports indicate that the masses of men have no clear conception as to why they fight. Because they are very much influenced by the home situation and particularly the letters from their families, it would seem desirable to take the initiative by radio, press, and cinema to orient the civilian population. There is a direct relationship between the state of morale among the troops and the number of neuropsychiatric casualties. This suggests that a much more influential and powerful liaison should be established between the Neuropsychiatry Division of The Surgeon General's Office and the Morale Services Division.
b. Leadership.-A more adequate understanding of psychiatric and mental hygiene principles should be given line officers. TB MED 12, dated 22 February 1944, outlines these but has 'no teeth.' The inclusion of these lectures in organized courses is more or less optional and probably no provision is made for their utilization in our vast Army overseas. It is felt that one of the important causes of the development of neuropsychiatric conditions is the lack of adequate leadership. This applies to officers in all ranks, commissioned and noncommissioned, who have charge of troops. A problem here is the rigidity of the system, which tends to prevent a sufficiently facile reclassification or readjustment to a responsibility commensurate with the capability of the individual. In this connection it should be emphasized that noncommissioned officers are key personnel and that their appointment should be made with the greatest care and their training include a considerable amount of direction in the handling of men. It is felt that the present system of casual or superficial selection of noncommissioned officers without thorough examination of their records or capabilities needs remedial attention.
c. Public relations.-Because of the extent of the neuropsychiatric problems and their effect upon the morale of the soldier as well as of the home front, a policy of absolute frankness should prevail, with all facts and figures regarding this subject given out only after check by The Surgeon General's Office. Because of the magnitude of the problem, consideration could advisedly be given to the appointment of a press representative within the Army, oriented to psychiatry, who could devote himself to aggressive leadership in formulating civilian attitudes and better understanding. The Neuropsychiatry Division was, until recently, greatly handicapped in giving out any information even to scientific groups about this field. This has now been partially corrected but we are still not permitted to give out any figures. It is felt that certain figures could be given out which would serve to furnish the public a much more accurate picture of the situation and avert suspicion of the Army, at the same time not causing any violation of any security protection.
V. POSSIBLE RAMIFICATIONS OF NEUROPSYCHIATRY
The field of neuropsychiatry embraces a study of the motives, attitudes, and
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behavior of individuals. As it concerns the Army it, of necessity, should include major activities within the Army. It can, however, present only a point of view, make suggestions, or possibly offer advice regarding motives, attitudes, and behavior. The following suggestions are made on the assumption that contributions of neuropsychiatry might be valuable to these particular endeavors.
a. Classification.-Entirely upon the basis of medical experience, the following defects are apparent in our present classification system:
(1) A large percentage of the neuropsychiatric casualties seen are related to misassignment.
(2) There is insufficient flexibility in reassignment and no assurance that a man trained for a particular job can be held in that job.
(3) There is a lack of adequate liaison between the Medical Department and the classification officers. WD Circular No. 100, dated 9 March 1944, is a step in this direction but there are many reports that this advice is ignored.
(4) The method of using a group of men to fill an allotment more or less regardless of their capacities is perhaps often necessary but it explains many of the misassignments. Further, when replacements are sent, apparently insufficient attention is paid to the different rates of mortality and casualties within specialized types of work so that many men are assigned to types of duty quite different from those intended for them.
(5) Oversea replacements are too often inadequately trained recruits from replacement training centers. They have never been a 'part' of an organized unit but know they are going into combat.
(6) The present classification system is based largely upon the man's experience and with minimal regard for his choice and with too little critical evaluation of his personality equipment.
b. Training.-It seems probable that certain defects of a psychiatric nature exist in our training organization and methods, which might advisedly be given consideration. Specifically, the replacement training center receives our recruits and, in most instances, is less capable, because of its temporary structure, to provide aids in adjustment of the men to new conditions than most other organizations or units within the Army. The officers and noncommissioned officers know that the recruit is assigned to them for only a limited period and there is no unit to which the individual can give his allegiance or with which he can make any permanent identification. Obviously, substitutive opportunities must be provided.
