Some Lessons of Wartime Psychiatry.I
- Author:
KENNETH SODDY, M.D., D.P.M.
Medical Director, Provisional National Council for Mental Health The intention of this contribution, which will be concluded in the next issue, is to review some of the lessons learnt by psychiatrists serving in the Forces in the World War; to indicate certain differences between the social conditions imposed by war and by peace; and to advance suggestions about the psychiatric service of the future. The scope of the present article is to describe the special contribution of the service psychiatrist to his own sphere and also some of the peculiar features of service life. In the next issue an attempt will be made to apply these rather specialized experiences to normal social conditions.
The subject has been dealt with more fully and more authoritatively by Dr J. R. Rees in his Salmon Lectures of 1945, published under the title ” The Shaping of Psychiatry by War ” (Chapman and Hall). The only excuse for writing this article is that it may reach a different public and spread information on these topics. The writer is deeply indebted to Dr Rees for an opportunity to be one of the military team and to work under his inspiring leadership for more than five years of war. The time is ripe, because the nations are now ruefully counting the cost and making their first attempts to repair the ravages of war. Therefore, it is very appropriate for us to estimate the extent of any benefits which may accrue from the last seven years’ experience. On all sides there are reports of human misery, loss, disease, starvation, the wrecking of hopes and the stultifying of progress. Yet there may be benefits to salvage from the wreck. It is at least constructive to turn over the rubble and pick out such useful material as may remain.
Certainly some aspects of Medicine achieved progress during the 1914-1918 War. Though to use war as a me&ns of social progress would be wasteful, to say the least ; yet not all wartime activities are destructive. It is the happy privilege of Medicine that even during a world catastrophe it can be constructive or remedial. In four great fields?orthopaedic and plastic surgery, hygiene and preventive medicine?opportunities were seized making possible the striking advances of the interwar period. Psychiatry also benefited, being, in 1914, only in its infancy outside the mental hospital. Psychiatry in that war had its first great chance of dealing with mental disorder in the community; and considering the scarcity of trained personnel, its achievements were such that the small band of workers may be justly proud of their record.
A New Orientation after 1918 One direct result of war experience was the increase in professional and public interest in that great group of human illness, which, although j mental in origin, is not covered by lunacy and mentaj , deficiency practice. The phenomenon of ” shell , shock ” threw the subject into sharp relief and ideas j were clarified about neurosis, psychopathic states* and mental subnormality. It was realized that good could be done provided the physician and the social worker had the necessary special knowledge? and (what is more important) the will and the patience to try.
At that period, psycho-analysis was making & I profound impression on the psychological world ‘ and public interest was aroused to such an extent | by the urgent problems thrown up by war that in i the 1920’s psycho-analysis became a popular cult> embarrassing to serious workers in this field. The effects of this premature popularity have been | harmful in that it attracted much that was unhealthy . and gave this serious science a reputation with the | public which it did not seek and did not deserve- However, in the latter part of the inter-war period, public curiosity found new diversions and the , bona fide workers were able to make their progress j in comparative peace. Progress, of course, was not limited to those entitled to call themselves psychoanalysts but was common to all those using an analytical and experimental type of approach.
The Present Opportunity
It is claimed that during the recent war psychiatry has made giant strides, particularly in menta’ hygiene and in prevention. As yet, the consider’ able public curiosity has not been gratified with sufficient information and sometimes the sohd 1 achievements are lost sight of in over-attention t0 , individual success or failure. There is novS| I experience of the workings of a centralized menta1 j health service, and the idea (reaffirmed in Dr [ Blackers’ Neurosis and the Mental Health Service j of the appointment of ” Medical Officers of Mentaj Health ” to a locality now has an established j precedent. But it is a precedent with a difference” So that while psychiatrists with the appropria^ 7 experience warmly welcome this suggestion, ye, I there are important differences of scope an opportunity to be assessed and turned to advantage_ ! It will be noticed that the following descripti01; refers to the army. This does not imply negleC of psychiatric experience in the other Service^ but is due to the writer’s own experience and als because the army organization is bigger and in son1 ways more general and more nearly related to civl life than the other Services.
