I Social Work in a Military Hospital
- Author:
SUBALTERN B. GAUTREY, A.T.S.
Military Social Worker In August, 1944, the Army Department of Psychiatry decided to train selected A.T.S. Officers as Military Social Workers in various psychiatric hospitals. The following is a brief survey of the work done since that time till March, 1946, in the largest military hospital dealing with psychoneurotic cases.
The range of cases dealt with has been varied but marital and family difficulties have been amongst the most frequent and difficult. The following table shows the number and type of problem presented :
Total cases interviewed .. .. 1,866 Average number of interviews per case 4 Distribution of main problems. Investigations regarding compassionate release or postings .. .. .. 91 Financial problems 167 Marital and family difficulties .. 226 Legal aid .. .. .. .. 74 Interviews to arrange After-Care 211 Home investigations .. .. .. 67 Housing difficulties .. .. .. 132 Compassionate leave investigations .. 521 Other domestic problems .. .. 377 In addition, 2,275 men were interviewed in groups before being discharged to civil life as medically unfit for further service. This was to discuss their resettlement problems and generally to give information concerning pay on leave, grants from the Ministry of Labour, etc.
It will be seen that this table merely shows a very rough division of cases. Under the heading ” Marital and Family Difficulties “, are included arrangements made for the relatives of patients to visit the hospital to interview the doctor and social worker. Accommodation is found for them, as they usually need to stay overnight, and, if necessary, we send reduced travel vouchers. The psychiatrist may feel that it will be helpful for the treatment of his patient for a wife to stay in the vicinity of the hospital for a longer period. Where there are financial difficulties, grants are obtained from the Commanding Officer’s Fund to cover the expenses of the visit.
If a visit to the hospital is impracticable and the psychiatrist feels that a more detailed picture of his patient’s home and relatives might be helpful, home visits are arranged. If in the vicinity of the hospital these are undertaken by the military social worker, and for others the Provisional National Council for Mental Health have been extremely helpful.
A large number of applications for compassionate leave are received and are investigated by the military social worker. If it is practicable the reason for the request is verified, always with as much speed as possible, so that the patient can feel that an interest is taken in his home anxieties and his possible desire to go absent without leave is thereby minimized.
Whenever the army scale of allowances is proved to be inadequate, a patient’s anxieties can be allayed by helping him to apply for additional grants such as Emergency War Service Grants, War Service Grants, Dependents’ allowances, etc. Also S.S.A.F.A. are frequently approached for their help in adjusting the family income to meet their needs.
Anxious relatives and friends are constantly enquiring about the health of the patients and these letters are dealt with by the military social worker after consulting the psychiatrist concerned. Also enquiries are received from civilian organizations, *n particular the After-Care Regional Officers, for particulars of former patients referred to them for help.
Compassionate Postings
As can be expected many applications for compassionate postings have had to be investigated. It is not always realized that even if the grounds ?f application are good, and have been corroborated, that such a posting may not prove a complete solution of the problem. A man may be posted as near as possible to his home, but this may prove to be at least twenty miles away. This is too far to Pe of any real assistance to his family and may merely increase his anxiety, as he feels eager to help but ls unable, materially, to do so. Even if he is actually living at home, the daily difficulties may Prove such a burden, in conjunction with his army work, that he becomes a liability to his home and to the army.
Case 1.?Pte. D., on the staff of the hospital, had a compassionate posting here, after his wife gave birth to a child when he had been in Burma two years. He accepted the child and was extremely proud of her and spent all his savings in providing clothes, etc. for her. He and his wife lived with her parents, but his wife’s mother made difficulties. She refused to allow them to sleep together, sleeping with the wife herself and making Pte. D. occupy a room with a young brother, although there was sufficient room in the house for other arrangements to be made. Both Pte. D. and his wife were, naturally, unhappy at this arrangement, but both were timid and the mother-in-law domineering. Eventually they were helped to find other accommodation and they settled down happily. ^atrimonal and Family Problems This is far the largest group and includes the most ornplex problems requiring close co-operation etween the psychiatrist and social worker.