Training could be more effectively given if the troops were more carefully graded psychologically as to their capacity to learn. This would entail the establishment of labor battalions, which have proved so effective in the utilization of manpower in the British Army and which certainly, to date, have reduced their neuropsychiatric discharge rate.
The training methods in certain camps might be given consideration, although it is recognized that certain methods are excellently carried out in one camp and poorly in another, depending upon the personal equation of the leadership. Consideration for effective teaching of the men and for their physical comfort is sometimes disregarded, despite instructions to the contrary. Too often their chief motivation is fear, and stress is laid upon the destructive possibilities rather than the constructive opportunities. Certain specific methods, such as desensitization to explosions and infiltration courses are, in some instances, disturbing experiences rather than desensitizing.
The Neuropsychiatry Division is attempting to formulate, through the neuropsychiatrists in replacement training centers, some constructive suggestions regarding training methods, to be the basis of consideration for possibly a more detailed survey of this field. A recommendation concerning the formation of labor battalions has been forwarded, through the Training Division of the Army Service Forces, to G-1.
Superficial impressions gained, to date, relative to training include the failure
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to make sufficient use of TB MED 12 and TB MED 21 (lectures on mental hygiene to officers and enlisted men); too frequent utilization of fear as the chief stimulus to learn; lack of adequate provision for training and the consequent usage of dullards and slow learners; lack of full appreciation of officers of their leadership responsibility, particularly to new recruits; and the overemphasis on competition in qualifying for marksmanship.
c. Selection.-Our most conspicuous psychiatric flaw relative to selection is concerned with officers. Except for those few who came into the Army by way of the draft, officers are not given a personality evaluation or psychiatric study. The British have been eminently successful in this field and now have established officer selection boards, including a psychiatric study, throughout the entire Empire. One indication of the seriousness of this failure to have psychiatric studies of officer candidates is the fact that between 45 and 55 percent of all officer retirements are because of neuropsychiatric difficulties. This figure, however, does not even remotely indicate the large number of officers who are failures in the command function of maintaining morale within their troops or who are otherwise inadequate as leaders. There is an increasing problem, with psychiatric ramifications, in the number of ineffectual high-ranking officers who are recognized as not being really adequate but yet not so grossly incompetent as to justify a reclassification. Consideration should be given to a more fluid status of ranks.
d. Motivation.-As indicated above, the motivation of the soldier to fight is not only a most significant factor in the achievement of victory but also determines the state of morale and mental health. There is a direct relation between the state of morale and the neuropsychiatric casualty rate and these are directly connected with the quality of the leadership.
Surveys have indicated that only two soldiers in five men believe they should be in the Army and many of them are fighting because the Army called upon them to fight and not because they feel threatened. Essentially such men are fighting for the Army and not for themselves, which implies an expected bargain-some sort of a return or reward for the servant.
To date we have failed, in varying degrees, in helping many soldiers appreciate that they are fighting for themselves; we have failed in some degree to make them feel that their efforts are appreciated; and we have failed to make the public fully aware of the need to fight this war. The latter is not the Army's responsibility but is essential to the Army's success.
Our Morale Services Division is making an excellent attempt to assist the command but the motivation must come directly from the command. Many reports indicate a lack of consideration for the individual, a lack of confidence on the part of the soldier in his officers, a lack of consideration in the form of privileges or concessions or evidences of personal interest in the soldier, a long line of broken promises, and petty restrictions. These are all of importance to the Neuropsychiatry Division because they produce neuropsychiatric casualties in direct proportion to their frequency and intensity.
It is believed that consideration might advisedly be given to a considerably enlarged Morale Services Division, with more direct contact with the command. Such a division should have a direct responsibility for civilian morale, since it is reflected in the soldier.
c. Demobilization and reconstruction-As far as the neuropsychiatric casualties are concerned, there is no adequate organized program for their care after discharge. The Army will receive the blame for breaking them and, while the Veterans' Administration will care for the frankly psychotic, the psychoneurotic patients (comprising 75 percent of the discharges in this field) will have to shift for themselves with no planned education of the families or the community and no planned provision for
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their further medical care. Under the present Veterans' Administration system, they will be pensioned and compensated to remain sick.
