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Chapter VI

Contents

CHAPTER VI

Preventive Psychiatry During World War II

Marvin E. Perkins, M. D.*

At the outset of World War II the psychiatrists in the United States Army had no organized program of preventive psychiatry or mental hygiene. In fact, the years preceding the war have been characterized as being ones in which psychiatry was practiced primarily for purposes of diagnosis and disposition; furthermore, it was not until after the entry of the United States into hostilities that a separate branch for neuropsychiatry was established in the Surgeon General's Office in February 1942.  It was not until another year had passed that an officer was assigned to the Neuropsychiatry Division of the Office of The Surgeon General for the purpose of developing a program of preventive psychiatry.2

The condition of military psychiatry with respect to its preventive orientation was hardly less developed than that of the general practice of psychiatry in civilian medicine. For although such eminent psychiatrists as Adolph Meyer, William Alanson White, C. Macfie Campbell, Thomas W. Salmon, and Elmer E. Southard had emphasized the potential value of the wider application of psychiatry, preventive psychiatry as such could not be regarded as a clearly delineated discipline. Some psychiatrists were active in the mental hygiene movement, identified with the National Committee for Mental Hygiene, but the greater number were not associated with this type of psychiatric endeavor.

EARLY DEVELOPMENT OF MENTAL HYGIENE

Before attempting to trace the development in the Army during the war years of mental hygiene, or preventive psychiatry, as it was later designated by some, it is necessary to review briefly some earlier applications of the term "mental hygiene." Both terms were expressions which for most practicing psychiatrists had indistinct meanings; at least, it may be said that they were subject to variable interpretation.

Deutsch3 has traced the variation in meaning of mental hygiene, since its introduction in this country in 1843 by William Sweetser. The original usage

*Chief, Psychiatric Services Division, Department of Public Health, Government of the District of Columbia. Formerly Major, MC, AUS.
1Caldwell, J. M.: Organization and administration of neuropsychiatry in the Office of The Surgeon General, 1942-1947. Mil. Surgeon 107: 19-25 Jul 1950.
2Menninger, William C.: Psychiatry in a Troubled World. New York, Macmillan, 1948, pp. 327-337.
3Deutsch A.: The history of mental hygiene. In Bunker, H. A.: One Hundred Years of American Psychiatry. New York, Columbia University Press, 1944, pp. 325-365.


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was intended to convey an approach to illness somewhat analogous to the current concept of psychosomatic medicine or comprehensive medicine. George Cook in 1859 used the term to embody the problems attendant on the promotion of mental health and the prevention of mental disease. Cook emphasized the importance of observations that the inception of mental disease was in childhood. He also singled out the family unit as the proper focus for mental hygiene measures. During the Civil War, Isaac Ray issued a book in which he defined mental hygiene as "the art of preserving the health of the mind." Ray's presentation was one which attempted to give the individual a kind of prophylactic guidance. In 1876 the concept was expanded by John P. Gray to include not merely the individual application, but also the community aspects of mental hygiene, relating it to sociologic and social science studies. Thus, before the outbreak of the Civil War, the term "mental hygiene" had been used for two quite different purposes:  (1) To define an approach toward the understanding of the etiology of an individual's illness in terms of the whole person (Sweetser), and  (2) to indicate the practice of instituting measures in the family setting before illness affected an individual of that unit (Cook). These contributions had been made by institutional psychiatrists. Interest in mental hygiene continued to be manifest so that by 1880 two other usages had been introduced:  (3) A formula for individual living (Ray), and  (4) an approach to prevention of mental disease by the study of social problems and action taken at community level (Gray).

These four concepts, different in focus and emphasis, may perhaps be considered as phases in the natural evolution of the mental hygiene movement. The first requirement is an awareness by the physician that the patient's symptoms present something which has meaning in terms of the whole person; second, that current unhealthy symptomatic reactions follow a pattern which has had origin in the setting of early family experience; third, that such reactions may be adjusted for the better or avoided by providing individual guidance; and, finally, that such personal problems have implications which extend beyond the individual patient, affecting the social group of which he is a part and also affected by measures taken through the group.

The first step is the inquiring receptive attitude of the physician; the second, a conclusion regarding etiology based upon observation; the third, an effort at application of new-found knowledge in individual treatment based on etiology; and, finally, a recognition of the social factors and need for group preventive measures. These steps are analogous to the traditional pattern of the development of epidemiology.4

Up to 1880 there was no organized effort among psychiatrists for a program of mental hygiene and no organized body of thought which could be called

4Gordon, J. E.: Evolution of an epidemiology of health.  In The Epidemiology of Health. New York, Health Education Council, 1953, pp. 24-73.


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preventive psychiatry. However, the increasingly comprehensive concept had made mental hygiene a subject of common interest among psychiatrists and social workers. The first mental hygiene organization in this country was a joint professional undertaking of psychiatrists, neurologists, and social workers, called the National Association for the Protection of the Insane and the Prevention of Insanity, which was established on 1 July 1880. The main effort of the organization was not the prevention of mental disease but, rather, the institution of reform measures of a humanitarian nature. The organization did not crystallize a "mental hygiene" or "preventive psychiatry" and, after a short controversial existence, disappeared sometime after 1886. Twenty-three years later, the National Committee for Mental Hygiene was organized, the result of Clifford Beers' experiences as a patient in a mental hospital, his account of those experiences, and his recommendations for an organized effort to improve the lot of the mental patient. The efforts of this organization were of importance to various spheres of activity including the establishment of community child guidance clinics, in some ways a prototype for the military mental hygiene clinic.5

MILITARY PSYCHIATRY AND MENTAL HYGIENE  BEFORE WORLD WAR II

The Civil War was a time of great ferment for the Army Medical Department. Many reforms were needed to meet the immediate problems of attending to the sick and wounded, and the term of office of William A. Hammond as Surgeon General was marked by vigorous action in instituting many of the necessary reforms. The important specialty of neurology had its beginning in the United States during the war as a result of the combined efforts of Hammond and S. Weir Mitchell. The former authorized the establishment of the Turner's Lane Hospital in Philadelphia for the study of nervous disorders and injuries and the latter was assigned for that purpose. The classical monograph by Mitchell, Morehouse, and Keen is an account of the neurologic studies made at Turner's Lane Hospital. These studies embodied careful clinical observations of the injured nervous system and, important as they proved to be in the fields of neurology and psychiatry, they were not concerned with either of the concepts of mental hygiene which had been defined before that time.

Early in World War I, Thomas W. Salmon, under auspices of the Rockefeller Foundation, studied the experience of the British in the management

5Deutsch, Albert: The Mentally Ill in America. Garden City, N. Y., Doubleday, Doran, and Company, 1937, p. 325.
6Mitchell, S. W.; Morehouse, C. R., and Keen, W. S., Jr.: Gunshot Wounds and Other Injuries of the Nerves. Philadelphia, Lippincott, 1864.


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of psychiatric problems and submitted a report which contains the following comment:7

Although it might be considered more appropriately under the heading of prevention than under that of treatment, the most important recommendation to be made is that of rigidly excluding insane, feebleminded, psychopathic, and neuropathic individuals from the forces which are to be sent to France and exposed to the terrific stress of modern war. . . . If the period of training at the concentration camps is used for observation and examination it is within our power to reduce very materially the difficult problem of Caring for mental and nervous cases in France, increase the military efficiency of the expeditionary forces, and save the country millions of dollars in pensions.

This recommendation, a relatively minor dictum in an important, thorough, and competent report, may well have been the basis for the practice of diagnosis and disposition referred to as in effect during the interim between the two World Wars. It may also have served as the basis for the optimistic opinion prevailing at the outbreak of World War II that effective prevention of psychiatric disorders would be accomplished by competent psychiatric screening. Lt. Col. Manfred S. Guttmacher, MC, who was assigned to the Neuropsychiatry Consultants Division during the latter part of World War II, for the purpose of providing professional supervision for the mental hygiene consultation services, made the following observation regarding preventive psychiatry during the First World War as it was reported in the official history:8

Chapter IV of the volume on the history of neuropsychiatry during World War I states that the cantonment neuropsychiatrist became the "guardian of the mental health" of his military organization. When one reads the entire chapter, it is apparent that this was in nearly every instance an ideal rather than a reality, since there was no formal organization of psychiatric facilities that brought psychiatrists into really close contact with enlisted or with officer personnel in the training camps. It is, however, clear that by the end of the First World War, it was realized that the training camps were fruitful fields for the early treatment of maladjusted trainees and that many of them could be prevented from becoming ineffectuals. But, prevention of psychiatric disorders by effective general indoctrination of the officers and the trainees was not conceived.

Psychiatry, in the interim between the two World Wars, suffered from several conditions. It lacked public acceptance and understanding to a large degree. As a specialty, it tended to be isolated from the general practice of medicine and, as specialists, psychiatrists had relatively little professional stature among other members of the medical profession. It was primarily interested in, if not preoccupied by, the problems of treatment. Little substantial knowledge had been accumulated by psychiatrists on problems related

7Salmon, T. W.: The care and treatment of mental diseases and war neurosis (shell shock) in the British Army. In Medical Department of the United States Army in the World War. Washington, Government Printing Office, 1929, vol. X, pp. 497-523.
8Guttmacher, M. S.: Army consultation services (mental hygiene clinics). Am.  J. Psychiat.  102: 735-748, May 1946.


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to selection of men, occupational classification and placement, or the prevention of psychiatric disability. In such circumstances and without an adequately organized body of information, it is not surprising that there were no well-formulated plans for the application of psychiatry to the practical problems encountered in the military service. As a further handicap, many psychiatrists were either not accustomed to collaborative effort with clinical psychologists and psychiatric social workers or were actually unaware of the potential value of mutual participation.

To recount the development of preventive psychiatry during World War II is to trace the changes in responsibility and utilization of three professionally allied disciplines: psychiatry, clinical psychology, and psychiatric social work. Psychiatrists, at the inception of the war, were predominantly engaged in diagnosis and disposition in hospitals and induction stations; psychologists were utilized in personnel work as officers of The Adjutant General's Department, but were not used in clinical activity;10   psychiatric social workers had no commissioned or enlisted status at all in their professional capacity.11  Each of these professions came to be employed in significantly new roles for the military service during the course of the war. The remarkable transition in the military roles of the psychiatrist, clinical psychologist, and psychiatric social worker took place largely in the training centers. It was in the training centers that the members of these professions became integrated into the effective military psychiatric team. The organized unit which resulted in this setting came to be known as the mental hygiene consultation service; and here the practice of psychiatry in this setting came to be considered as preventive psychiatry. For purposes of following the development of preventive psychiatry in World War II, this account will deal almost exclusively with development in the training center setting.

DEVELOPMENTAL PHASES IN REPLACEMENT TRAINING CENTERS

It may facilitate a review of the development of preventive psychiatry in the training centers to divide the period into four transitional phases. Because the growth of the different mental hygiene consultation services showed definite variations, there was no completely consistent developmental pattern in the field, although there were certainly similar problems to be dealt with in each replacement training center. The course of development of the individual unit seemed to be most dependent upon the psychiatrist's previous experience,

9Menninger, W. C.: The role of psychiatry in the world today. Am.  J. Psychiat. 104: 155-163, Sep 1947.
10Zehrer, F. A.: The clinical psychologist in the United States Army, 1953.  HD: 730 Neuropsychiatry.
11O'Keefe, D. E.: History of psychiatric social work in World War II.  HD: 314.7-2.


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his comprehension of the problems to be met, his preference in formulating a plan commensurate with his own abilities, his capacity to interpret these matters to command, and his ability to enlist the support of command in translating the whole into effective action. Because of the importance of the individual in establishing a mental hygiene consultation service, the developmental pattern at a given post was likely to be distinctly different from that of another only a short distance away. One consequence of such variation was that in practice some part of the field was consistently ahead of official directives concerning nearly everything which finally became established as approved policy. When official policy was published, that part of the field which had lagged behind the others in development tended to be brought up to the standards of the more advanced practices as approved. For these reasons the phases which will be described are arbitrarily fixed to reflect the principal emphasis of the time as contained in official directives.

Classification Phase

The initial phase may be called the "Classification Phase" in which the primary interest was in getting the right man promptly into training for the right job with the least waste of time and money. This phase began during the mobilization period, before our entry into active hostilities, and was carried on for the most part by psychologists and classification specialists.

One of the early steps in the development of consultation services for replacement training centers was initiated on 13 December 1940 when The Adjutant General sent a letter to the chiefs of arms and services proposing that the Adjutant General's Office undertake the following:12

1. Attempt to locate Reserve officers qualified in the testing field to permit assignment of one such officer to each replacement center after attendance at the replacement center school.

2. Request an increase in commissioned officer quotas for each center, stating that G-1 and G-3, informally, had indicated a favorable disposition toward an increase in authorized strength for this purpose.

The letter pointed out that selectees who reported to replacement centers from reception centers would have received an initial classification, including General Classification Test lA. However, it was anticipated that considerable reclassification would be needed during the period at the replacement center and it was considered that the services of psychologists who could administer and evaluate various aptitude tests would be useful in selecting students to attend various courses. The letter cited the earlier favorable experience of the Air Corps in selecting students for the technical school at Chanute Field,

12Ltr, TAG to Chiefs of Infantry, Cavalry, Field Artillery, Engineers, Signal Corps, Ordnance, Chemical Warfare Service, Coast Artillery, QMG, SG, CG Armored Force, 13 Dec 40, sub: Additional commissioned personnel for replacement centers. AG: 210.31 ORC.


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Illinois. Recommendations were requested as to whether the services of these specialists were desirable at the various replacement centers. With but one exception, all responded favorably to the proposal.13

A radiogram was sent to the commanding generals of the nine corps areas requesting that they report names of available Reserve officers qualified as practical psychologists or classification experts. These men were to attend a 30-day course of instruction and then be assigned to replacement centers.14  As a result of this wire, 18 officers were reported to The Adjutant General as potentially useful in the contemplated assignments, including 5 captains, 11 first lieutenants, and 2 second lieutenants.15

During the same week, a memorandum mentioned that consideration was being given to the assignment of a second lieutenant Reserve officer to one of the Infantry replacement centers.16  This Reserve officer, a Regular Army master sergeant, was one of several considered for assignment to the Infantry replacement centers, the majority of whom were warrant officers and sergeants of the first three grades with considerable experience in administration. The plan at that time was to assign 8 such officers to the Infantry replacement centers as had been requested.

Thus, in December 1940, at least 20 Reserve officers were being considered for assignments. This marks the first step in the direction of establishing an agency at replacement training centers to assist responsible commanders in the effective utilization of manpower. The development of the mental hygiene consultation services in part came from this early movement. Of these officers, 7 held Reserve commissions in the Infantry, 5 in the Medical Corps, 3 in the Field Artillery, and 1 each in the Judge Advocate General Department, Advocate General's Department, and the Quartermaster, Cavalry, and Sanitary Corps.

The Adjutant General conducted the 30-day course of intensive instruction starting in January 1941. It covered the procedures of personnel administration with particular reference to replacement centers. After attendance at the school17 these officers, who included practical psychologists, classification experts, and other administrative officers, went on to their variously assigned posts where some were assigned as classification officers.

13Ltr, Chief of Cavalry to TAG, 17 Dec 40, recommended that the assignment of such personnel be not considered for the Cavalry Replacement Center because ". . . it would appear that the services of a practical psychologist would be confined to assisting in the selection of individuals intended for horse elements and those intended for motor elements, which can be accomplished satisfactorily from individual classification cards." AG: 210.31 ORC.
14Radio, TAG to CG each CA, 13 Dec 40. AG: 210.31 ORC.
15This does not include Second and Fourth Corps Areas whose responses were not on file with the others.
16Memo, TAG to Chief of Infantry, 17 Dec 40. AG: 210.31 ORC.
17The training of commissioned classification officers preceded the formal organization of The Adjutant General's School which was accomplished on 13 June 41.  Hist Div WDSS.


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The Engineer Replacement Training Center at Fort Leonard Wood, Missouri, received one of this first group of officers assigned to replacement training centers for the purpose of supplying expert guidance in the fields of classification and personnel counseling. This officer (1st Lt., AGD, later Maj., MAC, Francis P. Wickersham) was assigned first as a classification officer, but on 3 December 1941 he was relieved of this duty and designated as psychologist to the Engineer Replacement Training Center. Thus was established the Office of the Personnel Consultant, as a branch of the Personnel Division. This officer was charged with the tasks of-

1.  Selecting men for special training.
2.  Maintaining a check upon individual progress while in special training.
3.  Advising as to the suitability for transfer of each man to the regular training company.
4.  Recommending separations from the service under Army Regulations (AR) 615-360, section VIII.

The last function was an important one, initially, for it was the personnel consultant upon whom the major responsibility rested for such recommendations. He soon sought the assistance and advice of psychiatrists in formulating such recommendations for discharge. Inasmuch as a psychiatrist was not immediately available for assignment to the Engineer Replacement Training Center, arrangements were made for consultations to be accomplished by the staff at the hospital.18   The wisdom of mutual effort in this area of activity was later to become generally recognized by making psychiatrists available for assignment to headquarters of each replacement training center. The basic directives during this period were concerned with establishing the necessary military occupational specialties19 and outlining the functions required to accomplish the mission of proper classification and assignment. Although the planning for this type of activity preceded our entry into hostilities, the comprehensive regulation was not published until May 1942.20

Classification was considered to be a means which would facilitate the placement of individuals in assignments which would be of most value to the military service. This would expedite unit training by proper utilization of various abilities and skills of the individuals. The anticipated objective was to be a substantial contribution to the production of an efficient combat or technical team in the shortest possible time.

The primary objective in replacement training centers as explained in AR 615-28 was to assign each man properly to the type of training which he could best absorb. This was to be accomplished in the classification section by

18Davidoff, E.: A summary of the history and the program of the personnel consultation service at Fort Leonard Wood ASFTC.  HD: 730 Neuropsychiatry.
19(1) WD Cir 12, 18 Jan 41.  (2) WD Cir 269, 26 Dec 41.
20AR 615-28, 28 May 42.


