Sunday, June 8, 2014

Combat Psychiatry by Eric Jaffe

The first lesson that should have been learned from the Great War was that many men would break.  America’s armed forces suffered one psychiatric casualty for every four physical wounds over the course of the conflict. The ‘fifth man,” some called him. The military had tapped Thomas W. Salmon, the same physician who’d created psychiatric services for immigrants at Ellis Island years earlier, to establish a mental health program for American soldiers heading overseas. “The extent of these casualties is almost beyond belief,” Salmon wrote in June 1917, upon reaching Europe in advance of U.S. troops. “I have not yet had access to the official records but apparently the neuroses constitute one of the most formidable problems of modern war.”

In a typical case of “ shell shock,” the term of choice during the Great War, a parade of stressors chipped away at a soldier’s stability. Days under fire, nights in a foxhole, little food and water, very little sleep. Then an artillery shell would explode nearby, maybe tossing him to the ground or killing a buddy, and something inside snapped.  By the close of the conflict a clear relationship had been established between the intensity of combat and the rate of mental breakdowns.* In early 1918 a military psychiatrist saw eighteen cases of shell shock during a full six weeks of low battlefield activity. Then he saw fifty-two cases during a harsh four-day attack, and forty-three more during a rough two-day raid.

Shell-shocked soldiers became noticeably delusional and confused. Some presented uncontrollable twitches. Some stiffened into fearful statues. Some had haunting visions of carnage. Some lost memories, or control of their emotions, or motor skills. Some showed a severe startle reflex whenever a door slammed shut, or a plate hit the floor, or a chair toppled over. Often these wounds followed a soldier home from war. One anonymous soldier, writing in the Atlantic Monthly in 1921, wished he could convey to the public “how dreadfully alone a shell-shocked man can be, even though surrounded by those who love him most.”

One glimmer of hope during the Great War was the realization that mental casualties who received urgent treatment near the front lines had a good chance of recovering. At first, American soldiers were evacuated hundreds of miles to the U.S. General Hospitals positioned far behind the front lines. In severe cases they returned stateside on a hospital ship. This delayed treatment gave the disabilities time to set in and enabled patients to embrace the ailment as a ticket home. On the contrary, the soldiers who received hot food, rest reassurance close to the lines often made quick and complete recoveries. The best care occurred within a few hours of onset and “within the sound of artillery,” wrote Salmon.

The combat psychiatrists deployed in 1918 used simple and effective methods. They were stationed in frontline triage areas, as opposed to traditional hospitals. They emphasized the honor of battle and reminded patients that their buddies were still out there fighting. Thy showed pictures of German prisoners to evoke patriotic responses. Soldiers suspected of malingering were given awful jobs, like digging latrines, to discourage any trickery. The numbers testified to their success: anywhere from 65 to 85 percent of soldiers treated within days of their breakdown returned to combat.

“In hospitals close behind the lines there is still the atmosphere of the front and a mental tone which comes from mass suggestion of men striving shoulder to shoulder,” wrote one psychiatrist at the time. “Out of danger, far from the front, perhaps among hero-worshiping friends, the invalid is unavoidably conscious of himself more as an individual and less a link in the battle line.”

After the war, however, many military psychiatrists suggested that only mental weaklings with underlying emotional instabilities had broken down in combat. This thinking held that any neurotic tendencies concealed in the comforts of civilian life would be exposed under the peculiar stresses of the military. “The neurotic is so intensely individualistic that under the new and rigid conditions of service he finds impossible to adapt and so breaks down.”  Officials thought that they had discovered a basic law of military psychiatry: stop individuals with mental instabilities from entering the service, and you’d stop soldiers from suffering mental wounds on the battlefield.

At any rate, in the immediate aftermath of the Great War, military leaders paid little attention to any of its mental health lessons. A military medical manual published in 1937 devoted just one of its 685 pages to mental health. Toward the late 1930s, as the prospect of another global war became distinct, military consultants made a critical mistake: they ignored what they’d learned about treatment on the front lines and instead pushed an aggressive stance toward screening-out the so-called weaklings. If civilian psychiatrists could eliminate psychoneurotic individuals during enlistment, then division psychiatrists would no longer be necessary during combat.

So it happened that the American military entered the Second World War having forgotten a key lesson from the first one. In late September of 1940, Winfred Overholser, the head of St. Elizabeth’s Hospital, sent a memo to President Franklin Roosevelt describing the potential advantages of establishing a screening system at induction centers. Money as much as medicine, encouraged this approach. Overholser estimated that neuropsychiatric casualties from the Great War had cost the country close to a billion dollars. In November the Selective Service System adopted an intense screening program  for new soldiers, and in 1941 the position of division neuropsychiatrist was dropped from personnel rosters.. By the time soldiers shipped out for World War II, the closest a military psychiatrist could get to the action was the general hospital.

Despite the heavy screening process, mental casualties piled into military hospital beds. By the middle of 1943 neuropsychiatric cases made up 15 to 25 percent of all battle casualties in many campaigns. An annual summary of the problem reported a hospital admission  rate of 60 neuropsychiatric cases per 1,000 men in overseas battles, compared to a rate of roughly 17 per 1,000 in the Great War. The disparity was startling. In the earlier conflict screenors removed just 2 percent of enlistees. This meant that even with an examination process at least four times more rigorous in World War II, the U.S. military had a psychiatric incident rate nearly four times as high as that in World War I.