Service Psychiatry at the Outbreak of War in 1939 To the Services themselves the inter-war period was a melancholy one of starvation and public neglect. The army in particular was aware of public apathy, even of hostility, and was conscious that the terms of service it could offer were not attracting the best recruits?neither officers nor men. The public can only blame itself if service Planning was not progressive in mental health matters?soldiers had little financial or moral encouragement to make far seeing plans. In 1939 the only psychiatry practised in the R.A.M.C. was the care of a few ” mental wards “, where the duties Were similar to those in civil mental hospitals. A few months before the outbreak the Services each appointed their consulting Psychiatrists, the army having one for the army at home, and one for the B.E.F. It is probably fair to remark that their duties at that time were regarded as being within the orthodox medical field. By this view, it was Proper for the consultant to concern himself with the establishment of special hospitals and outpatient clinics for dealing with psychiatric casualties, and with the appointment of suitably qualified Personnel to run them. Events turned out otherwise, because the consultants held the view that the Proper function of Service Psychiatry was the Prevention of psychiatric breakdown.
The Preventive View of the Problem
How can psychiatric casualties be prevented in firne of war ? The answer is that they cannot be wholly prevented, but their incidence can be very much reduced by an organization which never }?rgets the ” human factor “. The requisites of s?und mental hygiene in an army include :
belief in the justice of the cause ;
belief in the soundness of the higher leadership;
(iii) efficient primary selection to exclude the mentally unfit; (iv) planned placing of men in roles for which they are suited; (v) efficient training methods and the inculcation of group feeling; (vi) careful, skilled and considerate officers ; (vii) planned indoctrination and up to date dissemination of information.
In 1939 the British Army was well off in the first mentioned of these desiderata; the third and fourth Vyere non existent; and the remainder were matters ?t individual chance?with often, it must be admitted, a surprisingly high standard. There were inherent possibilities in scientific Election, which in the 1914-1918 war had achieved Considerable success in the American Army. Also was known that Germany had been pioneering 111 military psychology and both the British Army and the R.A.F. had conducted small scale experiments in selection. But there was no plan for aPplication of selection and nobody within the organizations concerned capable of advances in mis field.
General Problems and the Psychiatric Answer The main shape of the problem was fixed by circumstances. War was declared and the country had unknown and possibly immediate military hazards to face; conscription laws were passed and operating ; several groups of militia were already serving; there was a great rush of volunteers. Soon the monthly intake was to exceed 50,000 men?a figure far beyond the scope of any testing system then available. All this made for a very embarrassed start for any proposed system of preventive mental hygiene. As a background moreover was preoccupation with the immediate campaign? not an encouraging circumstance for long term plans. The expansion of the army itself created a problem the size of which is not generally realized. We required a force of over three million men in the field, whereas the peacetime strength of the army was under 150,000 of which half were overseas, the remainder being home garrison and training units. Add to this the Reserve and the Territorial armies, the former rusty and the latter only partially trained, and the number did not exceed 500,000. If only up to date fully trained soldiers were counted on for training purposes the expansion was nearly fifty-fold. And yet 350,000 British soldiers were in action at Dunkirk. Where were the instructors to come from ? If even one instructor was provided for every ten men, who would meanwhile fight the war ? The situation called for every quality of improvisation on which the British pride themselves, and in addition, the most rigorously economical use of man power. Psychiatry contributed its help to the latter.
The order in which these problems were tackled was determined by the urgency described above. The priority could be arranged as follows :
(i) the provision of a service to remove psychiatric battle casualties from the battle area and to provide emergency treatment. (ii) the elimination from the service of all men mentally unfit to serve. (iii) The proper selection of recruits on entering the service and the selection of future officers, N.C.O.’s and specialists. (iv) The fostering of unit morale by help and guidance on man management and the solution of human problems. (v) Care of psychiatric illness occurring apart from battle stress.
Many readers may be surprised at the lowly position of No. (v) and may not approve of the seemingly scant respect paid to Medicine’s traditional function. Yet taking the situation as a whole, remembering that the security of the nation was at stake, what other answer was possible ? As problem and answer became more defined, the psychiatric service grew up on an area basis. It was not easy to obtain support for this at first, because the natural plan would have been to provide special hospitals for psychiatric in-patients and specialist psychiatrists at the larger military hospitals for out-patient consultations. It was an innovation to insist on a service able to go to local units (like the army hygiene authorities), and naturally at this time there were few statistics to support the contentions. The fact that just over a year from the outbreak of war, in addition to a senior psychiatrist at each Command Headquarters, an Area Psychiatrist was stationed in each military area, speaks well both for the efforts of the Consultant and for the adaptability of the military authorities.