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personnel, officer and enlisted, who had either psychological or personnel training, or both.

The testing program designed to furnish an estimate of a man's ability, included the Army General Classification Test, the nonlanguage test 2 abc, trade tests, aptitude tests, and individual tests. The latter were to be given as required to the men who were unable to adjust to the Army without assistance because of a low mental ability. It was pointed out that such individuals may have been adjusted to a stereotyped mode of civilian living, but upon entry into Army life they experienced difficulties because of the sudden change. The individual testing of these men was to be accomplished only by a personnel consultant, because the result of such testing would be a factor in determining whether the man would be considered suitable for military service after training in the special training unit, or whether discharge from the service should be effected without benefit of such training efforts.

The function of the special training unit was to instruct enlisted men who were not immediately suited to assimilate regular basic training.  Individuals who were found in the course of regular training to require special assistance were assigned to the unit. This group included the illiterates, non-English-speaking enlisted men, and slow learners. Two other groups could be assigned also-the emotionally unstable and those physically unable to carry out assigned duties.

It was pointed out in the regulation that personnel in this unit would have to be carefully selected for interest in the type of work of the unit and interest in the individuals who required such training. The only mention of the use of psychiatrists was in connection with their possible utilization in the special training units: "A personnel consultant will be assigned to each special training unit and use will be made of psychiatrists or neuropsychiatrists who may be assigned to the replacement training center."

At Fort Monmouth, New Jersey, 1st Lt. (later Maj.) Harry L. Freedman, MC, was assigned to duty as assistant to the Personnel Officer, Headquarters, Eastern Signal Corps Replacement Training Center, on 23 December 1941. A short time later he was assigned to a position of direct responsibility to the commanding general (20 January 1942). From this staff relationship, a service was developed which was intended to be functionally distinct from the usual services supplied within the hospital or as an outpatient clinic of the hospital. Lieutenant Freedman stated it as follows:21  "Out of this relationship an organization and structure was conceived with functions which could be utilized as services to all sections of the Command. It was, therefore, possible to develop a new resource to the Command, in a staff section to be known as the Mental Hygiene Unit."

21Freedman, H. L., and Rockmore, M. J.: Developmental history of the mental hygiene unit in the Army, 1946. HD: 730 Neuropsychiatry.


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Using the staffing pattern of the community psychiatric clinic as a guide, Lieutenant Freedman first obtained the assignment to his staff of an enlisted man who was a professionally qualified psychiatric social worker already on duty with the classification section. This was probably the first time that a social worker was assigned to perform primary duties of this profession in the Army. The unit was officially established at Fort Monmouth on 24 February 1942. It was called "The Classification Clinic" which clearly reflects the main emphasis of the period. The professional triad was completed 15 March 1942 when a qualified clinical psychologist, an enlisted man, was assigned to the staff.22

Concurrently, other psychiatrists in replacement training centers had been moving independently toward establishment of a psychiatric unit in response to local requirements and with the tacit approval of the Neuropsychiatry Branch of the Office of The Surgeon General.

At the Engineer Replacement Training Center, Fort Belvoir, Virginia, an outpatient clinic had been established by Capt. (later Lt. Col.) Bernard Cruvant, MC, in May 1941 to meet the local needs for psychiatric services which could not be properly satisfied by hospitalization.23  A referral procedure was mimeographed and distributed with a resultant increase in the number of psychiatric consultations. Liaison with the basic training supervisor was established in June 1941 and mutual effort was exerted toward solution of a problem having to do with the training program. As a result of this, a reclassification questionnaire was formulated to assist in the function of the reclassification board, of which the psychiatrist was a member. The further development of staff responsibilities and function in the training program was hampered by the psychiatrist's assignment to the station hospital which required more and more of his time. The result was that the main function of the psychiatrist was as a consultant in the outpatient clinic of the station hospital. The facility established at Fort Belvoir was the first in the Army to be called a "Consultation Service."24

At the Antiaircraft Replacement Training Center, Camp Callan, California, Capt. (later Lt. Col.) Julius Schreiber, MC, inaugurated a program in June 1942 which at first had its primary mission as an outpatient clinic to keep down the number of psychiatric admissions to the hospital.25  A realization that more needed to be done led Captain Schreiber to work out a program which

22See footnote 21, p. 179.
23Cruvant, B. A.: Symposium on psychiatry in the Armed Forces; replacement training center consultation service. Am. J. Psychiat. 100: 41-46, Jul 1943.
24See footnote 8, p. 174.
25(1) Stilwell, L. E., and Schreiber, J.: Neuropsychiatric program for a replacement training center. War Med. 3: 20-29, Jan 1943.  (2) Schreiber, J.: Psychological training and orientation of soldiers. Ment. Hyg. 28: 537-554, Oct 1944.


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was meant to inform the soldier on the issues at stake and thereby contribute to his motivation and morale.26

At the Ordnance Replacement Training Center, Aberdeen Proving Ground, Maryland, another station hospital physician had concluded that steps needed to be taken to assist in the adjustment period of the new soldier. A program of mental conditioning by means of lectures was recommended on 15 August 1942 by Maj. (later Lt. Col.) R. Robert Cohen, MC. He conducted lectures to trainees on personal adjustment and emphasized the importance of an informed group of key personnel in the mental hygiene of trainees.27

Meanwhile, other significant developments for military psychiatry were taking place. In the Office of The Surgeon General, establishment of the Neuropsychiatry Branch had been accomplished in February 1942 as a subdivision of the Medical Practice Division. Lt. Col. (later Col.) Patrick S. Madigan, MC, was the first chief of the branch.28

At a Selective Service seminar for psychiatrists of the Medical Advisory Board and the Army Induction Board on 5 April 1941, Lt. Col. Madigan had emphasized the importance of screening:29

In preparing for an adequate defense of our country in the present emergency, it is extremely important that we exercise meticulous care and precaution in selecting only those individuals whose mental, intellectual, and personality suitability can reasonably be expected to adequately adjust to the requirements of military life, not only for one year's training, but for the following ten years as a reservist. Soldiering must be considered as a possible vocation that is inherently and of necessity constricted in its requirements and standards. Those who do not fit into this general pattern because of personality traits or other indications of unsuitability may be quite adaptable to other pursuits in a civilian status in our general plan of a total defense of our country. There should, therefore, be no criticism of those who fail to meet the standards which experience has shown to be the best possible for an effective Army.

He had concluded with the following admonition:

The most important function of psychiatrists to the Advisory Board and induction centers is to keep in mind that the Army is one of the elements of national defense and its present mission is one of preparation for an offensive-defensive type of warfare. It is in no sense a social service or curative agency. It is neither to be considered a haven of rest for the wanderer or shiftless, or a corrective school for the misfits, the ne'er-do-wells, the feeble-minded, or the chronic offender. Furthermore, it is neither a gymnasium for the training and development of the undernourished or underdeveloped;

26Schreiber, J.: Morale aspect of military mental hygiene. Dis. Nerv. System 4: 197-201, Jul 1943.
27(1) Cohen, R. R.: Mental hygiene for the trainee; method for fortifying the Army's manpower. Am. J. Psychiat. 100: 62-71, Jul 1943.  (2) Cohen, R.R. Factors in adjustment to Army life: a plan for preventive psychiatry by mass psychotherapy.  War Med. 5: 83-91, Feb 1944.  (3) Cohen, R. R.: Officers and their relation to a mental-hygiene program for trainees. Ment. Hyg. 28: 368-380, Jul 1944.
28Annual Rpt, Neuropsychiatry Branch SGO, FY 1943. HD.
29Madigan, P. S.: Military psychiatry. Psychiatry 4: 225-229, May 1941.


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nor is it a psychiatric clinic for the proper adjustment to adult emotional development. Therefore, there is no place within the Army for the physical or mental weakling, the potential or prepsychotic, or the behavior problem.  If a person is a behavior problem in the civilian community, he will most certainly become a more intensified problem in the Service.

A year later, Lt. Col. (later Col.) William C. Porter, MC,30 was warning of the "danger that we military psychiatrists may become psychiatrically overzealous and reject men who are capable of performing satisfactory military service and who are legally liable for service in the Army." Colonel Porter was pointing to the consequences of too fine a screening policy. Pointing out the need "to take stock," he posed the problem as follows:

. . . .Should we become more zealous in screening out potential and actual mental risks, or should we recognize that there is a field of usefulness in the Army for some persons who have theoretic disqualifications? Unfortunately, in our discipline we have no formula which may be applied in selection of mental risks. Each psychiatrist applies to his work such training, experience, and aptitudes as he may possess. He may have had no actual military experience and may be only indirectly aware of the psychologic hazards of the service and of the system of handling problem cases in a military organization. Unless he is personally familiar with these factors, he is apt to judge a risk from the standpoint of his experience in nonmilitary hospitals or in private practice.

Colonel Porter formulated the question, which had begun to create doubts among psychiatrists with regard to screening, thus:31

. . . . Whether the neuropsychiatric examiners have rejected too many men who might have become satisfactory soldiers, whether by rejecting all questionable persons more harm has been done them than would have occurred if they had been exposed to military life, whether there is a place in the Army for certain types of mental deviants are cogent questions.

In April 1942 Colonel Porter, Chief of Neuropsychiatry, Walter Reed General Hospital, sent a memorandum to Brig. Gen. C. C. Hillman, Chief of Professional Services, Office of The Surgeon General, outlining a plan for assignment of neuropsychiatrists to replacement training centers.32  This was proposed as being consistent with the opinion of certain psychiatrists that there was a need to provide psychiatric advice away from the hospital setting. The objectives were to be: to assist in the adjustment of the soldier to minor difficulties of maladaptation; to provide assistance to the unit commander by screening out "obvious mental defectives, psychopaths or prepsychotics" who presented administrative, disciplinary, or training problems; and to "sell practical psychiatry to the line." Colonel Porter suggested that men between the ages of 30 and 40 be specially selected for this assignment and be given a 6-week training course in "administrative duties, relationship to the line, military orientation and indoctrination in practical psychiatry."

30Porter, W.  C.: Military psychiatry.  War Med. 2: 543-550, Jul 1942.
31Ibid.
32Memo, Lt Col W.  C. Porter, MC, to Brig Gen C. C. Hillman, 3 Apr 42.  SG: 211 Neuropsychiatry.


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Colonel Madigan was favorably impressed by a report, made during the month of June, of the first 5 months of activities of the classification unit at Fort Monmouth. On 25 July 1942, The Surgeon General recommended that "qualified neuropsychiatrists be assigned to headquarters at each replacement training center."33 The Director of Training, Services of Supply, supported the recommendation.34  Following this, The Surgeon General recommended on 20 August: ". . . if the plan is approved, that the allotment of officers for duty at each replacement training center be increased by one Major, Medical Corps, to allow the assignment of a neuropsychiatrist."35

On 15 September, the Military Personnel Division, Services of Supply, initiated instructions to The Adjutant General through the Assistant Chief of Staff, G-1, to announce allotment of 1 major, Medical Corps, for each replacement training center under the Army Ground Forces.36  An announcement of a similar allotment for each replacement training center under Services of Supply was held in abeyance because of impending transfer of allotments under AR 170-10, 10 August 1942. At the time of the issue of this authorization Col. Roy D. Halloran, MC, had succeeded Colonel Madigan.37

On 30 October 1942, The Adjutant General sent out the following letter as a result of having received requisitions for psychiatrists which had been previously authorized:38

1.  In connection with your recent requisition for a neuropsychiatrist, it is intended that this officer be used to establish a clinic or similar setup for the replacement training center in accordance with the following plan.

a.  The assignment of neuropsychiatrists to replacement training centers is intended to assist those normal individuals who may have correctible maladjustments to Army service and 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.

b.  The general functions of the neuropsychiatrist will be as follows:

(1)  To institute an advisory service, assisted by a qualified psychologist and such other personnel as may be made available, to aid the newly inducted soldier to make a satisfactory adjustment to his military duties.

(2)  To aid, by professional methods, individuals who have been brought to the neuropsychiatrist s 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.

(3)  To study and recommend remedial measures for those individuals who manifest behavior problems.

33Ltr, SG to CG SOS, 25 Jul 42, sub: Assignment of psychiatrists to replacement training centers. SG: 211 Psychiatrists.
34Memo, Brig Gen C. R. Huebner to ACofS for Personnel SOS, 12 Aug 42, sub: Assignment of psychiatrists to replacement training centers. SG: 211 Neuropsychiatry.
35Memo, Lt Col P. A. Paden, MC, to Dir Mil Pers SOS, 20 Aug 42. SG: 211 Neuropsychiatry.
36Memo, Dir Mil Pers SOS to SG, 16 Sep 42, sub: Assignment of psychiatrists to replacement training centers. SG: 211 Neuropsychiatry.
37See footnote 28, p. 181.
38Ltr, TAG to CGs various Replacement Training Centers, 30 Oct 42, sub: Assignment of neuropsychiatrists to replacement training centers. AG: 210.31.


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(4)  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.

(5)  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 service.

(6)  To aid in the morale program of the station by the use of the neuropsychiatrist's specialized training and knowledge.

c.  Individuals will be referred to the neuropsychiatrist through the classification officer by any one of the following:

(1)  Staff sections.
(2)  School directors.
(3)  Chaplains.
(4)  Company, troop, or battery commanders.
(5)  Provost Marshal.

All requests for action of the neuropsychiatrist will contain or be accompanied by a statement of the reasons therefor.

d.  The neuropsychiatrist will recommend disposition of the cases referred to him by any one or a combination of the following methods:

(1)  Reclassification, where considered advisable.

(2)  Special programs, corrective in character, cooperatively developed through conference with school directors, company, troop, or battery commanders, staff sections, and others.

(3)  Psychiatric observation and treatment.

(4)  Recommend admission to hospital with view to discharge on Certificate of Disability for Discharge because of disability (within this category are psychotics, severe psychoneurotics, epileptics).

(5)  Recommend disposition by a board of officers convened under Section VIII, AR 615-360 (within this category are psychopathic individuals, mentally deficient, chronic alcoholics, drug addicts).

e.  Cases scheduled for action by boards of officers will be handled as provided by pertinent regulations.

2.  It has been drawn to the attention of this office that certain replacement training centers already have similar facilities established which are operating satisfactorily. The special importance of this service during this critical training period and, therefore, the necessary careful selection of personnel, cannot be overemphasized. Since there is a shortage of officers with a suitable background for this duty, it is desired that duplication of experienced officers be avoided.

3.  In view of the above, it is requested that The Surgeon General will be informed, as early as is practicable, with the following information:

a.  Whether or not a similar service is now functioning under a neuropsychiatrist at your installation.

b.  The names and qualifications of the neuropsychiatrists.

c.  A recommendation as to the desirability of transferring that officer to fill the vacancy.

This letter may be considered to mark officially the end of the classification phase. From the foregoing account, it is seen that individual psychiatrists had already exceeded the bounds of classification and were performing some of the functions outlined in the above letter. However advanced the application of


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psychiatry was in certain portions of the field, military psychiatry at large was not yet ready to exploit immediately the broad area of responsibility and activity as encompassed in this letter. A part of the difficulty, no doubt, rested with the traditional resistance of the military to innovations; part was lack of understanding by psychiatrists as to how to apply clinical experience in this broad way. Doubtless, also, there was some reluctance on the part of psychiatrists to give up the illusion of screening as the best contribution which psychiatry could offer. For although there was growing concern that psychiatry had failed at induction centers,  it might yet succeed in screening at the next point of contact with the soldier-a better screening process might be accomplished at the replacement training center.

Notwithstanding the doubts of some experienced psychiatrists, the wisdom of careful selective screening grasped the imagination of many and was a significant factor which had led to the assignment of psychiatrists to replacement training centers. In fact, to the new Chief of the Neuropsychiatry Branch, Office of The Surgeon General, Col. Roy D. Halloran, screening appeared to have accomplished almost all that had been expected in October 1942:39

Neuropsychiatric screening has been developed at induction centers to a far wider degree than during the last war, and neuropsychiatric service at this point is considered of paramount importance, however tedious and demanding. In spite of the relatively large and necessarily rapid mobilization, evidence already indicates that a greater percentage of potential neuropsychiatric misfits have been prevented from entering the armed forces than during a comparable period in the last war.

He cited a need for a second echelon of screening to provide for the elimination of those who had been missed at the induction centers:40

It is inevitable that under the most exacting examination possible some will be missed. An attempt must be made to weed these out during the training period. Accordingly, steps have been authorized already to place well qualified neuropsychiatrists on the staff of replacement training centers. The soldier after induction goes to a reception center and spends anywhere from a few hours to a few days becoming oriented, getting his uniform and going through certain forms of introduction, and then proceeds to the replacement training center. Here for the first time the problems incident to the new life in the Army begin to appear. The function of the psychiatrist at the replacement training center will be concerned with adjusting normal individuals and detecting and eliminating the mentally unstable who are or may become a distinct liability to military training, discipline and morale during the early weeks of training.

This was reiterated again approximately 6 months later by Colonel Halloran and Lt. Col. Malcolm J. Farrell, MC, at the 99th Annual Meeting of the American Psychiatric Association in May 1943.41  Maj. (later Lt. Col.) John

39Halloran, R. D.: Presentation of the subject of Symposium II.  In Sladen, Frank J.: Psychiatry and the War. Springfield, Charles C. Thomas, 1943, pp. 421-431.
40Ibid.
41Halloran, R. D., and Farrell, M. J.: The function of neuropsychiatry in the Army. Am. J. Psychiat. 100: 14-20, Jul 1943.


