|OFFICE OF MEDICAL HISTORY AMEDD REGIMENT AMEDD MUSEUM|
HISTORY OF THE OFFICE OF MEDICAL HISTORY
The Mental Hygiene Consultation Services
Manfred S. Guttmacher, M.D.
In the World War I history of neuropsychiatry,1 it was stated that the borderline psychiatric cases-the potential neurotics and psychotics-could provide a most fertile field for preventive psychiatry. It was also stated that the cantonment neuropsychiatrist "became the guardian of the mental health" of his military organization. Such worthy thoughts were actually more idealistic than real. Although some psychiatrists did occasionally leave the base hospital to do some preventive work in the field with line officers and enlisted men, there was no formal organization for such a preventive psychiatry endeavor. Psychiatric screening boards were appointed in camps to facilitate continuous screening, and surveys were conducted to eliminate the unfit-all of which was admittedly unsatisfactory from a rehabilitative procedure viewpoint.
At the beginning of World War II, the major emphasis was again placed on screening but more sage counselors, aware of the problems of World War I, realized that screening alone was insufficient to solve all the expected and unexpected neuropsychiatric problems.2
ORIGIN AND DEVELOPMENT
As early as April 1942, Lt. Col. (later Col.) William C. Porter, MC, Chief, Neuropsychiatric Service, Walter Reed General Hospital, Washington, D.C., sent a memorandum3 to Brig. Gen. Charles C. Hillman, MC, Chief, Professional Service, SGO (Surgeon General's Office), outlining a plan for the assignment of neuropsychiatrists to replacement training centers.
Colonel Porter strongly favored taking psychiatrists out of station hospitals and placing them up "front" near the line in both training and combat areas. His famous words, "Treat them within the sound of the artillery," were reiterated many times. The objectives of his plan were to (1) adjust the soldier to "his minor difficulties of maladaptation"; (2) "select out obvious mental defectives, psychopaths, or prepsychotics who have passed induction board or other entrance screen, provided the unit commander has referred the man as a problem in training, discipline, or administration"; and (3) "sell practical psychiatry to the line." To initiate this plan, he suggested that a specially selected small group of 10 neuropsychiatrists between 30 and 40 years of age be given a 6-week training course to orient them in the duties of training center psychiatrists that they would be expected to perform.
Shortly thereafter, Lt. Col. (later Col.) Patrick S. Madigan, MC, Chief, Neuropsychiatry Branch, SGO, officially recommended that neuropsychiatrists be assigned to the headquarters of each replacement training center. The Surgeon General4 took immediate action to bring these recommendations to the attention of higher authority. Later, The Adjutant General allotted personnel spaces for 15 more Medical Corps officers, neuropsychiatrists with the rank of major, to the headquarters of the AGF (Army Ground Forces) replacement training centers. After the commanding generals of the 13 AGF replacement centers had requisitioned these psychiatrists, The Adjutant General5 sent out a followup letter to assure their utilization in establishing psychiatric or behavior clinics independent of the camp hospital. Aware that in certain training centers such clinics were already functioning, the letter also cautioned against duplication of effort.
Recommended functions.-In outlining the functions of the center psychiatrist, this letter showed excellent foresight. The psychiatrist was "to eliminate those mentally unstable individuals who are or may become a distinct liability to military training, discipline, and morale during the early weeks of training," but he was, quite appropriately, to devote his time to the more normal individuals who may have developed correctible maladjustments to military service. An advisory service was to be instituted consisting of the psychiatrist, a psychologist, and "such other personnel as may be available." Eventually, Red Cross and military social workers and psychiatric social workers were added to the advisory team. The main purpose of the advisory team was to assist the new inductee in making a satisfactory adjustment in the Army. The duties of the psychiatrist were further detailed as follows:
(1) To aid, by professional methods, individuals who have been brought to his
attention, in order to make full use of their training and capabilities, or to recommend reclassification of those who are being trained in a skill beyond their capacities; (2) to study and recommend remedial measures for those individuals who manifest behavior problems; (3) to recommend for immediate discharge from the service such men who, because of mental or emotional factors, cannot function adequately or who present a hazard to the other men; (4) to develop a liaison with line and medical officers for the purpose of instructing and developing a better understanding of the principles of mental hygiene as applied to the military services; (5) to aid in the morale program of the station by the use of the neuropsychiatrist's specialized training and knowledge.
Although the letter anticipated the sources of referral to the center neuropsychiatrist, it overlooked mention of two of the chief sources of referral, the other post medical units and the courts-martial agencies. It did mention (1) staff sections, (2) school directors, (3) chaplains, (4) company, troop, and battery officers, and (5) provost marshals.