The early days of the area work were not without their humours and perplexities for the officers concerned. Although well indoctrinated themselves, most were inexperienced in the ways of the army, and there being no precedent, they found that their senior officers usually had little idea how to use them and at first they had to create their own jobs. It is a common experience in the medical and social world that the provision of a facility reveals a demand not widely recognized?an incidence of this is in Dr Blacker’s Survey which shows that the pressure on psychiatric clinics is greatest where they are most numerous per head of population, and least where facilities are fewest. The army experience bore this out, and in a very few weeks psychiatrists were uniformly overworked and had to be reinforced until there were more than 300. The first reason for the rapid and maintained expansion was that psychiatry was able to define and deal with the problems raised by the dull and the unstable, which hitherto had had to be borne by their fellow soldiers, to the serious internal weakness of the service.
Special Problems and their Solution
It is only relevant to dwell on those aspects of army psychiatry which bear immediately on our post-war plans, and the problem of the battle casualty can be summarily dismissed. The circumstances in this category are peculiar to warfare and mainly concern logistics?getting the right people to or from the right place at the right time. It was not a major concern of the home army during the early part of the war, and it was later that this important task was tackled as part of the overseas campaigns. Experience was rich and varied, but more suitable for description in another place.
Elimination of the Mentally Unfit
(a) The Subnormal The extent of the difficulties caused by the mentally subnormal and the unstable came as a great shock to the army and to that small proportion of the general public who were interested. Yet it could have been foreseen that at least 10 per cent, of the population was too dull of intelligence to learn modern soldiering. It would have been reasonable to infer that men who in civil life had remained unskilled labourers would not learn the intricate handling of lethal weapons. Soldiering had long outgrown the cannon fodder phase I the days when digging was the most important ‘ task of the infantryman and the rifle his only weapon. Anyone who doubts this had better learn the infantry soldier’s job?the use of the six or so complicated precision instruments which are his weapons ?learning to co-operate with Armoured Fighting Vehicles of all shapes and speeds, and with the Air Force?and not least the gentle art of killing and not being killed, using two legs and such natural cover as happens to exist.
It was not surprising that in the middle of the rush expansion phase the army was embarrassed by the dull and subnormal. One dull man hampers the work of the whole platoon and draws upon , himself the impatience of his instructor and the | irritation of his fellows who are forced to repeat and repeat exercises for his benefit. Out of his bewilderment and humiliation is born another maladjusted and unreliable soldier. Nor is the j formation of the so called ” awkward squad “> the segregation of the dull, either a truly humane or economical answer; such a squad is scarcely the pride of the army, which is not backward in saying so ! But the most serious result was the effect on the normal man, the waste of time and . delay in training, the employment of instructors on useless work. ,
The psychiatrist was able to supply the answer because of his familiarity with the phenomenon j of dullness. The inability of medical boards to exclude dullards was the root cause of the problemThese boards were neither equipped with the necessary technical procedure nor had the time available to ascertain dullness, and (more important) had no mandate either from authority or from [ public opinion to do so. The only exception was mental deficiency so gross as to be obvious to even a cursory verbal examination. The unintelligent borderline defective was accepted for military service, partly because there is little public informs- > tion about the number and limitations of this class, j and partly because of emotionally conditioned ^ thinking based on eugenic fears about the main | burden of sacrifice being confined to our finest and ^ fittest young men. To the extreme upholders oi the eugenic view it might seem logical to put all dull and unstable men in the ” front line “so that the bulk of the nation’s casualties will occur j among the constitutionally inferior?thus improving I the natural stock in the next generation. Such a ?: view might have something to recommend it (were an end to justify the means) had not the national existence depended on the efficiency the armed forces. Such men are bad soldiers, and the retention of bad soldiers, whether as individuals or as groups, endangers the security of the whole and is not to be tolerated.
The solution lay in the creation of a separate Corps whose main function was labouring?the building of roads, railways and fortifications, and Particularly docks and railheads with the various Expeditionary Forces. Within this corps an environment was created sufficiently uncomplicated for limited ability and such Units usually quickly showed all the signs of smartness and keenness betokening good morale. Nor did they suffer from the criticisms of other Units, who could only Judge them by their results, which were good.