W. C. MENNINGER,
Colonel, MC.
MEMORANDUM FOR: The Assistant Chief of Staff, G-1
10 NOVEMBER 1944
Through: The Commanding General, Army Service Forces.
Subject: Psychoneuroses.
1. This memorandum has been prepared in compliance with the request of The Assistant Chief of Staff, G-1, dated 12 October 1944, for full information on present policies, plans and procedures for the diagnoses and treatment of individuals with psychoneuroses.
2. General.
a. It should be understood that psychoneurosis constitutes only one type of neuropsychiatric disorder, which along with psychoses, psychopathic personalities, mental deficiency and neurological disorders, represents a major medical problem in civilian life as well as in the Army. From 15 to 30% of combat casualties are neuropsychiatric and over 90% of these are cases of psychoneurosis. 30 to 40% of cases evacuated from overseas theaters are neuropsychiatric and of these approximately 75% are psychoneurotics. Approximately 70% of the 219,000 men who have received medical discharges from the service because of neuropsychiatric disorders are cases of psychoneurosis.
b. Psychoneurosis is a sickness which always represents maladjustment of the individual to his situation. It may develop in a normal individual under severe stress or become evident in a less well organized individual under slight stress. The causes for the present high rate of psychoneurosis in military personnel are believed to be:
(1) Stress of military service, including danger, regimentation, separation from home, etc.
(2) Deficient motivation and incentive.
(3) Classification and job assignment.
(4) Unit leadership.c. The retention and utilization of individuals with psychoneurosis has been determined by War Department policy which has varied from time to time depending upon the manpower needs. At one time all those with psychoneurosis were discharged for disability regardless of the extent of incapacity. At present those who are capable of performing any duty and for whom assignments are available are retained in the service. Those for whom no assignments are available may be discharged under the provisions of Section II or Section X, AR 615-360. The type of discharge is dependent upon the degree of incapacity.
3. Diagnosis.
a. Policy. The policy of this office is to confine the term, psychoneurosis, to those individuals who in professional medical judgment exhibit the signs and symptoms which satisfy the criteria for that diagnosis as established by generally accepted medical knowledge and practice.
(1) The criteria differ in no essential way from those customarily used in medical practice among other nations or in civilian practice
(2) The mere existence of 'nervousness,' neurotic traits, attitudinal or motivational problems is not regarded as justifying the term, psychoneurosis.
(3) There is no evidence that a new clinical entity is occurring among military personnel which would justify introduction of a new diagnosis in medical terminology.(4) It has been suggested that cases of psychoneurosis should be designated by other terms in the hope of escaping the stigma attached to psychoneurosis. This office is strongly opposed to such a policy. There is ample evidence as to the unwisdom
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of employing euphemisms for well established medical entities. The difficulty is not with the term, but rather with the attitude toward and understanding of the term.
b. Procedures. Individuals may either report voluntarily to a medical station or be sent by their commanding officers because of ineffectiveness or evidence of disorders. Initial diagnosis is made by a medical officer who may or may not be a qualified psychiatrist. Before any individual is discharged from the Army for psychoneurosis, he must be studied in a hospital and his diagnosis confirmed by a board of medical officers, the majority of whom are not psychiatrists, in most instances. The board proceedings in turn are subject to review of higher authority. In addition, consultants in neuropsychiatry of high professional standing constantly inspect the diagnostic studies and the accuracy of this diagnosis in each service command.
c. There is nothing to indicate that the diagnosis of psychoneurosis is being misused generally. It is understandable that the term has received publicity because of the large number of cases which have been encountered and the widespread misunderstanding as to the meaning of the term.
4. Treatment. The present policy provides for the treatment of all individuals with psychoneurosis. This is in contrast to previous policy which provided for the disposition of cases without benefit of treatment. In spite of this change in policy, however, the emphasis which can be placed on treatment depends upon the current policy regarding disposition and utilization of individuals with psychoneurosis.
a. Policy. Treatment policy includes the following points:
(1) All cases of psychoneurosis will be treated. Those individuals to be discharged, however, will not be retained merely to receive maximum benefit of treatment except in the cases where the psychoneurosis has been incurred in combat.
