CHAPTER VI
Liaison With Other Agencies
Malcolm I. Farrell, M.D.
SCOPE
The relationships of the Neuropsychiatry Consultants Division, SGO (Surgeon General's Office), to other agencies increased from almost none, early in 1942, to such prevalence as to be impractical of detailed description. This division was concerned with a major source of manpower loss which confronted the Medical Department and the War Department. It dealt with intangible subjects which had captured a tremendous amount of public interest and concern. Further, it was the sole source of professional advice in the War Department on problems of the mental health of personnel. As a result, more and more demands were made on the division by public, governmental, and military agencies. Therefore, the personnel of the division were increasingly occupied with matters of training, personnel policies and procedures, morale, military justice, rehabilitation, and, later, the problems of redeployment, not to mention the growing difficulties of providing satisfactory treatment for neuropsychiatric patients. Further, representatives of the division were called upon more and more to prepare staff studies and to participate in surveys by other War Department agencies. All of these activities resulted in an increased liaison with these agencies.
OFFICE OF THE SECRETARY OF WAR
Close liaison was established early in the Office of the Secretary of War, particularly through Mr. Harvey H. Bundy, Sr., Special Assistant to the Secretary. Mr. Bundy kept that office informed on special projects and, by making well-timed requests for information or by expressing interest in certain areas, called these projects to the attention of higher headquarters. Thus, early in 1943, a brief summary of the progress made in the Neuropsychiatry Branch (later, Neuropsychiatry Consultants Division) during its first year of organization was dispatched in the form of a memorandum.1 This memorandum stressed the efforts made in the following areas: Neuropsychiatric examinations on induction and mobilization, Army regulations, and circular letters for guidance; the use of
1Memorandum, Lt. Col. Malcolm J. Farrell, MC, Assistant Chief, Neuropsychiatry Branch, Surgeon General's Office, for the Assistant Secretary of War, 13 Feb. 1943, subject: Nervous and Mental Diseases in the Army.
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mental hygiene clinics and other outpatient neuropsychiatric activities in replacement training centers; the training of military neuropsychiatrists in general hospitals and at the School of Military Neuropsychiatry; the use of lectures and the plans for using films on various Army posts to give a better understanding of fear and anxiety. It stressed that this war was different and required newer methods and concepts of operation.
Later, Mr. Bundy2 expressed the interest of the Secretary of War in the psychoneurotic problem in the Army, and said: 'It is my understanding from the various reports and studies which have been made that the problem is primarily one of command and that there is need to educate the officers with troops of their relationship to the problem.' He referred to the possible expansion of training and morale pamphlets and the possible use of motion pictures. Although, in his reply, Maj. Gen. Norman T. Kirk,3 The Surgeon General, did not mention the War Department technical medical bulletins4 which were already in use, he did infer that morale was a command problem and that his office was assisting the Morale Services Division, ASF (Army Service Forces), with technical advice.
Office of the Under Secretary of War.-Col. (later Brig. Gen.) William C. Menninger, MC, Director, Neuropsychiatry Consultants Division, made excellent contact with Brig. Gen. Edward S. Greenbaum, Executive Officer, Office of the Under Secretary of War. Because of this close liaison, it was possible, in response to an informal request, to send a frank, pertinent 7-page letter containing comments and suggestions regarding the discharge of neuropsychiatric patients.5
This letter included a frank report from Italy, which bluntly spelled out some of the reasons for the lowered morale and bitter feelings found among many casual replacements. Based on these data, it was strongly advised that consideration be given to four major issues: Motivation, leadership, job assignment, and rotation policy. Further suggestions were made regarding procedures at the time of discharge; the use of proper caution in maintaining the confidentiality of the discharge diagnosis; and rehabilitation, including overall responsibilities, coordination, and educational efforts. Subsequent events, procedures, and even regulations showed that this close liaison and especially this letter had considerable influence upon the molding of command policies.
In the Office of the Under Secretary of War, Col. Marion Rushton, JAGD, a lawyer with unusually keen insight regarding psychiatry, maintained a close liaison between the branch he represented and the Neuro?
2Memorandum, Harvey H. Bundy, Special Assistant to the Secretary of War, for The Surgeon General, 2 Aug. 1944, subject: Psychoneurotics in the Army.
3Memorandum, Maj. Gen. Norman T. Kirk, The Surgeon General, for Mr. Harvey H. Bundy, Special Assistant to the Secretary of War, 9 Aug. 1944, subject: Psychoneurotics in the Army.4(1) War Department Technical Bulletin (TB MED) 12, 22 Feb. 1944. (2) War Department Technical Bulletin (TB MED) 21, 15 Mar. 1944.
5Letter, Col. William C. Menninger, MC, Director, Neuropsychiatry Division, Surgeon General's Office, to Brig. Gen. Edward S. Greenbaum, Executive Officer, Office of Under Secretary of War, Washington. D.C., 9 May 1944, subject: Discharge.
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psychiatry Division. He was especially concerned with discipline, disciplinary barracks, and rehabilitation centers and was also interested in the salvageability of military offenders with psychiatric disorders.6 In March 1944, Capt. (later Maj.) Ivan C. Berlien, MC, of the Neuropsychiatry Consultants Division, was designated as liaison officer to work with Colonel Rushton on disciplinary problems.
As the contact grew, it resulted in the referral of more individual problem cases for solution, particularly medicolegal problems, and in the development of an Army-wide policy regarding military prisoners. In May 1944, at a Seventh Service Command conference, the question of routine neuropsychiatric examination of all enlisted men prior to general courts-martial was raised.7 At the time, the Neuropsychiatry Consultant Division's liaison officer stated that routine neuropsychiatric examination was not feasible because of (1) the shortage of neuropsychiatrists, (2) the large number of general prisoners, (3) the very limited number of accused soldiers in whom mental competency was an issue, and (4) the increased time that courtroom testimony would expend for an already limited psychiatric staff. Consequently, the need for pretrial neuropsychiatric examination was left to the discretion of the court as clearly stated in the courts-martial manual.8
At the Under Secretary's 'Conference on the Rehabilitation of Military Prisoners,' Fort Leavenworth, Kans., 14-16 November 1944, the Director, Neuropsychiatry Consultants Division, proposed a '12-point' program for the participation of neuropsychiatry in the formulation and operation of an effective rehabilitation program (pp. 502-503).
A uniform clemency policy for military prisoners with neuropsychiatric disorders was also developed. The chief points of this policy were (1) to recommend clemency for those prisoners who obviously were too feebleminded to make possible their restoration to duty and (2) to recommend for clemency only those who were not antisocial to the extent that the Army would be releasing a menace to the community to which the men returned.
The Neuropsychiatry Branch was likewise active in implementing the efforts of the Bureau of Prisons, U.S. Department of Justice, in conjunction with the Selective Service System to rehabilitate and induct certain qualified Federal prisoners and certain ex-officer prisoners of the U.S. Disciplinary Barracks, Fort Leavenworth.
Further psychiatric participation in disciplinary problems included psychiatric orientation of every officer and enlisted man associated with the
6Memorandum, Capt. Ivan C. Berlien, MC, for Col. William C. Menninger, MC, Director, Neuropsychiatry Division, Surgeon General's Office, 27 Apr.
1944, subject: Liaison With War Department.7Memorandum, Maj. Ivan C. Berlien, MC, for Col. William C. Menninger, MC, Director, Neuropsychiatry Division, Surgeon General's Office, 23 Aug. 1944, subject: Neuropsychiatric Examination of Enlisted Men Brought Before GCM [General Courts-Martial].
8A Manual for Courts-Martial, U.S. Army. Washington: U.S. Government Printing Office, 1 Apr. 1928.
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rehabilitation of prisoners, and increased emphasis upon the return to duty from disciplinary barracks and centers.
One of the outstanding advances made during the previous year was the development and increased emphasis placed upon group therapy in the rehabilitation centers, thus making it possible for psychiatrists to reach many more men therapeutically.9
PERSONNEL DIVISION, G-1
Psychiatric Rejections
Perhaps, the most important problem which concerned the Neuropsychiatry Consultants Division and the Personnel Division, G-1, War Department General Staff, was the number of psychiatric rejections at induction.
The following memorandum illustrates the difficulties in this area:
WAR DEPARTMENT
WAR DEPARTMENT GENERAL STAFF
Personnel Division G-1
Washington
5 AUGUST 1943
WDGAP 201.5
MEMORANDUM FOR MILITARY PERSONNEL DIVISION, ASF:
Subject: Rejection of mental cases at induction stations.
1. Attention is invited to the inclosed summary which indicates that 9 percent of the total number of men processed during the month of June were rejected for psychiatric reasons. This rate of rejection is creating unfavorable public reaction, and has aroused criticism in the Selective Service System. It is further reported that such procedure is providing a haven for malingerers and other individuals who seek to evade service with the Armed Forces.
2. It does not appear reasonable to this Division that approximately 1 out of every 10 men who are presented at induction stations are psychotic to a degree which would disqualify them for military service or justify the assumption that they may become charges of the Government.
3. The Secretary of War directs that an immediate investigation be made of the procedure currently followed at induction stations in interpreting the instructions pertaining to rejections for mental causes, that remedial action be initiated without delay and necessary corrective measures not within the authority of the Commanding General, ASF, be referred to the Assistant Chief of Staff, G-1, for further corrective action.
M. G. WHITE,
Major General,
Assistant Chief of Staff.