% this simple solution thousands of men were Siven the chance of honourable and satisfactory service instead of a life of frustration and trouble. (6) The Psychologically Unstable
, The notion that men can be turned into soldiers py a mere Act of Parliament has been proved wrong lr* two wars. Yet the nation was enormously 9?mforted by the passing of the Conscription Act ln 1939, apparently unmindful of the long period ?f training ahead before such conscripts would be soldiers. In fact, Dunkirk and Singapore were lQst and North Africa a somewhat chequered military experience, before the fruits of that Act }yere gathered. Behind this story of hope deferred ues the story of the individual unsuccessful soldier ^hose presence delayed training and wasted strength. Men in this group are of normal intelligence, and suffer from no disease known primarily t? physical and somatic medicine. They are Psychologically inferior?not capable of making adjustments to the conditions of military life ; arid their number runs to many scores of thousands. The induction and training period is not easy for the recruit and there is an inevitable incidence of Neurotic breakdown. This phenomenon has little direct relationship with bravery or cowardice in the held. Few men are sufficiently long-sighted to appreciate the future dangers of action while still ^ training. This is perhaps unfortunate for man?ind : maybe there would be fewer wars if humanity were more farsighted ! The precipitating causes of breakdown are more subtle and ^ore intimately connected with the present. The change of environment is much more drastic ^an the mere alteration of work and surroundings. o the loss of home life and of the immediate SuPP0rt and love of relations and friends there is added the loss of individuality. Perhaps the hardest blow to the recruit is the loss of the ‘^dividual esteem of those nearest him, and there is a nasty gap before those other esteems, loyalties a?d affections are available which the army has to ^her, not ungenerously, to those fitted to accept them. It will be difficult for those who have never PjVen military service to understand that complete Verification with the group which occurs in a good unit. The sense of comradeship, of unity, is remarkaole and for many men will exceed in depth any ^otional relationship previously experienced. Without this binding force, devotion to duty and .self-sacrifice could not occur. Most men need a angible love object and it is far easier to die for 0ne’s mates than for an abstract idea, or for the good of the country which may just then be dunning one for income tax arrears.
Unfortunately this essential identification was not universally attained. It requires a certain basic emotional adaptability and those too heavily dependent on previous attachments could not achieve it. In mild form this resulted in the chronic grumbler, the man who remained a civilian at heart, often taking pride in this not entirely mature reaction. In more severe form was the neurotic breakdown and the psychopathic delinquent. The mild form is usually kept in check by discipline with only slight loss of efficiency. The severe form presents an intractable problem, the cause of much wasted time and effort unless handled with psychological insight. The duty of the psychiatrist here was to define the condition and arrange for swift and unobstrusive removal, if intractable, from the military sphere.
The decision to remove the unstable was hotly debated, the Eugenists again resented the biologically inferior being removed to comparative safety ; other unwilling soldiers disliked the way in which these men could ” work their ticketMost people resented the way in which some of these men on discharge lived at home and sometimes earned four times as much money in industry? though in fact the industrial history of such men was rarely as rosy as that and as a class they are best known to the National Health Insurance authorities or Public Assistance. Fortunately sane counsels prevailed ; the difficulty is one of fundamental adjustment, no amount of dragooning can make such a man a reliable soldier ; so that if a suitable type of Army occupation could not be found, these men were discharged. A certain amount of effective placement was done, but in the main it had to be remembered that the primary duty of the Army was to fight the enemy and it could not carry passengers.
The decision to discharge the unfit was possible because army psychiatrists were able to assess the degree of unfitness more accurately than any other agency hitherto. But doctors are so used to fighting the battles of their patients that this weeding out and discarding came strangely to the majority of psychiatrists, who were in this matter, acting primarily in the army’s interest and only secondly in the interests of their patients. This necessary bias, distasteful as it may seem to many, must be borne in mind when attempting to assess the value of the work done. So that, many of the stories told about specialists being hood-winked by their patients are wide of the mark, because the psychiatrist was primarily engaged in assessing military usefulness. In recommending discharge he did not necessarily believe the ” hard luck ” story told him by a disingenuous patient. Moreover, he was in no sense engaged in moral judgment as to the worthiness of the individual. Such stories always seem to imply that discharge from the army is a reward to be given only to deserving cases?an idea with which the Army could by no means agree, nor did many men so discharged feel that they had achieved anything meritorious.
