Psychiatry and Military Manpower Policy: A Reappraisal of the Experience in World War II 9780231888790

Citation preview

GRADUATE SCHOOL OF BUSINESS, COLUMBIA UNIVERSITY

HUMAN

RESOURCES

STUDIES

Psychiatry and Military Manpower Policy A REAPPRAISAL OF THE EXPERIENCE IN WORLD WAR II

by ELI GINZBERG JOHN L. HERMA and SOL W. GINSBURG, M.D.

KING'S CROWN PRESS C O L U M B I A U N I V E R S I T Y , NEW 19 5 3

YORK

C O P Y R I G H T 1 9 5 3 BY COLUMBIA U N I V E R S I T Y P R E S S

KINO'S CROWN IS AN I M P R I N T UNIVERSITY MAKINO THAT

PRESS

END,

AT

NOT

REASONABLE

AUTHORS

HAVE

TOWARD

HAVE

USED

INCORPORATING

ECONOMY

WITH

OF

MATERIAL

COST.

PUBLISHERS

COLUMBIA

PURPOSE

SCHOLARLY

FORMATS

INTERFERE

BY

THE

MINIMUM

THE

STANDARDIZED EVERY

FOR

CERTAIN

AVAILABLE

PRESS

ESTABLISHED

THAT

LEOIBILITY.

ASSUMED

COMPLETE

DOES THE RE-

S P O N S I B I L I T Y FOR EDITORIAL S T Y L E AND FOR PROOFREADING.

Library of Congress Catalog Card Number:

53-12344

P U B U S H E D IN GREAT BRITAIN, CANADA, INDIA, AND P A K I S T A N BY G E O F F R E Y C U M B E R L E G E , OXFORD U N I V E R S I T Y LONDON, TORONTO,

BOMBAY, AND

PRESS

KARACHI

M A N U F A C T U R E D IN T H E U N I T E D S T A T E S O F AMERICA

Conservation of Human A RESEARCH

Resources

PROJECT

GRADUATE S C H O O L O F B U S I N E S S , COLUMBIA

UNIVERSITY

T h e CONSERVATION OF HUMAN RESOURCES p r o j e c t was estab-

lished in 1950 within the Graduate School of Business, Columbia University, by General Eisenhower. Philip Young, then Dean of the Graduate School of Business, assumed responsibility for the general administration and supervision of the project from its inception until the spring of this year, when he became Chairman of the Civil Service Commission. Eli Ginzberg, Professor of Economics in the Graduate School of Business, is Director of the project. Sponsoring

Organizations

AMERICAN

CAN

COMPANY

BIGELOW-SANFORD CARPET CITIES

SERVICE

CLUETT,

COMPANY

COMPANY

PEABODY AND C O M P A N Y

COLUMBIA

BROADCASTING

SYSTEM

CONSOLIDATED EDISON C O M P A N Y OF N E W CONTINENTAL CAN E.

YORK

COMPANY

I . DU P O N T DE N E M O U R S AND C O M P A N Y

GENERAL

ELECTRIC

GENERAL

FOODS

COMPANY

CORPORATION

RADIO CORPORATION OF STANDARD O I L THE

NEW

COMPANY

YORK

AMERICA (New

COMMUNITY

Jersey) TRUST

In addition to the foregoing, the Ford Foundation has also contributed to the financing of the project.

STAFF DIRECTOR E L I GINZBERG,

Ph.D. ADVISOR

HOWARD M C C . SNYDER,

Major General,

M.C., U.S.

Army

CONSULTANT SOL W . GINSBURG, M . D . ,

Psychiatry

RESEARCH ASSOCIATES

Manpower and Personnel Social Psychology H E N R Y DAVID, P h . D . , Labor History J O H N L . HERMA, P h . D . , Psychology JAMES K . ANDERSON, A . B . , DOUGLAS W . BRAY, P h . D . ,

RESEARCH ASSISTANTS

Economics* Labor Economics* R Y A N , Captain, U.S. Army, Social SMUTS, M . A . , Economic History

DALE L . HIESTAND, M . A . , I . PEGGY M O S E S , M . A . , FRANCIS J . ROBERT W .

