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Chapter 8, Part 3

Medical Science Publication No. 4, Volume II

FUNCTIONS OF A PSYCHIATRIC CONSULTANT TO A DIVISION, AND TO AN ARMY*

HYAM BOLOCAN, M. D.

The major function of the Division and Army psychiatrist is the conservation of manpower by the prevention, diagnosis and treatment of psychiatric problems, whether they be manifested by combat casualty or disease in which the functional component is primary.

The Division psychiatrist is attached to the staff of the Division Surgeon, the Army psychiatrist to that of the Army Surgeon. Both act in an advisory capacity in all matters concerned with morale as well as those psychiatric.

Because of the similarities in their duties, for the purpose of this paper they will be considered together.

A. Prevention

No program of prevention can be properly effective without adequate statistical records. The Division psychiatrist should keep statistics as to the number and type of psychiatric cases seen, with figures broken down to at least company and, on occasion, platoon level. The Army psychiatrist in turn receives a regular copy of this report together with notations as to reasons for unusual changes. However, statistics alone are insufficient, for only an intimate knowledge of the situation and the personalities involved can permit the proper recommendations to be made.

A high NP rate may reflect any of the following situations:

    1. Severe and prolonged exposure of a unit to combat.

    2. Assignment of a new inexperienced medical officer.

    3. New troops.

    4. Impending breakdown of an officer or NCO.

    5. Lack of confidence in the leader.

    6. Breakdown of the rotation system.

    7. Rotation anxiety.

    8. Use of medical channels for attempted evacuation of those with administrative problems.

    9. Inadvertent shelling of men by friendly troops.


*Presented 30 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.


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1. Severe and Prolonged Exposure of a Unit to Combat.

One expects psychiatric casualties in any given campaign just as one expects surgical or medical casualties. However, just as good preventive medicine accompanied by proper medical discipline can cut down the number of casualties due to malaria or cold injury, for example, good preventive psychiatry can cut down on the number of psychiatric casualties. Lavin points out the need for repeated orientation of command regarding the problem of rest and regular rotation of units (1). Secondly, one must remember that treatment and prevention are somewhat inseparable in that the unnecessary evacuation of one man may affect the morale and fighting efficiency of a whole platoon equally desirous of escaping a stressful situation. Thirdly, good psychiatry practiced during the pre-combat period is likely to lessen the number of breakdowns during combat. However, a word of caution is in order here. Experience has shown that less emphasis should be placed on the possibility that a man seen prior to combat will break down, and more emphasis placed on the fact that he might be useful.

2. The New Medical Officer

(a) The Battalion Surgeon. The battalion surgeon is responsible for psychiatric first aid and the treatment of those cases which, the tactical situation permitting, can best be handled at his level. By maintaining good medical discipline he is able to avert the unnecessary loss of manpower and to prevent the use of medical channels for the evacuation of those patients whose cases are properly administrative problems.

The battalion surgeon, often young and only shortly out of medical school, when newly attached to a unit may have some difficulty in reconciling his civilian attitudes with the military setting. Trained to use extensive and time-consuming laboratory procedures and dedicated to the idea of investigating every possibility, he may unnecessarily evacuate those with psychosomatic problems. Furthermore, in the military setting where the patient is subject to more hazardous duty than the physician himself usually faces, guilt may be stimulated. Such guilt may become attached to the idea that the physician is missing serious organic illness for which he will be condemned. This is particularly true of physicians newly attached to a unit who have not yet had an opportunity to form strong ties of identification with the group. It is the duty of the psychiatrist to give these officers strong support by educating them to the fact that, in a setting where healthy men are under continuous risk of losing their lives or being seriously wounded, one must not evacuate on the basis of possibilities alone. For example, new battalion surgeons frequently evacuate


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patients with notes on the E. M. T. tag for "for x-ray" or "for GI series." Such notes tend to fixate symptoms and cause dissatisfaction in the soldier when the procedure is not eventually carried out. The psychiatrist should warn the battalion surgeon against such notes. In those cases where the note has already been written, and in those cases where repeated visits of a soldier to the battalion aid station have caused doubt, it is a good idea to have the man examined by an "informal board" consisting of the psychiatrist and two other medical officers at clearing station. The findings are then imparted by note to the battalion surgeon so that he may have strong supporting opinions in maintaining the man on duty.

