CHAPTER XX
Psychiatric Social Work
Daniel E. O'Keefe, Ph. D.
Psychiatric social work in World War II was a young and vigorous profession faced with an unprecedented challenge which was met by the skillful and imaginative efforts of its members. Its value to the Army also became sufficiently clear to establish it as one of the professional functions within the Army Medical Department. Psychiatric social work by definition is that social work practiced in direct and responsible relationship with psychiatry in mental hospitals, mental health clinics, and other psychiatric facilities as a part of the activities of a clinical team, which may include psychiatrists, psychologists, psychiatric nurses, occupational therapists, and other professional personnel concerned with the prevention and treatment of mental diseases, behavioral disorders, and other psychological abnormalities.
HISTORICAL NOTE
In 1905, the first psychiatric social workers were employed in neurological clinics, in the Massachusetts General Hospital, Boston, Mass., and in Bellevue Hospital and Cornell Clinic, New York, N.Y. The following year, psychiatric social work was initiated at the Manhattan State Hospital in New York City, by the New York State Charities Aid Association. Here, the psychiatric social worker visited patients' families to obtain collateral information needed by psychiatrists, relative to family background and past life experiences. Later, to the duties of the psychiatric social worker was added the function of preparing families for the return home of mental patients.
When the United States entered World War I, leaders of the psychiatric social work profession foresaw the need for providing care for the mentally ill in Army and Navy hospitals and, in 1918, initiated a training course for psychiatric social work at Smith College, Northampton, Mass. As the flow of neuropsychiatric casualties increased, the Army Medical Department requested the American Red Cross to supply psychiatric social work personnel to military hospitals. The first trained worker was assigned on 1 September 1918, to the U.S. Army General Hospital No. 30, Plattsburg, N.Y., which was established for the treatment of functional neuroses. This worker's duties were to assist the medical officers by
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obtaining information regarding the personal, family, and community background of the soldiers under treatment, as an aid in diagnosis, treatment, and plans for aftercare.
After the war, in March 1919, the Surgeon General of the U.S. Public Health Service requested the American Red Cross to organize a social service program within Federal hospitals similar to that already existing in civilian hospitals for mental diseases. The U.S. Public Health Service had been made responsible for the care of veterans. The Red Cross assumed full responsibility for outlining the social service program, formulating policies, recruiting personnel, and assisting in the organization of the work. Because Federal hospitals served large areas, it was essential that the worker be equipped not only to give aid to the psychiatric staff but also to assist local Red Cross chapters in assembling social data, interpreting recommendations for treatment, and helping the discharged patient accomplish the necessary social and other rehabilitative measures for his recovery. Because there was a serious dearth of trained personnel, the Red Cross offered special scholarships and cooperated with existing schools of social work in a program of training. By January 1920, there were social service departments in 42 Federal hospitals. The Red Cross continued to carry the full responsibility for these programs until 1926, when the Veterans' Bureau organized a social work section as a part of its medical services and began taking over the social service programs in veterans' hospitals. The Red Cross continued to maintain departments of social work in 17 Army and Navy hospitals and in St. Elizabeths Hospital, Washington, D.C., during the peacetime interval.
With the exception of a period in 1933, when legislation restricted hospital benefits for veterans, the social work program for military service personnel and veterans continued to expand under the leadership of the Red Cross and the Veterans' Administration.
EARLY EFFORTS
When the expansion of the Army began in 1940 and 1941, the lessons learned at the close of World War I, and subsequently during the days of peace, were forgotten, and social work was not considered an integral part of the military medical organization. Some of the responsibility for this state of affairs must be placed on the field of social work which had established no working relations with any of the branches of the Armed Forces before Pearl Harbor. One indication of the situation was the fact that the National Roster of Scientific and Specialized Personnel of the National Resources Planning Board did not list social work as a profession. Since psychiatry at this time also did not receive adequate recognition within the Army, psychiatric social work had neither leadership nor high level support in the mobilization period of World War II.
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Participation of American Red Cross
The early expansion of the medical facilities of the Army and Navy clearly indicated that the psychiatric services would grow rapidly and that the psychiatric social services in the Red Cross program would become increasingly important. Because of obligations imposed by its Congressional Charter, the American Red Cross was committed to provide social work personnel, when such were requested by the Surgeons General of the Army and Navy, to staff the expanding military psychiatric services. In February 1942, a psychiatric social work consultant service was developed by the Red Cross with the purpose of establishing leadership for high standards of psychiatric social work practice in the military program. In June 1942, the Red Cross was requested to assign a psychiatric social worker to the Classification Clinic, Fort Monmouth, N.J., and later, additional requests were received from consultation services in ASF (Army Service Forces), AGF (Army Ground Forces), and AAF (Army Air Forces) training centers. Subsequently, assignment of Red Cross personnel was requested for all medical installations having neuropsychiatric patients, such as Navy hospitals, Army general hospitals, the larger station hospitals, and, later, the convalescent hospitals. Red Cross social work personnel were sent overseas to military hospitals in all theaters of operations. They worked in Army psychiatric centers, in general hospitals, in field hospitals, and on hospital ships returning neuropsychiatric patients to the Zone of Interior.
Role of American Association of Psychiatric Social Workers
After the outbreak of World War II, one of the immediate problems faced by the psychiatric social work profession was the limited number of qualified personnel available for assignment, not only to Red Cross programs but also to the many civilian agencies, hospitals, and clinics which needed the services of psychiatric social workers. The official professional organization of psychiatric social work was the American Association of Psychiatric Social Workers. Among its myriad concerns, at this time, was the need for a centralized Association office which could provide information and leadership in regard to personnel matters.
In September 1942, the Association requested a grant from the Rockefeller Foundation in order to accomplish two major objectives: (1) To centralize data on personnel and vacancies in psychiatric social work and (2) to establish a more vital and immediate relationship with professional education for psychiatric social work. This involved plans for recruiting students for psychiatric social work, for developing scholarship plans to finance students, and for channeling new materials and areas of practice to the schools of social work. It was hoped that such new data might
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modify the full 2-year psychiatric social work training program and aid in the preparation of advanced courses for trained and experienced workers.
The Rockefeller Foundation approved funds for this project, and on 19 October 1942, the War Service Office of the American Association of Psychiatric Social Workers was established and continued its operations until 1 December 1945. This office was under the direction of Mrs. Elizabeth H. Ross, the former Secretary of the Association. Through her guidance and leadership, the War Service Office became the central contact point and source of information for social workers in the military services as well as the professional resource from which later the Neuropsychiatry Consultants Division of the SGO (Surgeon General's Office) received much valuable advice in the development of the Army psychiatric social work program.
Among the important early accomplishments of the War Service Office was a survey of membership which was the starting point for many personnel questions and which enabled the Association to establish an accurate accounting of its personnel resources. As an outgrowth of this study which showed that only 35 percent of the membership of the Association were using their specialized training and experience in direct working relationship to psychiatry, it was seen necessary to define psychiatric social work and psychiatric social worker in order to identify clearly the specialty and its practitioners. This definition has been referred to on page 605.
Another important responsibility of the War Service Office was the support which it gave to the various committees of the Association, such as the Advisory Committee to the Red Cross and the War Committee. It also channeled current information to the Committee on Professional Education and to the Publications Committee which enabled these committees, in view of their developing relationships with the war effort, to be aware of the current situation in the field of psychiatric social work.