Upon the receipt of this memorandum, Brig. Gen. George F. Lull, the Deputy Surgeon General, with the assistance of Col. Roy D. Halloran, MC, Chief, Neuropsychiatry Branch, submitted by endorsement,10 a preliminary report, in which the following was proposed:
9A complete description of psychiatry in correctional institutions is given in chapter XVII, 'Psychiatry in the Army Correctional System.'
10Memorandum, Maj. Gen. M. G. White, Assistant Chief of Staff, G-1, for Military Personnel Division, ASF, 5 Aug. 1943, subject: Reduction of Mental Cases at Induction Stations; 1st indorsement thereto, 18 Aug. 1943.
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* * * that a Committee of nationally recognized civilian neuropsychiatrists, together with the Chief of the Neuropsychiatry Branch of this office, be appointed to conduct an investigation of induction procedures and make appropriate recommendations, in compliance with paragraph 3 of basic communication. This Committee will consist of Drs. Winfred Overholser, Superintendent of Saint Elizabeths Hospital, Washington, D.C.; Arthur H. Ruggles, past President of the American Psychiatric Association, Providence, R. I.; Frederick W. Parsons, former Commissioner, Department of Mental Health, New York, N.Y.; Raymond W. Waggoner, Professor of Psychiatry, University of Michigan, and neuropsychiatric consultant to the Selective Service Headquarters, Washington, D.C.; Karl M. Bowman, President-elect of the American Psychiatric Association, and Director of the Langley Porter Clinic, San Francisco, Calif.; Titus H. Harris, Professor of Psychiatry, University of Texas, Austin, Tex., and Colonel Roy D. Halloran, MC, Chief of the Neuropsychiatry Branch of the Army.
In this preliminary report, The Surgeon General also endeavored to rebut the statements made in the original communication from G-1, pointing out that, in June 1943, neuropsychiatric discharges comprised 38.4 percent of all medical discharges. Although this was more than five times as great as the next single cause, it did not cover all neuropsychiatric disorders, since many more were discharged under section VIII, AR (Army Regulations) 615-360. It noted that neuropsychiatric casualties in oversea theaters were running higher than the American Expeditionary Forces rate in World War I, 'in spite of the fact that in this war 6-9 percent of all men examined at induction centers are rejected for neuropsychiatric reasons, whereas, only 2 percent were so rejected in the last war.' This induction rate of rejection, the 6-9 percent also, included-
* * * those with a history of treatment for a mental condition, psychopaths, alcoholics, the mentally deficient, homosexuals, and emotionally unstable persons who are frequently diagnosed as psychoneurotics and who cannot make any adjustment to military life, especially under combat conditions. These individuals are chronic troublemakers, have a very detrimental influence on others, and are actually dangerous in many instances. Constant appeals are coming from overseas to prevent the induction andoversea shipment of these types.
Regarding psychoses and malingering, the preliminary report stated: 'Actually, relatively few psychotic individuals appear at the induction board, and * * * malingering is the exception rather than the rule.' Further, in response to the specific issue of excessive psychiatric rejections raised by G-1, the preliminary report stated: '* * * this office has been considering the advisability of increasing rather than decreasing the stringency of the neuropsychiatric induction screening process."11
The committee, as proposed, was appointed, and in the brief time allotted to the members, they not only covered every service command and interviewed many persons at all levels of the Army but also submitted a brief but comprehensive lucid report with far-reaching effects (appendix D), which essentially supported The Surgeon General's position as ex?pressed in the aforementioned rebuttal.
11It is pertinent to note that the belief in the efficacy of psychiatry screening 'died hard.' It was still believed to be the answer to the vast increased incidence of neuropsychiatric disorders.-A. J. G.
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Since The Surgeon General was frequently contacted, formally and informally, concerning the personnel problem, the Consultant in Neuropsychiatry attempted to keep him informed of current situations and progress. A very good and comprehensive example of such a communication was 'Extent of Neuropsychiatric Problems in the Army,' dated 15 June 1944 (appendix E, p. 807).
Psychiatric Admissions and Discharges
Even as late as the fall of 1944, considerable concern was still being expressed about the large number of neuropsychiatric casualties. Speculations were made as to the causative factors, especially the possibility of overzealousness among psychiatrists.
Apparently, an article appearing in the 23 September 1944 issue of Collier's magazine, entitled 'Repairing War-Cracked Minds,' lent stimulus for further investigation. The Assistant Deputy Chief of Staff12 requested "* * * that G-1 study the problem to determine what improvements can be made in our procedures and publicity in the handling of psychoneurotics.' This memorandum particularly mentioned that Army psychiatrists '* * * are overdoing their diagnosis of psychoneurosis and are overdoing the publicity on this subject.'
Since G-1 forwarded the memorandum to The Surgeon General, the Neuropsychiatry Consultants Division embarked upon another study which consumed many hours during the fall of 1944.
Tue Surgeon General's viewpoint
In reply, the first of a series of memorandums was submitted by The Surgeon General to G-1 on 10 November 1944 (appendix E, p. 814). This memorandum dealt mainly with the diagnosis and treatment of psychoneurosis, including published material and directives, as was specified in the instruction from G-1 and did not go into the matter of prevention to any great length, nor did it supply specific recommendations as these had not been requested. Upon receipt of this memorandum, Lt. Col. Westray B. Boyce, WAG, who was the staff officer of G-1 during this study, stated that a second memorandum was desired which would place emphasis on pre?vention and make specific recommendations. It is believed that this second request represented an important change in thinking on the part of G-1 and the War Department.
In the course of subsequent joint conferences in this area and as a result of the information presented in the various memorandums that were supplied, along with an earlier NATOUSA (North African Theater of Operations, U.S. Army) memorandum and articles in Health, it became
12Memorandum, Assistant Deputy Chief of Staff, for the Assistant Chief of Staff, G11, 28 Sept. 1944, subject: Psychoneurotics.
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apparent to G-1 that psychiatrists were not the cause of psychiatric cases and that, if anyone was responsible for their occurrence, it could be command itself, since command controlled the factors which determined mental health of military personnel. This second request could be thought of as representing the War Department's acceptance of the command's responsibility in the psychiatric problem. Further, it sought advice from The Surgeon General on what could be done in policies and procedures which would decrease the loss of manpower from this cause. The reply to G-l's request was prepared and submitted on 7 December 1944 (appendix E, p.817).
The Inspector General's investigation
Meanwhile, the Inspector General had been called into the picture and instructed to conduct a major investigation of psychoneurosis in the Army. Maj. Gen. Howard McC. Snyder, Brig. Gen. Orval R. Cook, Col. Glen C. Salisbury, and others representing the Inspector General's Office held preliminary conferences with the personnel of the Neuropsychiatry Consultants Division and then proceeded with their investigation. They enlisted the aid of five civilian psychiatrists who were duly sworn in and accompanied the representatives of the Inspector General's Office in their field inspection trips. The members of this committee were as follows:
Dr. Karl M. Bowman, Professor of Psychiatry, University of California School of Medicine; Director of the Langley-Porter Psychiatric Clinic, San Francisco, Calif.; President of the American Psychiatric Association.
Dr. C. Charles Burlingame, President, The Institute of Living, Hartford, Conn.; Chairman, Committee on Public Education, American Psychiatric Association; Associate in Psychiatry, Columbia University, New York, N.Y.
Dr. Frank Fremont-Smith, Director, Josiah Macy, Jr. Foundation, 565 Park Avenue, New York, N.Y.
Dr. Harry C. Solomon, Professor of Psychiatry, Harvard Medical School, Cambridge, Mass.; Director, Boston Psychopathic Hospital, Boston, Mass.
Dr. Edward A. Strecker, Professor of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pa.; Member of the Advisory Committee on Psychiatry to the Secretary of War and the Secretary of Navy.
Report of investigation.-The Inspector General presented his report on 17 December 1944.13 An interesting statement contained on page 5 of this report is as follows: 'Actually, the majority of these cases are not neuropsychiatric conditions because medical officers wish to make patients
13Report, The Inspector General, to Assistant Chief of Staff, G-1, 17 Dec. 1944, subject: Psychoneurotics.
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out of them, but because the line officers have been unable to make soldiers out of them.'
The conclusions (recommendations) contained in this Inspector General's report are as follows:
CONCLUSIONS:
1. That the term 'Psychoneurosis' has been abused and becomes a stigma because of its indiscriminate use in the Armed Forces.
2. That too many ineffectives are still being accepted at induction stations, which situation might be improved if commanding generals of the service commands were instructed to issue directives to the induction stations in their commands to reject a selectee if there is reasonable doubt of his meeting the physical and mental qualifications for full duty.14
3. That psychiatrists should place emphasis on eliminating, during the early period of training at replacement training centers, inadequates and those who are militarily inadaptable, and thereafter concentrate their attention toward building morale and adjusting men as effective soldiers. The diagnosis of 'Psychoneurosis' should not be utilized in the discharge of such soldiers, in consequence of which they are enabled to draw compensation without in any way having contributed to the war effort while in the service.
4. That a large proportion of the medical discharges for 'Psychoneurosis' have been brought about because of the difficulty experienced by line officers in effecting the administrative discharge of inadequates and of persons inadaptable to the service.
5. That there are at present an insufficient number of psychiatrists, psychiatric social workers and clinical psychologists in the Army to carry on an adequate program of preventive psychiatry and, therefore, that the number of this type personnel undergoing training at psychiatric schools should be increased.