Independently and almost contemporaneously, mental hygiene units under diverse names were established in various training centers. Lt. (later Maj.) Harry L. Freedman, MC,6 in February, 1942 established the Classification Clinic at the Signal Corps Replacement Training Center, Fort Monmouth, N.J. This clinic operated through the adjutant of the training center. Capt. (later Maj.) Bernard A. Cruvant, MC,7 established his clinic at the Engineer Replacement Training Center, Fort Belvoir, Va. He used the term "Consultation Service" which was later generally adopted for all such mental hygiene clinics. The Belvoir clinic was frequently used by the Surgeon General's Office for training psychiatrists who were to be assigned to Consultation Services, not only because of its proximity to Washington but also because of its efficiency of operation.
Capt. (later Lt. Col.) Julius Schreiber, MC, established a clinic at the Antiaircraft Replacement Training Center, Camp Callan, Calif., similar to the one at Fort Belvoir. The relationship of motivation to the morale and efficiency of the soldier was emphasized by Captain Schreiber,8 and he skillfully used the camp newspaper, pamphlets, and other media to disseminate information and advice.
The Consultation Service at Camp Callan originated as an outpatient clinic of the Station Hospital. In a somewhat similar manner, Maj. (later Lt. Col.) R. Robert Cohen, MC, Chief of Neuropsychiatry, Station Hospital, Aberdeen Proving Ground, Md., in August 1942, began to lecture to incoming trainees of the Ordnance Training Center on personal adjustment
problems. He believed that these lectures would aid in preventing the occurrence of common neuropsychiatric disorders. In the summer of 1943, the Consultation Service of the Ordnance Training Center was organized, and Major Cohen was appointed its psychiatrist. He wrote a number of articles9 which emphasized the importance of assisting the new inductee in adjusting to the Army.
EXPANSION OF CONSULTATION SERVICES
In the fall of 1942, 13 new Consultation Services were established in AGF replacement training centers. The psychiatrists assigned to direct them were specially selected on the basis of their civilian experience in mental hygiene and related fields. Fortunately, most of these psychiatrists remained at the same posts throughout the war, and their efficiency increased with experience. They became more familiar with the local specialized training methods and the particular problems of the training center. It became evident, however, that it required time for line officers of the training centers to understand and acquire confidence in the psychiatrist and his methods.
There was general agreement by professional personnel of the Consultation Services that they performed more effectively if assigned to the headquarters of the center rather than if assigned to the hospital or the post surgeon.
In March 1943, Col. Roy D. Halloran, MC, recommended to Brig. Gen. Charles C. Hillman, MC, that Mental Hygiene Units (Consultation Services) should be established in all replacement training centers. At this time, there were Consultation Services in 16 of 33 basic training centers. As a result of Colonel Halloran's recommendation, all AGF and ASF (Army Service Forces) basic training camps had Consultation Services by the end of the summer of 1943. It was generally acknowledged, as reported by Colonel Halloran, that these units had proved of great value in assisting command in the adjustment of new recruits.
Conferences.-The first conference of Consultation Service psychiatrists was held in Washington, D.C., in the fall of 1943. This was a 3-day meeting held in the Neuropsychiatry Consultants Division, Surgeon General's Office. Many problems were discussed but the main conclusion was that motivation was the most important factor influencing the mental health of the soldier. Thus, it was agreed that closer liaison between the training center psychiatrist and the morale building agencies should be established.
In March 1944, a conference of all the psychiatrists directing the
FIGURE 40.-Army Ground Forces Retraining Center psychiatrists' meeting, North Camp Hood, Tex., March 1944. Left to right, front row: Maj. George S. Goldman, MC, Lt. Col. Malcolm J. Farrell, MC, Maj. Samuel H. Kraines, MC, Maj. Alfred L. Abrams, MC, Maj. Juul C. Nielson, MC. Left to right, middle row: Maj. Jesse O. Arnold, MC, Maj. Richard F. Richie, MC, Maj. Harry E. August, MC, Maj. Oscar B. Markey, MC, Maj. Robert C. Hunt, MC. Left to right, back row: Maj. Vincent L. Frankfurth, MC, Maj. James Houloose, MC, Maj. Harry N. Roback, MC, Maj. Matthew Molitch, MC.