ADMINISTRATIVE

Administrative Assistant* Statistical Assistant PATRICIA STEGMAN, Secretary J E A N N E T O M B L E N , Secretary to the Director BRYNA BALL,

STEWART K N A P P ,

•National M a n p o w e r Council Staff

Work

Foreword IN 1950 General Dwight D. Eisenhower established the Conservation of Human Resources project to continue and expand studies in the human resources field initiated at the Graduate School of Business of Columbia University in the 1930's. The principal objective of the project is to increase basic knowledge in the field of human resources and thereby provide a solid foundation for policies aimed at conserving this most valuable national resource. The Conservation of Human Resources Progress Report, Summer, 1953, summarizes the results of the project's investigations through the middle of this year. Some of these results have been published either in book form or as articles in scholarly journals. We consider it desirable to introduce at this time another method for making our findings available. We have decided to issue a series of monographs entitled Human Resources Studies in order to reach a wider audience than is possible through journals for those aspects of our work which are not suited for full-scale book publication. A major objective of this monograph series is to present our preliminary approaches and findings in the hope that we will profit from criticism and suggestions while our larger investigations are still under way. During the latter part of World War II and especially at the time of the Battle of the Bulge, General Eisenhower was hard put to meet manpower requirements, particularly in the combat element of his forces. He was disturbed to

[v]

find that the United States was apparently so close to the end of her manpower reserves. Experiences during the war and the tabulations available after the war pointed to tremendous losses of manpower which resulted from men being rejected for military service or being prematurely separated because of emotional disability. From the start of the Conservation of Human Resources project in 1950, the staff has been actively engaged in a major study of The Ineffective Soldier to determine the reasons for this serious manpower loss. We are conducting this investigation with the full cooperation of the Department of the Army and of other governmental and nongovernmental agencies. Since the military manpower experience of the United States in World War I I was greatly affected by the role of the psychiatrist in military service, our study led us to seek the cooperation of a representative group of psychiatrists who had been on active military duty during the war. We were sure that if we could tap their experiences and, even more important, their later reflections upon these experiences, we could move ahead more securely in the development of our research plan. This monograph tells the story of our effort to obtain the cooperation of a group of psychiatrists, the remarkable response to our request, and the important guidance which we received from their answers. To a large extent, this monograph is their work. We were the catalysts but they were the authors. We have decided to publish our analysis of their replies because we feel that this reappraisal of World War I I experience is at once a significant contribution to military history and to future research. The title we have selected is descriptive not of our analysis but of the framework of the problem.

[vi]

We hope and expect to profit further from the assistance of these psychiatrists, as well as from the criticisms and suggestions of other experts who take the opportunity to review our plan for the study of The Ineffective Soldier which forms the last chapter of the monograph. We are indebted to Major General Howard Snyder, Advisor to the Conservation of Human Resources project, who reviewed successive drafts of the manuscript and made valuable suggestions. E L I GINZBERG DIRECTOR, CONSERVATION HUMAN R E S O U R C E S

Graduate School of Business Columbia University September, 19J3

[vii]

OF

Cooperating BENJAMIN

Psychiatrists

BALSER

IRVINO

College of Physicians and Surgeons Columbia University New York, N. Y. IVAN

C.

WILLIAM

BERLIEN

JACK

EWALT

DANA W.

FARNSWORTH

Massachusetts Institute of Technology Cambridge, Mass.

BROSIN

University of Pittsburgh Pittsburgh, Penna. TEMPLE

DUNN

Massachusetts State Dept. of Mental Health Boston, Mass.

BRILL

University of California at Los Angeles Los Angeles, Calif. HENRY

H.

The New York Hospital New York, N. Y.

Detroit, Michigan NORMAN

DRIBBEN

Albany Hospital Albany, N. Y.

BURLING

MALCOLM

J.

FARRELL

Cornell University Ithaca, N. Y.

Walter E. Fernald State School Waverley, Mass.

JOHN

ROBERT

CALDWELL

Army Medical Center Washington, D. C. DALE

CAMERON

U. S. Public Health Service Washington, D. C. JOHN M.

DAVID

FLICKER

St. Mary's Hospital Passaic, N. J.

COTTON

Payne Whitney Clinic The New York Hospital New York, N. Y. CALVIN

FELIX

National Institute of Mental Health Bethesda, Md.

