CHAPTER XXIII
Reconditioning of Psychiatric Patients
Colonel Edward F. Quinn, Jr., MSC, USA (Ret.)
BACKGROUND
Before the spring of 1944, the official attitude of the Army 'toward psychiatric illnesses was a mixture of fatalism and disinterest; treatment was discouraged.'1 In fact, AR (Army Regulations) 615-360, 26 November 1942, specifically denied definitive treatment for psychiatric patients. On 15 December 1943, Changes No. 16, to AR 615-360, stated that patients with conditions incident to service, after recovery within a reasonable period of time (presumably with or without treatment), could be returned to duty. Liberally interpreted, this meant that psychiatric patients, if treated and rehabilitated within a reasonable period of time, could be returned to duty. However, many psychiatric patients, regulations notwithstanding, had, before this time, received some sort of treatment.
Occupational therapy and recreational diversional activities, used in civil hospitals for many years, had been introduced into the Army hospitals with the civilian psychiatrists and the American Red Cross arts and crafts and recreational workers. In the Army, these civilian psychiatrists, now military officers, soon discovered that disposition procedures were frequently long drawn out affairs, especially for psychotic patients recommended for transfer to State hospital care. They, therefore, attempted some measure of treatment so that these patients as well as those with severe neurotic tendencies could be sufficiently improved to be discharged to their own custody or to that of immediate relatives, thus materially speeding up the process and freeing much needed beds. There were no official directives or standards to insure uniform methods of treatment so that any treatment given varied not only from post to post but also from psychiatrist to psychiatrist.
EVOLUTION OF RECONDITIONING
The reconditioning of psychiatric patients, and, for that matter, the entire reconditioning program, was an evolutionary process and a collective effort. Born of necessity to conserve manpower from an administrative
1Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948, p. 293.
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standpoint, and for that and other more subtle reasons from a psychiatric standpoint, it became in reality a combination of the diversified efforts of several professional media to rehabilitate the sick and injured.
Convalescent Programs Authorized
Late in 1942, military and civilian opinions were being expressed relative to the development of special accommodations for convalescent patients. As an aftermath of such discussions and opinions, the War Department, on 11 February 1943, issued WD (War Department) Memorandum No. W40-6-43, which authorized convalescence and reconditioning in hospitals. Although the convalescence program actually proceeded faster than the reconditioning program, there had been and there followed some effort in reconditioning and rehabilitating patients, including those with psychiatric problems.2 'On 21 June 1943, ASF Headquarters approved the program The Surgeon General presented,'3 recommending the use of convalescent programs. Occupational therapy was in prior use, especially for psychiatric patients. It was officially authorized for general hospitals on 12 August 1943, with the issuance of Circular Letter No. 149, Office of The Surgeon General, U.S. Army.
Reconditioning Programs Authorized
More than a month after occupational therapy had been officially recognized, and 3 months after the convalescent program had been approved, The Surgeon General, in Circular Letter No. 168, 21 September 1943, prescribed a convalescent reconditioning program for general hospitals. The prime objective of this program was to return recovered medical and surgical patients to duty in the best possible condition. At this time, however, there were no provisions to include psychiatric patients in the program.
Apparently, the program did not develop as rapidly as was desired because, on 10 December 1943, The Surgeon General issued Circular Letter No. 203, by which all service command surgeons and commanding officers of all general hospitals were directed to establish reconditioning programs without delay; further, that all patients be included whether or not they were expected to return to duty. Psychiatric patients in general hospitals were mentioned, but they were to be placed in specific centers or on special wards; they were not to be intermixed with other patients.
2Pilot studies at England General Hospital, Atlantic City, N.J., at the Regional Hospital, Camp Swift, Tex., and at three ASF (Army Service Forces) replacement training centers.
3Smith, Clarence McKittrick: The Medical Department: Hospitalization and Evacuation, Zone of Interior. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1956, p. 120.
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Reconditioning of Psychiatric Patients Recognized
It was not until 1 April 1944 that War Department Technical Bulletin (TB MED) 28, the first comprehensive directive on the treatment of psychiatric patients, was issued. This presented, in detail, various treatment procedures but did not officially include psychiatric patients in the reconditioning program. A change in TB MED 28, issued on 15 April 1944 as TB MED 32, stated, as follows:
Except for those patients capable of returning to duty, neuropsychiatric patients are not to be included in the reconditioning program but are to be handled separately and provided with the program outlined above. There should be cooperative efforts between the two programs in the utilization of special instructors and physical facilities. Psychoneurotic patients, as a group, cannot maintain competition in the physical training of the reconditioning program, and their failure not only affects them adversely but grossly interferes with the effectiveness of the program for the individuals for whom it is designed.