Consultation Services in the AGF replacement training centers was held at North Camp Hood, Tex. (fig. 40). The major portion of this meeting was given to the presentation and discussion of the "Advisor System." Maj. Samuel H. Kraines, MC,10 had initiated and developed this "system" at the TDRTC (Tank Destroyer Replacement Training Center) at Camp
Hood, in February 1943. It was an attempt at prophylactic psychiatry on a mass scale. Specially selected and instructed noncommissioned officers in each company were used as advisers to the maladjusted soldier in the unit. Although Major Kraines apparently achieved success with the "Advisor System," the psychiatric group formally disapproved of the practice. The consensus was that noncommissioned officers were not adequately qualified, trained, or experienced to carry out effectively such a program and that command channels were ignored and circumvented.
Variations in Staffing
The staffs of the Consultation Services varied in size; only three had two psychiatrists. In one of these, which was in a camp where half of the trainees were Negroes, the second psychiatrist, Capt. Rutherford B. Stevens, Jr., MC, did an excellent job. The number of other assigned personnel, such as psychologists, social workers, and clerks, varied widely and was not always proportional to the camp strength. In one training center serving 7,500 troops, there was only one psychiatrist and one part-time clerk; whereas in another, serving 28,000 troops, 1 psychiatrist, 20 psychologists and social workers, and 20 clerks composed the staff. This staffing frequently depended upon how vociferously the psychiatrist demanded necessary personnel and how his efforts were accepted by the local command. The personnel needs, as outlined in War Department Technical Bulletin (TB MED) 156, of June 1945-1 psychiatrist and 1 psychologist to 12,000 trainees; 1 Red Cross psychiatric social worker to 20,000 trainees; and 1 military social worker and 1 clerical worker to 3,000 trainees-were considered minimal.
The rank of psychiatrists and psychologists also varied in the Consultation Services. In the AGF training centers, the policy was not to advance psychiatrists beyond the rank of major and psychologists beyond the rank of first lieutenant. Yet in the Army Service Forces, psychiatrists and psychologists performing the same duties were, respectively, advanced to lieutenant colonel and major. This inequality was not conducive to the best morale of psychiatric personnel. Further, keeping the psychiatrist at a lower grade did, in many instances, hamper his influence and reduce any effectiveness he might otherwise have achieved.
Clinical Psychologists and Psychiatric Social Workers
Two groups of nonmedical professional workers were found to be essential for the efficient functioning of the consultation services. They were clinical psychologists and psychiatric social workers.
Clinical psychologists were in scarce supply, and only near the end of the war were they available in sufficient numbers for assignment to every clinic. Enlisted personnel (MOS 289) carried out much of the routine psychometric work. Commissioned clinical psychologists were primarily responsible for supervising the psychological testing program and for recommending the duty assignment of clinic patients. They carefully studied and analyzed the individual's experience, aptitude, and preferences. In addition, the clinical psychologists (generally designated as personnel consultants early in the war) kept abreast of the current Army personnel needs which were always of paramount consideration in job placement. Despite the limitations of available positions, appropriate recommendations for change of assignment proved to be a rather successful therapeutic technique.
Social work was carried out by qualified Red Cross social workers and enlisted personnel. The number of Red Cross psychiatric social workers, however, was limited to the extent that these workers could be provided only for about one-third of the Consultation Services. In those units where both Red Cross and enlisted workers were stationed, there was, as a rule, a demarcation of functions. The Red Cross workers dealt mostly with community agencies and specially selected cases in which the root of the soldier's problem involved unfavorable home conditions or a marked degree of dependence upon the family.
As the functions of the Consultation Service and the work of the enlisted social worker became better defined, the scope and importance of that worker increased. In October 1943, psychiatric social work was first declared a military occupational specialty (MOS 263). In May 1944, such enlisted personnel were listed as critically needed specialists for the first time. This classification reasonably assured that they could be held in social work positions despite the Army's manpower needs. The "freezing" of enlisted psychiatric social workers created some difficulties. The Army Ground Forces were reluctant to use MOS 263 and generally used MOS 289 (Personnel Consultant Assistant), a less critical category. The Army Air Forces did not use MOS 263 until near the end of the war. It was not until June 1945 that TB MED 154, entitled "Psychiatric Social Work," was issued. Although rather late, it did give a much clearer definition of the duties and techniques of the military psychiatric social worker.
Relatively few fully qualified psychiatric social workers were available, although some military social workers and medical case workers had had considerable civilian experience. The Army psychiatric social work
was done by many such workers in allied specialties who received on-the-job training and supervision. Since the scope of military psychiatric social work was less complex than its civilian counterpart with its family and community ramification, these Army-trained workers gained considerable experience and competence. Military social workers remained on an enlisted status throughout the war, even though many efforts were made to obtain a commissioned status for them. Although WAC (Women's Army Corps) social workers and clinical psychologists were in the minority, those that qualified did effective work in the few Consultation Services to which they were assigned.