ROY

GRINKER

Michael Reese Hospital Chicago, 111.

DRAYER

RICHARD

Pennsylvania Hospital Philadelphia, Penna.

JENKINS

Veterans Administration Washington, D. C.

[ix]

LAWRENCE

S.

KUBIB

FLORENCE

New York Neurological Institute New York, N. Y. THEODORS

LIDZ

NORMAN

Yale University New Haven, Conn.

PHILIP

MCKERRACHER

WILLIAM

C.

LAUREN

JOSEPH

MENNINOER HARRY

MICHAELS

A . WARREN

STEARNS

Tufts College Medford, Mass.

MITTELMANN

New York University New York, N. Y.

GEORGE

STEVENSON

National Association for Mental Health New York, N. Y.

MURRAY

Boston University Boston, Mass. H.

SOLOMON

Harvard University Boston, Mass.

Harvard Medical School Boston, Mass.

JOHN M .

SMITH

Pennsylvania Hospital Philadelphia, Penna.

Mcnninger Foundation Topeka, Kan.

E.

ROCHE

University of Pennsylvania Philadelphia, Penna.

Regina General Hospital Regina, Saskatchewan Canada

BELA

REIDER

Mt. Zion Hospital San Francisco, Calif.

Louis L I N N Mt. Sinai Hospital New York, N. Y. D. G.

POWDERMAKER

Vanderbilt Clinic Columbia University New York, N. Y.

RAYMOND

PARSONS

WAGGONER

University of Michigan Ann Arbor, Mich.

Barnes Hospital St. Louis, Mo.

[x]

Contents I. II.

PSYCHIATRY WHAT

AND M I L I T A R Y

DO T H E DID MEN

FIGURES

MANPOWER

MEAN

BREAK

1 8

in.

WHY

IV.

A D J U S T M E N T IN M I L I T A R Y AND CIVILIAN L I F E

37

V.

HOW

46

VI.

THE

CAN M A N P O W E R INEFFECTIVE

23

BE

SOLDIER

[Xi]

SAVED

56

I

Psychiatry and Military Manpower D U R I N G World War II almost a million men were rejected for military service because of emotional defects, and an almost equal number were separated prematurely from the services—that is, prior to demobilization—because of emotional instability, ineptitude, or undesirable traits of character. These startling facts suggested that careful evaluation of this problem area might yield constructive suggestions for the more efficient utilization of our country's manpower resources. The objectives of the Conservation of Human Resources project were formulated as follows: 1. To identify and evaluate the major areas in which significant wastes of manpower occur 2. To discover the factors responsible for these wastes 3. To make recommendations which can contribute to reducing or eliminating these wastes The work of the project was facilitated by the availability of a unique source of data about certain aspects of our national manpower resources. The Armed Services had preserved not only the individual records of each man, but significant statistical tabulations about various groups of men who had performed at varying levels of competence. There is probably no comparable collection of personnel data in the world. The ineffective soldier was selected as the focus for studying the relation of personality factors to performance within the military environment.

[1]

The staff of the project took some preliminary steps in preparing for this study. One such effort was to tabulate, on a county by county basis, Selective Service data about the number of registrants who were rejected for military service during World War II because of mental or emotional disabilities. A second step was to review the studies already published on the causes of emotional breakdown in the service and to gather the available data on the numbers who had been separated prematurely from the service. A third step was to consider points of similarity and difference between military and civilian life in an attempt to learn about the extent to which the "military situation" was likely to contribute to malperformance. An outline of these preliminary efforts was presented in the Progress Report of June, 1951, in the section dealing with "Psychoneurosis and the Army." At the outset the staff was confronted with the challenge of developing appropriate tools for the analysis of case materials. Much of the progress made during this century in understanding the human personality has been based on clinical experience with emotionally disturbed people. Since the ultimate objective of the Conservation of Human Resources project is the development of recommendations aimed at the more effective utilization of large groups of people rather than isolated individuals, the exclusive use of clinical categories in the analysis and evaluation of military case materials was inappropriate. Moreover, previous efforts to interpret these mass data exclusively in clinical terms had not turned out satisfactorily. Even a cursory acquaintance with the popular and scientific literature dealing with military psychiatry during World War II indicates the limitations attendant upon attempting to interpret the [2]