(2) Each case will be regarded as a medical emergency requiring prompt treatment.
(3) Cases will be regarded as sick men needing medical treatment rather than disciplinary cases needing punishment or threats.
(4) Military discipline will be maintained.
(5) Treatment will be by or under the supervision of psychiatrists. Other personnel will be utilized including line officers, other medical officers, clinical psychologists, Red Cross, etc.
(6) Treatment facilities will be centralized in order to control policy and procedures and to compensate for the existing shortage of trained personnel.
(7) Patients will be segregated from nonpsychiatric cases in most instances.
(8) The majority of cases will be kept out of hospitals for treatment.
(9) Patients will be given a full time program including training, education, orientation, physical reconditioning and occupational therapy.
(10) Full use will be made of accepted medical treatment methods including drugs, individual and group psychotherapy and adjuvant therapy.
(11) Every effort will be made to supply an incentive for recovery.
b. Procedures.
(1) Treatment in combat zones is conducted at battalion aid stations; division clearing stations; designated clearing companies known as 'exhaustion centers' and evacuation hospitals at Army level.
(2) Treatment in base areas is conducted in dispensaries; training center mental hygiene clinics; hospital outpatient departments; station and general hospitals; neuropsychiatric centers; and the reconditioning programs at convalescent centers.
c. Results.
(1) Combat cases: 40 to 60% return to full combat duty, 80 to 90% to duty of some sort.
(2) Base area cases: Approximately 50% return to full or limited duty.
5. Disposition. It is recognized that many individuals who are discharged from
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the service because of psychoneurosis are able to adjust satisfactorily in civilian life. They are discharged because they are incapacitated for military service, and not because they are incapacitated for civilian life. In this respect they may be no different from many others who are discharged from the service for medical and surgical conditions and well able to get along satisfactorily in civilian pursuits. Military life makes demands upon individuals which are far greater than those incident to civilian existence. The stress of combat is such that anyone will develop a psychoneurosis if exposed long enough. There has, however, been a tendency to abuse medical channels for the disposition of military personnel who are ineffective for reasons other than sickness or injury. This has in great part been due to an unwillingness of command to dispose of individuals who are inapt, inadaptable and poorly motivated by administrative means. A more simplified means than now exists and a clear cut statement of policy concerning the disposition of such individuals is desirable.
6. Prevention. Control of the factors which determine the incidence of psychoneurosis rests within the province of command. Preventive measures carried on by the medical department, therefore, must be largely educative and advisory. They are along the following lines:
a. Education of line officers and enlisted men on the recognition, causes and prevention of psychoneurosis.
b. Motivation. To foster attitudes and beliefs conducive to effective military performance.
c. From a study of the causes of actual cases of psychoneurosis appearing among military personnel, make recommendations to the command concerning provision of incentive, job assignment, training, discipline, etc.
7. Publicity. There is an obvious need for the education of the public concerning the diagnosis of psychoneurosis. Roughly, 500,000 men have been rejected at induction stations with this diagnosis and almost 200,000 have already been discharged from the Army. These men face the problem of adjusting to civilian life. Unless the public misunderstanding concerning the meaning of this term is dispelled, readjustment to civilian life will be needlessly difficult and essential care such as provision for medical treatment and rehabilitation will not be made. It is the policy of this office to initiate and pursue public education, stressing the following points:
a. The term psychoneurosis does not mean insanity.
b. Psychoneurosis does not mean cowardice.
c. Most men with psychoneurosis are able to work and live a normal life.
d. The public must be prepared to encounter a considerable number of these cases.
8. Current Trends. A reprint of the article 'Current Trends in Military Neuropsychiatry' by the Assistant Director of The Neuropsychiatry Consultants Division and The Chief of The Mental Hygiene Branch of this office is attached herewith as Tab F because it is pertinent to the present study. It outlines the present concepts of this office regarding the nature, mechanisms, treatment and prevention of psychoneuroses.
9. Current Directives. A brief summary of all directives concerning the past and present policies and procedures for the diagnosis, treatment and disposition of psychoneurotics and copies of the directives are appended as Tabs.