The military psychiatric social worker performed many related duties in the Consultation Services. The initial histories were usually taken by these social workers. The more professionally qualified workers did preliminary social work studies and evolved treatment plans to fit each individual patient. They decided which patients had to be seen personally by the psychiatrist and which needed further testing and interview by the clinical psychologist. Some workers, under the supervision of the psychiatrist, actually treated the simpler maladjustments. Many social workers did excellent and valuable work in the field. Preexamination company and battery interviews were conducted in most cases. The social worker not only interviewed the company officers but also visited the noncommissioned cadre and fellow trainees of the patient. Thus, they obtained a broad picture of the patient's personality makeup, his progress in training, his social adjustment, his personal attitudes, and his behavior abnormalities. Followup visits to the company areas were made after the original workup to ascertain whether recommendations were properly understood and carried out. This so-called "leg work" produced a close liaison between field units and the Consultation Service and was often responsible for obtaining many of the good results.
CONSOLIDATION OF EFFORTS
With the publication of WD (War Department) Circular No. 48, issued on 3 February 1944, a new program for prophylaxis in mental health was advanced by the War Department. The circular contained outlines of three lectures on personal adjustment for enlisted men and a 6-hour lecture course for officers on personnel adjustment problems. The enlisted lectures were to be given during the trainees' first 2 weeks in the Army. All lectures were to be given by medical officers, preferably psychiatrists. The purpose of the lectures for the new trainees was to give a better understanding of common personal adjustment problems that may arise upon entering the Army and to present more effective methods of handling adverse emotions and feelings. The object of the
officer lectures was "to train company officers and noncommissioned officers in the importance of mental health in the Army, personality structure of the normal man, the causes of nervous break-downs, recognition of signs and symptoms of poor mental health, and measures to maintain mental health in the command." A few weeks later, the outlines for these lectures were published in more detail.11
Lectures for large groups of new soldiers were difficult to present. However, if the size of the group was decreased, more frequent lectures were required, involving more of the medical officers' time. The effectiveness of the lectures varied, depending upon the skill of the lecturer, his method of presentation, and the social and intellectual level of a particular group of trainees. Training aids were used extensively by psychiatrists. Some motion pictures were available, such as the British film, "The New Lot." Unfortunately, a corresponding American film was not completed soon enough to be used. Training charts, pamphlets, cartoon booklets, and even marionettes proved useful as training aids. The lecture outlines for officers proved to be most satisfactory. Both TB MED 12 and TB MED 21 were periodically revised to conform with the changes in existing situations.12
Psychiatric Problems of Basic Training
In 1944, in response to a request from the Office of the Secretary of War seeking information about psychiatric problems, the Neuropsychiatry Consultants Division made an interesting survey of 14 AGF and 7 ASF basic training camps. Constructive suggestions about psychiatric problems of their organizations, especially in connection with training, were requested of consultation service psychiatric personnel. Their comments are summarized, as follows:
2. Psychiatric Understanding of Training Officers:
4. Training Methods:
5. Infiltration Courses and Rifle Training:
6.Relation of Basic Training to the Development of Psychoneurosis:
7. Labor Battalions:
8. Orientation Problems:
To me the greatest violence that is done to basic psychiatric principles is in the handling of men in the average guardhouse. These are men with poor morale, otherwise they would not be there. Instead of attempting to raise their morale, everything is done to crush their spirit. Every guardhouse should have a competent morale office and a full program of rehabilitation.
9. The Dispensary:
On 15 September 1944, Maj. (later Lt. Col.) Manfred S. Guttmacher, MC, was assigned to the staff of the Neuropsychiatry Consultants Division, with the primary duty of supervising the 35 Mental Hygiene Consultation Services in the AGF and ASF replacement training centers. Major Guttmacher had had 2 years' experience directing Consultation Services in Antiaircraft Replacement Training Centers. During the year he was in the Surgeon General's Office, Major Guttmacher personally inspected all the Consultation Services.
Before Major Guttmacher's arrival in the Surgeon General's Office, a meeting of all training center psychiatrists had been planned. In order to obtain desired information and to stimulate interest in this meeting, Major Guttmacher sent a questionnaire to the chiefs of all the Consultation Services. The replies not only brought out much of the desired information but also determined the agenda for the meeting.