As of August 1943, the Army was discharging 115,000 men a year for neuropsychiatric reasons – by far the most of any category. It was an unprecedented pace. From a perspective of military manpower, it was also an unsustainable one.

By Fall the entire approach to American psychiatry was being questioned. The underlying principle of the screening program was that everyone who broke down in war had entered the service with an identifiable mental weakness, but reports from the field told a very different story. During the rough Sicilian campaign, a veteran division produced more psychiatric casualties than a group of fresh troops.  That didn’t mean veterans weren’t tough – but rather that the rigors of war could break even strong minds… If screening were to weed out everybody who might develop a psychiatric disorder, it would be necessary to weed out everybody.

A comprehensive military psychiatric program would not only keep abnormal minds out of the Army, it would treat the normal ones in it. This shift in strategy was reinforced through a series of official directives issued between September and November of 1943. The surgeon general circulated a letter to every medical officer summarizing the new stance. Mental casualties would be considered urgent cases, and treated urgently. They should be labeled “exhaustion”- not “war neurosis” or “shell shock” or the like – to soften the stigma of the problem, to underscore its universality, and to suggest imminent recovery. The psychological and physical factors that led to a breakdown should be detected early and, whenever possible, prevented from escalating. General policy was moving away from the elimination of manpower and towards its conservation.

Executing this initiative meant moving psychiatrists up near the action, but high military officials ignored several calls to re-institute the division neuropsychiatrist. One early request, made back in April of 1942, had been rejected on the grounds that psychiatrists couldn’t perform their job “under the present type of mobile warfare.” Anther request, made the following March, had been rebuffed by an officer who didn’t believe “anything of real value can be accomplished by psychiatrists with the division in combat.”  Only after Surgeon General Norman T. Kirk took the matter to Army Chief of Staff George C. Marshall – a notorious skeptic of mental casualties – was the position approved.

In December 1943 the Army ordered all sixty of the newly appointed division neuropsychiatrists to Walter Reed Medical Center, for a three-day orientation, an intellectual boot camp in military psychiatry. The proceedings were led by Lieutenant Colonel William C. Menninger. He emphasized early detection, helping officers develop a keen eye for the personality changes, emotional outbursts, and general anxiety signaling mental casualties. The second pillar of his program for prevention was motivation. In 1943 too few American soldiers possessed sufficient morale – “a will to fight stronger than a will to live.” One out of every three soldiers felt their task in World War II was not worthwhile, according to a survey. And American troops hardly even knew anything about their enemy. Psychiatrists feared this low fighting interest made troops particularly susceptible to the stresses of war. In response five “Why We Fight” films were produced, directed by Frank Capra with the help of Ivy League psychology and sociology experts and a writer by the name of Theodor Geisel- better known as Dr. Seuss.

A strong preventive program might minimize mental casualties, but by 1943 no one suffered the illusion of eliminating them so treatment was the other main topic at the Washington conference. Each of the division got a copy of War Neurosis in North Africa by Roy Grinker and John Spiegal, considered ‘the Bible” of Combat Psychiatry at the time. But the entire morning session of December 15 was given over to Fredrick R. Hanson, described as clever, energetic, and possessing a “low and calm” voice, Hanson had been way in front of the division psychiatrist curve. He recommended the position be created all the way back in an August 1942 communication to the surgeon general. His work in the North African theater, in the spring of 1943, confirmed that fatigue played a leading role in mental casualties. Treat exhaustion, Hansen believed, and you’d improve psychological stability.

As a result, Hansen devised a fairly simple regime of rest and reassurance for psychiatric cases. He put them to sleep for long periods with barbiturates, awakened them only for meals, then after a day or so discussed the universality of fear and urged them to rejoin the fighting. It was very much in the style of combat psychiatry from World Wear I, and it was equally effective; Hansen returned 60 percent of his cases to combat within four days, and 89 percent of those remained in action month later. Hansen’s lessons, above all others, would guide the work of division psychiatrists on the battlefield.

As a general ruler, the sixty division psychiatrists were greeted  with suspicion and granted little in the way of authority. Their commanders expected them to make wholesale discharges. Some were called “nut-pickers” who belonged in lunatic asylums, not among units of good old “red-blooded” American soldiers. Many officials still felt psychiatric cases were simply weaklings or malingerers. At the most, they saw the new division neuro-psychiatrists as a tool for disposing of soldiers who didn’t meet their models of manhood. Even officers who acknowledged the existence of mental casualties were hesitant to put recovered cases back at the front for fear other troops would no longer respect them.

The topic didn’t really enter civilian discourse until the infamous “slapping” incidents involving General George S. Patton in late November 1943. . . “It has come to my attention that a very small number of soldiers are going to the hospital on the pretext that they are nervously incapable of combat. Such men are cowards, and bring discredit on the Army and disgrace to their comrades who they heartlessly leave to endure the field of battle which they themselves use the hospital as a means of escaping.” Patton’s own formal apology to Eisenhower revealed a belief that only tough love could treat “mental anguish.” It closed with the supercilious suggestion that by slapping each broken soldier, Patton had “saved an immortal soul.”

* [ however, the specific act of killing as an important cause ‘shell shock’ (PTSS) was not recognized until after WWII]