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W. Appel, MC, ascribes the delay in recognizing the extent of the problem as being mainly due to the absence of reliable figures.42

The difficulties in this matter were reported in July 1943:43

Efforts have been made to improve screening at induction and training centers. At the induction centers large numbers of men are processed as rapidly as possible. But the time for examination is too short; psychiatrists lack adequate background information on the men; and psychiatrists are scarce. All these problems have been faced frankly, and appropriate measures instituted. But no test yet devised is so perfect that it can detect all the psychopaths and potential psychoneurotic individuals on brief examination. If a screen were tight enough to eliminate anybody who might possibly develop a nervous breakdown, it would be so tight as to eliminate nearly everybody.

A second screening process is now instituted at the Replacement Training Centers. There, a trained staff of psychiatrists, psychologists, and psychiatric social workers, cooperating with line officers, chaplains and others, further observe the newly inducted soldier.

From the foregoing, it is clear that there was strong impetus for assigning psychiatrists to replacement training centers for what was considered to be a need for more screening of unpromising individuals.

Psychiatric Screening and Consultation Phase

The second phase brought psychiatrists into collaboration with the psychologists and classification specialists. In certain instances competition rather than collaboration resulted. This was undoubtedly because of overlapping areas of responsibilities outlined in The Adjutant General's letter of 30 October 1942 quoted above and AR 615-28. In most cases, this was satisfactorily resolved at the local level without benefit of clarifying directives from the War Department. The following letter illustrates that there were still ambiguities 2˝ years later:44

I am enclosing a copy of our new SOP which came out yesterday as a result of further conference with the C. O. and is the culmination of nine months of interpretation of the function of a Mental Hygiene Division, the administrative keynote of which has been differentiating its function from that of the Classification and Personnel Consultant's subsection of the Personnel Division. In this respect WD Cir 81 helped define both the administrative and functional relationship of this Division to the Command. This SOP now clears up the anomaly of having two Consultation Services existing side by side with overlapping responsibility.

During this period, the function of the psychiatrist was initially to be the prevention of psychiatric casualties by a process of eliminating individuals during training who would not be likely to serve profitably in the military

42Appel, J. W.: Cause and prevention of psychiatric disorders in the U. S. Army in World War II. HD: 314.7-2.
43Annual Rpt, SG, FY 1943. HD.
44Ltr, Maj H. L. Freedman, Mental Hygiene Div ASFTC, Camp Plauche, La., to Maj M. S. Guttmacher, SGO, 18 Apr 45. HD: 730.


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service. This was, in essence, the type of activity that Maj. Thomas W. Salmon, MC, had recommended in his report in 1918.

This phase began during a period when an increasing awareness was developing that two important tools were not accomplishing the hoped for results in meeting the manpower problem. Reaction against the classification and assignment system-"vocationalism"-mounted during 1942 in the Army Ground Forces because under the system a disproportionately large number of men in the lower mental groups were being assigned the combat arms for training.45  This produced many problems in the training situation in which psychiatric knowledge was deemed to be of value and, in some measure, helped to create a receptive attitude in the Army Ground Forces command toward establishment of the position of a staff psychiatrist. At the same time, realization grew that psychiatric screening as it was being performed at the induction stations would not alone accomplish the objective of prevention of psychiatric disorders and that psychiatrists could not be expected to eliminate all potential psychiatric casualties at the induction station. Without any intent to minimize the enormity of the task which was attempted, or reflect discredit upon those who labored conscientiously at it, it must be recorded that psychiatric screening at induction failed as a primary method of preventing the great majority of losses caused by psychiatric disorders. Although induction screening unquestionably served a useful purpose when individuals were eliminated who were mentally defective, overtly psychotic, psychopathic, or severely psychoneurotic, this group comprised only a relatively small proportion of the numbers who came to require psychiatric attention in the military service.46

By the end of the first 2 weeks in November 1942, 13 psychiatrists had been assigned to replacement training centers. In March 1943, there were 16 consultation services in the 33 training centers when Colonel Halloran recommended to Brigadier General Hillman that such units be established in all replacement training centers, including those of the Army Service Forces. By the middle of May 22 replacement training centers had neuropsychiatrists assigned and by the end of summer, all Army Ground Forces and Army Service Forces replacement training centers had consultation services.47  This condition did not persist, however, because the Army Service Forces had not yet published a directive making mandatory the establishment of mental hygiene consultation services in all Army Service Forces Training Centers. In this the Army Service Forces was more than 2 years later than the Army Ground Forces.

45Palmer, R. R.: The procurement of enlisted personnel: the problem of quality. In U.  S. Army in World War II, The Army Ground Forces, The Procurement and Training of Ground Combat Troops. Washington, Government Printing Office, 1948, pp. 1-86.
46Farrell, M. J.: Psychiatric lessons learned in the Army. Rhode Island M. J. 30: 582-586, Aug. 1947.
47Semimonthly Rpts, Med Practice Div SGO, 1942 and 1943. HD: 024.


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With the assignment of psychiatrists to replacement training centers, new problems came into relief which had not been previously encountered. Where the development of such a facility had proceeded spontaneously, it indicated a receptive attitude on the part of the command or medical officers. The papers of Lieutenant Freedman,48 Captain Cruvant,49 Major Cohen,50 and Captain Schreiber51 indicate the importance of this factor. It is doubtful if such development could have proceeded without the wise leadership and support of responsible local commanders and senior medical officers. Such support, however, was not to be uniformly experienced by all psychiatrists in establishing new consultation services.

Other difficulties arose, even when command support was satisfactory. Perhaps the first of these was because of a lack of clear understanding by both commanders (including medical) and the psychiatrist as to the psychiatrist's place in the training situation, what his duties were to be, and how he was to implement them.

The usual assignment procedure for the psychiatrist on orders to open a new consultation service was for him to report to the training center after spending a week of temporary duty at one of the established consultation services. Some were also briefly seen in the Neuropsychiatry Branch of the Surgeon General's Office by Colonel Halloran. With an orientation thus acquired and armed with the only directive pertaining to his new assignment, the psychiatrist reported to the training center.

The psychiatrist assigned to the Infantry Replacement Training Center, Camp Wolters, Texas, arrived on 27 November 1942 after having spent a week at the Engineer Replacement Training Center, Fort Belvoir, Virginia. He had conferred with Colonel Halloran and Colonel Farrell and was advised that his task was to organize and develop a mental hygiene consultation service for prevention, treatment, and disposition of maladjusted soldiers. Upon arrival he was first assigned to the special training unit several miles from the main camp. However, within the same day he was reassigned to the Infantry Replacement Training Center as Acting Assistant Classification Officer, with functions as an integral part of the Classification Section.52  At Camp Roberts, California, the psychiatrist arrived 6 December 1942 following 1 week of temporary duty at Camp Callan, California, Antiaircraft Replacement Training Center. He was immediately assigned to S-1 (Personnel) at Headquarters Field Artillery Replacement Training Center and given a desk in the Classification and Assignment Section. During a period of orientation to the organ-

48Freedman, H. L.: The services of the military mental hygiene unit. Am. J. Psychiat. 100: 34-40, Jul 1943.
49See footnote 23, p. 180.
50See footnote 27(1), p. 181.
51See footnote 26, p. 181.
52 Hunt, R.  C.: History of the consultation service, Camp Wolters, Texas. HD: 730 Neuropsychiatry.


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ization, procedures, and training of the replacement training center, he studied the official guide for the setting up of the program: The Adjutant General's letter of 30 October 1942, subject: "Assignment of Neuropsychiatrists to Replacement Training Centers."53  The psychiatrists who were assigned to establish consultation services at North Camp Hood, Texas,54 and Camp Abbot, Oregon,55 also reported lack of clarity as to responsibilities and relationships. The psychiatrist at the latter camp thought some advantage resulted from this in that it allowed for local development according to the requirements and response of the group being served. However, he thought acceptance of the services may have been delayed by the absence of definite regulations.

A difficulty frequently encountered was a lack of sufficient personnel to accomplish more than a modest amount of the program prescribed. At several camps, little or no stenographic help was available for a time. At North Camp Hood social histories were taken by line officers except during a brief period in 1943 when an American Red Cross social worker was assigned. These line officers were individuals of varying skills who were unassigned for one reason or another. Since they were rotated every 1 to 3 months, this resulted in unreliable case histories and demanded continuous effort in training new officers by the psychiatrist. In the 31 months of performance no enlisted social worker or clinical psychologist was available.56  Psychiatrists at other posts fared better. The psychiatrist at Camp Abbot, and later Fort Lewis, was able to meet the problem of finding qualified enlisted men for interviewers by accepting "near-qualified" personnel with good educational backgrounds and interest in the work. He then put them through a concentrated and personalized training program supervised by the staff. A comprehensive manual of procedures was devised for reference.57

This kind of success depended upon factors not always amenable to the psychiatrist's efforts at solving his own personnel problem. As it was expressed by one psychiatrist who had experienced considerable difficulty in this matter:  "Those consultation services which have been able to build up to a satisfactory size have done so due to the special help and understanding on the part of the local commands by taking personnel away from other sections in the camp."58  Confirmation of this observation came from another source: "Throughout its operation the MHCS [Mental Hygiene Consultation Service] has had to con-

53Houloose, J.: History and statistical summary-psychiatric service, Field Artillery Replacement Training Center, Camp Roberts, California, 1943-1944. HD: 730 Neuropsychiatry.
54Kraines, S. H.: A brief history of psychiatry at the Tank Destroyer Replacement Training Center, Camp Hood, Texas, December 1942 to July 1945. HD: 730 Neuropsychiatry.
55Eisendorfer, A., and Fowler, D. D.: History of the Fort Lewis consultation service-an outpatient psychiatric clinic. HD: 730 Neuropsychiatry.
56See footnote 54.
57See footnote 55.
58Ltr, Maj G.  S. Goldman, MC, Consultation Serv IRTC, Camp Wheeler, Ga., to Maj M. S. Guttmacher, MC, SGO, 19 Oct 44. HD: 730 Neuropsychiatry.


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sistently borrow men from other units because insufficient personnel is allowed under the present table of distribution."59

Lack of space to establish a clinic was a handicap which some were able to convert to an advantage. Maj. James Houloose, MC, while at the Field Artillery Replacement Training Center, Camp Roberts, never formally established a separate clinic, but maintained a desk in the classification section. He utilized willingly the various orderly rooms for his examinations and interviews. This allowed him to keep in continuous contact with battery headquarters and to develop a working acquaintance with commanders, noncommissioned officers, and trainees of the units. While he gathered information of use in his function as psychiatrist, he explained his role and taught psychiatric concepts. This was a practical and effective manner of continuously orienting battery cadre.60  Maj. Robert C. Hunt, MC, at the Infantry Replacement Training Center, Camp Wolters, Texas, was similarly assigned desk space in the classification office, but "conducted a traveling clinic; interviewing soldiers in six area dispensaries." He saw the noncommissioned officers and officers in their orderly rooms to discuss individual problems with a mutually valuable exchange of information and resultant education. He had appreciated at the beginning of his assignment that he "had much to learn about the Army and that the Army had much to learn about psychiatry."61  This was an effective approach in the conciliation of varying views on problems of common interest to command and psychiatry.

Of the functions outlined by the authorizing directive, the most familiar one to most psychiatrists from civilian experience was that of consultation. It was also the function that was inevitably first in demand. Being both most in demand and most familiar to the psychiatrist from his clinical practice in civil life, it was often the first function to receive attention. The accomplishment of the consultation function entailed various operations:

1.  Referrals:  These came from the unit commander, dispensary surgeon, personnel officer, classification and assignment officer, school director, chaplain, judge advocate, provost marshal, information and education officer, special services officer, and American Red Cross representative.

2.  Evaluation:  This was the process of utilizing the professional techniques appropriate to the presenting problem and the individual referred.

3.  Reports and recommendations:  These were made either to the individual himself or to the interested staff officer after psychiatric evaluation had indicated the advisability or desirability for certain action to be considered or taken.

4.  Followup:  This was the establishment and maintenance of an effective program to appraise the effectiveness of the recommendations and the progress being made by the soldier after return to duty.

59Brewer, F. W.: History of mental hygiene consultation service, Infantry Advanced Replacement Training Center, Camp Livingston, Louisiana, 29 Aug 45. HD: 730 Neuropsychiatry.
60See footnote 53, p. 189.
61See footnote 52, p. 188.


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The last was frequently undeveloped during the early period because of a lack of personnel commensurate with the magnitude of the consultation requirement. In response to this need, the principal function in the replacement training centers immediately after establishment of a consultation service was that of consultation or of screening.

The variable manifestations of failure in the adjustment process were used as a basis for referral for psychiatric evaluation. Some of these were: complaints for which no physical basis could be found on medical examination, difficulty in concentration and learning, undue anxiety on the rifle range or infiltration course, unusual awkwardness, insubordination, unfriendliness to fellow trainees, depression, tremulousness, insomnia, and frequent petty military offenses. The principal purpose in obtaining an evaluation was selectively to eliminate the potentially maladjusted individuals-hence the frequent use of the term screening when consultation was described.

One of the difficulties in the screening at basic training centers which psychiatrists soon experienced was expressed as follows by an officer at Camp Croft, South Carolina:62

. . . .The greatest hazard in the psychiatric screening of soldiers in the army is that, once given an awareness of the omnipresence of maladjustment, the inexpert observer, in his endeavor to find a case, may make a case. Too often a man will be referred to this service in the early weeks of his cycle when he is displaying a moderate and understandable anxiety which is indicative of nothing more or less than his difficulty in orienting himself away from the home to the army. For the military authorities to show undue concern over this serves only to crystallize a neurotic reaction pattern in men who might otherwise attain an adequate adjustment.

Experience demonstrated that those who appeared hopelessly inadequate on arrival often were able to complete training and were never seen in the consultation service. Major Hunt at Camp Wolters described this type of trainee:63

. . . .The typical example is an eighteen year old, group IV on AGCT. He tells the Classification interviewer that he has always been weak and sickly, that he can't stand crowds or excitement and is afraid of guns. On filling out the questionnaire he indicates that there is a family history of nervous or mental illness, his health is generally poor, he has had to quit jobs because of his health, he is nervous much of the time, does not like to mix with people, cannot work well when watched, is bothered by headaches, dizzy spells, and back trouble, has worrisome problems at home, thinks his induction into the army was a mistake and does not think he can become a good soldier. This is all prognostically bad, of course, yet many of this sort do finish training.

It came to be considered that most personal adjustment problems could be and should be dealt with by the platoon or company commander. Such officers

62 Frankfurth, V. L.: A brief history of the development and functions of the consultation service, IRTC, Camp Croft, S.  C., 9 Dec 44. HD: 730 Neuropsychiatry.
63Ltr. Maj R. C. Hunt, MC, Hq  IRTC, Camp Wolters, Tex., to Maj J. W. Appel, MC, SGO, 9 Nov 45. HD: 730 Neuropsychiatry.


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were assisted by conferences with the psychiatrist on problem cases. Often such a conference between the company officer and a member of the clinic staff resulted in the desired improvement without the need for the soldier to be formally referred to the clinic for evaluation. However, if initial efforts failed to provide the necessary solution, the soldier was referred to the mental hygiene consultation service.

Among the soldiers referred were individuals who lacked the intellectual, cultural, or emotional requirements for prompt adjustment to military service. In addition to the slow learners, there were individuals who gave the appearance of being mentally deficient, but who responded to appropriate training with a performance which indicated that the basic problem was not one of low innate intelligence, but rather one of insufficient previous opportunity. Another group of soldiers referred were men who had not mastered the English language. All of these individuals were placed in the special training units at various training centers. Where such units were in operation, the mental hygiene consultation service was presented with a problem predominantly related to the maladjustment of trainees with defective intelligence.

For some time following its establishment at Camp Croft, the consultation service functioned mainly as a psychological screening service for the special training unit. During this period, the emphasis in function was on psychometric evaluation and recommendations for discharge under appropriate administrative regulations. So long as the special training unit was active, the main body of referrals came from it and defective intelligence was seen as a frequent basis for the maladjustment. The experience of the psychiatrist at the Fort Bragg Field Artillery Replacement Training Center was similar:64

As in any new medical setup where the most pressing and striking cases take precedence initially, the severe mental defectives were the first to claim attention and most of the psychiatrist's time was taken up in the organization of a psychometric program and the actual giving of intelligence tests. Since it was keenly felt that casual estimation of mental age was futile and misleading, the Replacement Training Center provided test materials for the Stanford-Binet Scale, Form L, 1937, and the psychiatrist proceeded to weed out most of the severe intellectual defect problems and bring them to the attention of the Center Reclassification-Disposition Board for discharge. The value of psychometry in the weeding-out process soon proved so great that the test-battery was expanded to include the 1937 Stanford-Binet, Form M, the Kent Emergency and the Porteus Mazes. An attempt to have laymen (platoon officers and noncommissioned officers of the Special Training Battery) learn and administer the E-G-Y was unsatisfactory, and the introduction of an enlisted psychologist finally solved the psychometry problem and enabled the psychiatrist to devote more of his time to strict neuropsychiatry.

With his full-time assignment to the replacement training center, the psychiatrist at Fort Bragg was able to extend his resources beyond diagnosis and disposition. This led him into activities of a preventive nature:65

64Abrams, A. L.: Structure and functions of a neuropsychiatric service in a replacement training center, Jul 1943. HD: 730 Neuropsychiatry (Fort Bragg).
65Ibid.


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. . . . We felt ourselves responsible for a "preventive psychiatry" which would prevent those unfit from getting to theaters of operations.

Accepting as its primary purpose the elimination of the mentally unfit from the Replacement Training Center situation so that they are never given a chance to burden and endanger the overseas combat units. . . . Our secondary purpose has been to salvage as many cases as possible.

The prevention was still one of screening, however.