Liaison with Surgeon General's Office
Shortly after its organization in October 1942, the War Service Office established contact with Col. Roy D. Halloran, MC, Chief Consultant in Neuropsychiatry in the Surgeon General's Office, to inform him that this civilian social work group was willing and anxious to be of assistance to the Army in planning for psychiatric services. An extract from the minutes of the first two interviews held with Colonel Halloran gives the picture of that time:
Colonel Halloran indicated that the psychiatric casualty rate already was higher than had been anticipated. Under combat it might magnify beyond conceivable proportions. Despite continuing efforts to obtain trained psychiatrists, the Army would not have enough during this war; they did not exist. It would have to draw heavily on all kinds of people who could maximate the usefulness of each psychiatrist: attendants, psychiatric nurses, and social workers, to name some. The Red Cross was pro-
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viding excellent psychiatric social workers, but still in relatively small numbers. Moreover, the peak of need was a long way off.
The Psychiatry Branch was anxious to launch a large-scale preventive program through consultation services in training and replacement installations. As a civilian hospital administrator, Colonel Halloran had found social workers of distinct help in caring for patients. But if he were to allocate a large number of social workers, he would put the best and the largest number, in the preventive programs. Hospitals would be his second choice for assignments, and disciplinary barracks third. Even though the expanded consultation program might utilize the experience of the Fort Monmouth Mental Hygiene Unit, and that of existing consultation services elsewhere, such as at Fort Belvoir, Virginia, and Camp Callan, California, no new service was contemplated as being a direct copy of any one unit then in existence.
Cautious doubt was expressed about any chance of success in seeking a classification for Army social workers-as Dr. George S. Stevenson (Medical Director, National Committee for Mental Hygiene) and other psychiatrists had advised. Any new area of Army assignment was sharply suspect, under the best of conditions, and any suggestion which held the possibility of depleting potential combat personnel was triply suspect during a fighting war. To obtain a new classification for enlisted men was severely difficult; to obtain a new classification within the commissioned category was close to impossible. Besides, officer status was far from the first thing to worry about.1
Survey of qualified personnel
It was apparent that Colonel Halloran desired evidence that there were enough qualified social workers available to the Army to warrant consideration as to their proper utilization and that quick findings would be extremely helpful. The secretary of the War Service Office, in consultation with a number of persons, such as the military social workers at the Fort Monmouth Mental Hygiene Unit, the staff of the American Association of Psychiatric Social Workers, Dr. George S. Stevenson and Dr. Marion E. Kenworthy, and a number of civilian psychiatric social workers, developed the first tentative standards for social workers. These included professional training in social casework which was considered to be the most desirable social work background needed by Army psychiatry.
On 17 December 1942, the War Service Office requested the graduate schools of social work to supply specific information about all male graduates who had completed a social casework major and whether each man had had courses in social psychiatry and a semester of student fieldwork in a clinic or hospital headed by a psychiatrist. Within a brief period of time, 30 schools of social work had completed and returned their lists of psychiatric social work graduates. Postcard questionnaires were then sent to 200 male casework graduates reported by the schools to have military addresses and to 900 with civilian addresses. The result of this postcard survey indicated an overwhelming interest and desire on the part of social workers, serving in other military assignments where their professional
1Ross, Elizabeth H.: Early Efforts of the War Service Office. In Adventure in Mental Health: Psychiatric Social Work With the Armed Forces in World War II. Henry S. Maas (editor). New York: Columbia University Press, 1951, pp. 180-181.
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skills were not being utilized, to be transferred to duties which would be of value in helping their fellow soldiers. Other replies indicated a variety of ways in which social workers were using their skills to some extent in classification or personnel assignments, in special training units, and as assistants to chaplains. These social workers also expressed interest in any appointment, however remote, to work in a psychiatric treatment or mental hygiene program. The evidence which was made available to Colonel Halloran in January 1943 was far more than required, and he launched, then, the first of many steps in a long series which eventually led to the authorized inclusion of soldier-social workers on the staffs of psychiatric services.
EXTENSION OF PSYCHIATRIC SOCIAL WORK
Participation and Consultation Services
In the early days of the war, some social workers with officer status, assigned to classification or personnel work, were utilized in special training programs which had been established to identify the illiterate, non-English speaking, or emotionally disturbed inductees.
As early as mid-1942, in at least two centers (Camp Callan, Calif., and Camp Wallace, Tex.), unofficial but active outpatient neuropsychiatric clinics were functioning with social workers participating in the clinic operations. At Camp Callan, the neuropsychiatrist, Capt. (later Lt. Col.) Julius Schreiber, MC, had developed an outpatient neuropsychiatric clinic which drew its patients from the dispensaries, the guardhouse, the hospitals, the special training battery, the Offices of the Personnel Adjutant and the Personnel Consultant, and other agencies. At Camp Wallace, the Office of the Personnel Consultant, where two psychiatric social workers were assigned (neither classified as a social worker), operated an official mental health service with the personnel consultant acting as the psychologist and the station hospital psychiatrist, Capt. Donald F. Moore, MC, as the director. A considerable number of patients were seen by this unit which functioned informally until early 1943 when the official consultation service was established with its own psychiatric director.
The first formal and completely staffed mental health clinic was developed at Fort Monmouth, where the usual team of psychiatrist, clinical psychologist, and psychiatric social workers functioned in a most effective way and set a pattern for the development of consultation services throughout the Army. This unit was established on 4 March 1942 by Memorandum No. 11, Headquarters, Signal Corps Replacement Training Center, Fort Monmouth, and designated as the Classification Clinic, with a psychiatrist in charge as director. The clinic was made an adjunct of the Office of the Adjutant and, except in those cases where purely medical action was
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indicated, operated through that office. The mission of the Classification Clinic was to-
a) institute such corrective measures as are considered appropriate by the Director to reduce or eliminate the individual's maladjustment, eradicate factors related to incipient causes, to adjust the individual to the extent necessary for performance of his duty as a soldier; b) determine by professional methods whether an individual whose case is brought to it for attention is in a group that, gauged by generally accepted practices, either does not utilize his capacity to the fullest possible extent, or is being trained in a skill beyond his capacity; c) recommend for discharge from the service such men who because of mental or emotional factors cannot function adequately or who present a hazard to other men.
In addition to the types of cases just mentioned, men showing indications of mental deficiency were also to be referred for evaluation. On 28 October 1942, Memorandum No. 30, of the same headquarters, established the Classification Clinic as a mental hygiene unit.
It was from the experiences of this clinic that Greving and Rockmore2 wrote one of the basic papers on psychiatric social work in the Army. Later, on 22 January 1946, at the American Association of Psychiatric Social Workers, New York City branch, Greving3 concisely summed up the concepts which might be considered unique to military psychiatric social work, as follows:
Social casework services had useful applications in problems of personal adjustment in the military setting. Administrative understanding and leadership were of paramount importance for military psychiatric social workers. Valuable experimentation was possible for the development of many new practices in professional supervision and in teaching. This included attempts to divide the total casework job so as to make possible the maximum service of partly trained individuals and the development of techniques on group methods. Basic casework service had to be adapted to the total military purpose or appropriate fractions of it in order to be effective. It was learned that recording could be consciously modified in length, type and content without losing its professional value, and that taking notes during the interview process did not necessarily curtail the quality of the relationship between the 'soldier-client' and the military psychiatric social worker. Each individual military psychiatric social worker and each unit had to arrive at a clear concept of helpfulness which required much more sharpness and specificity than is usually required of civilian agencies. Military psychiatric social workers had a chance to appreciate afresh the significance of brief contacts and small services. The Army gave a new opportunity for demonstrating in practice that social casework skills were independent and separate from the skills and responsibilities of psychiatry.