Vocational Selection in the Services ? In reducing the problem of the dull and unstable to manageable proportions and in advancing a planned procedure for such matters, psychiatry made a major contribution to efficiency, and cleared the ground for other important functions. The care of the psychiatric sick was undertaken in its acute phases, but, by arrangement with civil medical authorities, was usually handed over to the Emergency Medical Service when chronic, about which procedure and its wisdom there are two schools of thought. However, to proceed, the next important contribution was the building up of an efficient selection system. This function is of course primarily the role of the vocational psychologist, but in the early days of the war it came within the purview of the psychiatrist, because the latter were already working within the Army organization, and able, by preliminary surveys and rudimentary efforts, to create a demand which psychologists could be called in to fill. Thereafter the two branches worked side by side in their proper spheres, psychiatry contributing work and advice on the psychiatric aspects of scientific selection. The principles followed were :
(1) to define in detail the various types of work and life within the army ; (2) to define the qualities needed to ensure a minimum standard of efficiency in each job; and further, the minimum personal qualities to ensure reasonable efficiency and (3) the examination of the individual soldier, to determine where he could most usefully serve.
Psychiatrists made a special contribution to the selection of officers, a task requiring more detailed care. Selection of soldiers for training to become officers depends mainly on three points : (1) an adequate standard of intelligence and of general education ; (2) proved efficiency as a soldier and (3) possession of personality qualities enabling a man to look after, lead and inspire other men under conditions of difficulty, hardship and danger.
Selections were made by close teamwork between regimental soldiers, psychologists and psychiatrists. The first named could assess military efficiency and supply the soldier’s view point on personality qualities?a valuable contribution. The second could assess intelligence and education by history and intelligence tests and could define, by personality tests, the general structure of personality, and the last named supplied clinical experience and the interpretation of the data obtained by all three. It has now been reliably established that this team method of selection has given better results than any other method hitherto employed. Morale and Man Management J The foundations of good morale in a service have ] been enumerated above, and much can be achieved provided that recruits have the necessary heart and will. Such morale is derived from national need and provided the basic structure of society is sound, can be developed by adequate and wise training. Nothing gives a soldier more confidence than mastery of his craft, and psychiatrists were able | to help much by advising on mass and individual training problems. However, after training is i complete and the soldiers are serving in the units in which they will eventually fight, there is still | much to be done-by the interpretation of sound psychological principles to officers and men alike. Area Psychiatrists, moving from unit to unit, t living in messes, meeting and mixing with soldiers | and, as far as possible, sharing their difficulties and hardships, were able to make a valuable contribution. They were constantly in demand for consultation on individual disciplinary conun- | drums, on court martial work and in discussion with commanding officers and groups of junior officers on the handling of men and their proper indoctrination. This meant a considerable widen- | ing of the sphere the psychiatrist would normally call his own and involved study and thought. | It was found almost universally that serving officers welcomed the fresh light thrown on old problems by those experienced in handling difficult psychological problems. No body of men can be trained I in licensed killing without stirring up much that is fundamental in human reactions, and in considering the situations which inevitably arose, psychiatrists as a class were possibly less prone to emotional judgments than soldiers who had never received any systematic training in dealing with emotional problems. In general, it might be said that the quality of the advice offered varied very much according to the ability of the adviser himself to absorb the fundamentals of the military situationThe undertaking of special surveys was a frequent result of such informal talks. For instance, units had at times found themselves worried by abnormally high rates of minor sickness or ” epidemics ‘ of absenteeism, often traceable on investigation to something sociologically unsound in the structure of the unit. This could be ascertained and remedies suggested. Special studies were undertaken on enemy psychology and morale ; on the design and use of new weapons or methods of warfare; on the employment of the partially disabled; and on rehabilitation of the sick and of returned prisoners of war. It is impossible to enumerate all the individual tasks undertaken in the interests or mental health.
The value of these many contributions is still a matter for careful assessment and debate, but it cannot be doubted that those working in this field have themselves learned much, and should be ? able to profit both from their successes and their mistakes. Much which has been learned is applicable I [o both war and peace, because fundamentally j ^ere is a similarity between the group structure / ?f an army at war and of a nation in its peacetime w?rk. But there are differences to be borne in ^ind, one being that the army for most soldiers Was a temporary phase in life. For such men the army existed only for the specific purpose of beating the enemy, and it did undoubtedly by its attitude to its own psychiatric problems contribute, though unwillingly, to the problems to be solved in peace-time life. In the next and concluding article it is proposed to examine these differences rather more fully and offer some speculations as to what can be done by organized psychiatry in the future. (To be concluded)
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.