The 3-day meeting, 8-10 January 1945, was held at the Ordnance Training Center, Aberdeen Proving Ground, Md., with 38 training center psychiatrists attending. The conference was directed by Col. (later Brig. Gen.) William C. Menninger, MC, Director, Neuropsychiatry Consultants Division. Sick call, motivation and orientation, the Negro trainee, redeployment, neuropsychiatric disqualification standards for combat, courts-martial testimony, and the use of psychological testing agents were among the topics freely and informally discussed. The chief general conclusions15 reached at the conference were as follows:
Motivation plays a vital role in determining mental health. Insufficient realization by the average soldier of the degree to which he and his family were threatened by the enemy has been a basic cause for high incidence of psychiatric disorders among military personnel. Attempts to develop healthy attitudes toward the war have been relatively ineffective. It is the responsibility of the psychiatrist to point out the medical importance of this problem and lend full support to the I & E [Information and Education] Division and the command in its solution.
Whereas the treatment and disposition of individuals suffering from psychiatric disorders must be continued, it is evident that the chief military value of a training center psychiatrist can be in the prevention of psychiatric disorders. The factors which determine mental health of military personnel such as motivation, leadership, training, job classification and assignment are functions of command. In these matters the psychiatrist can function only as an advisor to the command. In order to carry out this mission, it would be necessary for him to act as a staff officer. At the present time, limitation of assisting personnel barely permits the psychiatrist time to handle his heavy case load of treatment and disposition. Assumption of duties in regard to prevention must be gradual and depend upon the feasibility of adding further trained personnel to the consultation staff.
Personal experiences.-Despite the seriousness of this author's supervisory function, the periodic inspections of the Consultation Services also
had their interesting and amusing moments. At one camp, the kindly commanding general asked to have his Consultation Service psychiatrist quietly replaced. This psychiatrist had sought the general's permission to eat with the hospital staff, with the complaint that "eating with all those line officers makes me nervous." Then, there was the training center where the general refused to allow men to be classified for limited service with the diagnosis of migraine unless it could be proved by roentgenograms. On a visit to a large western training camp, the inspecting psychiatrist pointed out to the commanding general that the high referral rate to the Consultation Services was only an index of his camp's poor morale. This statement was greeted with a volley of oaths befitting the proverbial sergeant and an accompanying declaration that one should not look for good morale in a camp with such a large proportion of Negro trainees. Within a week, the camp had a new commander. The Inspector General of another camp was telling of the invaluable service of the Consultation Services. He said that he had recently asked a warehouse sergeant what he did if a soldier kept complaining that the shoes issued him did not fit. The prompt reply was: "Send him to the Major at the Consultation Service."
Relationship With Command
The attitude of command influenced the Consultation Services just as it did all other agencies of the camp. For instance, the interpretation of Section VIII, AR 615-360, 26 November 1942, varied from a very liberal view to a very rigid one. Some commanding generals felt that ineffectual and behavior problem cases should be eliminated from the Army as soon as possible. Others felt that it was unjust and unwise from a morale standpoint to permit such persons to escape from their patriotic duties. So, where the policy was more liberal, the clinics referred many more men to the "Section VIII" boards. At the other extreme, such recommendations were not only disapproved by the commanding general but it was also impolitic for the psychiatrist to advise such disposition too frequently. There were many instances where the psychiatrist, with all due respect to command, had to follow a course tempered with justice. Often, commanders would eventually recognize their responsibilities and accept a more middle of the road policy. Rapidly shifting manpower needs and contradictory directives were mentioned as factors which often made it difficult for the psychiatrist to adjust his medical judgment to current policy. In that event, he could only give his best medical advice to the commander.
The usefulness of the Consultation Services was looked upon with considerable skepticism by many older Army officers in high staff positions at the training centers. Some believed it was wrong to exhibit so much
consideration for the individual soldier. They believed that this was mollycoddling and would weaken the fighting man. They averred that the mere existence of such clinics gave public and official recognition to the individual soldier's maladjustment or anticipated maladjustment. They also scorned the personal adjustment lectures, fearing that malingering would increase by giving the inductee medical information which he could divert to his own use. Such fears and worries were disclaimed by subsequent experience. Eventually, a great deal of dependence was placed on the staffs of the Consultation Services by most of the training officers. Through the combined efforts of the training officers and the Consultation Services, 80 percent of the maladjusted soldiers were able to complete their training, and those not amenable to corrective measures were expeditiously removed. It is impossible to estimate how much the war effort was benefited by disqualifying, during the training period, those serious psychiatric trainees who were mentally and emotionally unfit for combat duty. Similarly, it would not be possible to estimate how much maladjustment was prevented through the indoctrination of officers and trainees in the general principles of personal adjustment.