The Army Air Forces also made use of mental hygiene units, the first one being developed at Drew Field, Tampa, Fla., in April 1943. Its purpose was to serve a group of maladjusted men requiring immediate disposition. Until February 1946, it served about 3,500 air force personnel being drawn from the Third Air Force and from several smaller nearby airbases. The
2Greving, F. T., and Rockmore, M. J.: Psychiatric Casework as a Military Service. Ment. Hyg. 29: 435-506, July 1945.
3Greving, F. T.: Group Treatment Potentialities in an Authoritative Setting. Ment. Hyg. 31: 397-408, July 1947.
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unit was staffed by a psychiatrist and an average of 10 social workers who had received complete or partial training in schools of social work throughout the country and two Red Cross social workers who were graduate social workers. The history of this unit has been written elsewhere.4
Personnel Shortages
As these developments were occurring, it became apparent that social casework practice in the Army was developing as a service to psychiatry and to the soldier-patient. Some of the reasons which contributed to the greater utilization of social workers in military casework assignments were the lack of sufficient psychiatrists; the volume of psychiatric casualties, both actual and anticipated; the limited number of qualified Red Cross social work personnel available; and the excessive cost of maladjusted soldiers, both in terms of economy and morale. The Red Cross made every effort to increase its personnel and, in 1942, developed a program for providing 75 scholarships per year for specialized training in medical and psychiatric social work for persons who had completed the first year of professional training in social work. This scholarship program was expanded until, in 1945, it provided 600 scholarships in schools of social work, a large percentage of which were awarded to students for the first year of their graduate training.
As the War Service Office continued to compile a registration list of qualified psychiatric social workers, there developed efforts to assign social workers to installations where their services could be most effectively used. This was a difficult task for there was no precedent to follow, and psychiatry itself was striving for recognition at the same time. The basic philosophy of military necessity which demanded that all personnel be considered in relation to their usefulness in contributing to the successful prosecution of the war effort forced social workers to prove their value in this light. As they were able to do so, requests for their assignment mushroomed. As an interim measure, lists of misassigned or newly inducted personnel with social work skills, prepared by the War Service Office, were used by the Neuropsychiatry Consultants Division to attempt to fill the needs. The variety of installations which found the contribution of social workers to be of value brought about a need to establish a specification serial number for military psychiatric social workers. Because of the leadership and resourcefulness of Mrs. Ross and the interest of Col. (later Brig. Gen.) William C. Menninger, MC, Chief, Neuropsychiatry Consultants Division, SGO, the detailed problem of establishing this classification was successful.
4Maas, Henry S. (editor): Adventure in Mental Health: Psychiatric Social Work With the Armed Forces in World War II. New York: Columbia University Press, 1951, pp. 24-43.
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SPECIFICATION SERIAL NUMBER 263 ESTABLISHED
On 23 August 1943, SSN5 (Specification Serial Number) 263 was designated for enlisted military psychiatric social workers. With this designation, the job of the psychiatric social worker was defined, as follows:
Under the supervision of a psychiatrist performs psychiatric casework to facilitate diagnosis and treatment of soldiers needing psychiatric guidance; administers psychiatric intake interviews and writes case histories emphasizing factors pertinent to psychiatric diagnosis; carries out mental hygiene prescriptions and records progress to formulate a complete case history; may obtain additional information on soldier's home environment through Red Cross or other agencies to facilitate in post discharge planning; must have knowledge of dynamics of personality structure and development and causes of emotional maladjustment.
The requirements were as follows:
Should have had at least two years of supervised experience in a public or private agency performing all or a major part of the above (social casework) activities; graduate work with a degree in social work granted by a recognized school of social work will satisfy the experience requirement.
The professional requirements were based on the necessity to define the minimum civilian background which would be safe to establish for soldier-psychiatric social workers assigned to work with psychiatrists and psychiatric patients. It was assumed and anticipated that there would be both psychiatric and psychiatric social work supervision. Along with this assumption, it was desired that individuals assigned to psychiatric social work duties should give evidence of (1) interest in working with people; (2) self-discipline in relation to problems of working with others; (3) desire to work on a professional level; (4) experience in working as part of a social service program; (5) appreciation of the wide range of human behavior; (6) some understanding of motivation and the components of a helping relation; and (7) skill in interviewing people with personal, social, or emotional difficulties. The Army definition, based essentially on job assignment, should not be confused with civilian membership organization standards or the variety of standards that were held elsewhere. This definition and the fact that it was subject to interpretation by classification officers made it inevitable that a very wide range of personnel would be assigned as military psychiatric social workers. A compensatory fact was that this definition was tested in the field by psychiatrists who found an increasing opportunity to compartmentalize the psychiatric social work job and thus utilize personnel who were not completely qualified.
Following the publication of this job definition, many enlisted men were able to obtain assignments which enabled them to use their civilian education and experience in social work. Even this influx of personnel was, however, insufficient to met the rapidly expanding needs of hospitals and
5On 18 October 1943, SSN was changed to MOS (Military Occupational Specialty).
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consultation clinics for additional social work personnel. It was necessary to institute a recruitment program within the WAC (Women's Army Corps) to obtain more personnel (fig. 52). As the first step, the War Service Office sent out letters of inquiry to schools of social work for information regarding former women students enlisted in the WAC who had fulfilled the training and experience requirements for the SSN 263 classification which had been designated for male military social workers.
On 29 February 1944, WD Circular No. 90, relating to the procurement of female technicians for medical installations, was issued. The alternate requirements for the psychiatric social worker, as stated in this directive, called for either: 'a) two years of social work; b) graduation from college with a major in psychology or sociology; c) two years of college with some work in psychology or sociology.' These requirements were considerably lower than those for men and caused great concern on the part of professional organizations interested in maintaining the highest standards possible under difficult conditions of shortages of fully qualified personnel.
On 20 June 1944, the standards for WAC personnel were revised
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in WD Circular No. 253, and the standards for their qualifications were brought into conformity with those for men.
To provide additional personnel for the incidental services connected with psychiatry and psychiatric social work, a new category was established termed 'psychiatric assistants.' Persons having only the qualifications originally established for the WAC psychiatric social workers were henceforth designated by this title.
Steps toward locating and reassigning qualified social workers were speeded further by WD Circular No. 295, issued on 13 July 1944. This circular added to the previous official job description by specifying that psychiatric social workers were essential to the proper functioning of the consultation service in training centers and as assistants to neuropsychiatrists in the neuropsychiatric sections of hospitals and hospital annexes in the Zone of Interior. Further, it directed that all personnel qualifying as psychiatric social workers, who were not being properly utilized, would be reported to The Adjutant General for reassignment.
TRAINING
After establishing the SSN 263 classification for psychiatric social workers, in August 1943, educational efforts to improve the quality of military psychiatric social work were concentrated in inservice training courses. The need for such a program developed spontaneously in hospitals and consultation services where military personnel were assigned to duty as social workers. Because of the critical shortage of fully qualified psychiatric social workers, it was necessary to lower the minimum qualifications to a level which included 2 years of supervised experience in a social agency as acceptable. This meant that instead of graduate social workers with a major in psychiatric social work, the Army was forced to use persons who had no professional education and little or no knowledge in handling patients with psychiatric difficulties.