6. That the term 'Operational Fatigue' is acceptable as applied to individuals who have broken down under combat stress or other hazardous conditions, but should be limited in duration to only a few weeks and should not be used as a discharge diagnosis.
7. That the discharge diagnosis of 'Psychoneurosis' should not be used for those individuals whose psychoneurotic condition is (a) doubtful, borderline, or mild, and (b) whose prognosis is favorable, and in those cases where recurrence, medical care, or hospitalization for the condition is unlikely.
8. That men breaking down in combat or in hazardous situations should receive the maximum benefits of hospitalization and convalescent facilities, which must include physical and psychological rehabilitation, vocational guidance, pre-vocational training, and resocialization, and to this end there should be established additional special treatment centers.
9. That inadequate individuals who have demonstrated inadaptability to the military service but who are not psychoneurotics in the true meaning of the term should be discharged administratively under the provisions of AR 615-369 as 'Inadaptable to the Service,' and not be afforded the dignity of a medical diagnosis.
10. That individuals who have suffered from 'Operational Fatigue,' and from whom further productive service appears unattainable, should be released to the inactive reserve for a period of not less than one year, and not only encouraged but assisted in entering a gainful occupation, or in resuming their formal education.
11. That full publicity of the psychiatric problem should be given in a factual manner, but directed toward showing that the huge number of men previously discharged with this diagnosis from the Army were, as a matter of fact, unfit for military duty or psychiatrically ill at the time of their induction; and, conversely, that those who were
14Even at this late date, the erroneous belief persisted that the psychiatrist had the capability of effectively identifying the potential psychiatric problem at the induction station.-A. J. G.
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not thus eliminated or found to be unfit have behaved magnificently under the most trying conditions, together with the fact that the better the human material, the higher the breaking point.
In this report were included the views of the Inspector General, as follows:
It is believed that the subject of 'Psychoneurosis' as affecting military personnel should not be regarded solely from a medical viewpoint because many line officers also came in daily contact with the problem, and knowingly or otherwise, they are, to a great extent, responsible for the degree of psychoneurosis which develops within their respective commands. It was for this reason that there were included in the group of officers and specialists conducting this inquiry several line officers with considerable combat and troop duty experience. The views of these line officers were given full consideration during the preparation of General Snyder's report, and many of their ideas were incorporated therein, along with those of general medical officers and the eminent psychiatrists called in for consultation. This, it is believed, has resulted in a balanced consolidation of opinions without too great influence being exerted by the professional viewpoint of neuropsychiatrists. Therefore, I concur in the conclusions arrived at, and recommend that they be given consideration in the study on psychoneurosis now being prepared by the Assistant Chief of Staff for G-1. However, because of the importance of this subject, and of its increasing effect on the Army as the war is prolonged, it is believed that this study should be continued or extended, and that The Inspector General be authorized at an appropriate time to send officers to both the European and Southwest Pacific Theaters of Operation for this purpose.
VIRGIL L. PETERSON,
Major General,
Acting The Inspector General.
Disagreement.-There now remained for G-1 the task of bringing together all these reports into a single document that would contain recommendations asked for by the Deputy Chief of Staff in his initial instructions. Although the various reports agreed on certain points, there was marked disagreement on certain other points. The chief disagreement between The Surgeon General and G-1 was as follows:15
* * * * * * *2. Generally TSG [The Surgeon General] and G-1 are in agreement on all points covered in this study except three major issues as follows:
a. TSG is opposed to the recommendation of TIG [The Inspector General] and G-1 for the use of the working diagnosis of 'Combat Fatigue' or 'Operational Fatigue,' for individuals who have broken in combat or under unusually hazardous duty to avoid the impediment of a psychoneurotic label for those who are returned to duty within a reasonable period of time. In lieu thereof, TSG recommends working and discharge diagnoses of the particular types of psychoneuroses without reference to the word 'psychoneurosis,' which is considered by G-1 to be just as much of an impediment.'
b. TSG is opposed to the recommendation of TIG and G-1 to prohibit the use of the diagnosis of psychoneurosis except for individuals whose psychiatric condition
15Memorandum, Assistant Chief of Staff, G-1, to Deputy Chief of Staff, 4 Feb. 1945, subject: Psychoneurotics.
16Apparently, the practical benefits of using special diagnostic terms for the emotional disorders of combat stress during the earlier phase of these stress reactions was better appreciated in oversea theaters than in the Surgeon General's Office. For example, in April 1943, II Corps in North Africa directed that the initial diagnosis for all combat induced emotional disturbances was to be 'Exhaustion.' The advantages were:1. No specific 'etiology' was implied (as was the case in World War I with 'shell shock' and in World War II with 'psychoneurosis').
2. Without resort to euphemism, this term 'exhaustion' reduced feelings of unacceptable failure in such casualties. Combat was subjectively fatiguing to almost all soldiers, and thus, 'exhaustion' was a logical designation.
3. Implied reversibility of 'exhaustion' with a brief period of adequate rest followed by a few days of reconditioning supported the success attained in the program that was actually instituted for these casualties.
4. Early symptoms, judged in the light of brief personal histories, represent a poor basis for formal psychiatric diagnoses. After 5 to 7 days, the condition of those casualties who were unable to return to combat could be better defined clinically, and thus, a formal psychiatric diagnosis could be made more ac?curately. Such accuracy in diagnosis increased when the soldier was evacuated farther to the rear for more definitive psychiatric care.-A. J. G.
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is such as to warrant discharge on CDD (AR 615-361). TSG believes the use of the working and discharge diagnoses, of the particular types of psychoneurosis should be permitted regardless of whether the individual is incapacitated for military duty or civilian life, as the case may be. TIG and G-1 feel that the resulting impediment of such entries in the medical record of those who are not incapacitated is an injustice and should be prohibited.
c. TSG is opposed to the G-1 recommendation that all inapt, inadequate or inadaptable individuals be initially processed under AR 615-361, which requires a medical board to determine whether they are psychoneurotic in the true sense of the term and warranting medical discharge, or merely incapable of adjusting to military service and warranting administrative discharge. TSG feels that the opinion of one psychiatrist is sufficient medical judgment for the board of line officers appointed to consider such administrative discharges. G-1 is of the opinion that a hospital board of medical officers is desirable in order that definite conclusions will be rendered after a period of observation and treatment.
The issue presented in paragraph 2b of this memorandum was of particular concern to The Surgeon General because it permitted laymen rather than physicians to make medical diagnoses and forced physicians to put arbitrary nonmedical terminology on medical records. There was strong resistance in the Surgeon General's Office to this, including that of General Lull.
Resolution.-The Deputy Chief of Staff, on learning of the nonconcurrence of The Surgeon General in the G-1 memorandum, presented previously, instructed the various agencies concerned to get together and propose a set of recommendations which were mutually agreeable to all. After a series of long and interesting conferences, this was accomplished, and a memorandum17 was sent forward having been concurred in by The Surgeon General, the Inspector General, the Air Surgeon, and G-1. Pertinent extracts of this memorandum are as follows:
4a. (1) That the term psychoneurosis has been employed too widely and indiscriminately in the Army. This has resulted in part from a widespread tendency to use medical channels of evacuation, reclassification and discharge in order to eliminate undesirable or inadaptable personnel.
(2) It was agreed that the term 'psychoneurosis' should not be used in individual clinical records in the Army and that the medical term for the particular types of psychoneurosis (such as 'anxiety reaction') be used, together with a brief
17Memorandum, Assistant Chief of Staff, G-1, for the Deputy Chief of Staff, 16 Feb. 1945, subject: Psychoneurotics.
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description of individual, type and amount of stress which induced the condition and the effect (if any) upon his functional capacity.
b. No diagnosis as indicated in par 4a (2) above should be entered on report of final physical examination of an individual being processed for administrative discharge unless so determined by a board of medical officers.
(1) Those noneffective individuals who are not sick and not in need of medical treatment should be returned to duty with a statement to this effect.
(2) Those who have received maximum benefit of treatment, who have no condition which warrants disability discharge but are inadaptable to military service should be discharged administratively.
c. Upon maximum benefit of medical treatment those individuals whose condition is such as to warrant medical discharge will be so discharged under existing CDD procedure with diagnosis as indicated in par 4a (2) above.
d. Release to the inactive reserve of those individuals who have become temporarily inadaptable to further military service as a result of stress experienced in combat was considered and strongly recommended. However, this question is integrated with the present study now being made of 'Utilization of Returnees.' It is believed this phase should be studied after full information is available from the study referred to.
e.In view of the manpower situation and the increasingly high rejection rate for neuropsychiatric disorders, registrants should be rejected only after definite evidence that they are below acceptance standards.
f.It was concluded that there are insufficient trained psychiatrists, psychologists and psychiatric social workers in the Army.
g. It was concluded that additional separate special treatment centers for handling combat-induced psychoneurotic patients not be established.
h. Part of the confusion on the part of the public about the subject of psycho?neurosis has been due to the complete black-out of publicity by the Joint Security Control Board of the Army and Navy until May 1944. Since then only fragmentary information has been released. It was agreed that publicity insofar as possible should be given in a factual, nontechnical manner.
i. Lack of motivation toward fighting the war has been a basic cause for the high incidence of ineffectiveness and psychoneurosis in military personnel.