Some officers, of course, were so set in their ideas that they never would admit to the effectiveness of the Consultation Services. Other training center commanders highly praised the work of these services. Maj. Gen. Ralph M. Pennell,16 Commanding General, Field Artillery Training Center, Fort Sill, Okla., expressed his opinions as follows:
It would be very presumptious for me to tell you Training Center Commanders how to organize or operate the Consultation Branch of your S-1 Section or the duties you assign to the neuropsychiatrist in that section. Particularly is this true since my organization is based largely on what I learned from observing the operations of these sections in other training centers which I visited. I shall confine myself to covering in a few words some of the good work accomplished by an exceptionally well qualified psychiatric officer.
First, he is never referred to by his formal designation. Doubtless, many men do not even know that he is a medical officer. He assumes the role of advisor and helper towards both the patients who may come under his observation and the battery commanders whose problem children they are. He has been able to train the classification personnel who interview incoming trainees so that they are able to spot men who may possibly have personal problems needing the attention of the battery commander and the psychiatric officer; that is, he discovers those who may give trouble before trouble arises. Battery commanders are given their names in confidence so they may be carefully observed from the beginning. A check-up over a period of months shows that probably 95% of those who are later before the psychiatric officer were spotted at this first interview by the classification section.
Second, he has gained the complete confidence of the battery and battalion commanders and they seek his advice and help in handling difficult cases. He has also interested the first sergeants who are usually good judges of men. Incidentally, he learns what noncommissioned officers do not know how to handle men and they are weeded out if proper instruction cannot change them. By comparisons between bat
teries of the number of men who have been cured of their fancied ills, he has secured a competitive spirit between the battery commanders. In other words, he has built up in these battery commanders a very strong interest in salvaging misfit personnel and building up in them a healthy spirit and frame of mind so that, instead of being sorry for themselves and wishing they were out of the Army, they complete their training with a new pride and self-confidence and with a desire to get out and take their part in winning the war.
Third, he works very closely with the summary court officer and the judge advocate to determine the most appropriate action to be taken in cases where offenses have been committed. I also use him to advise me as to the appropriateness of sentences adjudged by the courts. This may take the form of a conference between the JA [judge advocate], psychiatric officer, and myself.
In short, this psychiatric officer has a healthy view toward his duties. He has established very friendly relations with all battery commanders. They believe in and trust his decisions and work together to solve the personal adjustment problems which arise. He has done this with a minimum of overhead or red tape.
During the first 48 hours of the training cycle, all new trainees were routinely interviewed by specially trained enlisted men. Men who had experience, aptitude, or genuine interest were selected for special assignments or attendance at the various post schools. The interviewers also noted new trainees who verbally or otherwise presented obvious psychiatric deficiencies. Enuretics, the very effeminate, those with significant psychosomatic complaints, and occasionally recent patients from mental hospitals were discovered early. The most severe were referred to the Consultation Service immediately (tables 18 and 19). Others were brought to the attention of the company commander and reported with their presenting problems to the center psychiatrist. Attempts were made to adjust these trainees to their new environment without psychiatric examination. Specific advice on how this might be accomplished was given to the cadre by
1Average percent of mean trainee strength seen each month.
5Basis on which rate was calculated is not known.
the Consultation Service Staff. It was generally preferred to have new trainees examined psychiatrically, if necessary, after they were given 3 or 4 weeks of camp experience. Trainees who were thus able to adjust, in spite of their initial problems, developed more confidence in themselves and became hardier soldiers. By the same token, premature examination and disposition would have tended to undermine the confidence of the line officers in the psychiatrists. An indication of the caseload handled by the consultation services and of the dispositions that were made is given in tables 20 and 21, respectively.
It is difficult to portray the vital activity-the comedy and the pathos-of the Consultation Services. Into them were funneled the misfits out of the host of bewildered civilians who were being transformed, in a few short months, into soldiers-a metamorphosis as miraculous as that of the caterpillar into a butterfly. There was a lad who was sent to the Consultation Services because of weeping. He was worried about his wife's having to carry their baby up and down the steps, which might affect her heart condition. His fear of getting bad news was so intense that he had not dared to send her his address. His civilian occupation had been painting flagpoles on New York office buildings and skyscrapers.