Military Inservice Training
Psychiatrists and qualified social workers had realized the training deficiencies in the variety of social work personnel in the service and, in order to raise the standards of efficient service to patients, had instituted training courses. For instance, at Camp Carson Convalescent Hospital, Cob., the inservice training program for social workers was considered to be the responsibility of the casework supervisor and his assistants. It had as its objective the development of each social worker in general skills and concepts, which would enable him to handle a wide variety of patients skillfully, and also the improvement of specific methods of handling each
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individual patient to insure maximum help to that patient. The program included the following methods:6
1. Prescribed introductory courses and seminars in which basic concepts of psychiatry and psychiatric social casework will be presented. The responsibility of the content and conduct of this phase of training will be delegated to the casework supervisor and to the psychiatrist.
2. Individual conference between social worker and his own supervisor. These conferences will be held at least once a week and will include discussion of individual cases, general principles of casework, group work and psychiatry and the application of these principles to individual case situations. The responsibility for the content and direction of these conferences will be shared between the supervisor and the individual social worker. The individual social worker will be expected to make maximum use of these conferences by keeping himself aware of his need for professional development.
3. Conferences of all social workers supervised by one supervisor. These conferences will be held weekly to discuss administrative matters and to encourage uniform development of professional skills and understanding among the staff. Common treatment problems can be discussed here. The responsibility for content and conduct of these courses will be that of the individual supervisor.
4. Social Work Staff Conference. This conference will be held weekly and all members of the social service staff will attend. The content will include any matter professional or administrative that the staff believes is pertinent. The responsibility for the content and administration of these conferences will be that of a committee of social workers. All social workers will be expected to contribute to these conferences.
Another social work inservice training program at Welch Convalescent Hospital in Daytona Beach, Fla., was organized on the basis of semiweekly meetings. The chief of the Neuropsychiatric Treatment Branch gave the general orientation which had, as its content, the following:7
a) Purpose of an inservice training program within the unit; b) orientation to social work in an Army hospital setting; and c) administrative setup of this psychiatric unit.
The second section of the program was devoted to the 'Dynamics of Human Behavior,' taught by psychiatrists and encompassed the following content: The Normal Psychology of the Development of Personality; Basic Concepts of Abnormal Psychology; Psychopathology for Psychiatric Social Workers; Social and Psychiatric Implications of Illness; Implications of Illness in the Army-the Meaning of Symptoms; Military Psychiatry; and Cultural Problems as They Affect the Individual.
The third section was 'Fundamentals of Social Case Work,' taught by social workers: The Meaning of Social Case Work-Basic Concepts; Case Work Differentiated From Psychiatric Treatment; Review of Current Literature; Basic Case Work Literature; History Taking As An Aid To Diagnosis; Treatment Methods in Case Work; Principles of Case Work Interviewing; Case Work As An Aid to Diagnosis; Case Work and Group Work Methods; and Group Psychotherapy. Each of these lectures was followed by a review of current literature.
The fourth section defined the 'Role of the Social Worker in this Convalescent Hospital': The Soldier in the Army-His Problems, Adjustments, Anxieties, Normal vs Abnormal Reactions; Original Contacts With the Soldier at Intake; Social Work Responsibilities; Group Psychotherapy on the Company Level; Case Work Contacts on the Company Level; The Use of Army Resources in Treatment Process and in
6Personal communication to author.
7Personal communication to author.
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Diagnosis; Classification and Assignment a Problem in Treatment; Administrative Problems of the Psychiatric Social Worker; and Methods of Recording the Case History.
The final section was devoted to 'Team Relationships': The Role of the Psychiatrist in the Clinical Team; The Role of the Psychologist in the Clinical Team; The Role of the Social Worker in the Clinical Team; The Function of the Red Cross in the Hospital Unit; and, finally, Summary of In-Service Programs.
There were many facilities, such as the Mental Health Unit at Drew Field, where training was early established for Third Air Force personnel and at the Second Air Corps Training Center where all 289 mental health personnel assigned to consultation centers were trained under a psychiatrist and a psychiatric social worker and an exceptionally good job was done.
The experiences of the Fort Monmouth Mental Health Unit had progressed so far that, in July 1943, the staff there proposed a tentative program for on-the-job training. Their experiences, together with those of Camp Carson, Colo., Camp Edwards, Mass., Camp Butner, N.C., Welch Convalescent Hospital, Daytona Beach, Fla., Percy Jones Convalescent Hospital, Battle Creek, Mich., and Mason General Hospital, Brentwood, Long Island, N.Y., were all used to develop a formalized training program. It was planned to organize training courses in the winter of 1944 which would be established at two centers, one in the East and the other in the West, which would meet the needs of the field. Mrs. Ross was commissioned to prepare the necessary material, which she did with the assistance of Maj. (later Lt. Col.) Manfred S. Guttmacher, MC. The goal of this program was to include the necessary orientation to psychiatry with adequate social casework orientation and on-the-job training. A plan was recommended to the Training Division, SGO, proposing that this course be established at Mason General Hospital and Camp Carson Convalescent Hospital. Approval was granted, but the cessation of hostilities made necessary the termination of these plans.
Because it was the opinion of the Neuropsychiatry Consultants Division that this material had considerable value, it was decided to revise the plans for the presentation of the course and make it available to all installations where social workers were assigned. Accordingly, the material was mimeographed and sent out to the neuropsychiatric consultants in the various service commands for them to distribute to the installations where they thought it would be helpful. The following subjects were outlined in the final draft:
I. Practices in military psychiatric social work:
a. Interviewing.-To present the principles, purposes and practices of psychiatric casework interviewing in a military setting and to delineate the responsibility of the interviewer to interpret the scope and facilities of the neuropsychiatric service. To emphasize his obligation to make the interview purposeful and meaningful to the patient and his delegated authority to seek information, to observe attitudes and to note behavior which would aid the unit in its specified psychiatric function.
b. Interpretation.-Responsibilities and factors of military relationship between individual psychiatric social workers representing their neuropsychiatric unit and other Army personnel who are carrying some responsibility for soldier patients.
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c. Administration.-Administrative structure of the neuropsychiatric unit and of the installation. Army policies and procedures and regulations affecting the practice of military psychiatric social work.
d. Resources available to military psychiatric social workers.-The purpose, pro?visions and administrative structure of technical services and specialists skills in related programs for unadjusted soldiers and soldier-patients.
II. Functional relationship to military psychiatry:
a. Personality structure and function.-To discuss the standards, development and behavior by which soldiers are considered, in Army terms, to be 'well adjusted.' To describe the stages in adaption to military experience from induction through discharge; mechanisms by which behavior is an expression of unconscious as well as conscious motivation; and the selective predisposing physiological, cultural, biological and social factors which account for individual difference and group alikeness.
b. Psychopathology for psychiatric social work personnel.-To present the extent and limitation of psychiatric social work duties in relation to psychiatric responsibilities for determining psychopathology within Army policy; to discuss origins, meanings, adaptive purposes and effects on the personality of the major psychoses and neuroses; physiological involvements; extent to which symptoms represent exaggeration of health responses; organic neurological changes resulting from nerve injuries. Military and social importance of the concept of psychoneurotic reaction to stress; types of mental character deficiency; diagnostic aids, significance of diagnosis and responsibility of military psychiatry for treatment.
c. Orientation to Army psychiatry.-To study the functions and administrative relation of psychiatry within Army medicine and in relation to Army purposes. Psychiatric responsibility for the study and/or treatment and recommendation on possible cases of mental illness and emotional disturbances, of mental deficiency, chronic alcoholism, psychopathic or criminally inclined personality, malingering; problems of discipline, morale and other functions of the command as they affect the individual and the military organization.
d. Group therapy.-Survey of group therapy as a psychiatric function; the purpose, general scope and practice within military psychiatry; the function of the military psychiatric social worker as a group therapist working under psychiatric supervision.