For The Surgeon General:
/s/ ROBERT J. CARPENTER,
Lt. Colonel, Medical Corps,
Executive Officer.
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MEMORANDUM FOR: The Assistant Chief of Staff, G-1
7 DECEMBER 1944
Through: The Commanding General, ASF
Subject: Psychoneuroses.
1. This memorandum has been prepared in compliance with the supplemental request from The Assistant Chief of Staff, G-1, dated 24 November 1944, for recommendations on the prevention of psychoneuroses among the personnel within the Army. Prevention is a major interest of psychiatry and it is the conviction of this office that it should make a major contribution to the mental health of the Army in this field, but this viewpoint in no way minimizes the magnitude of the treatment job.
Treatment needs are traditionally a function of the doctor and because it is an entirely intra-medical department problem, the field of treatment has been further developed than prevention. Preventive efforts necessarily involve the matter of policy in many of the branches of the War Department, particularly with G-1 and also in a major degree with G-3. Machinery for liaison between these groups and The Surgeon General's Office has never been sufficiently close for The Surgeon General to initiate assistance or express opinion on policies until they are in effect, and such a liaison could not exist unless by invitation from G-1 or G-3. Policies have been placed into effect, which we believe definitely influence mental health which might have been modified had they been evaluated from the point of view of their effect on mental health.
It should be understood that medicine, and especially psychiatry, is fundamentally interested in the normal as well as the pathological. It is believed that in those instances where policy affects the motivation, the feelings or the behavior of people that psychiatry might make a contribution as to the possible effect on the mental health of such policy. Such an opinion would represent one and only one perspective of any particular policy, and it is not presumed that it would or should be the final basis for a decision.
2. Combat.
a. Recommendations designed to decrease the incidence of psychoneurosis in combat have already been submitted. These cover tactical rotation, tour of combat duty, privileges for combat soldiers, replacement policy, training, classification, abuse of medical channels for disposition and leadership. Reference is made to Memorandum to The Assistant Chief of Staff for G-1 from The Surgeon General, Subject: 'Prevention of Manpower Loss From Psychiatric Disorders,' dated 16 September 1944.
b. Colonel William C. Menninger, Director, Neuropsychiatric Consultants Division, Office of The Surgeon General, recently conducted a similar study in the European Theater of Operations. A copy of his report is attached. The findings of this report corroborate those presented in the memorandum referred to above * * *.
3. Motivation.
a. Insufficient realization by the average soldier of the degree to which the enemy threatened his personal welfare is believed to have been a basic cause for the high incidence of psychoneurosis among military personnel. It is believed that the attempts to motivate personnel would have been more effective if:
(1) More information indicating enemy intent and ability to harm the United States had been presented to military personnel.
(2) The command had made greater use of communication media in the dissemination of information.
(3) The agencies and programs concerned with motivation of personnel had received (1) earlier and more complete knowledge of existing War Department problems, plans and policies; (2) more effective administrative support in providing program time and qualified personnel.
4. Discharge Methods.
a. Enlisted Personnel.
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(1) Administrative disposition of individuals who are inapt and unadaptable is frequently not accomplished because of the difficulties inherent in the present system and because of the reluctance of Commanding Officers to use this method. As a result, some of these individuals develop psychoneuroses from being kept in situations which are beyond their capabilities and others from the confusion arising out of repeated hospitalizations.
(2) In the past, the number of men who have been discharged by CDD has reflected preponderantly the Army's manpower needs rather than the occurrence of disabling physical defects. In general, an individual should not be discharged for disability when he is capable of performing limited service.
(a) Many men who are on limited service for physical defects are disabled only to the extent that they are not capable of performing full combat service. They are not truly disabled for limited service or for civilian life.
(b) Some men are on limited service, not because of existing defects, but because it is recognized that they would develop disabilities if exposed to combat service. A good example of this is an individual with neurotic tendencies.
(3) There are many men who are relatively ineffective for reasons other than health, but past policy has resulted in the labeling of these individuals with medical diagnosis, warranted or not, in order to effect their discharge. In connection with this, it would appear advisable to have a clear-cut expression of policy of the War Department concerning the abuse of medical channels in discharging personnel from the service.
b. Officers.