This was duly approved by the Chief of Staff personally and by the Secretary of War who stated that he thought it a 'sensible solution' to the problem. A summary of the report was also sent to the Commander in Chief who replied as follows:
25 MARCH 1945.
My dear Mr. Secretary:
Thank you for your letter of February 28, 1945, in which you further outline the scope of the psychiatric problem in the Army.
I fully appreciate the magnitude of the task of caring for the soldier who is emotionally sick as a result of combat, as well as the man whose service maladjustment is but a reflection of a long existent inadequacy.
It would seem that your program provides equally well for both groups and should be a material aid in their ultimate civilian adjustment.
Sincerely yours,
FRANKLIN ROOSEVELT
The Honorable Henry L. Stimson,
Secretary of War, Washington, D.C.
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Result.-WD (War Department) Circular No. 81, dated 13 March 1945, appeared shortly after the investigation and represented the chief immediate result of this study. It is an interesting sidelight that section III of this circular was taken almost word for word from the paper presented by Lt. Col. Malcolm J. Farrell, MC, and Maj. John W. Appel, MC, to the American Psychiatric Association the preceding spring, entitled 'Current Trends in Military Neuropsychiatry.'18
It was not until the magnitude and nature of the neuropsychiatric problems were dramatically brought to the attention of G-1, through the many investigations in which Colonel Boyce was personally involved, did close liaison develop between the two divisions (p. 102). When the assignment of Colonel Boyce as Director of the Women's Army Corps was anticipated in July 1944, Maj. Gen. Guy V. Henry, Assistant Chief of Staff, G-1, requested the assignment of Lt. Col. Frederick R. Hanson, MC, the psychiatric consultant for the Mediterranean theater, to his office. This assignment brought decided advantages. Colonel Hanson had had considerable combat psychiatric experience, and his opinions were highly respected. He attended the staff meetings of the division in order to keep in touch with developments as they occurred and, then, would be able to relay immediately to the Neuropsychiatry Consultants Division staff information concerning G-1 policies and activities that were psychiatrically significant.
MILITARY INTELLIGENCE DIVISION, G-2
Because of the nature of the activities of G-2, much of the contacts were confidential or secret, and many were not set down in writing. The personnel of the Neuropsychiatry Consultants Division, in cooperation with G-2, assisted in the interviews and coaching of individuals concerned with certain operations for special secret assignments. They also conducted, in the Zone of Interior and abroad, numerous surveys revolving around factors that influenced morale or contributed to psychiatric casualty formation. Information obtained from such surveys and from ETMD (Essential Technical Medical Data) reports concerning the effects of climate, exhaustion, monotony of food, length of service in isolated posts, types of duty, and lack of relief and furloughs; attitudes toward the enemy, their propaganda, prisoners, and ideals; attitudes toward the USO and Army publications; and fear of enemy weapons, such as the 88's, were relayed to G-2. Therefore, liaison was maintained throughout the war.
TRAINING DIVISION, G-3
Some of the most important contacts with G-3 were concerned with pointing out the various factors involved in mental health and their rela?
18Farrell, M. J., and Appel, J. W.: Current Trends in Military Neuropsychiatry. Am. J. Psychiat. 101: 12-19, July 1944.
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tionship to motivation, morale, leadership, and training. One such communication19 stated:
It is believed that a basic underlying cause for the high rate of neuropsychiatric disorders is the inadequate motivation of the average soldier for warfare. It is well established that there is a widespread lack of personal conviction among military personnel as to the issues involved in this war. Large numbers of both officers and enlisted men still do not realize what personal harm the enemy has done, is able to do and intends to do to them and their families. As a consequence, they lack the resolve and determination necessary to withstand regimentation, separation from home, exhaustion and danger of death or mutilation.
It then mentioned other contributing and related causes, among them, 'inadequate training.' This memorandum was particularly important in the evolution and publication of War Department Technical Bulletins (TB MED's) 12 and 21 which became instruments of orientation and training of officers and enlisted men and were designed to prevent or diminish psychiatric breakdown. The memorandum further stressed command responsibility, pointing out 'the problems of mental health are the problems of morale-and morale is a problem of leadership,' and it offered psychiatric assistance with these problems.
HEADQUARTERS, ARMY SERVICE FORCES
Basic Conflict
As stated earlier, psychiatry was not only a medical specialty concerned with the prevention and treatment of sick soldiers but was also concerned with the major source of manpower loss which confronted the War Department. Consequently, The Surgeon General was under constant pressure to implement policies and procedures for which the Medical Department no longer had primary responsibility because of the War Department reorganization of 9 March 1942.20 This produced highly involved and prolonged negotiations throughout the war between the Army Service Forces and The Surgeon General and has been well told in the references cited and need not be repeated here. The reorganization of 9 March 1942 took away from The Surgeon General the powers of classification, assignment, and promotion of medical personnel, as well as the authority to determine policies and procedures relative to hospitalization and discharge of patients. The prerogatives were given to the General Staff, AGF (Army Ground Forces); to Headquarters, AAF (Army Air
19Memorandum, Lt. Col. William C. Menninger, MC, Chief, Neuropsychiatry Division, Surgeon General's Office, for Maj. Gen. Ray E. Porter, G-3, undated, subject: Mental Health of Military Personnel.
20(1) Smith, 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. (2) Millett, John D.: The Organization and Role of the Army Service Forces. United States Army in World War II. The Army Service Forces. Washington: U.S. Government Printing Office, 1954. (3) Cline, Ray S.: Washington Command Post: The Operations Division. United States Army in World War II. The War Department. Washington: U.S. Government Printing Office, 1951.
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Forces); and to Headquarters, ASF (Army Service Forces). It must be remembered, however, that this action, relieving The Surgeon General of his traditional functions, occurred during the dreadful days following Pearl Harbor, when vigorous efforts were required to make the Army combat ready.
It is noteworthy that a highly qualified and judicial historian of the Army Service Forces, John D. Millett, now (1966) president of Miami University, Oxford, Ohio, finally came to the opinion which was shared by other highly placed ASF staff members; that is, that the Medical Department should have been given more self-determination. 'This conclusion seemed to be the prevailing one among ASF organizational planners as World War II came to an end.'21
Officer Assignments
To illustrate the nature of the problem which complicated the position of The Surgeon General and of other technical service chiefs, two of the serious topics will be mentioned here.
Incompetent officers.-One was the quality of the officers. 'The service commands tended to be the dumping ground for all the field grade officers whom the Army Ground Forces found unsatisfactory. This produced a difficult personnel situation and helped to explain why some of the technical services and perhaps even the Army Air Forces distrusted the service commands. Lt. Gen. Brehon B. Somervell and the commanders of the service commands could only make the best of a troublesome situation.'22 The problem of separating incompetent officers, especially those of field grade, was never solved. It was, however, the source of some of the dissatisfactions which eventually manifested themselves in the discharge rate because of low morale.23
Malutilization of specialists.-Another important complication was the method of assignment of officers. In a study made by Maj. Gen. Frederick
H. Osborn, there is an examination of the Army tradition-
deliberately overstated for the purpose of emphasis, that all Army officers are interchangeable units, each of whom can be given on-the-job training within the Army which will fit him for any Staff or command function. * * * The theory that a good artilleryman or regimental commander will, with proper seasoning, make an equally good G-1 or G-2, runs counter to the policy and practice of other large scale enterprises whose success can be and is measured by their ability to operate at a profit. Adjust?ment to modern conditions of war requires that the Army recognize the specialized
21Millett, op. cit., p. 329.
22Ibid., p. 371.
23Menninger, William C.: Psychiatry in a Troubled World: Yesterday's War and Today's Challenge. New York: The Macmillan Co., 1948, pp. 516-536. (This discusses some needed changes in the Army including officer-enlisted man relationships (Doolittle Board); the method of assignment of officers (Osborn Report); civilian attitudes toward the Regular Army, Regular Army attitudes toward civilians; officer selection, promotion, isolationism, and personnel policies.)
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nature of the work to be performed by many of its top staff officers and offer thorough training in universities and in industry to the men slated to fill these positions.24
Inherent in the recognition of the need for specialists in this statement was support for senior medical consultants who were only slowly accepted by line officers.
Malutilization of medical officers.-To more than 75 percent of the 2,400 psychiatrists in the Army who looked to The Surgeon General for leadership, but who were under the direction of the service commands, the issue of decentralization was not explained. To them as well as to many other medical officers in the Zone of Interior, it was clear that they were at a disadvantage in regard to assignment, promotion, and caseload distribution. Until 1944, most medical officers in service commands were also handicapped in their professional and administrative duties because of the lack of good communication with the Surgeon General's Office with regard to policy indoctrination, interpretation of regulations and directives, training, and the initiation of new methods as they evolved in the Office of The Surgeon General to meet contingencies.
It is a curious commentary that line officers utilized technical experts, often civilian, to help them in the ceaseless fight to keep ahead of the enemy in such areas as radar and the detection of submarines. They were reluctant to accept the same thesis in the medical and surgical area and, especially so, in the psychiatric area. Until late 1943, it was obvious that as many men were being discharged from the Army as were being inducted and that among the inductees were men of poorer quality than those being discharged.25
Medical Policies and Command
Most medical officers and psychiatrists were only too well aware that discharge policy was largely determined at command levels by line officers rather than by the use of medical criteria. They were also aware of the effect of easy discharge upon the morale of other military personnel. However, most medical officers were willing to be good soldiers, so that they followed the directives to the best of their ability. Since there were many and frequent changes and inconsistencies, it was not easy to know, at the time of such changes, the intent of command relative to medical or administrative discharges, until service command headquarters furnished definite instructions.
