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 http://johnshaplin.blogspot.com/2010/09/on-killing-by-lt-col-dave-grossman.html]
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