Various methods were devised to screen the new arrivals. The screening process at the Fort Bragg Field Artillery Replacement Training Center utilized officer and enlisted cadres who had been educated to the problem of the emotionally unstable by a series of lectures. This indoctrination worked satisfactorily and helped the cadres to deal at first hand with many problems in which the psychiatrist participated as an adviser only. Referral was accomplished by telephone; forms and questionnaires having been discarded as unnecessary. At Camp Croft the basic trainee was seen soon after arrival on the post by personnel of the classification section. This was primarily to conduct a vocational interview, but the interview was utilized additionally for the screening of men with mental disorders. The interviewers, who were enlisted men, had been instructed to refer any trainee about whom there were doubts concerning his ability to adjust. Trainees so referred were then evaluated by the senior psychiatric caseworker who scheduled appointments at the consultation service for those who were most in need of further evaluation. Generally, these were men who were depressed, acted eccentrically, admitted enuresis or other undesirable habits, appeared extremely effeminate, or who claimed to be conscientious objectors.

An interesting observation was made at Camp Wolters, Texas, when a system of spotting potential casualties was begun at a later time:

. . . .Early in our work with the method we were able to demonstrate statistically that one third of the interviewers were doing most of the spotting, and some were doing practically none. These data were given to the section chief, and I never asked just how he handled it, but from then on the interviewers all spotted approximately the same numbers, and the coverage was more complete.66

During the training cycle, any member of the training command staff could refer cases to the clinic for examination. At Camp Croft the referral method found to be most satisfactory included the following points:67

1.  Responsibility for referral rested with line officers.

2.  The telephone was used to make the referral because it was considered a most ready and convenient means of communication and was conducive to a more lucid statement of the problem than the written method of referral.

3.  Recording of the problem, as it was received, was accomplished on a 3 by 5 card and entered upon a daily schedule sheet.

66 See footnote 52, p. 188.
67 See footnote 62, p. 191.


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The company commander of the trainee was notified in every instance when a referral had not originated with him. In some instances, a soldier came to the clinic as a self-referral. However, the primary sources for referrals were company commanders, dispensary surgeons, staff judge advocates, chaplains, and the Red Cross. Cases referred from the dispensaries were to have had a recent physical examination prior to referral. If a report of such an examination was not available, the psychiatrist was responsible for the determination of physical status.

Sometimes an elaborate operating procedure was prescribed for the referral procedure. An example of this is the first memorandum at the Replacement Training Center at Camp Crowder, Missouri. This publication announced that a neuropsychiatric consultation service for the replacement training center had been established on 10 June 1943. It was stated that full advantage of the service had not been taken. This memorandum established procedure as follows:68

1.  Platoon officers were to interview each trainee prior to completion of the first 2 weeks in the replacement training center (both basic and specialist trainees).

2.  Trainees having difficulty adjusting were to be reported to the company commander and a checklist was provided as a guide for determining those who required referral to the neuropsychiatric consultation service.

3.  The company commander was to interview the men considered maladjusted or of dubious value to the military service and submit a report to the director of personnel.

4.  The report to the director of personnel was to state that all men assigned within the past 21 days had been interviewed and none required referral, or a list of those requiring referral was to be appended.

5.  In the latter instance, a memo was to be appended for each soldier requiring referral stating  (a) the problem,  (b) a specific example of the difficulties, and  (c) an estimate of his potential value. If the report were made on a soldier in specialist training, information was also to be included concerning the progress he was making in the specialist course.

Problems which were considered a matter of misassignment were handled by the classification branch, but those which had some degree of personal maladjustment as well were referred to the neuropsychiatric consultation service. This memorandum specified the channels through which consultations were to be sent, requiring an indorsement, with pertinent information, including recommendations as to possible disposition, and provided that when "neuropsychiatric examination reveals that reclassification or reassignment will enable the enlisted man to make a more satisfactory adjustment, this will be done."

68Hq ASFTC, Camp Crowder, Mo, Personnel Memo 23, 7 Oct 43. HD: 730 Neuropsychiatry.


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The cumbersome referral system was changed approximately a year later by a directive which provided for referral directly to the Chief, Neuropsychiatric Consultation Service, Personnel Division.69  The referring organization was made responsible for the soldier's appearing, with all his medical records, from post installations.

Intake procedure varied between consultation services, depending upon the available staff. At Camp Roberts, California, in the Field Artillery Replacement Training Center, the procedure in accomplishing consultations was geared to the psychiatrist as the only member of the staff. Requests for consultation came through the post personnel office from the battery commander or other individuals. The trainee was initially interviewed at the orderly room of his organization, where care was exercised to make the situation as private as possible. Then the progress record of the trainee was reviewed and consultation was held with the trainee's noncommissioned officer and platoon leader. Other sources utilized for information which might be an aid in making a diagnosis or in planning for the adjustment of the trainee were: unit dispensary, station hospital, and civilian social agency educational or employment records.70

By way of contrast, the intake procedure at Camp Wolters was more elaborate. The clerk first entered information from the enlisted man's personnel records (Form 20) on the consultation service face sheet; the chief social worker then scheduled an appointment. At the time of the appointment the social worker saw the patient first for a history; then the psychiatrist saw the patient. If the personnel records disclosed an Army General Classification Test of under 75, the enlisted man was routinely sent to the personnel consultant for a psychological evaluation before being scheduled in the mental hygiene consultation service.71

At Camp Croft, the soldier was scheduled for an hour and was seen initially by the psychiatric social worker who prepared a history. Depending upon the nature of the problem and the amount of time available, the personality development was carefully traced, exploring the most pertinent areas thoroughly. These workers used the Wechsler Individual Mental Abilities Scale if mental deficiency was to be evaluated. A questionnaire with 20 neurotic trends was used as a key to further history taking. The psychiatrist reviewed the history before seeing the patient and was able to get to the problem with minimum time spent in investigation. The problem had been pointed up by this process and it left further development of the case to him. His was the responsibility for diagnosis, treatment, or recommendations for disposition. In cases which required supplemental information, the American Red Cross was requested to

69Hq ASFTC, Camp Crowder, Mo., Personnel Memo 3, 22 Aug 44. HD: 730 Neuropsychiatry.
70See footnote 53, p. 189.
71See footnote 52, p. 188.


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provide social histories. Followups in the individual units were conducted by the enlisted psychiatric social worker.72

At North Camp Hood, Texas, all emergency cases were seen immediately by the psychiatrist. The procedure with routine cases was spread over a 3-day period, incorporating one feature of the adviser system. On the first day the social worker took an essential background history and returned the soldier to his unit with three request forms. One was for a report on his medical status; another was to obtain a report from his commanding officer; and the third was a request for the adviser or platoon sergeant to report to the clinic on the second day. On the second day the adviser furnished the social worker or the psychiatrist with a complete social case study of the soldier's activities in camp. This information was most valuable since it was the result of a day-to-day observation of the patient's activities, attitudes, and abilities. On the third day the referred soldier was examined by the psychiatrist with social history, medical report, commanding officer's report, and the adviser's observations.73

Yet, in spite of the familiarity of the psychiatrist with the clinical procedures involved in consultation and with well-planned screening, referral, and intake procedures, he still found that military psychiatry required a somewhat different evaluation than his previous civilian experience permitted him to anticipate. The symptom complexes presented by the soldiers seemed to be familiar insofar as diagnosis was concerned. The difficulty was in translating diagnosis into an evaluation of the man's fitness to perform in the military service so that proper recommendations could be made. The advantages of illness-secondary gains-were comparatively greater than had been present in ordinary civilian practice. Therefore, although the presenting symbols were familiar, the setting was not, and it took a while for the psychiatrist to appraise the problems in terms of the new situation. Maj. S. H. Kraines, MC,74 refers to this as the "military orientation of the psychiatrist" and Maj. (later Lt. Col.) George S. Goldman, MC,75 writes of the emotional adjustment required before an effective consultation function could be accomplished. As the psychiatrist shifted his sights to new aims, these of necessity were concerned with what would be best for the group being served. He became familiar with matters of motivation, incentive, morale, factors of stresses and supports in groups as well as individuals. As he did so he became better equipped to recommend consistently and meaningfully to staff officers in individual cases and for groups.

However, formulation of recommendations was difficult because policy with regard to many matters in the utilization of manpower fluctuated con-

72See footnote 62, p.  191.
73See footnote 54, p. 189.
74Kraines, S. H.: Psychiatric orientation of military nonmedical personnel. In Manual of Military Neuropsychiatry. Philadelphia, W. B. Saunders, 1944, pp. 481-505.
75Goldman, G.  S.: The psychiatrist's job in war and peace. Psychiatry 9: 263-276, Aug 1946.


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siderably. This had its unsettling effects upon the training center psychiatrists whose recommendations were required to reflect the perspective of each new directive. Recommendations were not always easily effected as a result of changes in policy. When emphasis was placed upon the training of individual combat replacements, transfers to a specialist training unit or to other branches of the service were nearly impossible. There was continuous uncertainty about which individuals would be considered as unfit. Early in the war conservation by utilization of reclassification procedures was directed:76

During the emergency, it is essential that manpower be conserved. Therefore, releases from active service will be granted only when in the interest of the Government or when the necessity therefor is extreme. . . . No man will be separated from active service because of disability, inaptness or undesirable habits or traits of character, unless the Government can obtain no useful service from him. Full use will be made of reclassification procedure and additional training in special training battalions.

This policy was to undergo many changes during this period when psychiatrists' services were being extended to all training centers. The Surgeon General summarized this evolution for the Assistant Chief of Staff, G-1, as follows:77

. . . .In the early days of the war there was no classification limited service. Men with psychoneuroses were marked full duty or were discharged. Limited service was authorized in the summer of 1942, permitting the retention of men with borderline or mild psychoneurosis. In March 1943 (Memorandum No. W600-30-43, Adjutant General's Office, March 25, 1943), attention was called to the need for preventing men with neuropsychiatric disorders from being sent overseas, and increasing numbers were retained on duty in this country. In April 1943 (Memorandum No. W600-39-43, Adjutant General's Office, April 26, 1943), it was directed that individuals with any neuropsychiatric disorder who could not be expected to render full military duty were to be discharged. In July 1943 (W. D. Circular No. 161, 14 July 1943, as amended by W. D. Radiogram, 29 July 1943), the classification limited service was discontinued and anyone who did not meet the minimum standards for induction was discharged except when his commanding officer specifically requested his retention for a specific assignment. Large numbers of men with mild psychoneuroses were discharged from the service by CDD [Certificate of Disability for Discharge], since anyone with a psychoneurosis of any degree was automatically below minimum standards for induction. In November 1943 (W. D. Circular 293, 11 November 1943), it was directed that no individual would be discharged from the service regardless of diagnosis if he was capable of performing effective duty. This resulted in the retention of many men with psychoneuroses in the service, but only those with mild transitory psychoneuroses could be sent overseas. As an amplification of this policy, S. G.  O. Circular Letter No. 194, 3 December 1943, directed that separations from the service would not be recommended merely because a man has, or has had, a psychoneurosis or similar disorder.

One of the effects of changing policy on disposition may have assisted the psychiatrist to seek better means than disposition to satisfy his own require-

76WD Cir 270, 27 Dec 41.
77Memo, Maj Gen N. T. Kirk for ACofS, G-1, 7 Dec 44, sub: Psychoneuroses. HD: 730 Neuropsychiatry.


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ments as a physician to individual soldiers. As Major Goldman at Camp Wheeler, Georgia, stated:78

. . . .We have not, of course, been able to maintain a constant policy as regards dispositions such as discharge, or as concerns therapy. We were better able to orient ourselves toward therapy during the time when discharge was extremely difficult to effect, although at the same time we saw a great deal of unnecessary and useless suffering. While our attempts at individual therapy have necessarily been somewhat limited, we have from the beginning tried to do as much as possible by educating the officers and cadre.

Particularly important to the effectiveness of the consultation service was its relationship to the reclassification-disposition board. This was facilitated at Camp Croft by the personnel consultant of the consultation service acting as classification officer of the board. The personnel consultant also served as recorder of the boards convened under provisions of section VIII, AR 615-360. At Camp Wolters a cumbersome board procedure was modified for increased effectiveness. For example, as much as a half day might be used to take detailed testimony from six witnesses to dispose of a single case of enuresis. This was shortened by having only one witness testify who usually was a noncommissioned officer knowing the man well. Additional documentary evidence such as certificates by psychiatrist, psychologist, and commanding officer were introduced. The psychiatrist was a member of the Section VIII board at this camp after June 1943. This practice was subsequently discouraged because, in effect, the psychiatrist might act as both witness and judge in some cases. The psychiatrist frequently had to familiarize board members with the intent of the provisions of the regulation under which the board was convened. When the turnover of officers detailed to such duty was rapid, there were delays and misunderstandings until interpretations could be made.

Although most of the psychiatrist's time at the outset was spent with the consultation and screening activities, circumstances were combining in 1943 to favor an increasing attention to the function of treatment. At Camp Wolters, Texas, after running a "discharge mill" for the first few months, the backlog of inapt soldiers had been processed by March; special training units were opened at reception centers in July 1943, materially reducing the large numbers of mental defectives which formerly had composed 75 percent of the problem cases. The staff was enlarged by the addition of a full-time stenographer and a social worker. Doubtless, similar circumstances were in process elsewhere.

As a clinically oriented physician, it was inevitable that the psychiatrist should select for treatment cases which he believed were likely to result in improved adjustment following treatment. Thus, one of the functions of the mental hygiene consultation service came to be the careful selection of candidates for treatment in an outpatient capacity. This was an important adjunct

78See footnote 58, p. 189.


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in assisting the adjustment of the individual soldier who, because of lack of motivation, defective attitudes, mental, emotional, or personality factors, had encountered problems in adjusting to military service.

Major Kraines79 believed that not only was diagnosis more effective while the man was still in his organization than after he was admitted to the hospital, but also psychotherapy was more effective in the training setting. He had observed the frequency with which symptoms recurred following the return of the soldier from the hospital to the stress of military life. On the other hand, adjustment during training by means of social and psychiatric measures resulted in more effective performance and fewer exacerbations of symptoms. As one psychiatrist stated it, psychotherapy was ". . . aimed at retaining the soldier in duty status, in the environment of his unit. It prevented many men from being hospitalized and removed from an ostensibly threatening environment to which they had not become acclimated."80  This was analogous to the method of treating combat casualties as soon as possible in the setting of the breakdown.

Treatment took many forms in application. Measures which the psychiatrist in civilian practice perhaps would not have rated high were successfully utilized. Intensive, or deep, therapeutic techniques were eliminated by press of circumstance prohibiting long-term relationships. Used as psychotherapy at North Camp Hood were explanation, reassurance, persuasion, and occasionally, authoritarian measures. When emotional disturbances secondary to environmental pressures were present, advice was given, help procured through the American Red Cross, and emergency furloughs obtained. Indirect therapy was provided through the company commander or adviser by acquainting them with the understanding of the soldier necessary to his good management. Reclassification and reassignment were considered therapeutics and for some, separation from the service was "treatment."

Therapy, at Camp Roberts Field Artillery Replacement Training Center, consisted of the establishment of rapport, explanation of the soldier's problems in terms of reality principles, and reassuring him of his ability to overcome the difficulty.

The training center psychiatrist was called upon to advise many individuals who manifested symptoms during the transitional period of adjustment to military service. Some of these individuals, abruptly severed from the supports and security upon which they had depended in civilian life, developed depression, anxiety, and in severe cases, panic. Maj. Arnold Eisendorfer, MC, in the training center at Camp Abbot and later at Fort Lewis, studied a group of these individuals and described them as the "passive personality

79Ltr, Maj S. H. Kraines to Maj M.  S. Guttmacher, SGO, 2 Oct 44. HD: 730 Neuropsychiatry  (Camp Hood).
80See footnote 55, p. 189.


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reaction type."81  These individuals were characterized as being intensely dependent upon a parent or parent-substitute with what had appeared to be an adequate social adjustment in civil life. The loss of the source of his security and satisfaction (job, sweetheart, family, avocation) was produced by entry upon military service. This was followed by the development of a syndrome, which Major Eisendorfer referred to as "acute nostalgic state." The importance of early treatment in these cases was emphasized and the results were gratifying. Treatment was based upon an understanding by the psychiatrist of the psychodynamics of dependence. The individual was given support by the psychiatrist until such time as his characteristic pattern of dependence could be transferred to the unit of which he gradually came to consider himself a part. While no claim was made that this type of therapy effected a cure, it was considered that one of the possible outcomes of successful management might bring the man to the threshold of newly found self-esteem and emancipation. This method of supportive treatment has been summarized by Major Eisendorfer as follows:82

. . . .When he comes to the neuropsychiatric service, he finds the psychiatrist receptive; immediately he unconsciously attempts to reestablish that emotional pattern he had had with his previous parental figure. This is called the transference situation. It is a rapport made with an individual in the immediate environment based on emotional ties which had been stimulated by a previous object of security. After a few interviews a considerable amount of the intense anxiety is eliminated. Once the initial panic is diminished, the practical part of the therapy is begun. The vital reasons for his being here are discussed in a language the patient can understand. The enormity of his disadvantage in this conflict because of his nervousness and dependency is constantly brought to his attention. Meanwhile, the soldier is beginning to make progress in training. The sense of accomplishment which accompanies such progress also helps to alleviate the initial anxiety; as he continues to make progress in training, he identifies himself more and more with the healthy soldiers about him, and the basic dependence on the ever-protecting parent is shifted to the powerful organization of which he now feels himself a more integral part. It is interesting to watch these men, as they gain confidence in themselves and their leaders, develop into soldiers who take pride in the role they have to play in the Army. The powerful Army and the cause for which it is fighting become a substitute for the benevolent protector, which was so necessary for their stability in civilian life. By this therapy we are not so naive as to believe that we bring about a cure. We simply attempt to substitute one type of dependency for another; we initiate a process of emotional conditioning which if continued leads to a satisfactory adjustment in the Army.

The aims and objectives of the treatment program at Camp Lee Army Service Forces Training Center were reported by Lt. Col. Samuel A. Sandler, MC. Out of the therapeutic relationship some interesting studies were made at this

81Eisendorfer, A.: Some salient dynamic factors of the passive personality reaction type. Ment. Hyg. 30: 226-234, Apr 1946.
82Eisendorfer, A.: Clinical significance of extramural psychiatry in the Army. War Med. 5:146-149, Mar 1944.