Newly arrived medical officers should be given written directives describing the routine for handling psychiatric casualties and outlining Theater or Division policies. Close personal liaison is desirable since medical officers are personally familiar with the personalities of the various officers in their outfit and are able to help the psychiatrist pin-point morale problems.

(b) The "New" Division Psychiatrist. The return to duty rate of the psychiatrist newly assigned to a Division usually follows a relatively set pattern. There is an initial period in which as he becomes less frightened by the possibility that a man may break down, and more impressed with a man's potential capabilities when forced to function, his return to duty rate gradually rises, reaching as high as 80 to 90 percent (depending on combat conditions, of course). As he remains with the Division, however, his return to duty rate begins to fall to around 40 to 60 percent. It is then that he begins to realize that his initial high return rate was due not alone to the fact that prompt and proper treatment was being utilized, but rather in reality represented a failure in the preventive aspect in that far too many patients who might have been handled by the unit itself were reaching him, and that these patients often had not been sufficiently ill in the first place to warrant evacuation. Thus as he becomes better acquainted with his educative role in the Division, the rate falls.

3. New Troops.

Troops committed to battle before they have had a chance to form strong ties of identification with the unit are more apt to break down. Furthermore, considerable time may elapse between the time of leaving Zone of Interior and arrival at a combat zone. During this period efficiency may no longer be at its peak and some lack of confidence in familiarity with weapons may have developed. If training has been accomplished on terrain different to that over which the combat rages, troops may be frightened by the unfamiliar as well as being physically unprepared.


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In the beginning of a new campaign such axioms may be forgotten and it is the duty of the psychiatrist not only to bring them to the attention of command but also to aid in the setting up of a program for the reception of new troops.

4. Impending Breakdown of an Officer or NCO.

Since the leader usually represents the strong "father" of the unit, any signs of weakness or his impending breakdown are as threatening to the individual man as the breakdown of a parent in the family constellation would be to the child. For this reason the psychiatrist should ever be on the alert for early history of signs of collapse in a leader so that possibly he may be pulled from future battle in time to prevent the breakdown of an entire unit. Personal liaison with battalion surgeons as well as questioning of incoming casualties among the men usually reveals the desired information.

5. Lack of Confidence in an Ineffectual Officer.

An incompetent officer will have an adverse effect on the mental health of his men. For this reason his removal should be recommended. However, in these cases, in contrast to those cases in which the officer has performed well, medical evacuation is not indicated, but rather a recommendation for the proper administrative action.

6. Breakdown of the Rotation System.

The Korean campaign was unique in that at no time was there a definite goal placed before the soldier in terms of just how much territory had to be taken or even just who had to be defeated before the war could be considered concluded. No man in the line knew for certain whether the Yalu River, the 38th Parallel or some other line was his eventual goal. This lack of a concrete goal about which to build phantasies of returning home may lead to feelings of hopelessness and despair with a tendency to give way to forces which cause breakdown and present an honorable way out. The establishment of a rotation policy helped offset this difficulty by giving the man a personally meaningful goal, something marked by a given point in time, a device apparently which makes more easy the bearing of anxiety.

However, this policy in turn gave rise to problems all of which were the direct concern of the military psychiatrist. Anything which tended to interfere with or prolong the date of rotation led to increased anxiety in the man involved. In one case an overzealous regimental commander held up rotation time of the men in his anxiety to maintain a certain strength. This was promptly reflected by an increase in psychiatric casualties. A report by the Division psychiatrist involved helped remedy the situation.


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7. Rotation Anxiety.

Sometimes the anxiety engendered by approaching rotation is so overwhelming as to cause a previously excellent soldier to break down. Unconsciously, reaching the desired goal sometimes stimulates guilt that friends will be left behind to face further danger and hardships. An unconscious fear of punishment for aggressive wishes is often projected onto fate with conscious fear of impending disaster. These patients represent difficult treatment problems. They respond quickly to rest but have an immediate recurrence of symptoms if sent back for the final days of their tour of duty. Because rotation sometimes depends not only on spending a certain length of time on duty, but also upon the quota assigned to the unit, there is often an unconscious wish on the part of the unit to have the man medically evacuated so that someone else may become eligible. However, this is somewhat unfair to the man involved. A partial solution lies in pulling men back to less hazardous jobs near their rotation time, but there are only so many openings in a given unit. No simple solution presents itself, so that personal communication with the man's officer is usually desirable in order that the most practical solution may be arrived at.