(1) The incidence of psychoneurosis in officers could undoubtedly be reduced if a more simple procedure than now exists were available for returning ineffective officers to civilian life. Commanding Officers reluctant to undertake the time-consuming and often unsuccessful reclassification procedures frequently make attempts to have ineffective officers discharged through medical channels. It should also be possible to more easily reduce the grade and responsibility of officers to a point where they could function without anxiety when they are assigned to positions which are beyond their capabilities.
c. General Effects of the Type of Discharge Used.
(1) The present policy of controlling the size of the Army by discharging large numbers of relative noneffectives by Section II or Section X, AR 615-360, 25 May 1944 (now AR 615-361 and AR 615-365) results in an increased incidence of psychoneurosis and tends to decrease the effectiveness of military personnel in general. This is because both of these discharges are honorable and because they imply a medical disability which is frequently not present. Unfortunately, a large percentage of military personnel sincerely believe that they could do more for the war effort as civilians than as soldiers. If honorable discharges are given to those who have been non-effective, and if in addition a medical disability is implied when it is not actually present, then an incentive to do effective duty is removed.
5. Personnel.
a. In view of the shortage of trained psychiatrists, the use of auxiliary personnel in the prevention and treatment of neuropsychiatric disorders is essential. Difficulties have been encountered in obtaining this personnel as a result of inadequate allotments of personnel to Medical Department installations and the absence of Tables of Organization in the case of Division Psychiatrists and Mental Hygiene Clinics.
6. Classification and Assignment.
a. When an individual is assigned to a job which he is unable to do, he may react by developing a psychoneurosis. A considerable percentage of individuals with
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psychoneurosis seen in Army hospitals would either not have developed their sickness or would have been able to continue in spite of it had they been assigned to less arduous jobs or jobs of a different type.
b. The degree to which medical judgment can be used to advantage either in formulation of policy or in administration of classification and assignment is not entirely clear, but would appear to warrant further study.
c. The dangers inherent in utilization of choice in job assignment are obvious. However were its adoption feasible, it is believed it would offer an important potential means of lowering the incidence of psychoneurosis.
7. Utilization of Manpower.
a. Elementary knowledge of human behavior indicates a wide variance in the mental and physical capabilities of men. These capabilities are the deciding factor on whether a man may be an executive or a clerk, an elevator operator or a longshoreman. There are many reasons why this elementary knowledge has not been effectively utilized in the organization of the Army. There is, however, a large group of men with limited mental capacity, but good physical condition, who, because of their mental limitations, cannot make effective combat soldiers.
b. A second group of handicapped individuals are the neuropsychiatric combat veterans, who have, to some degree, become non-effective for combat, but in whom we could prevent the further development of maladjustment if they could be appropriately and adequately assigned in noncombat positions. Not only could they be rehabilitated, but they would not be included as neuropsychiatric casualties to be discharged. If such assignment possibilities were available, it would be a step toward the prevention of the development or aggravation of neurotic symptomatology. In the best utilization of manpower, adequate provisions should be made for the appropriate assignment of veterans returned on rotation. Another step, the retraining of selected neuropsychiatric cases, although not actually reducing the incidence of neuropsychiatric difficulty as it occurs in the Army, would reduce the incidence of the number of men discharged for this disability. Such a retraining plan should follow along the lines of the experiment conducted at Belvoir, Aberdeen and Lee in the spring and summer of 1944.
8. Leadership.
a. As mentioned in previous memoranda, the quality of unit leadership is an important factor in determining the incidence of psychoneurosis. This office is not sufficiently acquainted with the leadership system to make specific comments or recommendations as to how it might be improved. Aspects of the problem * * * appear to merit further study * * *.
9. Training.
a. There is a high incidence of neuropsychiatric casualties during the soldier's first three months in the Army, at which time they are in basic training. Some of these maladjustments seem to be definitely related to training methods. An individual with a low intellectual capacity cannot effectively compete with men of superior, or, often even with average intelligence, and definitely cannot absorb training at a rapid rate. His only defense is the development of personality difficulties. Another factor affecting the soldier's adjustment in the situation is the temporary nature of the organization which he joins in the basic training camp. His officers are temporary and he knows that he is temporary, with the result that no close loyalties can be formed. Too often, the soldier goes out as a replacement and is assigned to a combat unit with no opportunity to become acquainted with the unit and entirely separated from any of the men with whom he trained.