Thus, as a modification of the directive, the psychiatric patients were included but with definite limitations.
Psychiatric Reconditioning Established
In the Surgeon General's Office, Maj. (later Lt. Col.) Walter E. Barton, MC,4 a psychiatrist and the assistant director of the Reconditioning Division (later the Reconditioning Consultants Division), with the support of the Neuropsychiatry Consultants Division, directed his influence and efforts to improving the psychiatric reconditioning program. This resulted in the issuance of ASF Circular No. 175, on 10 June 1944, followed shortly therafter, on 30 August 1944, by TB MED 80. These directives detailed the reconditioning program for psychiatric patients and included 'any patient who has even a remote chance for salvage for additional military service * * *."
PRINCIPLES AND AIMS
The philosophy of psychiatric reconditioning followed several basic principles:5
1. Regard every case as salvageable.
2. Start treatment as early as possible.
3. Avoid the hospitalization of psychoneurotics.
4. Remove situational factors if possible.
5. An individual or group approach as indicated.
4Colonel Barton was originally brought into the Neuropsychiatry Consultants Division, on 17 April 1943, to develop the occupational therapy program. On 19 August 1943, he was assigned to the Reconditioning Division as Director. On 3 February 1944, Col. Augustus Thorndike, MC, was appointed as Director, and Colonel Barton then assumed the position of Assistant Director.
5Farrell, M. J., and Appel, J. W.: Current Trends in Military Neuropsychiatry. Am. J. Psychiat. 101: 12-19, July 1944.
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6. Individual's capacities must be recognized.
7. Planned activities can serve as a trial at duty.
8. Proper job assignments are most important.
Smith6 commented on the convalescent reconditioning program as follows:
Convalescent reconditioning applies to all specialities but it is of vital importance to psychiatry not only because of its specific value in functional disabilities but also owing to the large number of such disabilities. Psychiatrists are fully aware of the value of a reconditioning program, and probably are better informed than most medical officers as to how it may specifically function. At some military installations a psychiatric medical officer has been appointed as reconditioning officer. In civilian life every physician who successfully treated psychoneuroses learned that treatment must be based on carefully planned purposive constructive scheduled activities. Psychotherapy was necessary, but in many cases failed to achieve results unless the work, play, rest, and exercise of the patient were organized constructively along principles of good mental and physical hygiene.
Barton,7 in summarizing the reconditioning program, stated:
Out of the renewed interest in the convalescent patient brought about by the necessities of war, it may be anticipated that increased attention will be given in civilian practice after the war to reconditioning. The reconditioning program begins while the patient is still in bed. A planned program of physical fitness training of educational reconditioning and of recreation has been instituted in all Army hospitals. An occupational therapy program stressing masculine interests, new activities, and useful work has been developed and coordinated with physical therapy and remedial exercise under medical supervision. Patients are removed from the over-protecting sympathy and sick-bed atmosphere of the hospital as soon as possible and segregated in a Reconditioning Unit to continue their convalescence. Progressive physical training, education and recreation are planned to direct attention from disability and illness to healthy activities that promote physical and mental fitness.
Rehabilitation, which has as its objective the retraining of individuals to overcome the handicaps of disabilities, the development of self-reliance and social adjustment and placement in useful work assignment, is largely the responsibility of other government agencies. The medical department of the Army can undertake the beginnings of such rehabilitation simultaneously with medical and surgical treatments. Rehabilitation programs of the blind, the deafened and the amputee were briefly presented.
ORGANIZATION AND OPERATION
Location
As provided by TB MED 80, a neuropsychiatric reconditioning center was established in each service command in hospitals especially designated to receive patients from overseas. The overall reconditioning program, however, was authorized for all hospitals of sufficient bed capacity to make the program worthwhile. The specially designated centers in 1944 were:
6Smith, L. H.: Treatment Activities in War Psychiatry. Am. J. Psychiat. 101: 303-309, November 1944.
7Barton, W. E.: The Reconditioning and the Rehabilitating Program in Army Hospitals. Am. J. Psychiat. 101: 608-613, March 1945.