8. Use of Medical Channels for Attempted Evacuation of Those With Administrative Problems.

Severe character and behavior disorders are likely to cause difficulties regardless of assignment. Such personality types often try to escape by evacuation through medical channels. Busy and harassed officers are likely to welcome this particularly if encouraged by lax medical discipline. This is sometimes understandable during the heat of battle but nevertheless not to be condoned. It is not difficult for the psychiatrist to educate the officers concerned that such laxity in the long run is destructive to the morale of the men as a whole. Furthermore, if he remains firm in his attitudes the way is often paved for more prompt administrative action. The Division psychiatrist should make the required recommendation for disposition in a written report. Accurate figures as to the number of character and behavior disorders seen together with the number that are repeaters are essential to both Division and Army phychiatrist in urging more prompt administrative action.

9. Inadvertent Shelling by Friendly Troops.

In battle, unfortunately, incidents may occur in which troops are subject to attack by friendly forces. The resultant number of psychiatric casualties is usually far larger than the number that would result from similar exposure to enemy forces. It is a striking demonstration of the fact that strong forces other than just exposure to combat play a


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role in the formation or prevention of the psychiatric combat casualty. One may assume, therefore, that the converse is true. In other words, frequent briefing of the troops with emphasis on the fact that they are part of a team, and of the role that supporting troops play in protecting them will help cut down the psychiatric casualty rate.

The Division and Army psychiatrist as well as being concerned with statistics regarding the number and type of frank psychiatric casualties are also interested in the following figures:

1. AWOL rate.

2. SIW.

3. Number and nature of stockade admissions.

4. Wounded and injured, with particular regard to the number of cold or heat injuries.

A high AWOL rate is usually indicative of poor morale. Glass (2) in a study of 200 each made the following observations. Absence without leave is not an immediate result of intense battle trauma, but is the product of cumulative days of combat. Two-thirds of the offenses were committed from relatively safe areas. While the offenders were almost unanimous in stating that they were motivated by nervousness or fear of combat, only 25 percent had requested medical evacuation shortly before the offense. These requests had been refused. He was not able to demonstrate any definite correlation between the psychiatric and AWOL rates. The AWOL rate, however, is strongly affected by morale factors and it is therefore the psychiatrist's duty to study the problem and make the proper recommendations.

The same may be said of the SIW rate. However, the statement that an overly harsh evacuation policy is likely to lead to an increase in the SIW rate is debatable. The number of threats to perpetrate SIW's among men returned to duty is extremely high, yet the number who do so in this author's remembered experience is low. It appears that one does not step out of one's pattern of behavior and the man with true combat exhaustion is more likely to continue until actual breakdown rather than escape by this type of activity.

Casualty lists should also be studied for any undue number of accidentally injured, or an excessive number of cold or heat injuries. These may represent consciously or unconsciously self-inflicted injuries and as such may directly reflect morale problems to be investigated. The number of stockade admissions and types of offenses committed are studied in order to try to pin-point units with remedial morale problems. A large part of the Division psychiatrist's time is consumed in interviewing men involved in pre-trial cases. His reports may be certified, thus not necessitating a personal appearance at the trial. Both the Division and Army psychiatrist work closely


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with the Judge Advocate's section at their respected levels, not only in making recommendations in the individual case but also in advising in matters of policy.

Education. A broad educative program is essential to fostering the principles of preventive psychiatry. Mention has already been made of the role of the battalion surgeon. In addition, close contact with the regimental surgeons and colleagues at clearing station permits the Division psychiatrist to disseminate a better understanding of the functional elements in all disease, as well as to prevent needless evacuation of patients with minor psychosomatic complaints under the guise of organic illness. This may be done at meetings or at informal "bull sessions."

Pre- and post-combat periods may permit time for briefing of line officers regarding the handling of problems. In addition, the Division psychiatrist is responsible for the training of his enlisted personnel.

The Army psychiatrist has even broader responsibilities. Prepared to travel a great deal, often in conjunction with other consultants, he will conduct at various echelons formal or informal talks on current psychiatric problems. It is his duty to see that the knowledge of regular visiting civilian consultants is disseminated to the largest possible audience and it is he who arranges the itinerary. In addition, periodic meetings should be instituted at Army installations at which programs of mutual interest may be shared with the Judge Advocate's section as well as the Military Police, the latter being interested in such problems as drug addiction and motivation for criminal behavior.