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mental hygiene consultation service on camptocormia and somnambulism concerning the psychodynamics of these two symptoms.83

An interesting development during 1943 was the adviser system which was initiated in February at North Camp Hood, Texas, in the Tank Destroyer Replacement Training Center by Major Kraines.84  The object of this system was to assist trainees with personal problems by providing specially qualified and psychiatrically oriented noncommissioned officers in each company to whom trainees would turn for advice. It was considered that morale would be enhanced by bringing good counsel to the unit level in a form readily available and easily acceptable. These advisers were to be selected by the company commander and to be responsible to him and work through him, calling to his attention morale problems of which he should be made aware. Advisers were initially planned to be the platoon sergeants; however, they were found to be too often engaged in punitive measures or too busy with administration to effect the desired relationship. Failing in this, the company commanders were then asked to select two qualified men for these duties. They were to be responsible to the company commander. Meetings with the advisers of each battalion were held by the psychiatrist every 2 weeks. General instructions were given them on the importance of understanding men, with specific instructions relative to cases referred from their units. To assist in the indoctrination of the advisers, a weekly publication called the Advisor Bulletin was produced. The specific duties of the advisers were:85

1. To be available to answer questions concerning problems of the trainees.

2. To seek out maladjusted men and endeavor to assist them.

3. To provide social case histories on men referred to the mental hygiene consultation services.

4. To assist in adjusting men seen by the psychiatrist, especially in the field of social contacts.

5. To conduct group meetings with trainees in their barracks, discuss trainee problems, answer their questions, explain the reasons for Army procedures.

Later another function spontaneously developed: to inform the psychiatrist of serious morale problems which had been relayed to the commanding officer, but upon which no action had been taken. The purpose of this effort was an attempt to find a method of supplying psychiatric understanding to many more individuals than the psychiatrist could himself reach.

83(1) Sandler, S. A.: The Army and the maladjusted soldier. Mil. Surgeon 96: 89-93, Jan 1945.  (2)  Sandler, S. A., and Rotman, S. R.: Adjusting the emotionally unstable soldier. Bull. U. S. Army  M. Dept. No. 85, Feb 1945, pp. 103-107.  (3) Sandler, S. A.: Camptocormia: a functional condition of the back in neurotic soldiers. War Med. 8: 36-45, Jul 1945.  (4) Sandler, S. A.: Somnambulism in the Armed Forces. Ment. Hyg. 29: 236-247, Apr 1945.
84Kraines, S. H.: The advisor system-prophylactic psychiatry on a mass scale. Ment. Hyg. 27: 592-607, Oct 1943.
85Kraines, S. H.: Managing Men: Preventive Psychiatry. Denver, Hirschfeld Press, 1946.


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Another type of applied psychiatry to groups commanded the attention of the Neuropsychiatry Branch, Office of The Surgeon General. There was active interest in Major Cohen's project in mental conditioning of new troops at the Ordnance Replacement Training Center, Aberdeen Proving Ground, Maryland. Members of the Surgeon General's Office worked in an advisory capacity and in close cooperation with the experiment being conducted to deliver talks on mental hygiene to new troops. Results seemed to be encouraging. The Training Division of the Services of Supply was contacted and was favorably impressed by the project. As a result of this, the experiments were enlarged to include the Quartermaster Replacement Training Center at Camp Lee, Virginia.

The activities of the Neuropsychiatry Branch were of such scope during the latter half of 1943 that consideration was given to its reorganization into a separate division under the Chief of Professional Service. Prior to the arrival of Lt. Col. (later Brig. Gen.) William C. Menninger, MC, as successor to Colonel Halloran in the capacity of Chief of Neuropsychiatry Branch, Office of The Surgeon General, it was proposed that a division of neuropsychiatry be organized. It is of interest that in this proposal the psychiatric activities in replacement training centers were considered to be a concern of the Psychiatry Branch rather than of the proposed preventive psychiatry branch, which would be interested in the broad application of educational mental hygiene activities by means of publications and other media, maintaining the necessary liaison with other staff agencies of the Army Service Forces. It is of further interest that the latter branch under the reorganization on 1 January 1944 was designated Mental Hygiene Branch. Captain Appel, who had been assigned 24 March 1943 as liaison officer between the Neuropsychiatry Branch and Special Services Division of the Army, became Chief of the Mental Hygiene Branch.

In summarizing the efforts in 1943, to encourage a truly preventive application of psychiatry in training centers, Captain Appel observed:86

An attempt to emphasize the preventive aspect of the training center psychiatrist's duties was made in the Summer of 1943 when a letter was [sent] out over the Surgeon General's signature to each of [the] training center psychiatrists, drawing their attention to the existence of the Information and Education Division-then known as the Special Services Division, informing them of the liaison with this Division which had been made by the Neuropsychiatric Branch of the Surgeon General's Office and instructing the psychiatrists to effect a similar liaison with the Information and Education organization in their own training centers. Then in the Fall of 1943 eight of the training center psychiatrists who had been most active in pursuing preventive measures were called into Washington by the Chief of the Mental Hygiene Branch for conference. Ways and means of pursuing preventive psychiatry were discussed . . . and representatives of the Information and Education Division were brought in to describe their facilities and activities concerning morale and motivation through their orientation and information program. Although this conference stimulated interest and clarified methods to some extent it was evident that the training center psychiatrists were so overburdened with

86See footnote 42, p. 186.


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the load of screening and disposal that not a great deal of headway in prevention could be expected.

Notwithstanding the high priority given the screening and consultation functions, with necessary concentration on matters of referral, intake, evaluation, and recommendation procedures, the need for methods directed at larger groups had continued to find expression.  Major Kraines' advisor system was one of these manifestations.  The effort in the various experiments in attitude conditioning at the replacement training centers near Washington was another.  At Camp Abbot, late in 1943, still another was started.  Weekly meetings were held by each squad leader with his squad.  Current events provided the themes, but free discussion was the principal objective.  This was considered to be an effective method of bolstering morale because ". . . .in the mind of the newly inducted trainee who had suddenly, as it seems to him, had all his freedom restricted, there occurs an unconscious inhibition of thinking and expression which results in the harboring of intense resentment which is directed against the authorities.  This program provided a means of ventilating this resentment and prevented dissension or impaired morale."87

Psychiatric experience during this period had resulted in the emergence of a new orientation.  Although he was concerned with the individual patient, the psychiatrist had found that he was unable to fulfill the larger mission if he confined himself to working with soldiers as individual problems of diagnosis and treatment.  There was a pressing need for the application of his knowledge to the problems which faced the individual, but the major effort would have to be directed toward groups.  This function could not be performed except in terms of the requirements of the group, with the understanding and support of its key members.  To obtain that support and understanding would be a major task during the following months.

On 3 February 1944, official cognizance was given to the importance of attitude conditioning activities which had been initiated independently at the replacement training centers at Aberdeen Proving Ground, Camp Callan, and North Camp Hood.  In a publication88 issued to stress the importance of adjustment, and first aid, it was asserted that prevention and control of neuropsychiatric cases was of equal importance to the maintenance of physical health.  Training courses were to insure that individuals would have ". . . a knowledge of personal adjustment problems in the Army; relation between emotions, feelings, and body functions; and a healthy viewpoint toward being a soldier."  Toward this end the subject and scope of a series of lectures on personal adjustment for enlisted men, and for officers and noncommissioned officers, were outlines.  The 1-hour lectures, of 3 and 6 total hours, respectively,

87See footnote 55, p.  189
88WD Cir 48, 3 Feb 44.


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were to be based upon technical medical bulletins which were then in preparation and were to be given by medical officers, preferably psychiatrists.  The complete outlines appeared subsequently as War Department technical bulletins, TB MED 12, 22 February 1944, and TB MED 21, 15 March 1944

Mental  Hygiene Phase

The first of the lecture outlines, published as TB MED 12, included six subjects that were considered to be of importance to noncommissioned and commissioned officers.  The subjects were:

Principles: modern conception of personnel adjustment and its importance to the Army officer
Personalities and the adjustment process
Motivation
Specific factors of stress in the Army affecting adjustment
Signs and symptoms, types of breakdowns, and
Measures to maintain mental health of command.

At about the same time, the other series of lecture outlines were subjected to field tests at Army Service Forces Training Centers, Aberdeen Proving Ground, and Fort Belvoir.  These lectures were approved early in March for publication and appeared as TB MED 21, with subjects listed as:

Personal adjustment problems in the Army
Emotions and feelings and how to handle them, and
A healthy viewpoint toward being in the service.

Early in the phase of development now under consideration, a meeting was held at North Camp Hood, Texas, by the training center psychiatrists of Army Ground Forces replacement training centers.  The purpose of this meeting was for the evaluation of the adviser system which Major Kraines had put into effect a year earlier.  The consensus of opinion of the visiting psychiatrists was reached on 17 March 1944 and expressed by one recorder as follows: 89

As practiced at TD RTC, North Camp Hood, and as demonstrated and described by Major S. H.  Kraines and his staff, the Adviser System delegates mental hygiene and psychiatric responsibilities to selected cadre-men in each company.  In actual practice, these men are called on to meet psychiatric situations beyond their capacity and experience.  The advisors are essentially untrained individuals who can presumably decide when and what kind of specialized medical care should be made available to the maladjusted trainee.  The trainee is encouraged to bring all his problems, psychiatric, social, personal, physical, to his advisor.  There is real danger in delegating such serious responsibilities to men of such limited experience and training.  Dangerous possibilities lie below the surface of many cases of maladjustment; suicide or other unpredictable complications may arise.  Only the psychiatrically minded or trained physician, or a trained allied professional under his supervision, should be burdened with such responsi-

89Rpt, Maj O. B. Markey, MC, sub: Conference on advisor system, as observed and studied at North Camp Hood, TDRTC, March 15-18, 1944.  SG: 337 (Camp Hood) C.


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bility. The proper supervision of a large number of advisors is professionally impossible for a psychiatrist charged with the mental health of a large command, ranging from 7,000 to 50,000 trainees, aside from cadre.

The system highlights and emphasizes facilities for the care of early maladjustments. There is the reasonable possibility that an aggressive method of seeking out the individual who may need help tends to weaken, rather than strengthen him. On the other hand, the soldier who must be resourceful enough to seek and find available psychiatric help, more readily develops self-dependence in the military situation. In that sense, psychiatry should be accessible and available, but not predominant in a training camp.

The system threatens to set up a separate channel of authority in the military family. The advisors are appointed by the company commander, but they are professionally responsible to the psychiatrist. Their reports necessarily bring in problems involving disciplinary relationships with the normal chain of command, from corporal to company commander. The latter, whose interest in the total health and adjustment of every member of his company is a command function, may be displaced by the psychiatrist, though this may not be the intention.

The aims of such a system are the same as those followed in the mental hygiene services offered in other RTC's. The method is different. Advantages accruing to the Advisor System, such as increasing attention to the help that trainees can be given; lectures to officer, cadre and trainees on military mental hygiene; cooperation with allied agencies (ARC, Orientation Officer, Hospital and Infirmary Surgeons) are indigenous to every adequate program of prophylactic psychiatry. No one "system" is necessary, for every local system has localized needs and every properly trained psychiatrist should be encouraged to use his own methods. In that case, he will be able to favorably exploit many of the sound practices offered by the Advisor System in operation at North Camp Hood, TD RTC.

Of the comments made, there were two which were considered of most serious character: the effect of placing too much professional responsibility in the hands of individuals ill-prepared to assume it, and the setting up of a hierarchy of a professional-type functionally separate from the traditional command structure of the Army. The valuable features of the program were recognized to be: the improved dissemination of information to cadre which would be of assistance in the exercise of leadership and training functions, the generalized awareness of the wisdom and usefulness of early attention to adjustment problems, and effective cooperative effort with other staff agencies of command.

Major Kraines later attempted, unsuccessfully, to modify his system at North Camp Hood to conform to the usual command channels by using the platoon sergeants as advisers. However, at other camps modifications of the adviser systems were adopted with success.

Although the conference at North Camp Hood had failed to win complete acceptance of the entire adviser system, it had stimulated interest in the problem of prevention. The value of the psychiatrist's advisory function to command was more clearly seen in this perspective. Major Hunt reported increased interest:90  "Previous to this time reports had been prepared at in-

90See footnote 52, p. 188.


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tervals of several months when there was a slack period. In May, this was changed to regular monthly reports . . . to bring to the attention of the commanding general situations which are affecting the morale and mental health of the command and which can sometimes be corrected."

Recognition of the mental hygiene consultation service as an important source of information was extended when training center psychiatrists were requested during April 1944 to formulate opinions regarding the factors contributing to the incidence of psychiatric disorders in basic training camps. Colonel Menninger directed letters of inquiry to psychiatrists in 14 Army Ground Forces and 7 Army Service Forces training camps. The replies were extracted and consolidated in a report to Mr. Harvey H. Bundy, Special Assistant to the Secretary of War, in June 1944.91  Comments were made summarizing the psychiatrists' views in matters pertaining to: leadership, psychiatric understanding required by officers and cadre, instructors, comments on training methods, infiltration courses and rifle training, relation of training to the development of psychoneurosis, classification and assignment, orientation problems of labor battalions, adviser system, and miscellaneous suggestions.

In this report the matter of leadership as it affected morale and the importance of a well-informed company commander were emphasized. To the psychiatrist the company structure resembled the family unit in the manner perceived by soldiers:92

There is frequent reference to the importance of the commissioned officer as he is related to morale and to the successful training of the soldier, with a direct relationship between these and the neuropsychiatric casualties. There is wide recognition by the psychiatrists of the similarity of the company, and a family and the soldier's response depends on the father-substitute: the unit commander. . .

One of the psychiatrists strongly recommended the preparation of a training bulletin on the subject of leadership, to be issued and placed in the hands of all officers. He summarized the contents as follows:

"A concise bulletin describing the psychiatric aspects of group leadership should be prepared. A few important concepts, such as the following, should be considered (in a language understandable to everyone):

"a.  The officer-soldier relationship as a duplication of the parent-child relationship.

"b.  The affectional interest of the parent person must be balanced against the authoritative and disciplinary aspect.

"c.  The magical power of the leader in affording protection and inspiring a feeling of confidence.

"d.  The need for inspiring troops with enthusiasm and motivation in getting the job done."

The newly authorized mental hygiene lectures might have been expected to begin to correct some of the deficiencies in the area of leadership. However, there was considerable variation between commands in the utilization of the

91Memo, Col W. C. Menninger to Mr. Harvey H. Bundy, 7 Jun 44, sub: Comments and suggestions regarding psychiatric problems occurring in basic training camps. HD: 730 Neuropsychiatry.
92Ibid.


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lectures. In some instances, both series were being given; in others, no lecture was given. It was the consensus that too many officers failed to realize their importance-the necessity for stressing their personal and paternal relationship to their men.

In addition to the factors inherent in the exercise of leadership in training (amount of the commander's understanding of the individual soldier; degree of emphasis on the use of fear of being killed, fear of punishment, or competitiveness as motivating forces), there were other factors which were considered to produce psychoneurotic symptoms:

1.  Difference in the mental capacities of the trainees who are all subjected to the same course at the same speed;

2.  Difference in the physical condition among trainees of different ages;

3.  Insufficient consideration that training is the trainee's first military experience, requiring much readjustment, all to be accomplished in a unit of temporary structure; and

4.  A lack of flexibility in arranging special opportunities for training and disposition.

Colonel Menninger went on to comment that:93

. . . .In addition, although not mentioned by the reports, an important psychological hurdle in training is inherent in the program: to learn to kill and avoid being killed. This ideology must be closely linked with motivation and tied into the mental hygiene presentations and the orientation lectures.

It is the consensus of opinion of most of the psychiatrists that it is the total pressure of garrison life which acts as the precipitating factor of emotional instability rather than any specific feature of basic training, as such. There is the unanimous opinion, or nearly so, that "we do increase the already existing psychoneurotic tendencies in certain individuals."  That we do produce psychoneurotic responses seems certain, although it is probable that the great majority of these occur in predisposed individuals.

The year 1944 saw articles published by various members of the staff of the Neuropsychiatry Division, Office of The Surgeon General, reflecting a strong trend toward prevention as the main aim of military psychiatry. Colonel Farrell 94 in a paper presented before the Iowa State Medical Society in April, indicated the importance of the training period as demonstrating the need for the development of preventive methods. Observing that the incidence of neuroses among trainees in training centers is highest during the third or fourth week of training, he pointed to the recent progress in providing for the mental hygiene lecture series. In a paper read in May at the Centenary Meeting of the American Psychiatric Association in Philadelphia, Col. M. J. Farrell, MC, and Major Appel 95 indicated that preventive measures were being pursued by

93See footnote 91, p. 206.
94Farrell, M. J.: Developments in military neuropsychiatry. J. Iowa M. Soc. 34: 387-391, Sep 1944.
95Farrell. M. J., and Appel, J. W.: Current trends in military neuropsychiatry. Am. J. Psychiat. 101: 12-19, Jul 1944.


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psychiatrists in three different areas: education, motivation, and environment as an adviser to commanders with regard to environmental factors of significance to mental health. These three areas for preventive activity were defined in a subsequent paper by Major Appel and Capt. (later Maj.) D. W. Hilger, MC.96  As used by these authors, education meant ". . . what is usually thought of as mental hygiene and actually amounts to the attempt to teach military personnel what has been learned about human nature from the study of mental disease. The premise is that this knowledge can be used by individuals for the maintenance of their own mental health and by commanders in their problems of leadership and morale."