III. Functional relationship to clinical psychology:
To discuss the types and purposes of commonly used individual and group tests of intelligence, aptitude and personality evaluation as administered in neuropsychiatric units in the Army and to observe their administration.
IV. Functional relationship to classification, assignment and separation:
Survey of the purpose, methods and procedures of military classification and assignment. Interpretation of Adjutant General Form No. 20, discussion of the current policies concerning the assignment of general, limited-service, and ex-combat personnel; practical implication of classification responsibilities during redeployment and of the point system and planned discharge.
Red Cross Inservice Training
To meet the growing requests for personnel, the Red Cross instituted an inservice training program of broad scope. This program included, as one of its particular aims, the development of projects for giving specific training or orientation in working with neuropsychiatric patients to social workers who had had no specialized training or experience in psychiatric social work. One such project was developed at the Army Air Forces Convalescent Hospital, Fort Logan, Colo. Another project was developed
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at St. Elizabeths Hospital, Washington, D.C., in which the emphasis was placed on training the hospital worker or staff aid group to render specific services to neuropsychiatric patients. Other training centers were developed within the five areas of the Red Cross to give, on a smaller scale, this type of orientation to workers.
STANDARDS OF PRACTICE
As military social work developed, no attempt had been made to standardize its practice. Therefore, to correct this situation, General Menninger directed Mrs. Ross to prepare a suitable guide for the social work specialty. Mrs. Ross's knowledge of casework skills and her detailed contacts with a large number of military social workers, in her capacity as Secretary of the War Service Office, made her admirably qualified to assume this responsibility. She worked in close cooperation with Major Guttmacher and General Menninger and prepared the first official document on military psychiatric social work practice. This was published as TB MED 154, 'Psychiatric Social Work,' and issued in June 1945.
TB MED 154 was intended to serve as a guide for military psychiatric social workers and psychiatric assistants, outlining their administrative relationships and professional duties. It also outlined the orientation of psychiatrists, classification officers, and other relevant military personnel relative to the qualifications of various types of social work personnel and their practice in this field.
The duties of military social workers covered specific social services 'which should be delegated by the neuropsychiatrists' and included the following:
1) Obtains information from Army units; presents history of material or interview content for the neuropsychiatrist, so that diagnoses, treatment and disposition are facilitated. 2) Will, under the direction of the psychiatrist, interpret the findings and/or the program of the psychiatric unit to agencies or persons concerned, such as, other medical personnel, unit commanders. 3) Will have the responsibility to explore and initiate effective use of opportunities and facilities within the Army structure, to aid in the solution of the patient's problem. 4) Aids in the reorientation of the soldier to his problem, making such recommendations for, and reports of, treatment and disposition to the psychiatrist as may be pertinent and possible. 5) Will assist, when directed, with group therapy, preventive psychiatry, or other programs for which the neuropsychiatrist is responsible. 6) Will aid in administrative procedures, including the preparation of necessary records, and reports, schedules, and other related activities.
The duties of psychiatric assistants were also defined and were as follows:
1) The selection and preparation of objective data related to patients, such as abstracting accessible medical and nonmedical records, maintaining records of psychiatric service, etc. 2) Delegated aspects of the administrative responsibilities of the psychiatrist, such as initiation of certificate of disability discharge forms, reports to Boards of Officers under AR 615-368 and AR 615-369.
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A warning was given that psychiatric assistants would not be assigned to the duties requiring direct contact with patients without providing adequate safeguards to patients by close supervision. This restriction was considered necessary because frequently, under the heavy pressure of large caseloads, additional personnel, less qualified, had to be used by the psychiatric units. For the improvement of these personnel, TB MED 154 stated:
Individuals with minimum qualifications for SSN 263 show a wide variation in these qualifications in their professional education as well as civilian experience. Their competency will therefore vary widely * * *. Many military psychiatric social workers have had no experience in psychiatric organizations prior to their Army experience. Among social workers will be found not only psychiatric social case workers and social case workers, but also personnel especially trained in social group work, social administration, community organization, and social research. Standards for the selection and assignment of military psychiatric social workers must be based on Army needs and policy; and, of necessity, these will require readjustments of civilian professional standards. A continuous on-the-job training program of lectures and seminars, particularly to orient the new worker, will contribute greatly to efficient service.
CONVALESCENT HOSPITALS
In 1944, the return of patients from overseas caused an acute shortage of medical and surgical beds. This lack of bed space coincided with the recognition that the neurotic patients did poorly when treated at general hospitals. These facts forced the establishment of convalescent hospitals and again increased the demand for psychiatric social workers. The need for these workers was so severe that psychiatric social workers were placed in a category of critically needed personnel.8
Twelve convalescent hospitals were established throughout the United States, to which approximately 50 percent of the psychoneurotic casualties were assigned. The overall and basic psychiatric aspects of the convalescent hospital program were integrated through the training courses provided by the neuropsychiatric training officer for general medical officers, social workers, psychologists, and other personnel. Considerable leeway, however, was given to the company commanders in their individual practice of psychotherapy. The psychologists were usually assigned to the battalion headquarters, and the social workers were assigned to the individual companies. Whitney,9 who had been assigned to the Fort Story Convalescent Hospital, Va., evaluated this experience as follows:
The presence of military psychiatric social workers enabled the five psychiatrists assigned to the group of 600 patients in the Neuropsychiatric Battalion to put into effect a psychotherapeutic program designed to afford the maximum possible benefit of treatment to each patient in the six- to eight-week period. No patient could go
8War Department Memorandum No. W615-44, 29 May 1944.
9Whitney, Forrest H.: Convalescent Hospital. In Adventure in Mental Health: Psychiatric Social Work With the Armed Forces in World War II. Henry S. Maas (editor). New York: Columbia University Press, 1951, pp. 97-98.
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unknown or unrecognized throughout his hospitalization, as he felt had so often happened previously. The workers usually carried a caseload of 20 to 30 patients, although occasionally the number reached 50. Each patient was offered a continuing relationship with a caseworker who was fully identified with the psychotherapeutic goals of the hospital. Thus, the patients had the opportunity to regain some security and strengthen their self-confidence which had been shaken by recent military experiences.
The social workers themselves found new satisfactions in their military experience. They used and deepened their skills in helping patients who, like the social workers, were a part of the gigantic war effort, but who had lost their capacity to be useful to themselves and to the military service. The social workers who had not previously worked in a psychiatric setting gained through training and experience knowledge about types of cases not known to nonmedical social agencies. All social workers found valuable their experiences in the technique of group psychotherapy which embodied the principles of individual treatment and speeded up some of the processes essential to enabling patients to use help. Living in the barracks afforded the social workers an opportunity to observe patients in their daily activities and relationships with many of the people in the hospital setting. However, the fact that the social workers were also barracks leaders, a result of the attempt to make maximum use of limited manpower, sometimes had the effect of draining the social workers' energy and carried the seeds of negative countertransference which had to be watched for continuously.
Although some social workers found for the first time that psychiatrists do not necessarily have all the answers for treatment of all patients, they appreciated the doctor's assumption of responsibility for decision on the disposition of each case. Basic to the entire program was the feeling of unity which the staff achieved through striving together for therapeutic goals and through providing one another with emotional support through the process of attaining those goals. This unity compensated for the pressures which were sometimes felt as a result of trying to be both a soldier and a professional social worker.