Then, there was the preacher of a small sect, not recognized as conscientious objectors, who was forced into the service and who, after a short time, decided to end it all. After wandering off into a swamp on the edge of his Georgia camp, he began cutting his wrists with a razor
1Includes enlisted men transferred to First Separate Training Battalion.
blade. Mosquitoes swarmed on him with such ferocity that he could not "take it" and ran out on the highway where he was rescued.
"Separation neuroses."-Pathological homesickness, aptly named "the separation neurosis" in the Army, was one of the striking clinical syndromes that developed in the new trainee. Essentially a reactive depression, it was generally associated with marked anxiety. It occurred mainly in the overdependent group and seemed especially prevalent in youths of Italian parentage. In the latter, an abnormally close attachment to the mother existed, despite the commonly large size of Italian families. Late weaning, a characteristic of this racial group, has been suggested as a possible contributing factor. Substitute dependence upon the wife was a presenting etiological factor in some cases of "separation neurosis." Most of the "separation neuroses" improved with the passage of time and under rather simple treatment techniques. Many soldiers reversed the problem and projected their own abnormal dependence upon the family, contending that the family could not get along without them. Red Cross field reports aided in having these patients realistically face the situation and accept their separation. There were, however, those whose ego structure was so weak that they could not adjust, and discharge in such cases was the most economical solution (fig. 41).
Enuresis.-Enuresis was a far more frequent problem than had been anticipated. Most cases were associated with mental deficiency or infantile and neurotic personality structures. There were a few cases in which it appeared as an isolated phenomenon in apparently stable individuals, for
any other defects that may have existed were not uncovered. This latter group, except for their specific deficiency, could have made capable soldiers. Thus, there was considerable inconsistency in the policy of discharging the enuretic. Extraclinical factors, such as manpower needs, the attitude of immediate superiors, and the attitude of command, all contributed to this inconsistency. Then, there were no sure techniques for curing enuresis, although many devices were tried. Waking the soldier at specified intervals, isolating from the rest of the barracks, deconditioning through shock of an electric current produced by the completion of an electric circuit by the urine, and elevating the foot of the bed and tying a towel knotted on the back or taping a 2-inch adhesive tape spool or small sack of sharp stones in the same area were all tried. A few malingerers feigned enuresis, but these were readily detected by the cadre through frequent and regular bed checks.
Homosexuality.-Homosexuality, although not very frequent, was always a difficult problem in the training centers. There was that pathetic group of homosexuals who had denied their abnormality to induction examiners and who had blindly hoped to adjust by living a robust life among thousands of normal military men. They frequently appeared voluntarily at the Consultation Service, desperately appealing for help. Others with strong latent tendencies developed psychosomatic disorders and acute anxiety states that also came to the attention of the Consultation Service. The handling of homosexual cases was often dictated by local command, and this also varied considerably. So the Consultation Service psychiatrist was again faced with a difficult and perplexing problem. As a rule, he was left with the ultimate function of interviewing the patient and seeing that justice was tempered with a mercy that was born of understanding.
Psychoneuroses.-The "psychoneurotics" made up, by far the greatest number of patients referred to the consultation services, with the anxiety states and the conversion hysterias predominating. The anxiety of the trainee was generally projected specifically toward some phase of the training, particularly the firing of the rifle, the battle course, and the conditioning marches. Patient reassurance from the training cadre, giving the individual insight into the nature and cause of his anxiety, pointing out that the specific focal point was merely a symbol of his attitude toward army duty as a whole, and adjusting him generally to army service, usually bore results. Many trainees expressed fear that they would never be able to kill another human being. In many instances, this was basically the fear that they themselves would be killed.
Distribution by diagnoses.-The percentage distribution of diagnoses in an Army Service Forces consultation service is shown in the following tabulation:
LOCATION AND PSYCHIATRIC STAFF
Replacement training center psychiatrists (with rank then held) and the station to which they were assigned are shown in the tabulation which follows. It should be noted that, because of transfer and reassignment, several of the psychiatrists are listed for more than one consultation service.
Camp Abbot, Oreg.:
Maj. Arnold Eisendorfer
Aberdeen Proving Ground, Md.:
Lt. Col. R. Robert Cohen
Lt. Col. Donald B. Peterson
Maj. Bernard A. Cruvant
Maj. William H. Kiser, Jr.