Although the mental hygiene lectures were the foremost example of the educational endeavor, other measures were being used including the informal personal orientation of commanders by psychiatrists and the use of various printed media in acquainting the military with psychiatric principles. In the field of motivation, the psychiatrist collaborated with the information and education officer who was charged with responsibility in this operational area. It was both as a collaborator and adviser that the psychiatrist was active in the modification of environmental factors. Here the psychiatrist's viewpoint was added to that of the personnel officer, training officer, legal officer, chaplain, recreation officer, and others who were concerned with the morale of troops. Final responsibility for the factors crucial to mental health was inevitably that of command. As an adviser, the psychiatrist could influence these factors indirectly by contributing toward the commander's understanding of significant environmental stresses. The role and function of the psychiatrist as an officer of prevention was becoming clearer and better defined in the training situation.

There was a new activity of certain replacement training center psychiatrists which was briefly referred to by Colonel Menninger in an address before the American Psychoanalytic Association in May 1944.97  This was referred to as the salvage of psychoneurotic patients, either for further Army service or for return to effective civilian life. In the frame of reference that considers a complete preventive program to include rehabilitation and disability limitation, this salvage of men was patently a comprehensive part of a developing preventive psychiatry. Colonel Farrell98 reported later in the year that the developmental training units, as they were termed, had been successful in the rehabilitation of neurotic patients outside of the hospital with a substantial number performing satisfactory duty after such training.

On 22 January 1944, Colonel Menninger had accompanied Generals Kirk and Hillman to a preliminary meeting concerning the proposed retraining of

96Appel, J. W., and Hilger, D. W.: Morale and preventive psychiatry. Bull. Menninger Clin. 8: 150-152, Sep 1944.
97Menninger, W. C.: Psychiatry and the Army. Psychiatry 7: 175-181, May 1944.
98Farrell, M. J.: Psychiatry in training centers. Bull. Menninger Clin. 8: 133-135, Sep 1944.


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salvable psychoneurotic soldiers. This meeting was attended by representatives of the Military Personnel Division, Office of The Adjutant General; the Training Division, Army Service Forces; and the Office of The Surgeon General. At successive sessions, plans were formulated for the development of three pilot retraining centers at the Engineer Replacement Training Center, Fort Belvoir (Va.), the Quartermaster Replacement Training Center, Camp Lee (Va.), and the Ordnance Replacement Training Center, Aberdeen Proving Ground (Md.). It was decided that Camp Lee would be the reception center for all incoming specially selected salvable troops to be retrained from the Second, Third, Fourth, and Fifth Service Commands. It was further decided that the initial distribution of these troops would be carried out by a special group of officers made up of 1 commanding officer, 2 classification officers, 2 neuropsychiatrists, 2 personnel consultant officers, and a special cadre of enlisted men to assist them in the examination and special assignment of these troops. It was anticipated that this initial classification and allocation would take about 2 weeks. The entire retraining program was to be set up within the existing organization of the replacement training centers selected, to which additional medical-officer and other personnel were added. The initial training program was to extend over a period of 2 months. Those soldiers benefiting by this training were to be assigned to specified duties within the Army; those failing were to be separated from the service.

In March 1944 it was considered that the experimental program regarding the retraining of selected psychoneurotic soldiers was progressing in a very satisfactory manner. On 15 February, Maj. (later Lt. Col.) William H. Everts, MC, visited the three replacement training centers where the special retraining and vocational centers had been established. A battalion of 440 men had been set up at each center, under the command of selected personnel. Specially assigned neuropsychiatrists, under the supervision of the replacement training center neuropsychiatrist, had been assigned to oversee the neuropsychiatric aspects. Men assigned to these training battalions, including officers and enlisted men, were enthusiastic and the commanding generals of the replacement training centers, being personally interested in the experiment, rendered every cooperation. In each instance, the commanding officer of the training battalion was directly responsible to the commanding general.99

After the war, General Menninger100 stated that of the entire experimental group, 70 percent were made available for limited assignment. An account of the experiment at Fort Belvoir was reported by Capt. (later Maj.) Stanley L. Olinick, MC, and 1st Lt. (later Capt.) Maurice R. Friend, MC, who referred to

99Semimonthly Rpts, Neuropsychiatry Consultants Div SGO, 1 Jan-31 Jan 1944; 16 Feb-29 Feb 1944. HD.
100See footnote 2, p. 171.


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the entire process as indirect group therapy. Of those who benefited under the regimen at Fort Belvoir, Captain Olinick and Lieutenant Friend concluded:101

The soldiers who benefited in this process need not have developed insight into their problems in order to derive that benefit. Nor are they to be considered as literally having "toughed it out . . . learned to live with their symptoms."  Rather, what happened was that the unresolved emotional drives responsible for the previous maladjustments were tested against a firm but tolerant and individualized reality; the drives were then reintegrated, sublimated, remobilized on a higher level.

It must be emphasized also, that this reintegration did not take place spontaneously, in response to simple environmental manipulations. Those who have worked with the men are confident that suitable work assignments, even in conjunction with placement close to their homes would not alone have been sufficient, except in a very few instances. What was essential to the reintegrative process was the experience of planned group living.

Colonel Cruvant102 who suggested that this treatment program might well be called "milieu therapy," stated that it appeared in 1941 that such a program would be effective with "situationally conditioned, emotionally maladjusted or physically sub-standard soldiers" as a result of his own experiences with the special training units. The results of the work done in these "Developmental Training Units (Experimental)" seemed to confirm such hopeful anticipation.103  However, the application of these units was never approved for general use because of the difficulty in making special assignments after training and the cost in terms of trainer personnel.

A brief résumé of the administrative efforts to increase the effectiveness of military psychiatry up to and including this period was published in 1944 by Colonel Menninger.104  Efforts were being increased to potentiate the effectiveness of psychiatry by the assignment and utilization of clinical psychologists and psychiatric social workers. During the latter part of April 1944, a directive was submitted for publication outlining the duties of clinical psychologists.105  At about the same time, Machine Records Division, Office of The Adjutant General, was requested to determine the number of psychiatric social workers in the Army. A directive pertaining to the use of these professional workers, then in preparation, appeared as War Department Circular 295, 31 July 1944, which outlined the functions of psychiatric social workers and designated them as critically needed specialists.

This amplified the previous authoritative description of the duties of psychiatric social workers (Specification Serial Number 263) which had been

101Olinick, S. L., and Friend, M. R.: Indirect group therapy of psychoneurotic soldiers. Psychiatry 8: 147-153, May 1945.
102Cruvant, B. A.: Pragmatic psychotherapy in military training centers. Am. J. Psychiat. 103: 622-629, Mar 1947.
103Senerchia, F. F., Jr.: Experimental unit for the retraining of psychoneurotic soldiers. A. Research Nerv. & Ment. Dis., Proc. (1944) 25: 87-93, 1946.
104Menninger, W. C.: Administrative aspects of neuropsychiatry in the Army. Bull. Menninger Clin. 8: 129-132, Sep 1944.
105This was published as WD Cir 270, 1 Jul 44.


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issued in 1943. It also underlined the importance of these workers to the psychiatric program. The rapidity of expansion of psychiatric facilities had not allowed for the social worker requirements to be met, notwithstanding the efforts which had been made to obtain the necessary numbers by means of classification procedures and the recruiting of women for the positions of psychiatric social worker and psychiatric assistant. All of these developments had been aided by the active interest and advice of Mrs. Elizabeth H. Ross, the secretary of the War Office of Psychiatric Social Work, a joint undertaking of the American Association of Psychiatric Social Workers and the National Committee for Mental Hygiene.

Increased demands were made upon the profession of psychiatric social work by the rehabilitation program for psychiatric patients at Army hospitals during the last half of 1944. As a result of a conference between the Chief, Neuropsychiatry Division, Office of The Surgeon General, and American Red Cross representatives, a large number of Red Cross social work personnel were approved for assignment to convalescent hospitals for the needs of psychiatric patients.

At a time when social workers from this source were already at a premium, a new, heavy request was thus made for such personnel.106 It was plain that renewed effort would be necessary to staff psychiatric social workers from military resources. To facilitate the development of this program, Mrs. Ross was appointed as consultant to the Neuropsychiatry Division on 21 December 1944. A similar development in clinical psychology had been earlier established on 8 June when Lt. Col. Morton Seidenfeld, MSC, Office of The Adjutant General, was appointed as liaison between the Classification Branch, Office of The Adjutant General, and the Neuropsychiatry Division, Office of The Surgeon General, for the purpose of selection, appointment, and supervision of clinical psychologists.107

More effort was yet to be expended in bringing the clinical psychologist and military social workers to the mental hygiene consultation service. A conference to this end was held on 10 November by Colonel Menninger and Major Guttmacher with representatives of the Classification Branch, Office of The Adjutant General, on the problems relating to utilization of clinical psychologists in mental hygiene consultation services. The need for clinical psychologists and psychiatric social workers was expressed by many psychiatrists at the time of the conference held at Aberdeen Proving Ground early in 1945.

The problem of evaluating the effectiveness of the lecture program as an instrument of the mental hygiene approach to problems of morale was a difficult one and objective means were never satisfactorily developed. A for-

106O'Keefe, D. E.: Development of military psychiatric social work. HD: 700.7.
107Semimonthly Rpt, Neuropsychiatry Consultants Div SGO, 14-31 Dec 1944. HD: 024.


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mal examination following the lecture series was not considered to be an appropriate method. It was pointed out that the value of the lectures was expected to be reflected in the mental health, morale, and operational effectiveness of units. However, statistical analysis of certain data might be of help in approaching the problem objectively. It was suggested that various rates might be reported as was customary with other medical statistics; i. e., rates based upon monthly recordings expressed in terms of the annual rate per 1,000 strength. It was believed that unit AWOL, sick call, company punishment, court-martial, venereal disease, discharges under the provisions of section VIII, AR 615-360, neuropsychiatric, and hospital admission rates might each provide useful indexes of the mental health of the unit. Interest in exploring this possibility further was expressed by the Neuropsychiatry Division: "If it seems advisable to adopt a simple workable reporting system of these data this office would be very interested in lending any assistance desired in devising the reporting forms and setting up criteria of evaluation so that the data might be correlated with other existing data related to mental health."108  No general reporting system for such data was developed and the utilization of these indexes was to be a matter of independent action in the field.

Certain objections to the lecture series were voiced soon after publication at staff level in Headquarters, Army Service Forces. It was considered that the lectures were in an area believed to be the responsibility of the morale services division and the orientation officer. A part of the difficulty, aside from the acknowledged overlapping of interest with morale services, was in understanding the ambiguous phrases personal adjustment and personnel adjustment. These had been selected after objections had been raised to the use of mental hygiene. It was agreed that although the subject material was presented in layman terms, the objective of mental health made it a technical subject which was properly the interest of the psychiatrist. Other objections were raised regarding: the inclusion of some "strictly orientation material," "the statement as to the inadvisability of the indoctrination of hate," and the sequence of the lectures as presented.109

Presenting the lecture series, even where the training program had been modified to include them, was not without difficulty. At Camp Roberts, California, Field Artillery Replacement Training Center, the personnel adjustment lectures were given as 2-hour lectures twice weekly to new groups every 2 weeks, although it had been suggested that a minimum of 6 hours be used for the lectures. Variations in educational background (6th grade to college graduate), in age, and in Army experience and ratings made presentation difficult.

108Memo, Lt Col W. C. Menninger, MC, to CG AGF, 29 Feb 44, sub: Index of mental health. SG: 353.-1.
109Memo, Col W. C. Menninger, MC, to Chief Prof Serv SGO, 5 Jul 44, sub: Report of conference on consideration of TB Meds 12 and 21. HD: 730 Neuropsychiatry.


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The psychiatrist reported: "There was criticism that the instruction was above the level of the group; that some 40 words were used that could not be found in the average desk dictionary." Attempts which were made to simplify the nomenclature and to keep within the educational mean only served to reduce the scope of the material.110

The psychiatrist at Camp Wolters observed that although it was too early to evaluate the effectiveness of the lecture program, the first three battalions given the instruction had had comparatively fewer maladjustments. He reported that lectures to trainees had not been instituted until September, although the lectures to the cadre had been started in June. In both instances, the amount of time was less than that prescribed: two 1-hour lectures per series.111

The changing character of the trainee population of some camps from inductees to overseas returnees was introducing a new problem: "As you know the number of redeployed troops is increasing progressively. I feel that our material for personal adjustment lectures in keeping with WD [Cir] 48, 1944 is inadequate. TB MED 21 of 1944 gives us some help but does not seem to get the job done as far as redeployed troops are concerned."112

On 15 September 1944, Major Guttmacher reported for duty in the Office of The Surgeon General. His projected primary duties were to be the supervision and coordination of the work done by the psychiatrists in the mental hygiene consultation services of the training camps, numbering about 40.113  One of his immediate duties was the assumption of responsibility for the preparations which had been under way for a few months for a meeting which would bring together all training center psychiatrists for an exchange of experiences gained in the nearly 3 years since the initial effort at Fort Monmouth. This meeting was considered necessary to take account of the demands being made upon psychiatry, the measures instituted to meet the needs of military service, the changing perspectives of psychiatric practice in the Army, and the requirements of the training center psychiatrists to accomplish their part of the military mission.

To obtain some advance information on these matters, Major Guttmacher addressed a questionnaire to the chiefs of mental hygiene consultation services, receiving replies early in December.114 Of 21 camps reported, the largest from the standpoint of numbers of trainees served was Camp Blanding, Florida, with approximately 44,000. The smallest was at North Camp Hood with less than 3,000. Eight psychiatrists served training commands with under 10,000

110See footnote 52, p. 189.
111See footnote 52, p. 188.
112Ltr, Capt C. J. Kurth, ASFTC, Camp Crowder, Mo., to Maj M.  S. Guttmacher, SGO, 2 Jun 45. HD: 730  Neuropsychiatry.
113Memo, Col W. C. Menninger, MC, to Maj Gen N. T. Kirk, SG, 9 Aug 44, sub: Projects under way in the Division of Neuropsychiatry. HD: 730.
114The replies from chiefs of mental hygiene consultation services to questionnaire sent by Major Guttmacher are filed in HD: 730 Neuropsychiatry.


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trainees; there were 7 replacement training centers with between 10,000 and 20,000 trainees; and 5 had 20,000 trainees and above; 1 psychiatrist did not report the trainee strength at his camp. With regard to anticipated gains or losses in the new year, 5 expected the trainee strength to diminish, 5 expected an increase, 8 foresaw no change, 1 reported his replacement training center would be closed, and 2 camps did not report with respect to this question.

In reply to a question "Do you do all the outpatient psychiatry for the trainees?" 19 replied in the affirmative, 2 of these indicating that emergencies were usually seen at the hospital. One shared the work about equally with the hospital outpatient clinic (Camp Plauche) and another considered that 20 percent of the trainee work was done at the hospital outpatient clinic (Camp Croft). The training cadre was also served by consultation services except at the Camp Plauche installation. The cadre varied proportionately with the size of the trainee strength from 600 to 7,250.

Most mental hygiene consultation services served no units or installations other than trainees and cadre, but a few also provided consultation service to service schools, separate battalions, hospitals, and units temporarily assigned to the post.

An average monthly caseload varied with the numbers being served from between 800 and 900 at Camp Blanding, Florida, to about 60 at Camp Roberts, California. All reported seeing old cases except the psychiatrist at Camp Plauche, Louisiana, who saw none. The psychiatrists at Fort Leonard Wood, Missouri; Camp Lee, Virginia; Mississippi Ordnance Plant, Flora, Mississippi; and North Camp Hood, Texas, were the only ones who reported seeing more old cases than new.

Only at Camp Blanding and Fort Lewis had a second psychiatrist been assigned; in addition, a psychiatrist was loaned to the consultation service at Fort Devens, Massachusetts, by the post Army Service Forces Training Center. Seven had no commissioned clinical psychologist or personnel consultant, but two such officers were assigned to Fort Devens and Camp Blanding. Red Cross workers were assigned to only 7 mental hygiene consultation services. Of those which had no Red Cross worker, 6 considered such an addition desirable, but 8 did not. Some of the latter qualified their answers by stating that the addition would be favorably received if the person were a trained psychiatric social worker; others did not consider a full-time assignment necessary because of adequate liaison provided by the Red Cross workers in the hospital or post; and another had a qualified social worker as an enlisted man which met the need in his situation.

Increases in staff were considered immediately desirable by 14 of the psychiatrists. Seven of these believed an additional psychiatrist was needed; 7 thought a commissioned psychologist was required, sometimes in addition to the additional psychiatrist and sometimes in lieu of another medical officer.


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Six psychiatrists felt the need for enlisted personnel in psychology and social work.

Criteria for staffing the mental hygiene consultation services had not yet been established, but in his reply Major August (Camp Blanding, Fla.) recommended that there be 1 psychiatrist per 11,000 trainees, 1 commissioned psychologist per 15,000 trainees, and 1 enlisted personnel consultant per 3,000 trainees. He also recommended that an appointment clerk, file clerk, stenographers, and clerk typists be provided.

The mission of the mental hygiene consultation service was formulated in December by 1 psychiatrist as follows:115

The difficulty, and frequently the impossibility, of attaining significant results through individual therapy due to the limitations of time and setting is well recognized. If important therapy is to be accomplished it must be of the prophylactic variety performed on a mass scale. This has been more and more recognized and the psychiatrist has been called upon more and more to supply this need through lectures on personal adjustment in the army given to all trainees, cadre and officers.

If a man appreciates well enough why we fight, and why, specifically, he fights, and if he believes in the rightness of our cause, he is not likely to become a psychiatric casualty at a replacement training center. It is to instill and to develop such an attitude that the consultation service has devoted itself.

Patently, by this time, the mission of the psychiatrist and the mental hygiene consultation service included the promotion of mental health. How this objective was accomplished was described by a training center commander during the same month in the following paragraphs:116

It would be very presumptuous 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 toward 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

115See footnote 62, p. 191.
116Exhibit B to Annual Rpt, Neuropsychiatry Consultants Div SGO, FY 1945. HD.


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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 batteries 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 courts. This may take the form of a conference between the JA, 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 had done this with a minimum of overhead or red tape.