At the Camp Carson Convalescent Hospital, the specific functions of psychiatric social workers were defined as follows:10
1. Intake Study.-This will consist of the history taking, initial discussion with patients of the manner they used at illness in their efforts to adjust, clarification with the patient with what he considers to be his adjustment difficulties and adjustment needs, stimulation of the patient's awareness of his own role in his recovery, and interpretation of the facilities of the program in terms of the patient's awareness of need. The interpretation will include explanation of services offered by the psychiatrist, psychologist, and group therapist.
2. Social Service Treatment.-This will consist of scheduled appointments arranged insofar as possible with the active participation of the patient. The social workers are not encouraged to initiate discussion of symptoms in these interviews but to handle such discussion of symptoms as the patient may bring up in such a way as to help the patient use the psychiatrist for the treatment of symptoms. The social worker is encouraged to discuss with the patient how he is using the facilities, to recognize the emergence of positive interest and strength in the patient and particularly to assist the patient in making the daily small decisions that confront him. Detailed discussion of past painful experiences are not usually helpful in short term therapy, consequently the social workers will focus the discussion on current matters, future plans, and, if necessary, on the contrast between recent experiences which precipitated illness and their present situation which enabled the patients to give up illness. Social service
10Personal communication to author.
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treatment will also include helping the patient recognize his need for psychiatric help. This is particularly true when patients find themselves incapable of making daily decisions, or become easily upset and constantly bring up symptoms with no improvement.
3. Referrals.-All referrals will be made on the basis of recognized needs for the referral by the patient. Discussion will precede a referral to enable the patient to accept the benefits that are expected to accrue from the referral. Each referral shall be followed up to determine if the expected benefit actually accrued.
4. Group Therapy.-Social workers who are capable of conducting group therapy will be afforded the opportunity to do so. The methods and goals in group therapy will be those that the psychiatrists decide shall be uniform for the clinical section. As a rule, it is expected that the content of group therapy discussions conducted by social workers will differ from those conducted by psychiatrists and psychologists since the social workers are specialized in evaluating social situations. Consequently it is likely that detailed discussion of anatomy, psychosomatic mechanisms, symptoms per se, etc., will be kept to a minimum and patients bringing these matters up for discussion should be advised to discuss them with the psychiatrists. However, such matters should not be completely avoided for brief, nontechnical discussion can help the patients understand their conditions and put this understanding to constructive use.
GENERAL AND SPECIAL HOSPITALS
As the pace of combat quickened, both Red Cross and military psychiatric social workers found new and different uses for their skills and learned to function in very different kinds of settings.
Overseas
Miss Irene Tobias,11 a psychiatric social worker of the American Red Cross, described her experiences in a general hospital during the Tunisia Campaign and, later, in a neuropsychiatric hospital, as follows:
In this setting of a military hospital overseas, the social worker had to function in a medium unlike anything for which her previous experience had prepared her. The usual physical setup and equipment were nonexistent. Elements of distance and difficulties of communication separated her from the accustomed, supporting close presence of an agency and supervision. Far away were the traditional aids of family and social resources. Functioning was severely limited by the short association with patients and by the pressure of the job. The casework tools-understanding and skill- stood pretty much alone and in these situations were put to a severe test of usefulness. But I do not think it can be doubted that at least the simple and concrete steps of casework can be used everywhere in military settings. The greater part of casework in any setting consists of these simple steps.
The objectives of the job were set by the Army. They were to help the sick or wounded to return to duty faster, or, if the soldier was to be discharged from the army, to help him become a more productive citizen. If the setting presented difficulties and frustrations, the rewards were commensurate. The traditional function of the social worker in helping the individual now coincided with helping to win the war. No social worker could ask for a greater opportunity.
Overseas the job called for more than professional skills. It called for the involve?
11Tobias, Irene: A Psychiatric Social Worker Overseas. Family Welfare Association of America, 1945, p. 45. [Pamphlet.]
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ment of the total personality. The professional and personal self became integrated in the adaptations made in entering overseas service. There were adaptations to be made in the mode of living, in the giving up of privacy, in changing tastes in food, in adjusting to military discipline and the consequent curtailment of personal freedom. All this became symbolized in putting on the Red Cross uniform which the Army never allowed to be taken off for any occasion while the worker was overseas. Out of this pool of adaptations came a sense of freedom of becoming oriented to this strange new world. Out of it, too, came a sense of extended range of capacities.
In this setting and confronted by the pressure of so many human needs, we did whatever we could, employing the total range of personal capacities.
Zone of Interior
Not only were Red Cross social workers involved in experiences similar to the ones described by Miss Tobias, but they often worked side by side with military psychiatric social workers. One example, described by Greenberg,12 was at the Mason General Hospital which was a 3,000-bed hospital, equipped for the treatment of soldiers suffering from various types of psychiatric illnesses:
The hospital staff consisted * * * of the doctors, nurses, attendants, psychologists, social workers, physical therapists, and other staff specialists who were mostly Army personnel, either in the enlisted or officer categories, but the social service unit consisted of both military and Red Cross social workers. All were assigned to specific wards and were responsible for the same areas of service. This administrative arrangement was made with the concurrence of the Red Cross Field Director.
The military social workers were all enlisted men and women, ranking from private to master sergeant. As was the case in other Army units, the social workers in Mason General Hospital ranged from those who had complete training and extensive civilian experience to those who had had no training and what, at best, could be considered only a dubious professional experience. None of the military social workers came with any social work experience in a civilian psychiatric hospital. A few had worked with psychiatrists before coming into the Army. For most of the workers, psychiatric terminology, concepts, and understanding had to be developed. For all of them, the true meaning of psychiatric social work in the Army-the real meaning of being a soldier social worker to other soldiers-was frequently elusive and often perplexing.
Deep sincerity and a desire to develop a practice which would be professionally acceptable and ultimately of greatest helpfulness to the soldier-patients characterized the day-to-day job of the military social workers [at Mason General Hospital].
[In this hospital], the total role of the social worker as conceived and developed * * * was predicated upon two facts: (1) the essential mission of the hospital was to diagnose and make disposition of all admitted patients as quickly as possible; and (2) the period between the patient's admission and eventual discharge carried for him many problems inextricably interwoven in his being a patient in a mental hospital.
The total job [of the social work staff] was broken down into five major responsibilities: 1) Orientation of new patients; 2) interviewing for a social case history; 3) continued service in relation to the patient's ward adjustment; 4) planning with the patient for his discharge; and 5) interpretation to relatives.
12Greenberg, Irving: Neuropsychiatric Hospital. In Adventure in Mental Health: Psychiatric Social Work With the Armed Forces in World War II. Henry S. Mass (editor). New York: Columbia University Press, 1951, pp. 63-67.
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Mr. Greenberg summarized some of his impressions of his experience at Mason General Hospital in the following way:
The definition of what the social worker did and how the social service job was accomplished could not always be interpreted adequately to the entire medical staff. Those ward physicians who continued in the hospital as social service 'grew up' learned for the most part what was clearly within the social worker's province and what was not. Unfortunately, what was true for any Army installation was true for Mason General Hospital, namely, rapid turnover in staff doctors. Individual social workers on the wards had to do the interpreting, the clarifying, and the eventual interlocking. Only toward the latter period at the hospital was there a systematic and regular presentation of social work as a fundamental discipline, with specific areas of responsibility in the overall treatment of neuropsychiatric patients. A review of this experience in an Army neuropsychiatric hospital leads to the following generalizations: 1) The military psychiatric social worker has to develop his own concept of practice; 2) he is at first completely dependent upon the prior experiences and basic confidence which psychiatrists on the staff have in utilizing social workers. As he goes on, he can begin to rely with greater security on that which he has created; 3) the social worker has to come to terms with the fact that the mission and needs of the Army are primary, and that the needs of the patient as an individual can be appraised and met only with reference to the Army's needs; 4) when the social worker defines his job and his purpose in clear terms for the Army and its hospital and then for the patient whom he serves, his contribution as a distinct professional person begins to have meaning; 5) the social worker can with dignity and professional value remain a social worker without having to cross into the realm of psychotherapy.