behavior of two million men in terms of such gross clinical categories as psychoneurosis or anxiety reaction. From the start, therefore, the staff of the project realized that a comprehensive attack on this large-scale problem would require a new approach and a new conceptual framework capable of accommodating, in addition to the personality factors, other determinants of the behavior of these soldiers. Further, such a framework would have to incorporate factors important in the Army's efforts to deal with these men. Foremost among them, we believe, are the administrative problems which face a social institution like the Army, the historical circumstances and conditions in which it operates, and the vast differences in the military situations to which soldiers were exposed and to which they reacted. Since we recognized that it would not be easy to develop an appropriate framework for the study, we sought the assistance of a representative group of psychiatrists who had had personal experience in the military services and who had had time to reflect upon it during the years since the end of the war. Toward this end the staff psychiatrist prepared a personal letter to his colleagues in which he presented the following broad questions: There are three points in particular to which we would like your reactions. The first deals in a very preliminary way with the whole and still baffling problem of the rejections and premature separations from the Services for psychoneurosis during World War II. As the Report states, "There is considerable range of opinion among psychiatrists as to what these startling figures . . . signify." In the light of your own experience and knowledge of this question, perhaps you would share with us your current thinking about this matter. The second problem deals with the men who broke down in the service. The people who broke down presumably dif-

[3]

fered in their personality structures and they obviously were exposed to great differences in external pressures. However, since I know this is a problem to which you have given considerable thought, we would like to know if there are any general ideas which you have about the factors involved in these psychiatric casualties. The third question which we would like to raise with you has to do with your reaction to the parallels and the differences between civilian industrial life and the military situation. Even as I write I realize that these are complicated and difficult matters and it may very well be that you would only be willing at this juncture to send us your hunches rather than attempt any definitive evaluation. At this time we would be very glad to have even your hunches. This letter, together with our Progress Report of June, 1951, was sent to fifty-three psychiatrists, including the members of the Committee on Military Psychiatry of the American Psychiatric Association and the members of the Committee on Cooperation with Governmental Agencics of the Group for the Advancement of Psychiatry. It was also sent to other selected senior psychiatrists who had served on active duty in World W a r I and as consultants in World War I I and who were therefore able to bring a wider perspective to the questions. Although no attempt was made to secure a statistically representative group, great care was taken to include individuals with different types of training, military experience, and civilian background. An effort was also made to include psychiatrists from every section of the country. Since a considered reply would require a substantial expenditure of time and effort, the letter was sent only to individuals who were known to have a deep interest in and concern with the problem and who were personally known to the staff psychiatrist. Hence most of the replies were written with considerable informality and

[4]

with the understanding that the anonymity of the writer would be preserved. Almost all of the psychiatrists responded, but many of the replies have not been used in the following analysis. Some were too sketchy; in other cases articles which had been published before were forwarded to us, but the psychiatrists did not evaluate the situation afresh. In still other cases the respondent suggested that he would prefer to discuss the problems with us, and we were fortunately able to do this in most instances. Although we learned a great deal from the published materials which we received, as well as from these personal exchanges, we have not made use of them in this analysis. T h e points of view thus expressed paralleled rather closely those presented in the letters. And we decided that quotations from the letters would be more reliable than paraphrased records of interviews. W e have organized the responses around the key questions which the staff psychiatrist posed in his inquiry: What do the screening figures mean? Why did men break down? Can military service be compared with civilian life? Since the respondents had been advised that the Conservation of Human Resources project was concerned with manpower policy, they added a considerable number of specific recommendations as to how military manpower might be saved. Their letters also contained valuable suggestions as to the best methods for undertaking research in this difficult field. These recommendations and suggestions are presented in the last two chapters. In the following analysis we have relied on direct quotations in order to avoid the dangers inherent in paraphrasing and interpreting subtle concepts. For each question we have sought to emphasize the consensus as well as to indicate the range of opinion. Furthermore, we tried to [5]