Maj. Harry E. August
Camp Blanding, Fla.:
Maj. Harry E. August
Capt. Morris J. Tissenbaum
Maj. Frank R. Barta
Fort Bragg, N.C.:
Maj. Alfred L. Abrams
Lt. Clarence P. Somsel
Camp Callan, Calif.:
Maj. Julius Schreiber
Camp Claiborne, La.:
Capt. Oscar M. Plotkin
Maj. Charles N. Sarlin
Lt. Daniel Silverman
Capt. George W. W. Little
Maj. James Houloose
Maj. Samuel H. Kraines
Maj. Joseph L. Knapp
Maj. Vincent L. Frankfurth
Camp Crowder, Mo.:
Maj. Nathaniel J. Berkwitz
Maj. Clarence J. Kurth
Capt. Edgar M. Braun
Maj. Paul T. Hartman
Maj. Albert Preston, Jr.
Capt. Elvin V. Semrad
Capt. Rutherford B. Stevens, Jr.
Lt. Lewis L. Robbins
Camp Ellis, Ill.:
Lt. Maurice R. Friend
Fort Eustis, Va.:
Maj. Manfred S. Guttmacher
Maj. Oscar B. Markey
Capt. Kurt R. Eissler
Camp Gordon, Ga.:
Maj. James B. Craig
Capt. Isadore H. Cohen
Camp Gordon, Johnston, Fla.:
Lt. Col. Soll Goodman
Maj. Bernard A. Cruvant
Maj. Harry L. Freedman
Capt. Benjamin Berger
Capt. Sidney J. Tillim
Maj. John J. Francis
Capt. Oscar M. Plotkin
Capt. Stanley L. Olinick
Indiantown Gap, Military Reservation, Pa.:
Lt. William H. Anderson, Jr.
Capt. Samuel J. Sperling
Camp Kohler, Calif.:
Capt. Joseph C. Solomon
Fort Knox, Ky.:
Maj. Matthew Molitch
Lt. Clarence P. Somsel
Camp Lee, Va.:
Maj. Fred F. Senerchia, Jr.
Lt. Col. Samuel A. Sandler
Lt. Col. Soll Goodman
Camp Livingston, La.:
Maj. Frederic W. Brewer
Fort McClellan, Ala.:
Capt. Benjamin Berger
Camp McQuaide, Calif.:
Maj. Kenneth G. Rew
Mississippi Ordnance Plant, Flora, Miss.:
Lt. Clarence P. Somsel
Fort Monmouth, N.J.:
Maj. Harry L. Freedman
North Camp Hood, Tex.:
Maj. Samuel H. Kraines
Fort Oglethorpe, Ga.:
Capt. Harold J. Binder
Camp Plauche, La.:
Maj. Harry L. Freedman
Camp Polk, La.:
Lt. Robert R. Shopback
Fort Riley, Kans.:
Maj. Juul C. Nielsen
Camp Roberts, Calif.:
Maj. James Houloose
Maj. Harry N. Roback
Camp Joseph T. Robinson, Ark.:
Maj. Oscar B. Markey
Capt. Dominick F. Chirico
Maj. James Houloose
Camp Sibert, Ala.:
Lt. Col. Soll Goodman
Fort Sill, Okla.:
Maj. Jesse O. Arnold
Camp Stewart, Ga.:
Maj. Manfred S. Guttmacher
Camp Wallace, Tex.:
Maj. Donald F. Moore
Fort Warren, Wyo.:
Capt. Paul M. Schneider
Capt. Rutherford B. Stevens, Jr.
Maj. Nathaniel J. Berkwitz
Capt. Stanley L. Olinick
Camp Wheeler, Ga.:
Maj. Elvin V. Semrad
Maj. George S. Goldman
Camp Wolters, Tex.:
Maj. Robert C. Hunt
Fort Leonard Wood, Mo.:
Maj. Eugene Davidoff
Capt. Norman Reider
Those who have had the opportunity of observing the Consultation Services in action throughout the Army are convinced that they should become an integral part of every Army Training Center in the future.17 They are unique units, created, tried, and proved by World War II.
There was a time when war was a simple business, requiring little training and almost no specialization. But that time is long past. It was assuredly not true of World War II, and it will be even less so of the scientific warfare of the future. Armies are no longer made up of masses of men but of individuals welded together into special functioning units. The individualized approach to the soldier's adjustment has come to stay. For the present, and at least for some time in the future, a well-integrated
organization composed of psychologists, social workers, and specially trained medical officers will be essential to the full efficiency of the Army.
Despite the amount of work thrust upon the training center psychiatrists, many considered it important to write articles presenting their procedures and results. Some of these articles were presented, during the war, at special meetings; some were published during the active fighting; and others, for security reasons, were not published until hostilities had ceased and security restrictions had been removed. All in all, the consultation service clinics compared favorably with the country's best civilian mental hygiene clinics.