MISCELLANEOUS ACTIVITIES
Disciplinary Barracks
In addition to installations already mentioned, psychiatric social workers functioned in other activities; for example, the disciplinary barracks which were in operation beginning in 1942. Initially, the tables of organization for disciplinary barracks included a psychiatrist; later, a clinical psychologist and one or more psychiatric social workers were authorized. Menninger13 has pointed out that one of the gratifying contributions of psychiatry was the initiation of treatment in almost every correctional installation. In these efforts, the psychiatrists were assisted by their colleagues, including psychiatric social workers. One example was the Milwaukee Disciplinary Barracks where over a thousand prisoners were received. At this installation, there were two psychiatrists, two clinical psychologists, and three social workers. The social workers were responsible for the initial interview of all prisoners. Then, after a classification procedure (pp. 503-506) which established the prisoner's treatment and rehabilitation program, social workers participated in the counseling program for prisoners who showed problems of maladjustment. These workers also participated in a group therapy program.
13Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948, pp. 197-201.
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Another procedure which was the responsibility of the social workers was to interview prisoners 2 months before their release in order to help them work out discharge plans. Social workers also utilized the facilities of the American Red Cross to establish liaison with community agencies in order to assist the prisoner after he was discharged.14
Combat Divisions
A second unique use of a few social workers was their assignment to divisions to assist the division psychiatrists.15 These men screened combat casualties and, in collaboration with the psychiatrist, determined whether the individual soldier could be restored to duty after a comparatively brief rest period or whether he would have to be evacuated from the combat zone for more intensive treatment. While these assignments were quite limited, they did form a pattern which came to be useful in the Korean War.
Liaison
In the coordinated teamwork between the American Red Cross and the Neuropsychiatry Consultants Division, a new development occurred in August 1944 when the Red Cross was requested to assign large numbers of psychiatric social workers to the neuropsychiatric reconditioning program. General Menninger described the goals of this program and emphasized the urgent need for and contribution to be made by psychiatrically trained social work personnel. To meet more adequately the needs in this program, as well as those in other treatment centers for patients with special disabilities, the Red Cross table of organization was revised in September 1944. A large proportion of the staff approved and budgeted for in convalescent hospitals was designated for psychiatric patients.
In accordance with Red Cross agreements with the War Department, psychiatric social workers participated at the request of psychiatrists in research and special studies. At the request of General Menninger, a psychiatric social worker was assigned to the Neuropsychiatry Consultants Division for a period of a year to assist in a followup study of psychoneurotic patients.16
14Brodsky, Irving: Disciplinary Barracks. In Adventure in Mental Health: Psychiatric Social Work With the Armed Forces in World War II. Henry S. Maas (editor). New York: Columbia University Press, 1951, pp. 99-117.
15The employment of social workers in divisions, Army 'exhaustion centers,' and hospitals overseas cannot be documented. They were utilized by psychiatrists, when available. Almost all were enlisted personnel who were performing other functions, and their assignment was a chance phenomenon or based upon their presence in a particular area at a particular time. Not all were fully trained. Most had only partial training and experience.-A. J. G.16Brill, N. Q., Tate, M. C., and Menninger, W. C.: Enlisted Men Discharged From the Army Because of Psychoneuroses; Followup Studies. J.A.M.A. 128: 633-637, 30 June 1945.
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PSYCHIATRIC SOCIAL WORK BRANCH, SURGEON GENERAL'S OFFICE
As early as 1942, military personnel on active duty, both psychiatrists and psychiatric social workers, had been in correspondence with the Neuropsychiatry Branch, SGO, seeking assistance in establishing programs which involved the use of psychiatric social workers. It was hoped that from the Surgeon General's Office would come the direction and planning which would enable psychiatric social work to achieve a more responsible position in the various psychiatric activities which were being undertaken in the Army medical program.
In 1943, when General Menninger became Chief Psychiatric Consultant to The Surgeon General, he made intensive efforts, with the assistance of the War Service Office and the cooperation of the National Committee for Mental Hygiene, to develop a position for a chief social worker to be assigned to the staff of the Neuropsychiatry Consultants Division. On 1 July 1945, after 2? years of effort, the Psychiatric Social Work Branch was established in the Neuropsychiatry Consultants Division. This author was assigned as the first chief of this newly created branch.
Proposed functions.-The chief of the Psychiatric Social Work Branch was given wide latitude for the use of independent professional judgment. He was considered a consultant and adviser to professional medical personnel in the Office of The Surgeon General and in Army installations, with the responsibility of advising, developing, and directing the social work program for The Surgeon General. He was to participate in the planning of preventive mental hygiene programs for troops in varied settings and activities where social work skills might aid in the promotion of morale or efficiency of the troops. He was made responsible for the development and standardization of methods and materials used in the practice of psychiatric social work in the Army. In this regard, he was free to consult with professional organizations and public and private associations in order to provide adaptations of such civilian social casework practice as were appropriate to improve Army practices. He was to establish methods of practice and to modify, adapt, and implement the military social work program for a wide variety of military personnel, including neuropsychiatric casualties, prisoners, and maladjusted soldiers. Further, he was to act in a liaison capacity with the chief of the Neuropsychiatry Consultants Division and the American Red Cross social work program.
Hutt and his associates,17 in a footnote to 'The Neuropsychiatric Team in the U.S. Army,' stated:
The team concept was applied not only in the field, but in the Surgeon General's
17Hutt, M. L., Menninger, W. C., and O'Keefe, D. E.: Neuropsychiatric Team in the U.S. Army. Ment. Hyg. 31: 103-119, January 1947.
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Office, War Department, as well. From July 1945 on, within the Neuropsychiatry Consultants Division, Surgeon General's Office, such a team, directed by a psychiatrist, included a chief of the clinical psychology branch and a chief of the psychiatric social work branch. These demonstrated in their daily program of work, in their planning, direction, and supervision of the Army psychiatric program, the smooth and effective functioning of the neuropsychiatric team in this high Army echelon. This organization resulted from much previous ground work and long range planning.
In terms of working relationships, each of the branch chiefs in the Neuropsychiatry Consultants Division was delegated the authority to operate his program and was always assured of the support of the director of the Division. At a daily staff meeting, each branch chief would briefly outline his activities and plans for that particular day so that all the staff members were cognizant of the status of plans and projects which each was undertaking. Once a week, a large staff meeting was held at which representatives of the Army Ground Forces, the Army Air Forces, and the American Red Cross would discuss the activities and interests of the various phases of the Army psychiatry program. In this way, those corollary agencies which were also interested in the broad aspects of the total psychiatric program for military personnel were kept aware of the plans and activities being carried on in the Neuropsychiatry Consultants Division. If an individual staff member needed aid to expedite certain phases of a project, he was always free to call on other staff members for assistance. For instance, when efforts were being made to develop adequate rosters of social work personnel on duty, it was the psychiatrist in charge of personnel who facilitated the acquisition of this information. Such cooperation was always available and readily given. Also, Mrs. Ross had been appointed as a civilian consultant and her services were likewise available and were frequently used.