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| Service Command | Center |
| First | Lovell General Hospital, Fort Devens, Mass. |
| Second | England General Hospital, Atlantic City, N.J. |
| Third | Fort Story, Va. (later Camp Pickett, Va.) |
Fourth | Welch Convalescent Hospital, Daytona Beach, Fla.; and Camp Butner, N.C. |
| Fifth | Wakeman General Hospital, Camp Atterbury, Ind. |
| Sixth | Percy Jones General Hospital, Camp Custer, Mich. |
| Seventh | Camp Carson, Colo. |
| Eighth | Brooke General Hospital, Fort Sam Houston, Tex. |
| Ninth | Mitchell Convalescent Hospital, Camp Lockett, Calif. |
Classification of Patients
For participation in the reconditioning program, patients were divided into the following four classes:
Class 4-Those who are bed patients or confined to wards.
Class 3-Ambulatory patients still requiring hospital care.
Class 2-Patients no longer requiring active medical treatment or hospital care.
Class 1-Patients most physically fit and whose return to military duty is anticipated.
Psychiatric patients generally participated in the class 4 and 3 programs in the hospital. When sent to the reconditioning section, they were usually placed in class 2 because most of these patients were returned to a limited-type duty assignment. However, those that were to be returned to duties which required the maximum degree of physical stamina were processed through the class 1 phase of reconditioning. Some patients did fail in the reconditioning program. These were returned to the hospital and appropriate action under AR 615-360 was taken.
Personnel
Trained personnel were needed for the reconditioning program, and like other phases of the psychiatric program, such personnel were in scarce supply. The personnel needed for the program included psychiatrists, clinical psychologists, psychiatric social workers, physical and educational reconditioning officers and instructors, and occupational therapists. Although efforts to recruit personnel in these categories were made, the supply never reached the demand. Therefore, in order to utilize personnel as economically as possible, the reconditioning section was established as close to the hospital as the facilities permitted and the personnel generally worked in both organizations. Enlisted assistants and instructors were specially selected by review of personnel records for people who had some of the necessary qualifications. Patients with special skills that contributed to the program were used and, at times, were actually transferred and assigned to the reconditioning staff.
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Duties.-In the administration of the reconditioning program, the duties of the various personnel were as follows:
(1) Psychiatrist.-
(a) Formulate and conduct the reconditioning program for the psychiatric patients in cooperation with the Chief of the Reconditioning Service.
(b) Conduct and supervise individual and group psychotherapy.
(c) Review and supervise work of psychiatric social workers and of occupational therapists, working with neuropsychiatric patients.
(d) Evaluate progress of the patients and recommend disposition.
(e) Assist in initial sorting of men and conducting sick calls.
(f) Receive reports from educational and physical reconditioning officers and instructors concerning patients' progress and advise them concerning the program.
(2) Clinical Psychologist.-
(a) Interview patients with regard to their skills, experience, and interests (initial questionnaire), and assist in the selection of patients who can be used as instructors.
(b) Advise the psychiatrist and reconditioning officer about the activity assignment of patients.
(c) Interview men prior to return to duty and make recommendations concerning their assignment.
(d) Administer psychometric and other special examinations at the request of the psychiatrist.
(3) Psychiatric Social Worker.-
(a) Interview patients for the psychiatrist.
(b) Assist in group psychotherapy under direction of the psychiatrist.
(c) Assist, when necessary, in occupational therapy, educational and recreational programs.
(d) Make recommendations concerning specific problems of individuals.
(4) Occupational therapists and occupational therapy aide.-To conduct the occupational therapy program as prescribed by the psychiatrist.
(5) Physical and educational reconditioning officers and instructors.-To carry out the physical and educational part of the program under the direction of the chief reconditioning officer with the approval and guidance of the psychiatrist.
Programs
Psychotherapy.-Individual psychotherapy because of personnel shortages and limited time was not done routinely. Special cases were referred to the psychiatrist, and if somewhat brief individual psychotherapy favored return to duty, it was accomplished. In dealing with such large numbers, group psychotherapy was a more practicable approach. Mental hygiene lectures (TB MED 12, 22 February 1944, for officers; TB MED 21, 15 March 1944, for enlisted men) and group discussions were found useful. Groups of 200 or more received these and other lectures, and smaller groups of 20 or 30 participated in group psychotherapy.