(a) Family 11 has been widely recognized Readjustment that many difficulties of family u * readjustment are experienced em fetVr?nS prisoners of war. It cannot be Phasized too strongly that the majority of these problems are also experienced by the man returning from long service overseas. He has experienced the same anxiety about his wife and family and has been subject to similar letters from well meaning friends, possibly making allegations against his wife. He feels different and out of everything when he comes back, finding his wife has changed so greatly. The wife, also, must realize that her husband too will have changed. The factors of separation, and the necessity of being a self reliant individual during their loneliness, have changed them both. The difficulties of readjustment are likely to be great and take a long time to resolve. Many men overseas have built up a fantasy picture of home, their wife, the children, their own private world. On their return it is all so different. In some cases even though the home is obviously broken up and the wife has no inclination to return to her husband, he cannot accept it. His home has been his anchor all the years away and he cannot face life without it. He will accept anything rather than the break up of his home. Then, sometimes, it is best to help him to realize that it is an untenable situation, he must find new interests and a different future from the one he has envisaged so long. A wife has usually looked forward desperately, during the time her husband has been away, to his return so that she may again lean on him. He, however, wishes to come home to be mothered and cherished, and is not ready to take over the responsibilities of home immediately. His wife must be helped to an understanding of her husband’s feelings and to accept the position of head of the family for a little longer. It has also been necessary to try and help the wife to accept the fact of her husband’s neurosis, to allay her anxiety with regard to insanity and again to reassure her that he is not less of a man because of his breakdown. The man may need a woman’s reassurance and help to allay his guilt at having broken down and having sustained a blow to his masculine pride.
Children, also, often find it difficult to accept the father’s return after so long away, and become troublesome and aggressive. Thus Pte. T. after disembarkation leave said that his small son was quite unmanageable. He obeyed his father, but now had become exceedingly difficult with his mother. Arrangements were made for the child to be referred to a Child Guidance Clinic.
srTT r , , ? The unfaithful wife, either in (b) Unfaithfulness. actuajjty or jn the imagination of the man, is often a precipitating factor in a soldier’s breakdown. A recent survey of neurosis among repatriated prisoners of war, found the incidence to be as high as 25 per cent. Among the cases in this hospital, infidelity in the wife has been found to arouse many varying reactions in the husband. Some men can condone the offence, realizing the difficulties that their wives have experienced during their absence, the loneliness and the monotony of their existence. In many, however, the idea of tolerating such a lapse is impossible. Their immediate reaction is divorce? at once. When it is explained this may take about eighteen months, their enthusiasm often wanes and they are prepared to reconsider their decision. Often they have not known of the situation before arriving home. Possibly there is an illegitimate child of whose existence they were unaware, and the shock of this discovery tends to warp their judgement. Time, however, may give a more objective view if they are not inundated by hasty advice from well meaning friends, relatives or outsiders. If they can be advised to consider whether, in fact, they still do love their wives and can tolerate the situation, there is then some chance of establishing a satisfactory marital relationship again. When there is an illegitimate child it has been found important to impress upon the man that he must decide whether he can accept the child. If so he must be prepared to accept it fully and not as a perpetual reminder of his wife’s lapse. Should he be unable to do this, but wishes to remain with his wife, then, providing his wife agrees, adoption is best arranged as soon as possible. Case 2.?An illustration of this type of case is Pte. N., who when he first came to the hospital, was full of aggression against his wife, who was then pregnant with a child of which he was not the father. At first he was determined that the child must be adopted and that no one must ever know; this seemed to him easy, as his wife was at that time evacuated in the country with their daughter, aged 3, but was planning to return home. He was discharged from the Army, but during his period in hospital he recovered from his first shock and fury against his wife. At first he took no part in hospital activities, ruminated on his misfortune and talked about it to everyone. Endeavours were made to ascertain the wife’s attitude to adoption, but she refused to come to the hospital, or keep appointments made for her locally. Before he left the hospital he was happier but still wanted the child adopted. He had recovered sufficiently to do a full day’s work in a factory near the hospital. He was recommended for the After-Care Scheme and six months later a follow-up showed that after the child was born he had decided to accept it. He was still resentful against his wife, but was settling down fairly well.
(rCpYiiai Another factor in the marDifficulties. ri,?se . difficulties of men returning from long service overseas is temporary impotence. It is quite frequent on their repatriation leave and when they come into hospital they are very depressed about it. The fear of impotence often grows up in a man during captivity, or long service overseas; he broods about it and fears that such things as the deprivation of food he has undergone, may affect his virility. When he goes on leave his anxiety produces the result he has feared. It helps enormously if the wife can be interviewed and helped to understand that her husband is no less a ” real man ” because of this temporary situation?that she, more than anyone else, can help him to regain his potency and that she must try not to be impatient with him or despise him.
Another type of patient who is extremely difficult to help is the syphilophobe. He may have run no actual risk of infection, or been exposed only once, but that one episode has produced such feelings of guilt that it is exceedingly difficult for him to be convinced that he is free from infection. These men are often depressed and their wives are acutely anxious about them, without realizing the cause of the depression. It thus becomes a social, as well as an individual psychiatric problem. If the man can explain the situation, and the wife can understand, it will probably help more than anything else. Nevertheless it is considered dangerous for any man to be advised to discuss this illness with his wife, unless she has previously been interviewed and considered mature enough to grasp it. The situation on leave can be distressing if the implications have not been foreseen, as the man may be afraid of infecting his wife and so refuse to have intercourse, or may find himself impotent because of his guilt towards her.