He supervises the indoctrination and training of new incoming psychiatrists, arranging for their assignments according to training and personality. Regular visits are made to each Division and all installations with psychiatrists so that there can be a mutual exchange of ideas and an opportunity to gain first-hand knowledge of existing conditions. Research is to be encouraged whenever possible.

B. Diagnosis and Treatment.

Division Facilities. Since the T/O & E lists no official NP equipment, the Division psychiatrist utilizes the equipment of the clearing company. He usually makes his headquarters at the holding platoon, and is thereby available for consultation with other medical officers. However, he should insist on separate tentage for psychiatric patients since it has been found that intermingling of psychiatric casualties with other patients leads to mutual contamination of symptoms. Furthermore, separation helps foster a return-to-duty atmosphere and facilitates the soldier's acceptance of the psychogenic nature of his complaints.


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A small wall tent is used for private interviews. There should be sufficient tentage so that, the tactical situation permitting, one hundred patients may be held at a time. Clearing company messing, latrine and shower facilities are shared. Maintenance should be carried out by the patients themselves, under the supervision of NP personnel, this being considered a form of occupational therapy. Although the T/O & E provides for nine NP technicians most Division psychiatrists worked with a staff of four to seven men. These help relieve the psychiatrist of much burdensome detail, are responsible for the keeping of accurate records, make pertinent observations on the patients, and by showing a warm, sympathetic, but firm attitude play an important role in the treatment.

Army Facilities. Army facilities are of two types, the hospital ward and the rehabilitation center. The number of beds to be made available depends upon the tactical situation. Army facilities are intended to handle direct admissions from Army and nearby Corps units (in some cases Corps and Army units utilize the nearest Division facilities) as well as to take all casualties evacuated from Division. When the Division's load is exceeded, Army units should be prepared to admit directly from the combat zone.

An attempt should be made to keep hospital admissions to a minimum and emphasis should be placed on transfer to the rehabilitation center. Here, there is little hospital atmosphere, a "return to duty" atmosphere is fostered and secondary gain eliminated.

The Army psychiatrist although not in charge of these facilities is responsible for their supervision, seeing that official policies are carried out.

Holding Policy. The Division psychiatrist is directly responsible for the diagnosis and treatment of those cases arising in Division. The Army psychiatrist supervises the diagnosis and treatment of cases carried out by other psychiatrists in Army installations, as well as by the Division psychiatrists.

Since the differential diagnosis and treatment of combat neuropsychiatric breakdowns is to be discussed this afternoon, no attempt will be made to cover the subject in this paper. However, this represents, together with preventive psychiatry, one of the major functions of the military psychiatrist. The diagnosis of those cases not directly related to combat presents the same problems as in civilian psychiatry, although disposition will of course differ. Fixed character and behavior disorders are not expected to respond to brief psychotherapy at any level. Therefore, decision as to disposition is based primarily on ability to function. In the case of aggressive character disturbances and antisocial personalities, psychiatric channels are not to be used as a substitute for disciplinary or administrative proceedings.


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The psychiatrist should not be frightened by labels. Patients who could in reality only be called ambulatory schizophrenics or mental defectives have performed well in the right assignment. Amazing "cures" have been reported in some enuretics, and passive-dependents when forced to do so have on occasion performed in a creditable fashion. Nor should the fact that a man is a "repeater" necessarily indicate a need for evacuation. This may merely be an acting out of his neurotic pattern rather than a real breakdown.

Notes from line officers should be honored whenever possible. Because of the rapid change in clinical picture, casualties evacuated should be accompanied by a note for the benefit of the next psychiatrist seeing the patient. For the same reason the psychiatrist should attempt to see patients as soon as possible after admission.

Follow-up studies are desirable. Close liaison should be maintained with G-I and the AG section so that questions of assignment may be discussed.

Other Functions. During the Korean campaign it was the Army psychiatrist's duty to draw up plans for the exchange of psychiatric casualties of war. Division psychiatrists as well as psychiatrists working at Army level took an active part in the exchange.

Because of the presence of foreign troops and on occasion the sharing of facilities, close liaison with foreign medical officers was desirable and sometimes was profitable not only from a professional standpoint but from the standpoint of personal friendships as well.

References

1. Lavin, Robert J.: Division Psychiatry. Medical Bulletin of The U. S. Army, Far East. Vol I, No. 8, page 137, July 1953.

2. Glass, Albert J., Lt. Col., MC: Supplemental Number, The Bulletin of the U. S. Army Medical Department, Vol. IX, pp. 62-63, November 1949.