Two factors had led to the selection of Aberdeen Proving Ground for the meeting of training center psychiatrists, one of which was its proximity to Washington, D. C. The other reason was "because of the fact that its consultation service is one of the most outstanding in the Army."117  The 40 psychiatrists which were to be assembled were a small but significant fraction of the fifteen hundred then on duty with the Army. The first general meeting of all training center psychiatrists was held on 8, 9, and 10 January 1945 at the Ordnance Training Center, Aberdeen Proving Ground, Maryland. In addition to representatives of the Neuropsychiatry Consultants Division of the Surgeon General's Office, other interested agencies were represented. These included representatives of the Information and Education Division, Army Service Forces; a representative of the Replacement and School Command, Army Ground Forces; representatives of the Adjutant General's Office; and representatives of the Office of the Director of Military Training, Army Service Forces. The conference provided the first 118 opportunity for all training center psychiatrists to meet as a group, exchange experiences, and receive orientation from staff officials regarding the reaction at headquarters level to the methods being utilized toward solution of problems which were of mutual concern.

Subjects presented for discussion were: the problem of sick call; motivation and orientation; returnees and redeployment; disqualifying neuropsychiatric standards for overseas service; military forensic psychiatry and legal responsibility; the role of the consultation service in training; the educational functions of the consultation service; the Negro trainee; the roles of the personnel consultant, Red Cross social worker, and psychiatric social worker in the con-

117Ltr, SG to CG ASFTC, Aberdeen, Md., 13 Dec 44, sub: Meeting of psychiatrists. HD: 730 Neuropsychiatry.
118Two earlier conferences of training center psychiatrists had been held, but this was the first meeting at which all mental hygiene consultation services were intended to be represented.


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sultation service; relationship of the consultation service to other medical officers; and the use of testing agents. Discussion was freely engaged in and conclusions of a diverse character were reached which were important to psychiatric applications in the military situation.

Of the several subjects discussed, some were of particular interest to the training center psychiatrists alone; others were of general psychiatric interest. Recurrent throughout the discussion was evidence of crystallizing opinion as to the role and function of the training center psychiatrist, his relationship to command, his liaison with other members of the training command staff, his relationship with other medical officers and units, his own contribution to the individual soldier and to groups, and the utilization of psychologists and social workers in joint effort. The significance of the services performed by the training center psychiatrists was expressed by Brig. Gen. Herbert J. Lawes, Commanding General of the Army Service Forces Training Center at Aberdeen Proving Ground; Brig. Gen. Arthur Trudeau, Assistant Director of Military Training, Army Service Forces; and Colonel Menninger. The importance of a focus upon the needs of the group was emphasized at the outset of the meeting. In the same vein, in deciding upon a priority among the various functions of the mental hygiene consultation service, it was considered that prevention should be first and foremost. On these points, Generals Lawes and Trudeau and Colonel Menninger were clear.

In his prepared lecture, Maj. Gen. Ralph M. Pennell, Commanding General, Field Artillery Replacement Training Center, Fort Sill, Oklahoma, made the following pertinent remarks:119

In the first place, medical and psychological personnel must be ever conscious of the fact that in the Army it is as important to think of the morale of the men of the total command as it is of the welfare of the particular individual referred because of personal difficulty. This should be remembered when making recommendations for individual men. Perhaps this is suggesting that medical and psychological personnel apply their skills in an unusual way. But as staff officers in the Army, it should be remembered that the primary mission of the Army is the building, training, and deployment of our Armed Forces in such a way as to defeat the national enemies and safeguard the nation. The Army insists that all possible be done for those who stumble or fall by the wayside in the dislocations which accompany rapid mobilization-but not at the expense of the primary mission.

In the second place, in dealing with unadjusted personnel, the impression should not be conveyed too readily to them that there is an easy way out of the Army by admitting to personality difficulties. I have seen certain questionnaires used by Consultation Services which make me wonder whether we are trying to cure the soldier or give him an opportunity to put down in writing all of his troubles-real or imagined-and so get out of the Army. The latter is an easy job for him to accomplish if our questionnaires suggest a variety of troubles he might report.

In the third place, Consultation Service officers have an opportunity in their various interviews of men to obtain an insight into and an understanding of many general camp

119See footnote 116, p. 215.


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situations. I am not suggesting that these officers violate any of their professional obligations to specific men by making public, material which is given to them in confidence. I am saying, however, that when matters of sufficient general importance are revealed that affect the total command, they should be brought to the attention of the responsible personnel. In this way, remedial action can be accomplished.

In the fourth place, Consultation Service personnel should consider the continuous education and training of commissioned and noncommissioned training officers as a part of their mission. It is sometimes possible through such training to prevent occurrence of maladjustment among the men. In a command, where the officers and noncommissioned officers are untutored, many more problems may be generated than can be handled by the limited number of officers available in the Consultation Service.

In  the discussion following General Pennell's paper, the gradual shift in emphasis from the treatment of the individual toward prevention was recapitulated. The experiences of combat psychiatrists had contributed an understanding of the importance of motivation, leadership, and proper assignment to be nearly equivalent with mental stability in the matter of preserving mental health. The psychiatrist had been afforded the opportunity to become effective in prevention through his position as adviser to staff officers. In his report of the conference, Major Guttmacher gave the chief conclusions reached during the conference as follows:120

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 the 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.

These two main points had been expressed by Major Kraines121 shortly after the meeting, at which time he stated his belief that half of the training center psychiatrists' time should be spent in the field studying the attitudes of officers and men; informally educating officers and noncommissioned officers; discussing with officers the development of group spirit and the fostering of an

120Rpt, Maj M. S. Guttmacher, sub: Meeting of consultation service psychiatrists held at Aberdeen Proving Grounds, January 8-10, 1945. SG: 337 (Aberdeen Pvg Gd) N, 1945.
121Ltr, Maj S. H. Kraines, MC, to Maj M. S. Guttmacher, SGO, 16 Jan 45. HD: 730 Neuropsychiatry


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aggressive attitude; advising officers in the handling of incorrigibles in their units; and seeing sick call reporters at the unit dispensaries. From this activity, then, a basis would be laid for recommending remedial measures. The role of the psychiatrist in the prevention of psychiatric disorders was published in War Department Circular 81, 13 March 1945. The scope of his field of activity was stated in a paragraph on utilization and prevention. After clearly stating that the responsibility for preventive psychiatry was one for command; and, further, that the majority of factors which determine the mental health of personnel were responsive to command action, the text of the circular continued:

. . . .The psychiatrist acts as adviser to the command. In training centers or in Army divisions as a member of the division surgeon's staff, he is to be regarded as having a staff function in advising the command on policies and procedures which affect mental health and morale. In certain divisions and in some commands there appear to be excellent morale and splendid accomplishment which are in part due to an ideal relationship between the psychiatrist, the surgeon, and the responsible officers of the commander. It is the responsibility of the psychiatrist to be alert to the situational factors which are precipitating psychiatric disorders and to recommend the measures necessary to alleviate or remove these factors. He should survey the training program from a psychiatric viewpoint, advise concerning schedules, the method of conditioning troops to battle situations, and adjustment to extremes in climate. He should pay close attention to such matters as the furlough policy and the handling of AWOL cases. Through collaboration with the personnel classification officer he should be able to prevent many psychiatric disorders by bringing a medical viewpoint to bear in the job assignment problems. He should be alert to evidence that troops are approaching the limit of their endurance and in need of rest. Equally, he should be alert to untoward effect of boredom from excessive idleness. He should advise other agencies which are important to the morale and mental health of the troops: the information and education officer, the chaplain, the Red Cross, and the special services officer.

Preventive Psychiatry Phase

The continuing demands of military circumstances had forced adoption of new policies with regard to utilization of manpower. As new policies were instituted, new methods were developed; as the new methods were applied, new problems were faced and solutions sought; as new solutions were proffered, new military roles were defined. Commanders, confronted with the difficult problems attendant on the requirements of a tremendous mobilization of military manpower, learned how to utilize effectively the skills of these three professions in a manner and to a degree never before realized in military psychiatry. As commanders found new significance and meaning in their relationship to psychiatry, psychiatrists also found new responsibility and perspective of considerable importance as a result of the wartime experience.

One of the important developments in military psychiatry came about as a result of an increased awareness that the needs of the group were of as great a concern for the military psychiatrist as were the needs of the individual patient. Preventive psychiatry had come to be the designation for that branch


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of military psychiatry which was concerned with the evaluation of the attitudes of men and the effects of environmental stresses and supports at play upon them. It was concerned with providing counsel and advice on measures required in the preventive effort, together with the reasons why particular measures were indicated. This was military psychiatry on a firm, positive basis. It made its contribution to the military community in constructive terms. It helped individuals to find a measure of success and satisfaction in an occupation that was for many soldiers reluctantly assumed and difficult. It helped commanders and staff officers in the appraisal of men, the selection of leaders, and the training of individuals of widely differing qualities and experience. It assisted in the maintenance of morale and promotion of mental health and treated individuals before serious reaction patterns were firmly established. It was a social psychiatry far removed from the earlier practice of rigidly excluding and eliminating any who might potentially have an emotional disorder. It was a psychiatry which took serious note of its responsibilities to the individual patient and to the community of which both the military psychiatrist and the individual soldier were members. This was a departure from the traditional role of the civilian psychiatrist; it was a definite advance from the traditional application of psychiatry in the military service. To indicate this broad scope, the term preventive psychiatry seemed most appropriate to many of those who were engaged in these activities.

Publication in June 1945 of the technical bulletin, TB MED 156, on the consultation service, provided an official reference to the function, organization, and procedure in training center mental hygiene clinics. These units, which prior to World War II had no military counterpart, were now firmly established as important resources to command. In internal organization, they were similar to civilian community mental hygiene clinics; in external relationships they were operated as the local mental hygiene unit for a circumscribed community of military personnel. Thus had been overcome a principal obstacle in the development of preventive psychiatry: the lack of a functional unit for bringing psychiatrists into intimate relationship with the problems of trainees and training cadre. Now psychiatry in World War II had produced in the training setting an organization which would facilitate the broader application of psychiatric theory and practice. Apropos of this, Lemkau122 has recently stated that improvement of health follows when "theory matures into operating procedure, when plans become people at work."  These steps had been taken by training center psychiatry.

The chief aim of the psychiatrist, clinical psychologist, and psychiatric social worker as a team was declared to be prevention of mental disorder as a contribution toward the ultimate objective of maximum conservation of man-

122Lemkau P.  V.: Local mental health services. Ann. Am. Acad. Polit. & Social Sc. 286: 116-125, Mar 1953.


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power. The relatively high incidence of psychiatric disorders during training had made prevention in this setting a problem of primary importance. In the accomplishment of the preventive program, the staff of the mental hygiene consultation service utilized psychiatric doctrine and methods to assist in the solution of problems which are the responsibility of command: morale, leadership, and motivation; basic loyalty and group identification; discipline and justice; training and satisfying occupational experience. From the foregoing list, it is apparent that psychiatrists and the ancillary professional personnel were not, and could not be, sole advisers in any of these areas. Actually, to be most effective in the prevention of psychiatric disorders, the staff of the mental hygiene consultation service had to work as an integral unit of the training command and maintain a close working liaison between mental hygiene consultation service personnel and other concerned officers of the training staff.

It is clear from the foregoing that the scope of the military psychiatrist's job goes far beyond the usual kind of civilian practice in which one may have become expert by long clinical experience. The way in which the psychiatrist became proficient in this was outlined by General Menninger:123

The psychiatrist . . . had to know the Army and its mission; he had to be able to identify himself closely with the Army; he had to reorient from his interest in treating one person to the prevention of mental ill health in groups; he had to attempt to apply the best of his psychiatric knowledge to the social situation in which he worked. . . .

. . . .His work specifically required him to know the structure of the Army and the methods that were used in the Army. He had to know the point of view of the men in the Army, what they were experiencing, what they were expected to do, how they felt about it, and the prevalent emotional stresses as well as the available emotional supports. Furthermore, he had to identify with the Army to the extent of believing in it, wanting to contribute constructively to it, and feeling of sense of pride in being a part of it.

The forging of effective relationships with other staff officers was essential for the psychiatrist's professional growth in military psychiatry. Therefore, perhaps the first important step to be taken was for the psychiatrist to realize that other staff officers were also concerned with the same basic problems as confronted him. The approaches of other staff officers to problems of motivation, utilization, morale, and leadership were from backgrounds which were at considerable variance with that of the psychiatrist. For the psychiatrist, then, to make a significant contribution he had to be clearly understood, both in terms of his evaluation of a given problem and his recommendations toward its solution. Because of difficulties in common understanding, resulting from varying backgrounds, it was necessary for the psychiatrist to be able to explain his concepts in terms which were readily understood by people unfamiliar with psychiatric terminology. The education of staff officers was facilitated by use of expressions which were readily understood by them. The reserve which was encountered in the application of psychiatric principles was often dissipated

123See footnote 2, p. 171.


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when it became clear that the problems were mutual ones and that they were more profitably approached as joint ventures with the psychiatrists contributing a fair share.

As in civilian life, psychiatrists encountered resistance to psychiatry among military personnel because of fear of, aversion for, or misconceptions regarding individuals who required psychiatric assistance. Such reactions were best dealt with by the continual familiarization of key personnel with the nature of emotional illness. The tendency to ostracize the psychiatric patient by means of punitive dispositions had to be handled by a consistently interpretative approach. In this the psychiatrist who could welcome constructive criticism of his own services was more effective than the psychiatrist who could not. For if he reacted to criticism with hypersensitivity, he tended to isolate himself from the military community, distinctly diminishing his effectiveness as the leader of the mental hygiene consultation service. Such isolation failed to promote the mutual understanding which was absolutely necessary for the military psychiatrist to serve effectively the organization to which he was assigned. The ability to provide satisfactory professional services to other members of the training staff was commensurate with mutual understanding of each other's role.

Of all the training cadre, the psychiatrist's relationship to the company commander was of primary importance. His was the direct responsibility for the individual soldier. How well he exercised his command was a potent factor in maintaining morale and promoting mental health. To assist him with difficult individual problems, conferences were held at which psychiatrist and company commander could discuss possible solutions. Colonel Cruvant characterized the intelligent line officer as a "bulwark" in the "early recognition, prophylaxis, prevention and prompt elimination of the psychiatrically unfit."124  In relation to the company commander, it was important that no confusion arise between medical function and command responsibility in the disposition of the administratively unfit soldier. In his relationship to the company commander, the psychiatrist was active at the basic level of prevention by promoting mental health. His advice to the company commander was for general application to help prevent a decline in morale and increase in neuropsychiatric disability. The lecture program to cadre and trainees was also directed at the promotion of mental health.

In addition to the level of prevention represented by promotion of mental health, other functions in prevention at other levels were practiced: specific preventive measures based on etiology; early diagnosis and treatment; limitation of disability; and rehabilitation.

Specific preventive measures within the strict sense of the term are not generally considered to be applicable to most psychiatric disorders-the etiology

124See footnote 102, p. 210.


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of many conditions being so characteristically multiple factor in type. However, in the military service, psychiatric disability had a distinct relationship to morale and the latter to leadership. Therefore, when the environment of the soldier was affected by policies set forth by command, these became factors that were considered as supports or stresses for the mental health of the individual soldier and, in a sense, factors of etiologic significance in the matter of psychiatric disability. Policies which were not cognizant of certain needs of the individual often acted as stresses which tended to estrange the soldier from his group. On the other hand, policies which were important to the preservation of mental health and the maintenance of morale were those which provided incentive, stimulated motivation, inculcated responsibility, and developed a sense of duty. Clearly, the psychiatrist in training centers had to be sensitive to policies, procedures, and environmental factors which acted adversely on morale and precipitated psychiatric disorders. When warranted, he recommended measures necessary to alleviate or remove stress factors. To function adequately in this capacity, the psychiatrist had to evaluate the total man-environment complex in light of the main objective: to make the soldier well-trained, properly informed, mission-oriented, and group-identified so that he would be more apt to be effective and to take satisfaction in his military life. Valuable policies and practices were those which enhanced the individuals self-esteem and considered him as a person when important matters concerning him were at issue. Insofar as these policies were modified in response to psychiatric evaluation and recommendation, the measures were, indeed, specific preventive ones.

When promotion of mental health and specific preventive measures of the order indicated above were insufficient, the trainee experienced symptoms which brought him to medical attention. Nearly always when this occurred, some degree of psychiatric disability was present. In such cases the aim of the preventive program shifted toward early diagnosis and treatment. Here, the dispensary surgeon was important in the preventive approach.

A good working liaison between the psychiatrist and dispensary surgeon was essential in the proper management of trainees in whom early symptoms of maladjustment were often referrable to various organic systems of the body. Apprehension in response to such symptoms often led the trainee to believe that he had heart disease, gastrointestinal disease, or other physical disorders. The proper management of the trainee required a point of view by the medical officer and psychiatrist of considerable importance to process of adjustment by the trainee. Every individual who presented a diagnosable symptom complex or personality disorder was not necessarily to be recommended for separation from the service; nor was hospitalization to be recommended for all who presented diagnosable conditions. Rather, maximum efforts were to be made to help the individual make a satisfactory adjustment in the training situations.


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In accomplishing this, it was important for an appropriate physical examination to be made, including, of course, an examination of the organic system referred to. A perfunctory or careless examination only exaggerated an already present anxiety, making subsequent management more difficult. When a well-conducted examination disclosed no physical disease, it was best for the soldier to be promptly so informed. If his anxiety persisted, the medical officer would interpret the soldier's symptoms as manifestations of a common response to the stress of training. Along with such an interpretation, reassurance was given by the medical officer that notwithstanding certain common difficulties encountered in training, most men were able to make the adjustment. Sometimes trainees were encouraged to discuss their problems and symptoms with friends because it was reassuring for some to learn that others had experienced similar disturbances or were carrying on effectively in spite of symptoms. Emphasis was placed upon exerting maximum effort in spite of defects as contrasted to the focusing of attention upon defects. This approach had the salutary effect of diminishing the tendency of the trainee to utilize symptoms or defects for purposes of primary or secondary gain. It was found that such management during the early period of adjustment of training allowed trainees soon to become asymptomatic, no longer requiring the medical officer's reassuring support. Cases of maladjustment which did not respond satisfactorily to the efforts of the company officer or dispensary surgeon were afforded a first echelon type of psychiatric treatment at the mental hygiene consultation service where similarly oriented treatment was offered. Thus, the trainee was seen early in the development of his symptoms, evaluated with regard to the training situation and the individual's potential, and afforded treatment which was appropriate to both.