Case 3.?Pte. M., had served three years overseas and was nearly due for leave in the U.K., when he had intercourse with a prostitute for the first time. Shortly after this he complained of a feeling of numbness in his genitals. He went on leave and, finding intercourse impossible, told his wife what had occurred. At the end of his leave he was still acutely depressed, and reported sick immediately he returned to his unit. After tests for V.D. had proved negative and he refused to accept reassurance, he was seen by a psychiatrist and admitted here. On admission he was depressed, introspective and cried most of the day. He still complained of lack of feeling and could not believe that he was free from infection. He wanted to see his wife, but said he was not worthy to do so. Mrs. M. was invited to visit the social worker at the hospital and she agreed. She was an upright little Yorkshire woman, who did not understand her husband’s illness at all. They had planned to have another child when he came on leave and she felt that she could not now do this. She took up a determined attitude of a wronged wife. She said she did not understand her husband’s act because she, herself, did not understand physical desire. She felt she had a good hold on him for life, if she took him back, but was prepared to keep him wondering about this indefinitely. Eventually she was helped to realize that she could accept his fault and that by appearing to want him physically again, she might help him to become potent and lose his fear of V.D. His psychiatric treatment included a course of E.C.T. He became more cheerful and, when he eventually left hospital, was planning to have another child.
Resettlement Advice
Recently a large number of patients have been discharged from hospital to return to civil life. AH these men have been seen and explanation given regarding arrangements made for their terming leave in relation to pay, allowances, etc., what facilities there are for applying for help for employment, Ministry of Labour training schemes and to whom they should apply if they are in difficulty. In addition a certain number of men are recommended for the After-Care Scheme of the Provisional National Council for Mental Health. It is felt strongly that the men should be considered, not only as an individual, but as part of a family social unit. In this connection a man may be recommended for the After-Care Scheme largely because it is felt his wife, or mother, may need help or advice. In addition to the usual resettlement difficulties, the wife, or mother, may feel the burden of the man’s neurosis too heavy to carry. The realization that she has someone to whom she can turn, and who will understand her difficulties, ean ease the emotional strain.
Case 4.?Major T. was a regular soldier, who had had several severe breakdowns in the past. He could not bring himself to tolerate the idea of civilian life and had no idea what work he could do. His wife, also, was exceedingly neurotic. She had married hoping her husband would be a tower of strength, but she had found that a very small breeze would knock him over. Their physical relations had always been unsatisfactory as she had never received any satisfaction from them, while he did not understand how his wife felt. Both were helped by a full discussion of their future, which both dreaded. He was recommended for After-Care and therefore felt he had something to lean on, while Mrs. T. welcomed the discussion of her difficulties and the prospect of understanding help in the future.
There have been several cases of men recommended for discharge but who have nowhere to ?? and do not know what employment to take up. Case 5.?Pte. B. was aged 34, and of very low grade intelligence and illiterate. His parents were dead and he had not been in contact with his brothers and sisters since 1934. He had nowhere to go on discharge. At first efforts were made to trace his relatives, but without success as they had moved and left no address. He said he would like to work on the land, in one of the Western counties, as he knew that area and had worked there before as a groom. Contact was made with a former employer who agreed to re-employ him in farm work and eventually accommodation was found for him in a nearby village.
Conclusion
In the hospital, it has been found that having social workers who are themselves in the army and have a knowledge of the military machine, has helped enormously in understanding the patients. One’s own difficulties in the army have given an insight into the problem that a civilian could not have acquired. The earlier a man’s total welfare and family situation can be considered, the more chance there is of being able to give constructive help. If these aspects are left until he is about to be discharged, it may be too late to do more than touch the fringe of the problem.
It is fully realized that the cases used to illustrate the points made, can only be accepted as readjusted in a limited sense. The stay of each man in hospital is unlikely to be longer than 3 to 4 months and in that time it is only possible to assess the possible future according to the adjustments he has made during his stay. The follow-up visits that were done have helped to substantiate this a little, but it is still all too possible that hopeful progress of these men and their families may not be sustained. It is thought that many of these problems will be met by social workers dealing with men recently demobilized, as they are not only to be found in men suffering from neurosis, as has been substantiated by the advice sought by the men on the staff of this hospital. It is hoped, therefore, that this somewhat fragmentary picture may be helpful to others engaged in similar work.
I wish to thank Colonel L. M. Rowlette, D.S.O., M.C. for permission to write this paper. Also Subaltern Elton with whom I have worked at this hospital.
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