The psychiatrists were especially under pressure by troop commanders to help in the discharge or transfer of ineffective soldiers. In spite of numerous, but weak-voiced, official statements to the contrary, it seemed
24Report, Maj. Gen. Frederick H. Osborn, Director of Information and Education Division, to Chief of Staff, 16 Nov. 1945, subject: Observations on Army Policy and on the Training of Civilian Reserves.
25Ginzberg, Eli, et al.: The Ineffective Soldier: The Lost Division. New York: Columbia University Press, 1959, pp. 72-87.
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as if Army Service Forces were committed to the thesis that the manpower pool was unlimited and that induction stations would continue to provide a sufficient number of good soldiers to fight the war. Therefore, Army Service Forces, in effect, encouraged medical (certificate of disability for discharge) and administrative (sec. VIII, AR 615-360) discharges until the unexpected magnitude of the number separated from the service forced a change in policy.
The effect of WD Circular No. 161, issued on 14 July 1943, was perhaps the best example of how line officers controlled separation policy. When the number of men released became alarming, WD Circular No. 293, issued on 11 November 1943, rescinded WD Circular No. 161 and, thus, slowed down the separation rate. However, medical officers, particularly psychiatrists, were blamed for misusing psychiatric diagnoses or causing soldiers to be neurotic when the number of men separated on psychiatric grounds increased from 4,000 to about 18,000 monthly. The Inspector General's report of 17 December 1944, after a thorough review in both the Zone of Interior and oversea theaters, absolved the psychiatrists of blame and placed responsibility upon command (pp. 103-105). Brig. Gen. Elliot D. Cooke, a line officer, member of the Inspector General's team which investigated this problem, was encouraged by command to publish his lively and informative findings.26 After the war, Gen. Dwight D. Eisenhower and General Snyder were sufficiently concerned with the overall manpower utilization problem to encourage a long-term analysis of the induction, selection, and separation policies of the Army by Prof. Eli Ginzberg and his associates, which appeared in three volumes and is a valuable review.27 Brig, Gen. William C. Menninger28 has also written an excellent account of these and related problems.
The most important contact concerning separation policy between the Neuropsychiatry Division and Headquarters, ASF, occurred in the summer of 1943. It was not until then that any reliable statistics were available concerning psychiatric casualty rates; therefore, up to that time, there had been no idea of the magnitude of the problem. When the figures were available, a letter with recommendations was forwarded to the Commanding General, ASF.29
This letter gave some supporting data and some of the limited statistics available at that time to show that the incidence of neuropsychiatric casualties was greater than anticipated. It then recapitulated all that the Neuropsychiatry Division had accomplished or was attempting to do. It
26Cooke, Elliot D.: All But Me and Thee. Psychiatry at the Foxhole Level, Washington: Infantry Journal Press, 1946.
27(1) Ginzberg, Eli, et al.: The Ineffective Soldier: The Lost Divisions; Patterns of Performance; Breakdown and Recovery. New York: Columbia University Press, 1959. (2) Ginzberg, Eli, et al.: Psychiatry and Military Manpower Policy. New York: King's Crown Press, 1953.28Menninger, op. cit.
29Letter, Col. John A. Rogers, MC, Executive Officer, Surgeon General's Office, to The Commanding General, Army Service Forces, Washington, D.C., 6 Aug. 1943, subject: Deficient Mental Toughness of Military Personnel.
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stressed the necessity for development of mental toughness and preventive psychiatry. A similar letter, omitting the progress made by the Neuropsychiatry Division, was sent to the Acting Chief of Staff on 11 August 1943.
Although attempts to follow up this letter were made, no action was taken as far as the Neuropsychiatry Consultants Division could learn other than the dispatch of the following letter, shortly after 6 August 1943 to all medical officers:30
1. In spite of the fact that a much higher percentage of unstable men have been kept out of the Army by induction screening, reports indicate that, nevertheless, the number of men developing nervous and mental breakdowns in combat is considerably greater than it was in the last war. There is increasing evidence that military personnel still do not have the full realization of the issues involved in this war which is needed to develop the mental toughness necessary to withstand separation from home, regimentation, and the physical dangers involved.
2. Medical officers are reminded of their responsibility for the mental as well as the physical health of military personnel. Wherever possible they will assist commanding officers in developing and maintaining a healthy attitude in mind in the command.
3. The specific goals to be attained are that each soldier:
a. Feels he has a reason to fight worthy of the sacrifices involved; whether this is to protect his family, to save his country, to preserve his way of life, will depend upon the individual soldier.
b. Feels angry at the enemy; most soldiers are more aware of what the Japanese have done to him than what the Germans have done or threaten to do.
c. Fears not fighting, fears the consequences of defeat, fears what his buddies will say if he doesn't do his share.
d. Has confidence in himself-in his ability to fight, his weapons, his skill, his strength, his importance.
e. Has confidence in his outfit, his country, his Allies-confidence that they will do their part if he does his, that they are backing him up.
f. Confidence in his leaders-confidence in his leader's ability and in his leader's own willingness to sacrifice himself for their common goal.
BY ORDER OF THE SECRETARY OF WAR:
J. A. ULIO,
Major General,
The Adjutant General.
MILITARY TRAINING DIVISION, ARMY SERVICE FORCES
From January 1944, the Neuropsychiatry Consultants Division enjoyed fairly close liaison with the Military Training Division of the Army Service Forces. Previous to that time, contacts were meager and incidental. Good relationships were established particularly through Maj. Samuel Goldberg, MC, who attended the Neuropsychiatry Consultants Division staff conferences usually once a week. Some of the more impor?tant liaison efforts were in connection with replacement training centers of the Army Service Forces, psychiatric films, and directives on the psychiatric aspects of training, especially TB MED's 12 and 21.
30Letter, The Adjutant General, to All Medical Officers, August 1943. subject: Deficient Mental Toughness of Military Personnel.
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Joint experimental study.-The most important contact with the Military Training Division was in the joint experimental study concerning efforts to salvage psychoneurotic patients. The War Department and the Medical Department were considerably alarmed at the large loss in manpower resulting from psychoneurosis. As a result, the policy of the Army had changed from one of discharge for psychiatric patients to one of salvage, if possible. Accordingly, on 18 January 1944, Colonel Menninger forwarded the following memorandum to Brig. Gen. Charles C. Hillman, MC, Chief, Professional Service, Surgeon General's Office:
1. What are we going to do to attempt salvage of the psychoneurotic at the level of the large station hospital and general hospital? General Kirk's letter states that where men can be salvaged at that level, they should be. But: (1) The present attitude in all station hospitals is to move the men as fast as possible; (2) there has never been a directive about any treatment plan for psychoneurotic patients (except in the theater of operations); and (3) to keep them in the hospital with the present physical setup for any kind of psychiatric treatment is probably detrimental.
2. Our suggestions for an attempted solution of the problems are:
(1) Follow up this directive recommended by General Kirk with a letter from The Surgeon General to hospital psychiatrists to initiate treatment on the salvageable cases.
(2) Utilize barracks adjacent to the hospital for housing. If these are not available, convert one or as many as necessary, open (W-1) wards into barracks as rehabilitation quarters for the psychoneurotic (and perhaps other limited service) patients.
(3) Develop a rehabilitation program in accordance with their capabilities, With as much military aspect as we can, and utilize occupation, education, and recreation. The psychiatrist can spend an hour or two, or whatever time is necessary, with his acute hospital cases-the rest of his time directing his program.
3. Results of such a plan, I believe, would be:
(1) We would begin putting some emphasis on treatment at an earlier stage. In this connection, I think, from the psychiatric viewpoint, the weakness of the plan in sending men to retraining centers is that these men in hospitals do not need retraining; they need psychiatric treatment.
(2) If a barracks is utilized, this plan would free a considerable number of beds in the hospital, yet the whole procedure would be as it should be: a medically directed program.
(3) In general, it could be set up in existing installations requiring no addi?tional psychiatrists, and most of the psychoneurotic patients presently held in the wards would be in this rehabilitation barracks.
(4) It is an extremely important point that a soldier, breaking in the Army, has his optimum chance for rehabilitation while still in the Army. Many of those discharged and sent home are looked upon with doubts and suspicion, are often refused jobs, become pension seekers, and are no good to themselves. Not only for manpower salvage but for the over-all good to the man and society, strenuous efforts should be made at treatment and rehabilitation. It is my belief that this is the most vulnerable point for possible criticism of the Medical Department of the Army.
4. This plan presupposes that there can be a major change in the opportunities for reclassification and reassignment.
5. An improvement even in this tentative plan would be to develop good outpatient clinics in our larger posts with neuropsychiatry being represented in the clinic. In this manner we would catch the failing soldier even at an earlier stage and he could
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be worked up in the clinic and sent to the psychiatric rehabilitation program in the hospital directly without ever actually being in the hospital. At most of our installations we do not have adequate out-patient clinics but I believe this would apply to all fields of medicine.
Since the function of putting a salvage project into effect involved the Army Service Forces headquarters, request was made for a meeting to discuss preliminary plans. Such a meeting was held on 23 January 1944,31 and it was tentatively planned to establish pilot, experimental replacement training centers at Fort Belvoir, Va., Aberdeen Proving Ground, Md., and Camp Lee, Va. These locations were selected because their proximity to Washington would permit easy accessibility for more careful and closer supervision.