10. Mental Hygiene Lectures.
a. On the assumption that a knowledge of elementary principles of mental hygiene were equally as important for Command to know as first aid, War Department Circular 48, dated 3 February 1944, prescribed six hours of lectures for officers and
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three for enlisted men. It is believed that these are not being given in most camps and posts although they have a high preventive value.
11. Restrictions by the Joint Security Board on Information Relative to Neuropsychiatry.
a. Because of existing restrictions imposed by the Joint Security Board, it has not been possible to publicly present the size and thus the actual status of the neuropsychiatric problems in the Army. Free utilizations of figures (without identifying units) would enable one to much more forcefully present and emphasize the importance of the problem with its attendant advantage as an aid to prevention.
12. Recommendations. In order to prevent psychoneurosis in military personnel, it is recommended that:
Combat:
1. In addition to the recommendations submitted previously,
a. The tour of combat duty for combat infantrymen as recommended previously be given an experimental trial on a limited scale.
b. Length of time of infantry combat duty be credited by authorization of a star or mark on the combat infantryman's badge for each thirty days of combat (or some such period).
Motivation:
2. The command itself makes more direct use of communication media in dealing with attitudinal and motivational problems in military personnel by:
a. Military leaders addressing personnel by radio, military press, motion pictures, etc.
b. Taking a more active part in the selection of subjects and formulating content of informational programs.
3. A standard operating procedure be made for War Department agencies to confer with the Information and Education Division on problems, plans, and policies which have a potential effect on the attitudes and beliefs of military personnel.
Discharge Methods:
4. A simplified procedure for disposing of inapt and unadaptable individuals be adopted.
5. The criteria for disability discharges (CDD) remain fairly rigid and not be subject to variation in relation to manpower needs.
6. When a surplus of personnel exists in the Army and it is desired to discharge the relatively ineffective group who are not sick, criteria other than medical be used to accomplish such discharges and that clear distinction be made between individuals who are ineffective by reason of sickness and those who are ineffective for other reasons.
7. A method which will facilitate the disposition of ineffective officers be adopted.
8. Consideration be given to the type of discharge used in view of its effect on the incidence of psychoneurosis and performance of effective duty.
Personnel:
9. Consideration be given to the training of psychiatric social workers.
10. Personnel allotments to hospitals be increased to provide for the assignment of psychiatric social workers and clinical psychologists.
11. Tables of Organization be provided to Division Psychiatrists and Mental Hygiene Clinics in training centers.
Classification and Assignment:
12. The advisability of extending the use of medical judgment in classification and job assignment be considered.
13. The possibility of introducing choice in job assignment be considered.
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Utilization of Manpower:
14. Consideration be given to the more effective utilization of the large group of limited capacity personnel by segregation in special units for assignment to duties commensurate with their limited capacity.
15. Assignments be provided for the effective utilization of neuropsychiatric combat casualties in the theater of operations.
16. Soldiers being returned from combat service overseas should not be assigned as trainees in basic training and that special consideration be given as to how they can best be utilized.
17. Further consideration be given to the plan for the retraining of selected psychoneurotic patients.
Training:
18. Consideration be given to establishing separate training schedules of graded difficulty, commensurate with widely divergent capacities to learn.
19. Consideration be given to developing specific ways and means of aiding the soldier in his initial adjustment from civilian life in the basic training centers.
20. Replacements who have trained together should enter combat units together in at least groups of two and three instead of being assigned individually.
Mental Hygiene Lectures:
21. War Department Circular 48 should be implemented so that it is effectively carried out throughout the Army.
B.P.R. Restrictions:
22. The policy as enunciated by the Joint Security Board on the release of information relative to the neuropsychiatric problem be liberalized.
NORMA T. KIRK,
Maj. Gen., USA,
The Surgeon General.