ascertain the issues on which our respondents have changed their opinion since World War I I , and, where possible, have presented the grounds for their earlier as well as for their present attitudes. The role of the psychiatrist in World War I I was unique in two respects. With minor exceptions, there was little in his civilian practice that prepared him for any one of the major roles which became his when he donned a uniform. He had never been confronted with the need to screen large numbers of men; to do short intensive therapy with large numbers of combat and non-combat casualties; to determine who should remain to fight another day and who should be separated from the service. The psychiatrist was responsible to a very large degree for these operations, and he had a further role to play in the determination of the basic personnel policies which established the framework in which these operations took place. The psychiatrist, however, was not the only one who found himself in a strange situation. The officer of the line, too, was confronted with major challenges for which he was poorly prepared. There was usually little, if anything, in his background which could guide him in a wholly new set of responsibilities; among these were his relations with this new specialist, the psychiatrist, whose decisions had such fundamental impact on his troop strength. As we have noted, our effort to elicit the help of psychiatrists was an outcome of our need for assistance in developing an appropriate framework for studying the interplay of personality factors and performance in a military situation. In detailing the replies to our inquiry we believe that we are making a small but significant contribution both to the history of American psychiatry and to the military history of World War II. We believe that [6]

this amalgam of facts, theories, and opinions about the psychiatric aspects of personnel management during the war, as seen in retrospect by the psychiatrists, is a contribution to the understanding of a tremendously important, but still largely obscure, facet of our national experience. However, in this monograph, we do not attempt a comprehensive evaluation of the role of psychiatry in World War II. Our interest is in appraising the psychiatric theories that underlay important personnel and manpower policies during World War I I and in ascertaining to what extent a representative group of psychiatrists continues to adhere to the points of view held then with respect to these theories. The passage of time undoubtedly leads to a blurring of many important factors. It is likely that our respondents have recounted the more extreme situations, particularly those illustrative of confusion and waste, since our inquiries stressed problems relating to the waste of manpower. For this reason the chapters that follow must not be construed as an objective account of either military psychiatry or personnel management in World War II. They are a contribution to theory and research. They do not pretend to be, nor should they be read as, anything more. Moreover, although this analysis is concerned primarily with a problem of military manpower, it requires only a moment's reflection to recall that the registrants who were screened were all civilians; and, further, that the men who were separated from the service again became civilians. If there is no sharp line between the civilian and the serviceman, there can be no sharp line between military and civilian manpower. Lessons learned in one field have distinct relevance for the other.

[7]

II

What Do the Figures

Mean

A PRELIMINARY analysis of rejection data for World War II revealed that of the almost one million men who were not accepted for military service for psychiatric reasons, the vast majority had no history of prior hospitalization and presented no evidence of major pathology. Nor did the data compiled on a county basis yield a consistent pattern in the rejection rates of either counties or states, although certain regions of the country, such as the agricultural Southeast, revealed a high rejection rate. These findings suggested a few additional questions, which we included in our letter to the psychiatrists. "Do certain regions of the country have a higher than average incidence of emotional instability? Is it possible that through 'selective migration' the more stable individuals move to regions with greater opportunities? Or do these differential rates reflect primarily variations in the administrative procedures used to screen individuals at the time of induction?" Comments on regional differences will be found in only a few of the quotations selected, although many more letters contained speculations about this problem. One group of our respondents held that although the rejection rates were very high—the overall ratio was 1 in every 18 registrants—they were not extraordinary. The opinion of this group is represented in the following quotation : I do not think the figures are startling. I think that they are natural, inevitable, and predictable; and that it is startling [8]

only that they were not anticipated. At the same time whether or not the induction stations rejected, and the Army separated, the right people, is another matter. Another psychiatrist indicated that though he was shocked at the very high percentage of men who were rejected, he "certainly was not surprised. I was brought up in the rural area of an Eastern State and I was quite aware how unstable a large portion of the young men were." He went on to say: "I think the startling figures merely signify that the level of emotional maturity of our people is deplorably low. Selective Service spotlights this regrettable state of affairs." O n e respondent questioned whether the figures were actually as startling as they appeared. He pointed to a "quotation from a Surgeon General's report after the Civil W a r in which separations from the service due to 'nostalgia' were just about at the same rate as our separations for neuropsychiatric difficulty." In seeking to understand why so many men were rejected and why so many more were prematurely separated from the service, one writer thought that the cause might be found in "our community educational procedures." He said: One thinks of this and the background of the development of the rights of the individual which characterizes our period, but which has failed to include an equivalent development of personal responsibility for one's associates as well as for one's self. A more typical attitude was reflected in the opinion that the figures "concerning rejection and discharge prove nothing save that we were struggling through a morass of futile confusion." Considerable support for this opinion can be found in our letters. For instance:

[9]

There were some areas of the country that had no psychiatrists and the rejection rate for psychoneurosis was therefore quite low. I have noticed during peace time that in the Southeastern States the rejections for neuropsychiatric reasons were almost non-existent—and the number of psychiatrists who were examining was also practically non-existent. A similar point of view is expressed below: I don't think that examiners ever knew what went on at the Draft Board level of selection. It seemed to me that from our sampling at the Induction Center one could not draw safely a conclusion touching on the prevalence of emotional disorder in the male community at large. I recall that from time to time our local Induction Center policies were changed more on the score of quota requirements than on any realistic psychological requirements. One psychiatrist went into considerable detail in pointing out that the high rejection and premature separation rates depended on a wide range of circumstances and influences: They reflect the back pressure of command against the acceptance of difficult things. They mean the desires of people to stay out of the service or antipathy to psychiatric screening which results in the induction of vulnerable people who have to be prematurely separated. They reflect pressure on localities to fill quotas. They mean soft-heartedness toward offenders who were given a break in the form of a psychiatric diagnosis instead of a court-martial. . . . They mean that many people in the community, including the draft boards, think that the army will make a man of a person and so take in vulnerable people without any provision to deal with their vulnerability. Another summarized his reactions to the screening procedures of the Armed Forces by saying that "most N P rejections were, and are, 'by guess and by God' ! " Many of the respondents called attention to specific administrative procedures which made an orderly process of

[10]

selection almost impossible. Inconsistencies of policy came in for a major share of the blame: My first reaction is that the NP criteria for induction were too cyclic. The standards varied throughout this three-year period with the result that the threshold either became too high and eligibles were rejected, or when fresh manpower was needed, there was practically no contra-indication to induction. It was during the "low threshold" periods, I feel certain, that so many of the psychiatrically unfit were inducted, probably to the dissatisfaction of many of the examining psychiatrists. Similarly, another writer stated: In 1942 when we set up screening standards, there was no active land warfare. VVe were told that we were to have a small but highly efficient army. We were led to believe that the fighting soldier was only one member of the team and that if a person was rejected from military service, he was not lost to the cause but played his part in production. Accordingly, our philosophy was to pick out of the recruit line the best people from an intellectual and emotional standpoint. Consequently, it is hardly fair to consider those who did not measure up to this yardstick as rejects. They were simply individuals placed lower on the scale. To further compound the difficulties, psychiatrists were screening men for different types of service which were not defined: I did not know for what purpose selection was being m a d e it was assumed it was for combat duty and this predicated a high degree of stability. A classification of non-combatant jobs was not available and medical categories were not imposed. This relation between selection and utilization is discussed in the following quotation from a different angle: All this comes back to a primary problem. Shall the military forces make arrangements from the outset for people whom [11]

one would not put in a combat organization? One of the major difficulties that any induction center encounters is the idea that has been current that all people accepted into the military service should be competent for any type of duty that might arise. Once one has accepted that thesis one is limited in what he can properly accept. Change that concept and the base for acceptance is greatly broadened. Another aspect of the problem is touched upon in the following reminiscence which purports to illustrate that decisions about acceptance or rejection were not always on psychiatric grounds, but were often purely administrative: When someone got hell for not meeting the quota the buck was passed all the way along the line. There were days in which four of us psychiatrists sitting at a Board would reject a man; the man would be kept around until 4:30 or 5:00 o'clock in the afternoon, and the Major in charge would induct him himself. T h e difficult relationship between the psychiatrist and the line officer alluded to above is elaborated in the following comment: Even then I might point out that in more than one instance the actual relationship in lower echelons was that the psychiatrist, in the carrying out of his routine tasks, was told to disregard these directives and was thus dependent upon the temper and attitude of his immediate commanding officer. As these quotations indicate, the blame for some of the difficulties that were encountered was occasionally shifted by our correspondents to the commanding officer. T h e importance of having a sympathetic officer in charge of an induction station is commented upon more frequently. O n e writer recalled the comment of a new commanding officer: "If all the g.d. psychiatrists were at the bottom of the river, we would get along all right."