Since the training center at Aberdeen was under the Chief of Ordnance, the one at Camp Lee under the Quartermaster General, and that at Fort Belvoir under the Military District of Washington, a meeting of the representatives of those offices was held on 27 January 1944, in order to acquaint them with the plans. A report32 of this conference by Colonel Menninger stated, in part, as follows:
* * * the tentative plan for the establishment of these units, setting forth the course the patient follows from the hospital, through a screening and classification group, Camp Lee, at which point they will be distributed to the units under the replacement training centers at Lee, Belvoir, and Aberdeen. Each of these three replacement training centers were given an allotment of 50 out of their total unit of 420 men to be filled from similar patients discovered by replacement training center psychiatrists in these installations. The remaining number in each group, 370, will come from the hospitals. One company of Negroes will be established at Camp Lee. Because of housing problems, these will not be called for until approximately the 1st of March.
* * * a team of psychiatrists, classification officer, personnel consultant, and training officers from each center will constitute the screening board at Camp Lee. Once the man arrives at his particular unit, a board consisting of the battalion commanding officer, classification officer, a psychiatrist, personnel consultant, and training officer will plan and execute the program, and are to be free to change the course for an individual man at any time, and will recommend assignment whenever the man has obtained satisfactory proficiency. It was agreed that a man might be competent and able to fit into one of the regularly established courses for the replacement training center students and when this was possible, such should be done. Furthermore, it was assumed that a transfer might be made between centers in order to avail a man of the opportunity to have a different type of training.
Most of the units did not feel that additional equipment would be necessary. It is tentatively planned to start the screening at Camp Lee on February 7th. On February 2nd at 2:00 p.m. another conference is to be called and is to be attended by the battalion commanders, classification officers, psychiatrist, personnel consultants, and training officers involved.
31Memorandum, Chief, Neuropsychiatry Division, the Surgeon General's Office, to Chief of Professional Services, the Surgeon General's Office, Washington, D.C., 23 Jan. 1944, subject: Conference Regarding Plans for Retraining Centers in Replacement Training Centers for Neuropsychiatric Patients and Returned Oversea Soldiers.
32Memorandum, Chief, Neuropsychiatry Division, the Surgeon General's Office, to Chief of Professional Services, the Surgeon General's Office, Washington, D.C., 27 Jan. 1944, subject: Conference Regarding Establishment of Retraining Centers in Replacement Training Centers for Psychoneurotics.
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To avoid loss of time and pending the publication of orders, an airmail letter33 containing instructions was dispatched to the four service commands which were to supply the trainees. Within a week, this letter was implemented by ASF Circular No. 40,34 giving authority and direction for the operation of the units, pertinent extracts of which are as follows:
II-TRAINING-1. Developmental training units (experimental) are hereby established at the Quartermaster Replacement Training Center, Camp Lee, Virginia, the Engineer Replacement Training Center, Fort Belvoir, Virginia, and the Ordnance Replacement Training Center, Aberdeen Proving Ground, Maryland, effective 7 February 1944, with a capacity of 500 each.
2. Mission.-The mission of these units is to determine the feasibility of conserving manpower by the training or retraining under existing training doctrine and instruction methods of individuals (male) who, due to psychoneurotic illnesses, are-
a. Unusable in the capacity for which trained, and/or
b. Of limited military value.
3. Personnel to be trained.-a. Personnel at general hospitals for whom there seems to be a reasonable chance of rehabilitation through reclassification and individual training in special fields.
b. Personnel presently at the three replacement training centers referred to in paragraph 1 who cannot meet the requirements of either POR [preparation of replacements for oversea movement] of POM [preparation for oversea movement (units)] due to psychoneurotic illness.
4. Method of selection.-Personnel selected for retraining in these developmental training units will not be sent if their illnesses are so severe as to make them definitely of no further value to the service.
a. Selection will be made from general hospitals in accordance with letter SPMDU, subject, 'Retraining for the Psychoneurotic Patient,' 28 January 1944.
b. From the replacement training centers enumerated in paragraph 1 by the respective replacement training center commanders.
5. Transfer procedure.-a. Allotments will be published by the Adjutant General upon recommendation of the Military Training Division, ASF, to the Second, Third, Fourth, and Fifth Service Commands, and to the respective replacement training centers.
b. Only one allotment of personnel will be published for this experiment.
c. Men recommended by the general hospitals within allotments for this training will be reported by TWX to the Adjutant General's Office (Classification and Replacement Branch), SPXOC-H.
d. The Adjutant General will reply to hospitals by TWX indicating the number of men to be shipped and specifying the desired date of arrival at Camp Lee, Virginia.
e. Personnel so transferred will be discharged from the hospital, returned to duty status, and ordered to report to the commanding officer of the Special Classification Group, Camp Lee, Virginia.f. Transfer to and from these developmental training units will normally be in grade.
g. The hospital will forward an abstract of the soldier's medical history and such other data and remarks as will aid the Special Classification Group to evaluate personnel adequately.
h. The Adjutant General will coordinate the flow to the Special Classification
33Letter, War Department, Services of Supply, Office of The Surgeon General, to The Commanding Generals, Second, Third, Fourth, and Fifth Service Commands (attention: The Surgeon), 28 Jan. 1944, subject: Retraining for the Psychoneurotic Patient.
34Army Service Forces Circular No. 40, 5 Feb. 1944.
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Group from hospitals so as to provide not to exceed 80 men per day until capacities of developmental training units are reached.
6. Special Classification Group.-a. For the purpose of properly classifying personnel from hospitals, a Special Classification Group is established at Camp Lee, Virginia.
b. The Special Classification Group will analyze all personnel ordered from general hospitals, determine the initial training which they will pursue, and ship them to one of the three centers indicated in paragraph 1.
c. Upon completion of its mission, the Special Classification Group will be disbanded.
7. Organization of each training unit.-An additional overhead allotment to the appropriate agencies will be made by the Military Personnel Division, ASF, for the period of the experiment.
8. Training.-a. Basic military training will be limited to the capabilities of the individual. It will not include all-night bivouacs or training requiring exertion beyond the capabilities of the group generally. Where desirable, training scheduled will be alternated between the two companies to provide in each company one-half day of technical training and one-half day of basic military training, organized athletics, and time for personnel and medical consultation.
b. It is desired that each center develop the training independently to determine the rapidity with which this personnel can be trained. Detailed records of the training accomplishment of all individuals will be maintained so that the conclusion of the training, the degree of effectiveness of this program, and the feasibility of its continuation can be determined.
9. Transfer of personnel from developmental training units.-a. Personnel will be reported to the Adjutant General for assignment as individuals when in the opinion of a board consisting of the battalion commander, the psychiatrist, and the personnel consultant, the individual is prepared for return to duty.
b. Personnel will be reported to the Adjutant General for transfer under classification numbers indicated by the board mentioned above.
c. Personnel incapable of completing any course of training in the subject installations will be discharged under section II or section VIII, AR 615-360, as applicable.
The experiments continued for a period of about 3 months, the operations of which are summarized from a report made by Lt. Col. William H. Everts, MC, who was the representative of the Neuropsychiatry Consultants Division.
1. c. Of this experimental group of 1,253 men, 880 (70%) were made available for limited assignment for the Zone of Interior in noncombatant units. This availability was determined upon the recovery which took place under controlled conditions in the training units and is not an indication of performance under conditions not similarly controlled. Of the remaining not reclaimed for military duty, the majority were benefited by this program prior to discharge from the service.
d. This was accomplished at a cost of 62 officers and 250 enlisted cadre, a 20% overhead for total personnel or a 26% overhead for salvaged personnel. This is exclusive of the special classification group which is referred to in paragraph 2 a. below.
e. All troops in this experiment were white with exception of one company which was colored.
2. Screening-
a. The problem of screening was one of considerable magnitude since approximately one thousand (1,000) of these troops were hospitalized personnel with neurotic illness from both overseas and continental organizations. The troops were heterogeneous as to major force, age, AGCT group and degree of emotional instability. This
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problem was met by an initial medical screening at the hospital and subsequently by a special classification group screening at Camp Lee, Virginia, where the emotional, physical, and occupational suitability for retraining was determined and allocation to the appropriate training centers was conducted.
b. All white personnel was equitably distributed to the three Army Service Forces Training Centers according to the above factors. In addition, each of the three training centers screened and supplied fifty (50) individuals through their own mental hygiene clinics.
c. The troops of the colored company which were trained only at Camp Lee, Va,, received the usual screening at the hospital and subsequently by the battalion classification group at Camp Lee.
3. Contributory Problems-
Administrative problems evidenced in these trainees which needed and were given immediate attention included furlough, lack of pay and family allotments, clothing and equipment shortages, assignment discontent, unwarranted promises, and incomplete or lost military records, Correction of the above matters produced a prompt improvement in morale and aided materially in the acceptance of their responsibilities as soldiers. In addition, prolonged or repeated hospitalization through medical echelons had contributed to the chronicity of their disability.