Yet another level of preventive effort was practiced in the important matter of occupation.  When definite disability was present of a type, which by reclassification or reassignment would result in productive service rather than total loss of the individual to the military service, the result was limitation of disability. Efforts at utilizing the mentally retarded and emotionally unstable were clearly directed toward this end. In solution of such problems, good liaison with the classification and assignment section was of most importance. In this area, the psychologist was often of most value as liaison between the mental hygiene consultation service and the personnel division.

Finally, rehabilitation as a measure of a complete preventive program was carried out at several training centers on an experimental basis with the mental hygiene consultation service staff participating. With this type of "milieu therapy" organized effort at all levels of prevention of psychiatric disability was engaged in and all the elements of a comprehensive program of preventive psychiatry were established in the training center. This development had taken place in units which in almost every instance were a part of the training center command.


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The mental hygiene consultation service as an integral part of the training division had developed as a result of a recognized need for professional services at this echelon. The advantages of this close relationship were several. For example, it had been found that when similar facilities were provided as part of a hospital outpatient service, the effectiveness of the mental hygiene consultation service in support of the training mission was considerably diminished. This was the result of a combination of factors having to do with the reaction of the referred enlisted personnel and the reaction of referring staff officers. An enlisted man tended to react to being sent to the hospital clinic in such a way as to undermine further his already weakened motivation for performing duty. He reacted as though it had been indicated to him that he was too sick to continue on duty. Furthermore, he lost identification with the mission of his organization. At the same time, unit commanders reflected much the same point of view in other ways. It was a common belief that the men should be sent to such a facility only when the commander was convinced that the men were not worth any further effort expended toward making them into soldiers. It was also feared that if members of the hospital staff did not fully understand the nature of referrals from the training organization, an easy exit from the difficulties of the adjustment period might be offered the trainee. It was found that when the mental hygiene consultation service was in the training area, and outpatient care provided in that setting, the suggestion of escape via the hospital was much diminished. Company and battalion commanders as well as other staff officers of the training division came to view the activities of the mental hygiene consultation service as being not in opposition to, but, rather, in concert with their own efforts.

Assignment of the mental hygiene consultation service personnel to the training command was important to establishing the esprit de corps so important to the maximum effectiveness of the team. It provided the mental hygiene consultation service personnel with strong incentive to become identified with the training command and its objectives. Furthermore, personnel of the training command more freely requested the help of the mental hygiene consultation service staff when it was part of the same command than when the services were supplied as part of the hospital service.

As a corollary to these observations, the optimum location of the mental hygiene consultation service was in a building in close proximity to the headquarters of the training center. The numerous necessary staff associations of the mental hygiene consultation service personnel with other staff and command agencies required the physical location of the clinic in the headquarters area. Because of the community of interests with the classification and assignment section in so many of the cases referred to the mental hygiene consultation service, it was most conveniently situated near that unit. The training center psychiatrist also had to maintain a close working relationship with officers in


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S-1, S-3, unit dispensaries, various companies, office of the post surgeon, office of the judge advocate, office of information and education, and the office of the chaplain. All of these important associations were best maintained by a central location so that frequent visits between staff officers could be conveniently arranged for collaborative effort.

Inversely, the effectiveness of the mental hygiene consultation service was considered definitely limited by its location in the hospital area or as part of the hospital outpatient service. Thus, at Fort Francis E. Warren, Wyoming, in June 1945, of 501 new cases seen, only 9 were referrals from company commanders and the type of service was narrowly restricted:125

The Consultation Service continues to be burdened with a large dispositional load which limits the time available for an adequate treatment program. Preventive psychiatry is almost nonexistent, the psychiatrist of the Consultation Service having had an opportunity to make only two mental hygiene talks in a period of five months. In discussing this matter, the Post Surgeon and . . . Executive Officer of the ASF Training Center, explained that the MTP schedule is so crowded that to date it has been impossible to find time for such mental hygiene lectures.

Too close a relationship to the hospital tended to minimize the number of valuable contacts made between staff members of the mental hygiene consultation service and the other officers of the training command. The mission of the mental hygiene consultation service in providing psychiatric services was adapted to the training mission of the organization which it served. This frame of reference tended to be obscured both to the medical personnel and training cadre, when the mental hygiene consultation service was physically placed in the hospital or hospital area. When this occurred, the professional services became less frequently sought by the training cadre and less appropriately given.

The Chief of the Mental Hygiene Consultation Service at Camp Crowder was assigned to the station hospital. The post surgeon, who was also the commanding officer of the hospital, believed all medical personnel should be directly responsible to him. The commanding general of the training center, however, thought it desirable for the training center psychiatrist to be assigned to him and this was in accord with the recommendation made from the Surgeon General's Office.

Still another example of difficulties in relation to the hospital staff association is disclosed by the psychiatrist's remarks concerning affairs at Camp Claiborne where acceptance by the training staff had also lagged:126

The situation at this camp is rather difficult. I am assigned to the hospital and operate under the jurisdiction of the neuropsychiatric ward. The functions of a con-

125Ltr, Lt Col J. H. Greist, Consultant in Neuropsychiatry, 7th SvC, to Surg 7th SvC, 7 Aug 45, sub: Report of inspection of consultation service, Fort Francis E.  Warren, Wyoming . . . 2 and 3 July 45. HD: 730 Neuropsychiatry.
126Ltr, Maj S. H. Kraines, Camp Claiborne, La., to Col W.  C. Menninger, 12 Aug 1945. HD: 730 Neuropsychiatry.


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sultation service are new to the hospital and difficult for them to accept. The training command also is adverse to activities of such a consultation service. . . .

In September 1945, the Eighth Service Command neuropsychiatric consultant visited Camp Claiborne, Louisiana. As a result of his visit, he reported: "This Mental Hygiene Clinic is unique in that its psychiatrist is assigned to the neuropsychiatric section of the Station Hospital. Heretofore such units have been independent of a station hospital. The present arrangement does widen the scope of hospital activities but is of no particular advantage to the Mental Hygiene Clinic."127  The situation, unsatisfactory as it was at Camp Claiborne, had, nevertheless, improved over the earlier character of service offered at this post. Before establishment of the clinic as subordinate to the hospital service, it had been under the direction of a nonmedical officer. This unit was then entitled the "Personnel and Separation Branch, Military Personnel Division."  The name suggests the strong emphasis placed upon the administrative character of the mission assigned by local authority. This is clearly indicated by the post regulation describing the Personnel and Separation Branch. Although the general scope of a mental hygiene consultation service was included in outlining the functions of this unit, far greater emphasis had been placed upon the procedures to facilitate the separation from the service of men who were to be discharged administratively.

In situations in which the mental hygiene consultation service was not overburdened by disposition problems, or too closely identified with the hospital mission, the preventive mission was furthered. Of the effective ways to approach prevention, the modification of attitudes, a traditional technique of mental hygiene, had been best developed in most instances. However, some efforts were made toward a statistical basis for preventive measures. Such studies were of two types: the continuing type of study of a particular problem to establish trends, and the brief studies of special problems when required. The former group included studies in which the mental hygiene consultation service regularly procured data on unit AWOL rates, unit incidence of venereal disease, and unit sick call rates. These rates were believed to indicate the presence of problems related to morale and leadership. When AWOL, venereal disease, and sick call rates were low, it was interpreted that supporting factors were effective or that stress was minimal. When such rates were high, further study was deemed necessary to elucidate the significant factors responsible so that recommendations could be formulated.

The psychiatrist at Camp Wolters attempted to evaluate the morale of the training company, first by measuring the productivity of each company, and later by figuring weekly sick call rates and transfers:128

127Ltr, Lt Col P. C. Talkington, to CO Sta Hosp, Camp Claiborne, La., 24 Sep 45, sub: Report of neuropsychiatric consultant's visit to station hospital, Camp Claiborne, Louisiana. HD: 730.
128Ltr, Maj R. C. Hunt to CG IRTC, Camp Wolters, Tex., 7 May 45, sub: Report of consultation service for the month of April 1945. HD: 730 Neuropsychiatry.


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An effort was made to work up statistics and charts on production efficiency of the company level. No honest statistical basis could be found and the project was abandoned. The men eventually lost have usually been in two or more different organizations before final failure, so that it is impossible to determine which organization should receive the discredit, and the number transferred as training deficients and the numbers pending at the end of cycle are much larger than the losses.

Because this study was a failure, weekly sick call rates and transfers were charted. It was suggested that morale level would be reflected by the degree that men would strive for hospitalization and emergency furloughs.

Questions were raised with respect to the reliability of this type of index to morale:129

 . . . .The relationship between morale and sick-call rate is by no means consistent; we have all seen occasional units with low morale and low sick-call, perhaps because artificial and repressive measures are used to hold down sick-calls. This illustrates the necessity of watching all possible morale indicators, including gossip and one's intuitive feelings about a group which shows nothing wrong statistically.

The use of repressive measures to keep indicators of poor morale from reflecting such circumstances was considered by another observer to warrant another index as a validating check against the incorrect morale indices: "It is a pity that the number of courts-martial is not published for each RTC and the average number of years in the sentences. This would give an opportunity for a comparative study on the means with which RTC's try to maintain morale."130

Two factors may have adversely affected the development of a statistical-epidemiologic approach to preventive psychiatry in the training centers, although an interest in this methodology was being manifested with regard to combat psychiatry. One of these was the loss of personnel at local installations as a result of personnel surveys. The result of such economy measures was to place greater burden upon the psychiatrist for detailed administrative matters connected with the operation of the consultation service. Another result was that such cuts did not allow assignment of additional required professional personnel to free the psychiatrist from strictly clinical responsibilities so that an effective preventive program could be developed. The effects of such measures were being felt shortly after the Aberdeen conference.

The second major factor in the failure to develop further the epidemiologic approach to preventive psychiatry may have been the beginning of demobilization when numerous training centers were scheduled to close beginning late in 1945 and continuing into 1946. Most training center psychiatrists became concerned with the problems of demobilization rather than the maximum utilization of manpower or the cause and prevention of psychiatric disabilities in

129See footnote 63, p. 191.
130Ltr, Capt K. R. Eissler, IRTC, Camp Fannin, Tex., to Maj M.  S. Guttmacher, SGO, 18 Jul 45.  HD: 730 Neuropsychiatry.


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the training situation. It was an understandable shift in interest which the nation at large shared following cessation of hostilities and promise of peace.

SUMMARY

One may define preventive psychiatry as that particular branch of medicine which studies disorders of intellect, emotions, and behavior in relation to the group as well as to the individual. Not merely concerned with individual ill health, it is also actively interested in the maintenance of the physical, mental, and social well-being of the man-environment complex. In the military service, preventive psychiatry had become concerned with stresses affecting groups of soldiers, and the supports which could be provided for the group. To obtain the kind of information needed for his counseling role in matters of mental health, it had been necessary for the military psychiatrist to utilize methods which were applicable to groups. Thus he studied the incidence and prevalence of a disorder, employing data related to these factors in the evaluation of etiology and construction of a program of prevention.

The evolution of preventive psychiatry was not a goal envisioned at the outset of World War II by most psychiatrists. Indeed, the meaning and use of the word "prevention" in military psychiatry had undergone great change. It had generally implied that psychiatric casualties were to be prevented by judicious examination at induction stations, applying standards that excluded the potential casualty. This had been current opinion among well-informed military and civilian psychiatrists alike: prevention and screening were considered to be practically synonymous. This view appeared to be consistent with the basic mission of the Army Medical Department in preserving and maintaining the fighting strength. It was based upon the ideal hope that the elimination of potential casualties before exposure to the stresses of military service would constitute a valuable contribution to the forging of a dependable arm for war. It was also foreseen that fewer pensioners for combat-incurred neuropsychiatric disabilities would result during World War II than had been the experience in the previous world conflict.

However hopeful men had been initially of the potential effectiveness of this means, the application of screening technique had left much to be desired. The psychiatric casualty was not eliminated, in spite of generally high rates of rejection at induction stations. Prevention of psychiatric casualties had not been achieved by the application of screening devices and classification practices; on the contrary, large numbers of men had been excluded or eliminated from contributing to the military effort. It can be fairly stated that these failures opened the way to developments which culminated in the establishment of a psychiatric prevention of a vastly different order than foreseen at the beginning of the war. With utilization of manpower a vexingly com-


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plicated, as well as supremely important, matter, psychiatry had to develop techniques which were distinct modifications of the diagnostic and prognostic skills that had been so confidently relied upon.

Most military psychiatrists in the training centers were trained to, or acquainted with, the psychodynamic concept of etiology for psychiatric disorders. The psychiatrist, acquainted with dynamic factors in etiology, possessed an attitude of scientific receptiveness which permitted observations to be made regarding the adjustment process among trainees. In this frame of reference, a psychiatric disorder was viewed as the symptomatic expression of a reaction to stressful inner conflict between the forces of an impulse to gain satisfaction and deterring forces against that end. The imposed deterring forces could be internal (conscience) or external (social). In the training circumstances, the latter tended to overshadow the former. The resulting struggle could be completely unconscious, completely conscious, or, perhaps, but vaguely perceived, with manifestations as symptoms or as aberrant behavior. This conflictual state could be affected by environmental factors acting as individual stresses or supports. The dynamically oriented psychiatrist became more and more concerned with environmental factors and found new avenues of approach to the evaluation and treatment of these conditions.

The soldier entered the military service with a whole set of experiences which conditioned his adjustive processes. He might enter into immediate and overt conflict with the new authority or group. On the other hand, a latent conflict might become activated and be expressed symbolically as a behavior disorder or a symptomatic emotional reaction. The internal conflict between forces thus might be a symbolic representation of an actual conflict in external reality. When the internal struggle was severe, symptoms emerged in various ways as a manifestation of the conflict between forces. It was at this point that the psychiatrist was frequently called upon for his services as a clinician because of the effects of these manifestations. Because the first requirement of the psychiatrist was for his clinical services, much effort was bent in the direction of extending such services to the individual. However, it was soon perceived that although individual factors were of significance, the perspective was often changed by an understanding of group factors. The entire man-environment complex had to be considered so that individual biologic and cultural factors could be evaluated in terms of the soldier and his group. Treatment was based upon such an evaluation and preventive techniques were directed with focus upon the group.

The clinician's role in the study of the individual patient is the traditional one from which epidemiologic studies have originated and was the foundation upon which a design for prevention was based. In his role as the physician to the ill individual, questions emerged which had significance for the group to which the patient belonged. In the mental hygiene consultation service the


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psychiatrist was in the advantageous position of being both psychiatrist to the individual soldier and adviser to the commander on matters affecting the mental health of the group. In the first instance he was afforded the opportunity of studying individual cases, drawing conclusions and formulating plans. In the second instance, he was in a position to present his observations, formulations, and conclusions to the commander directly for consideration and action.

This dual role forced a clarification of the differences between the preventive and clinical roles in military psychiatry. The aim of both is to interfere with symptom formation; however, one of the principal differences between the clinical psychiatrist and the preventive psychiatrist is in the unit of study. The former is concerned with the individual who seeks help for himself or has been referred for assistance; the latter is concerned with essentially the same phenomena as they affect the group.

Symptoms could be alleviated by methods directed toward modification of stress or support factors. If the stress to be diminished was an inner dynamic factor, or, if the support to be augmented was an individual resource, the methods used were a modified form of psychotherapy. On the other hand, if the modifiable stress or support was a quality of the individual's surroundings, the methods were those of environmental manipulation. Preventive psychiatry aimed both at the early amelioration of symptoms in the individual by the modification of individual etiologic factors, as well as at the prevention of the development of the same disorders by group studies and group measures.

From the foregoing, it will be seen that steps in the historical development of mental hygiene were rapidly retraced in the establishment of a preventive psychiatry in the military service. This psychiatrist, armed with a holistic approach to the patient's problems, came to see these in terms of disorders arising in the unit analogous to the family, and subject to modification by measures focused at the group. The use of an individual prophylactic guide for each soldier was issued in the form of lectures and pamphlets applied in groups. The broad implications for the group, in addition to the individual soldier's adjustment problem, had been acknowledged and was being met by appropriate preventive measures.

The close of the war found training center psychiatrists engaged in a preventive program which was largely carried on by means of attitude conditioning and staff advisory functions. The increased utilization of psychiatric social workers and clinical psychologists had contributed significantly to this program. Preventive psychiatry based upon a statistical epidemiology appeared to be on the threshold of development. Since psychiatric disorders had important sociologic, psychologic, and somatic components, they were potentially amenable to study by epidemiologic methods. Epidemiologic methods, applied to the problems of psychiatry, might have provided a basis for recommending preventive measures and establishment of a body of preventive psy-


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chiatric principles. Although not trained to be an epidemiologist, the psychiatrist was familiar with manifestations of contending dynamic forces within the individual; therefore, the epidemiologic concept of mass disease as a manifestation of contending forces between host and environment would not have been an unfamiliar frame of reference. Similarly, multiple causation of disease as an epidemiologic principle would be familiar to psychiatrists trained to consider multiple factors in the determination of symptom formation. As modern epidemiology utilizes the contributions of various allied disciplines, so also did military psychiatry, in that the psychiatric team studied the soldier in relation to his fellows and environment, employing the professional viewpoints of the psychologist and the social worker. Although the way appeared to be opening for the development of an epidemiologic approach, the efforts in this area were preliminary in nature.  

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