OFFICER PSYCHIATRIC SOCIAL WORKERS
Although efforts had been made to obtain officer status for social workers throughout the war, this effort was not successful until after the termination of hostilities. During the war, a few social workers had been commissioned as clinical psychologists, because the original qualifications for this specialty accepted social casework as a qualifying experience. Some of these officers were able to function as social workers in particular situations, while others were assigned only to psychological duties. Later, qualifications for clinical psychology became more restrictive.
On 8 February 1946, with the issuance of War Department TM (Technical Manual) No. 12-406, MOS 3605 was established for the position of 'Military Psychiatric Social Work Officer.' The duties and qualifications for this position were as follows:
Directs or supervises the psychiatric social work in a hospital or clinic. Develops a social service program and establishes social work policies under supervision of the
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psychiatrist; assists psychiatrists in the coordination of the social work activities with those of the clinical psychologist, the Red Cross, and related services; supervises through the reading of records and conferences, the social casework activities of the enlisted psychiatric social workers; plans, with the psychiatrist, on-the-job training for psychiatric social workers and for psychiatric assistants and takes part in appropriate instructions; undertakes social work treatment of such special cases as may be assigned by the psychiatrist.
Must have completed academic requirements and supervised field work in an accredited school of social work, with a major in psychiatric social work; or have completed academic requirements and supervised field work in an accredited school of social work, with a major in social casework, plus at least six months supervised experience in a psychiatric agency.
On 29 December 1945, with the issuance of WD Circular No. 392, psychiatric social work was included as one of the specialties in the Pharmacy Corps of the Medical Department, and announcement was made of the opportunities for appointment in the Regular Army for such individuals who had held commissioned status during the war. This was a step forward in progress but did not provide opportunities for commissions to those enlisted men who had the required qualifications. With the publication of TM 12-406, which defined the qualifications of officer psychiatric social workers, personnel qualified in this specialty were eligible for commissioned status.
To enable qualified personnel to obtain commissions, a request was forwarded by The Surgeon General to the Reserve Officers' Branch, Adjutant General's Office, in January 1946, asking that consideration be given to the establishment of a section within the Reserve component for qualified psychiatric social workers.
STATISTICS
Throughout the war, one of the major difficulties was to maintain a current roster of the assigned psychiatric social workers. One chief reason for this problem was the lack, for a long time, of a classification serial number for social workers. Another reason was that persons having social work qualifications were classified under other specification serial numbers such as SSN 289, Personnel Consultant's Assistant, and SSN 275, Classification Specialist. In the Army Air Forces, all social workers were classified as SSN 289, Medical, until 18 August 1945. Because the definition of psychiatric social worker contained the qualifying phrase 'should have the following experience' instead of 'must have,' it developed that many persons were classified as SSN 263, who were qualified by military experience only-an unknown but large group.
In February 1945, the Resources Analysis Division, SGO, obtained a report on the number of psychiatric social workers assigned to ASF installations. This report noted that psychiatric social workers were not included on the reporting form, 8-19, by the following hospitals: Station
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Hospital, Camp Edwards; Valley Forge General Hospital, Phoenixville, Pa.; Darnall General Hospital, Danville, Ky.; Thomas M. England General Hospital, Atlantic City, N.J.; Wakeman General Hospital, Camp Atterbury, Ind.; and Mitchell Convalescent Hospital, Campo, Calif. This group of hospitals, each with a large neuropsychiatric service, probably utilized between 75 and 100 personnel with the MOS 263 classification. Other installations reported 290 assigned psychiatric social workers. Combining the reported group with the unreported one, it was assumed that approximately 400 persons were engaged in social work duties in ASF installations. These figures did not include the psychiatric assistants. By another survey, the number of Wacs so assigned was estimated to be 247. This total of 647, in turn, was not comprehensive because psychiatric social workers and psychiatric assistants were also utilized in the Army Air Forces and Army Ground Forces, but statistical data from these echelons could not be obtained. A small group of psychiatric social workers was known to be functioning in oversea installations but actual count was impossible. Their number was probably less than 25.
In August 1945, another count of the ASF installations revealed that approximately 711 persons were classified and assigned as psychiatric social workers or psychiatric assistants. At this time, also, no information was available from Army Air Forces, Army Ground Forces, and oversea installations.
While these figures were not accurate, certain facts and trends could be extracted. Social workers were concentrated in general and convalescent hospitals. Consultation services (Mental Hygiene Consultation Services) were generally adequately staffed in the ratio set forth in TB MED 156 which stated there should be 1 psychiatric social worker for each 3,000 trainees. A shift of social work personnel from neuropsychiatric sections of station hospitals to the reconditioning facilities was noted when these were established. A small but increasing number of social workers were assigned to rehabilitation centers and disciplinary barracks. Only a handful of social workers functioned as assistants to division psychiatrists, but their services were considered to be of great value. There were no known assignments to redistribution centers or induction centers in the report of August 1945. It is interesting to note that at this time, when the greatest number of personnel were assigned to social work duties, the Military Personnel Division, SGO, had, on hand, requisitions for 201 enlisted male social workers and 4 psychiatric assistants. WAC recruiting had terminated, or there might have been additional requests for these personnel. In view of the difficulties which beset the program of establishing psychiatric social work in the Army, this accounting of the filled and unfilled positions, numbering approximately 1,000, is an index of the high value placed on the services of social workers before V-J Day.
It should be pointed out that, along with the expanding use of mili-
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tary psychiatric social workers, the American Red Cross was also trying to expand the number of its social work personnel. It had started an active recruiting program, as far back as 1941, to attract more psychiatric social workers. Personnel were recruited through the American Association of Psychiatric Social Workers and from schools of social work. A scholarship program for second-year psychiatric social work students was developed in 1942-43. It was estimated that approximately 300 qualified psychiatric social workers served in the Red Cross Hospital Program during the war-one-third overseas, one-third in administrative and supervisory positions, and one-third specifically in assignments with neuropsychiatric patients in Army general, station, and convalescent hospitals, and mental hygiene units.
SUMMARY AND RECOMMENDATIONS
The writer, who left military service in February 1946, attempted to review and summarize at that time some of the accomplishments of military social work. He wrote:
Military social work offered an opportunity for civilian social case work to function in a setting of close alignment with, and responsibility to, military psychiatry. From this experience, and based on the pressures of time and volume of need, certain concepts appeared which might be considered unique to military psychiatric social work. As a major contribution, military psychiatric social work was able to demonstrate by on-the-job effectiveness its role as a most important aid to military psychiatry. Many psychiatrists had their first opportunity to work closely with social workers in the Army, and from this experience there developed a new awareness of, and appreciation for, the contributions which social work can make in helping with the emotional problems of soldiers. Conversely, many social workers had their first opportunity to work under the direction of psychiatrists. This opened up new areas of usefulness to them. It gave many of them the incentive to learn more of the interrelationships of the clinical team of psychiatrist, social worker, and psychologist, which proved so effective in the treatment of the emotionally unstable soldiers.
At the time of separation from the service, the following recommendations were made:
1) That military psychiatric social work personnel, both in officer and in enlisted status, continue to be used in appropriate military settings; 2) that the proposed plans to establish a training program for psychiatric social work personnel at Brooke General Hospital, San Antonio, Texas, be implemented; 3) that the proposal to include social work personnel in commissioned and in enlisted status in the Tables of Organization for Medical Installations be approved; 4) that liaison be maintained by the Surgeon General's Office through professional representation with the recognized social work organizations in order to utilize their facilities for planning, training, and maintaining acceptable standards of social work practice in medical installations.18
18It was possible to state, in 1950, when preparing an article for 'Adventure in Mental Health' on the Army's Psychiatric Social Work Branch, that each of these recommendations had been implemented.-D. E. O'K.