4. Operation of Units-
The Developmental Training Units of each camp were voluntarily set up in accordance with their own physical and administrative dictates.
a. The Unit at Aberdeen Proving Ground, Maryland, [Lt. Col, R. Robert Cohen, MC, Chief of Neuropsychiatry Service] was designated and operated as a separate battalion, under the direct control of the Commanding General, ASFTC. The battalion operated its own Personnel and Classification Sections. This direct access to vital records was essential to prompt and efficient solution of problems which were definite morale factors: pay, furloughs, allotments, decorations, and assignments. The condition of records received justifies the need of immediate battalion supervision. All military and technical training and recreational activities functioned under direct battalion control, with existing post agencies and schools providing technical training facilities.
b. The Fort Belvoir Unit [Maj. Bernard A. Cruvant, MC, Chief of Neuropsychiatry Service] operated as a semi-isolated separate battalion, responsible directly to the Commanding Officer of the Army Service Forces Training Center. Technical training was supplied by existing post agencies, offices, and schools, in accordance with the recommendations of the Development Training Unit. Military training and recreational activities were conducted directly by the units. The battalion also operated and possessed its own consultation service, classification section, dispensary, recreation hall, company day rooms, mess halls, post exchange and chapel. Officers and enlisted cadre were quartered within the unit area.
c. The Unit at Camp Lee [Maj. Fred F. Senerchia, Jr., Chief of Neuropsychiatry Service] was designated as a part of and was physically located within a training regiment. Rations, quarters, and administration were under regimental control, whereas the application of training doctrines and function as well as disposition of the trainees was entirely under battalion control.
d. Though all three battalions functioned effectively and efficiently, experience indicates that, for the best interests of the trainees themselves and of the other troops of the camp, a battalion of a semi-isolated, separate type is more desirable.
e. Experience further dictates that colored developmental units should have a colored cadre and be maintained with other colored organizations.
5. Results-
There was a total of 880 (70%) troops retrained to an assignable level. Of the
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white troops, 805 (or 72%) and of the colored troops, 75 (or 52%) were retrained and made available for assignment.
6. Operating Overhead-
a. Actual operations required 62 officers and 250 enlisted cadre for the three experimental units (1253 trainees).
b. Experience gained during the progress of the experiment indicated that a more efficient organization would consist of a Battalion Headquarters of eleven (11) officers and 29 enlisted cadre; and companies of 6 officers and 30 enlisted cadre. On this basis, three two-company battalions as used in the experiment would have required 69 officers, 267 enlisted cadre for 1320 trainees. This slight increase in overhead would be necessary for continuous functioning. The suggested battalion headquarters would be capable of administering up to 6 companies of 220 men each.
7. Conclusions-
Experimental Units have retrained the personnel as stipulated in Section II, ASF Circular No. 40. Graduates have been reported to the Adjutant General for proper assignment. A definite determination of their usability must, however, be based upon the 30-day performance ratings submitted by the organizations to which assigned for duty.35
The Neuropsychiatry Consultants Division considered that these experiments were highly successful. However, in spite of repeated recommendations of the director that the experiments be continued, ASF headquarters refused permission to continue, on the grounds that there was already an oversupply of limited-service personnel available for reassignment.36 In fact, just as it was being demonstrated that many soldiers could be used in limited-service categories, the War Department, because of the oversupply, published two new sweeping directives aimed at separating these men as expeditiously as possible, by either medical or administrative means for 'the convenience of the Government.'37
Thus, it can be seen that the struggle to retain marginal manpower as seen in these units came to naught. While it could be demonstrated in these special training units that approximately 70 percent of previous noneffective personnel, mainly those ineffective for psychological reasons, could be placed on a limited type of duty, the central problem was the cost of this training and the limited need for this type of personnel. From a humanitarian standpoint, it was no doubt better to proceed from Colonel Menninger's idea38 to help these people regain their self-esteem and not discharge them as psychoneurotics. Indeed, not only humanitarian considerations were involved, since most of these men, if untreated, were almost certain to become pensioners of the Federal Government. Yet, this was wartime and the other side of the question had to be considered. The hard facts were
35As far as can be determined, no followup study of performance was ever accomplished.-A. J. G.
36(1) Memorandum, Director, Neuropsychiatry Division, for Director, Military Personnel Division, ASF, Washington, D.C., 29 July 1944, subject: Establishment of Separate Training Battalion. (2) Memorandum, Director, Military Personnel Division, ASF, for The Surgeon General, Washington, D.C., 5 Aug. 1944, subject: Retraining of Soldiers Previously Disabled by Psychoneurotic Disorders. (3) Memorandum, Director, Neuropsychiatry Division, Surgeon General's Office, for Director, Military Personnel Division, ASF, Washington, D.C., 10 Aug. 1944, subject: Retraining of Soldiers Previously Disabled by Psychoneurotic Disorders.
37(1) See footnote 25, p. 111. (2) Army Regulations No. 615-360, 26 Nov. 1942.
38See footnote 37 (2) above.
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that well-trained personnel required to train such ineffective personnel were a scarce category. More pertinent still was the fact that the country was surfeited with individuals with mental or physical defects who could only be assigned positions in the continental United States. Indeed, as stated by the Military Personnel Division, ASF,39 this glut of limited-service personnel would make impossible the further assignment of personnel who would complete such special training.
The basic error involved was in the too easy acceptance of the limited-personnel category-the prevailing tendency in most of World War II to easy access of hospitalization for minor physical symptoms and verbal complaints of soldiers relative to nervousness, anxiety, and their associated somatic tension states. This was further compounded by the overliberal use of the term 'psychoneurosis.' The word 'psychoneurosis' blinded both the patient and physician and created a climate in which the individual with some degree of honorable acceptance could utilize the subject's state of physical and mental discomfort, situationally induced to avoid the social obligation of a citizen at war. Hospitalization, a priori, conferred status upon their complaints. Easy discharges from the service for psychoneurosis made difficult any effort to motivate other individuals similarly designated to assume any type of duty except that which promised the least degree of stress. Only by a thorough change in attitude of both line and medical officers to this typical wartime phenomena could there be produced a significant change in the climate under which war must be fought and that unhappiness and discomfort are not disease, and one must carry on despite their presence.
INFORMATION AND EDUCATION DIVISION, ARMY SERVICE FORCES
With the transfer of Lt. (later Maj.) John W. Appel, MC, to the Neuropsychiatry Branch, early in 1943, for the purpose of instituting a program of preventive psychiatry, it was considered essential that a close liaison exist between the Information and Education Division, ASF, then known as the Special Service Division, which was charged with the moral program of the Army.
As time went on, this liaison was developed to a remarkable degree. Full consideration of the developments are discussed in chapter XIV, 'Preventive Psychiatry.'
A most important joint effort between the two offices was the evolution of a paper-and-pencil test known as the NSA (Neuropsychiatric Screening Adjunct).40 Induction stations began using this test on 1 October 1944. The test was designed to identify inductees who were in need of further
39See footnote 25, p. 111.
40War Department Memorandum No. 40-44, 19 Sept. 1944.
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psychiatric examination. Thus, where few qualified psychiatrists were on duty, psychiatric examination could be reserved mainly for men so screened by the test. Where sufficient psychiatrists were present, all inductees were given a psychiatric examination. Although considerable effort was directed toward correlating the validity of NSA, the war ended before the data could be evaluated. (See also pp. 185-188.)
HEADQUARTERS, ARMY GROUND FORCES
The liaison with the Army Ground Forces was not successful until late in the military effort. The first contact occurred during 1942 when attempts were made to assign neuropsychiatrists to combat divisions. The Ground Forces were bitterly opposed to such a move, and it was not until The Surgeon General himself forced the issue at War Department level that the recommendation was approved. The personnel of the Army Ground Surgeon's Office were not psychiatrically oriented, and although friendly, they regarded with suspicion all projects presented by the Neuropsychiatry Consultants Division. They did not favor the elevation of the Army psychiatric consultant to the same rank held by the medical and the surgical consultants. They were opposed to the division psychiatrist's being on the division surgeon's staff, but favored his placement in the clearing company. Many more conferences were required with Headquarters, Army Ground Forces, than with any other agency when approval was required for neuropsychiatric directives.
Maj. Alfred O. Ludwig, MC, Consultant in Neuropsychiatry for the Seventh U.S. Army, was appointed to the Office of the Army Ground Surgeon in August 1945. From then on, liaison was very close. Major Ludwig attended the Neuropsychiatric Consultants Division staff meetings regularly, to the mutual benefits of both offices.
HEADQUARTERS, ARMY AIR FORCES
Good personal relationships were maintained with the psychiatrists assigned to the Air Surgeon's Office, even though that office operated more or less independently of the Surgeon General's Office, particularly in matters relating to aviation medicine. Maj. (later Lt. Col.) John M. Murray, MC, was assigned late in 1942 as the chief psychiatrist in the Air Surgeon's Office. Frequent consultations were held between the neuropsychiatric elements of both offices, and when Lt. Col. Donald Hastings, MC, succeeded Colonel Murray on 13 October 1944, the same relationship continued. Colonel Hastings was also a frequent visitor to the Neuropsychiatry Consultants Division and its staff meetings. This close liaison was continued with Maj. Douglas D. Bond, MC, who succeeded Colonel Hastings, in August 1945.
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LIAISON WITH OTHER DIVISIONS, SURGEON GENERAL'S OFFICE
There was always a close relationship between neuropsychiatry and the other major branches of medicine in the Surgeon General's Office. An understanding of psychological factors in physical diseases and the reverse was fostered. Relationships were especially close with the Medical Consultants Division, whose members were very sympathetic and understanding in psychiatric problems. Officers of the two divisions frequently collaborated in special projects. The first meeting of the service command consultants, on 25 and 26 October 1943, was a combined meeting attended by both medical and neuropsychiatric consultants (fig. 24). In subsequent meetings of either division, the representatives of the other were invited to attend so that mutual problems might be discussed and all might be aware of developments.