Occupational therapy.-Since occupational therapy was considered of particular benefit to psychiatric patients, it received considerable impetus in the reconditioning program. The more masculine types of such therapy were sought, but the arts and crafts were also found popular and useful. Ingenious and devious means were found to interest the patient and keep
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him occupied. Group projects were often instituted such as landscape gardening, furniture and toy construction projects, camp paper publication and printing, and handyman repair services.
Education.-The educational program was directed toward several areas. Good morale being conducive to good health, efforts to improve orientation and motivation received considerable attention. The Orientation Branch, Morale Services Division, ASF, supplied the reconditioning services with considerable printed material as morale training aids. Films such as 'Why We Fight' were used. War developments, the 'four freedoms,' war leaders, and the like, were discussed by staff and guest speakers. Even patients with combat experience were enlisted to augment these programs. 'G.I.' movies, 45-minute programs, which included special short subjects, travelogs, song shorts, sport shorts, and newsreels were used in a lighter vein yet nonetheless were effective. USAFI (U.S. Armed Forces Institute) courses were encouraged, and many patients subscribed to further their knowledge and education.
Recreation.-Psychiatric patients are notoriously reluctant to participate actively in competitive sports and physical recreational activities. Good supervision, planning, and encouragement usually aided in obtaining good participation. Thus, certain sports such as softball, volleyball, badminton, and certain other minor sports became popular with psychiatric patients. Competition was developed in these but the more aggressive contact sports found little interest among the psychiatric group.
Music and entertainment.-Major efforts were directed toward popularizing group participation in these entertainment fields. Group sings and bands were frequently organized for this purpose although passive participation with USO shows and guest entertainers had some therapeutic effect.
Physical reconditioning.-Ritualistic calisthenics, walks and hikes, gymnasium work, and other more routine physical activities did not find much favor, especially with psychiatric patients. It was soon learned that such activities could be made more popular if competitive features were added or the time spent in more sportlike physical activities.
Typical daily program.-A sample program for psychiatric patients8 on a typical day was as follows:
Hour | Activity |
| 0630 | Reveille. |
| 0700-0730 | Mess. |
| 0730-0800 | Fatigue details. |
| 0800-0850 | Physical Reconditioning: Conditioning exercises, gymnasium work, sports, and games. |
| 0900-1100 | Education and Training Classes or Occupational Therapy; Business administration, radio, electricity, communications, automotive mechanics, woodworking, graphic arts, muic, dramatics, photog?raphy, agriculture, arts and crafts. |
1100-1115 | News analysis. |
| 1115-1130 | Mail call. |
| 1130-1200 | Free period. |
| 1200-1300 | Mess. |
| 1300-1400 | Group psychotherapy, 3 times weekly; educational hour, 2 times weekly (concerned with orientation, motivation program) guest speakers, current problems, panel discussions, military and vocational films. |
1400-1530 | Physical reconditioning and recreation: Competitive games, sports, athletics, swimming, hiking, bicycling, and outings. |
| 1530-1700 | Free period for elective activities (attendance at one compulsory). Off-duty education, language classes, technical classes supplementing shopwork, photography, music, band practice, show rehearsals, gardening, arts, and hobbies. |
| 1715 | Retreat. |
| 1730 | Mess. |
| 1900-2030 | Entertainment: Movies, USO shows, concerts, guest entertainers, soldier shows, dances. Saturday afternoons and Sundays, open. |
8Barton, W. E.: Psychiatric Patient in Reconditioning Program. Dis. Nerv. System 6: 159-162, May 1945.
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CONCLUSION
The concept of reconditioning military personnel was developed to ease manpower shortages, as its primary aim. Although psychiatrists were aware of the need and benefit of adjunctive therapies for psychiatric patients and had in many installations utilized these methods, no official or uniform procedures had been authorized. Initially, the reconditioning program was intended for those nonpsychiatric patients who needed further recuperation from illness or injury. The initial lay military attitude toward psychiatric patients was one of hopelessness and that any attempt at treatment was a waste of time. However, this attitude changed. Good results obtained by psychiatrists in returning psychiatric patients to duty in the combat zone, and the gradual realization by hospital commanders of what could be done with such patients in the Zone of Interior, helped break down prejudicial barriers against these patients. Thus, the all-out effort at treatment gained approval. Even patients whose physical and mental condition warranted separation from the military service eventually were included in order that they reach maximum improvement before discharge. Thus, another progressive step was made in military psychiatry.