Close liaison was enjoyed with the Physical Standards Division. Matters of induction standards and criteria for discharge were freely discussed, the recommendations of this division being sought and accepted in such matters.
Close cooperation with the Personnel Division resulted in the proper
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placement of psychiatrists who were assigned out of their specialties. All major and most of the minor transfers and special appointments of neuropsychiatric personnel were made after discussion with the Neuropsychiatry Division and according to its recommendations.
The Neuropsychiatry Division maintained close liaison with the Hospital Division. The many questions of policy relating to treatment and evacuation required a major portion of the time of the representatives of the neuropsychiatric office. The Hospital Division had representatives at all major conferences on psychiatric matters. Space does not permit even a synopsis of the numerous problems which constantly had to be met because of changes in the military and administrative setting. Fortunately, there are excellent accounts of the major issues described by Smith, Armfield, and Menninger.41 As mentioned earlier, the volumes by Millett, Cline, and McMinn and Levin42 are useful correlative references in order to gain a better insight into the total manpower problem as well as the operational difficulties facing The Surgeon General.
The Director of the Neuropsychiatry Division made a practice of sum?marizing the psychiatric problem, particularly for the information of The Surgeon General. One particular letter was significant because it represented a rather complete summary of all aspects of the neuropsychiatric problem as seen through the eyes of Colonel Menninger as of 15 June 1944 (appendix E). In it, one can recognize many changes on previous opinions. It recognized the inadequacy of screening; emphasized the need of treatment; and strongly showed the relationship between morale and the psychiatric case. It pointed out that lax and vacillating manpower policies powerfully affected the rates of discharge of psychiatric administrative reasons.
MISCELLANEOUS, TECHNICAL, AND OTHER AGENCIES
Office of the Inspector General
The contacts of the Neuropsychiatry Consultants Division with the Inspector General's Office were mainly in a professional, advisory capacity in the investigation of special problems. No continuous liaison was maintained. On three occasions, however, officers of this division were placed on temporary duty with that office. First, in January 1944, when the Assistant Director accompanied the representatives of the Inspector General to the Port of Embarkation, Hampton Roads, Va., to supervise the physical examinations of personnel returned from a replacement center in North Africa. Second, on 1 March 1945, when the chief of the Psychiatry
41(1) Smith, op. cit. (2) Medical Department, United States Army. Organization and Administration in World War II. Washington: U.S. Government Printing Office, 1963, pp. 463-495, 525-538. (3) Menninger, op. cit.
42(1) Millett, op. cit. (2) Cline, op. cit. (3) Medical Department, United States Army. Personnel in World War II. Washington: U.S. Government Printing Office, 1963.
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Branch accompanied a party from the Inspector General's Office for temporary duty in the Pacific Ocean Areas in connection with the special G-1 study on psychoneurosis. Third, on 29 March 1945, when the chief of the Neurology Branch accompanied a similar party on the same mission to the European and Mediterranean theaters.
Office of the Judge Advocate General
The contact between the Neuropsychiatry Consultants Division and the Office of the Judge Advocate General was, for the most part, on a consultative basis. The majority of the contacts consisted mainly of the reference of legal cases and problems for professional psychiatric opinion. Elsewhere in this volume, there is a complete description of the close liaison established in such problems as disposition of homosexuals, the simplification of commitment laws, and the preparation of TB MED 201, 'Psychiatric Testimony Before Courts-Martial,' issued on 1 October 1945.
Theaters of Operations
Liaison with the theaters of operations was notably poor early in the war, especially with the Southwest Pacific Area. Oversea theaters were autonomous, and the theater commanders had relatively complete authority within their commands. At first, contacts were extremely meager and, then, only through informal personal communications. Professional consultants in oversea theaters were strictly forbidden to contact the Surgeon General's Office except through formal channels, which made it practically impossible to obtain useful information. Indeed, in the Southwest Pacific Area, the consultants were threatened with banishment to the hinterlands if they transgressed the order.43 Gradually, however, such practices were eliminated, and it was finally possible to send and receive badly needed professional information.
It was not until late in the military effort that any representative of the Neuropsychiatry Division had the advantage of making a visit to a combat theater to learn its problems at firsthand. Some of the major visits were Major Appel's visit to the Mediterranean theater; Colonel Menninger's to the European theater; and Colonel Farrell's and Major Berlien's to the Southwest Pacific Area.
Bureau of Medicine and Surgery, U.S. Navy
A close and friendly liaison existed between the personnel of the Neuropsychiatry Branch of the Bureau of Medicine and Surgery of the U.S.
43Obviously, documentation of this statement was not feasible, but it had been substantiated orally by consultants who served in the theater.-A. J. G.
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Navy, especially with Comdr. (later Capt.) Francis J. Braceland, MC, and this division. Information and copies of directives available to one office were continuously made available to the other. Each office was generous in its response to requests for advice on certain problems, and both were able to present united fronts on questions vital to military psychiatry. The directors and other representatives of the two offices often appeared together before congressional committees, at professional meetings, and at meetings in which mutual problems were discussed.
Selective Service System
The Neuropsychiatry Consultants Division always maintained a close liaison with the Selective Service System. Numerous conferences were held between various members of the medical staffs of both organizations. This liaison, while not very effective at first, was made closer when Dr. Raymond W. Waggoner was appointed neuropsychiatric consultant to the Selective Service System, in September 1943. Following his appointment, many difficulties disappeared which, singly, were of little consequence but, collectively, led to major misunderstandings.
One of the most important accomplishments resulting from the unified actions of the two offices was the launching of the Medical Survey Program, in October 1943. A detailed description of this program is contained in chapter VIII, pages 177-185.
American Red Cross
Army Regulations No. 850-75 provided for the American Red Cross to act as a liaison between the Army and civilian agencies for welfare purposes. Since these duties included social work, a close liaison developed between this division and the Office of the Psychiatric Social Work Consultant, particularly Miss Florence Brugger, who occupied the position of consultant from 15 February 1942, until 15 December 1942. Miss Dorothea Schuyler succeeded Miss Brugger, serving until October 1944, and was succeeded by Mrs. Imogene Young.
Through the cooperative efforts of the two offices, psychiatric social workers were recruited by the Red Cross for service in military installations in the Zone of Interior as well as overseas. In addition to assigning psychiatric social workers to general, regional, and station hospitals and, later, to convalescent hospitals, the American Red Cross also provided psychiatric social workers in the consultation services of mental hygiene units. These workers contributed greatly to proper diagnosis, treatment, and disposition. In many instances, they worked in cooperation with military psychiatric social workers. In such cases, the Red Cross workers handled the liaison with the community, while the military workers cared for the situation within the military organization.
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Allied Armies
Close liaison was established with the directors of psychiatry in both the British and Canadian Armies (fig. 25). This relationship was firmly established by visits of these individuals to the United States. In the fall of 1943, Brig. John R. Rees, RAMC, Chief Consultant in Psychiatry to the British Army, and Lt. Col. George R. Hargreaves, RAMC, his assistant, visited the Neuropsychiatry Consultants Division on a courtesy tour of inspection (fig. 26) of medical installations in the United States and Can?ada. Lt. Col. John D. Griffin, RAMC, the Chief Consultant in Psychiatry to the Canadian Army, joined the group of visitors. In addition to conferences with the various members of the Neuropsychiatry Branch, the British and Canadian visitors made personal contacts with other officers in the Surgeon General's Office and the War Department.
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On 5 November 1943, the British officers, accompanied by Colonel Farrell, visited medical and psychiatric installations of the Second and Fourth Service Commands, particularly the Engineer Replacement Training Center at Fort Belvoir. They were particularly interested in the basic training infiltration course and in the activities of the psychiatric consultation services.
On 15 November 1943, Colonel Farrell and Colonel Menninger, then Fourth Service Command Consultant in Neuropsychiatry, accompanied Brigadier Rees, Colonel Hargreaves, and Colonel Griffin on a 15-day tour to visit various medical military installations in Canada.
During Colonel Menninger's visit to the European theater in August 1944, this liaison was further cemented by a visit with Brigadier Rees. The director was able to see British military psychiatry function at firsthand.
On 10 November 1944, Brigadier Rees returned to this country for the purpose of delivering the Salmon Memorial Lecture, in New York City,
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N.Y. Previous to this, he had the opportunity to visit the Surgeon General's Office and to accompany the director on another visit to Army installations in the Midwest. On 15 November 1944, Brigadier Rees and Colonel Menninger attended the Under Secretary of War's conference on rehabilitation held at the U.S. Disciplinary Barracks at Fort Leavenworth. Both officers presented papers.
As a result of this liaison, information, publications, films, and direc?tives were made available to the psychiatric services of the United States, British, and Canadian Armies. The advantages of such an admirable liaison are self-evident.
Civilian Organizations
It was impossible for members of the Neuropsychiatry Consultants Division to respond to all the requests by civilian organizations for lectures and scientific papers. As might be expected, the greatest number of such contributions were made to organized psychiatric groups. Many papers written by members of the division were published in both professional and lay journals. These were assembled in periodic bibliographies of limited publication through the Surgeon General's Office.