[12]

In addition to such basic difficulties as the inconsistency of policy changes, many psychiatrists called attention to the difficulties of functioning properly under any set of policies because of the extremely short time allotted for the examination of the draftee: I believe the . . . method of psychiatric evaluation of inductees is woefully inadequate. I recall the procedures of having about 120 inductees pass hurriedly before the desk of the psychiatrist, in their "birthday clothes," self-conscious, and answering the few routine questions which were asked. Before the examination, the psychiatrist was presented with the school records, forwarded by Selective Service, which he glanced through quickly, and which may have given some information of intellectual status but certainly no indication of the emotional picture. There were never [at this station] any social service or adequate medical histories accompanying the recruit. Another respondent, concerned about the inadequacy of the examination, remarked: These were the hectic days during which my examinational procedure consisted of four rapid fire questions, "How do you feel?" "Have you ever been sick?" "Are you nervous?" "How do you think you will get along in the Army?" O n e day I saw 512 men. At least one psychiatrist found it impossible to continue to work under such conditions: Before I went into the service I worked with a draft board but soon quit in frustration. I could not in all fairness judge who was fit for duty when I had only a few minutes for superficial questions and for a quick estimate of personality. T h u s I could not use my psychiatric tools. A unique explanation for the acceptance of a large number of questionable cases was presented in his letter: For twenty-two months I worked on an Induction Board in [a large city on the West Coast], At first the work was very easy,

[13]

slow and we had plenty of time to examine at great length many draftees. The abundance of time happened to make little difference at this particular stage of the game (1940). An army doctor was then in charge of the medical section who had the idea that the more men he accepted the sooner his promotion would come through. As a result the rejections for NP causes ranged from one-tenth of one percent to nine-tenths of one percent during this early period. One respondent stated that "differences in attitude toward rejection of selectees occurred not only in different sections of the country but also in different examiners in the same Induction Section." That the regional problem referred to at the beginning of this chapter was a real one is suggested by the following comment: The patient-doctor relationship in more sparsely populated areas is an important variable. (Northeast—Vermont and New Hampshire—have hardly any psychiatrists even now; Northwest had very few during the war.) If the rural doctor who knew the people well was made the selector, he could tell how his people would adjust away from home. Here may I parenthetically state that the boys from the Southern hills in the service looked withdrawn, artistic and were often diagnosed schizophrenic, with no reference to their taciturn cultural pattern. Another aspect of the same problem is pointed up in this excerpt: A new factor that I did think of during the war period as I watched the flow of psychiatrists into practice, and saw their ivory tower of personal relationship and lack of appreciation of broad community factors, has led me to a new kind of conclusion . . . Are perhaps the rejection mistakes of World War II psychiatrists partly due to the fact that where there was a supposedly "rule psychiatric examination" it was made by men located almost 100% in urban communities?—men who [14]

had limited knowledge of the capacity of kinds of people who exist in large numbers in spacious country communities.

Many of the psychiatrists now recognize that in addition to the administrative and personnel difficulties that complicated screening procedures, the validity of the theory for screening was open to question. As one of them put it, " I am convinced that entirely too much confidence was placed upon screening as a preventive for psychiatric breakdown in the armed services." Another felt that the high rejection rates were the result of the psychiatrists' rejecting "potential neuropsychiatrie casualties." Reflecting on the situation as it existed at the time, one psychiatrist stated that he was concerned by two points: "What does the term psychoneurosis really mean to the particular examiner and in turn to the mass of examiners? . . . Rejections for psychoneurosis were apparently made on snap judgment at best in the great majority of cases." The range of ideas held by the psychiatrists with regard to predicting breakdown is epitomized by the following somewhat sarcastic comment: I think the concept of what constituted potential neuropsychiatrie casualties varied according to the number of psychiatrists involved, in the ratio of about one different concept per psychiatrist.

The limitations of the then prevailing theory of screening are set forth by one respondent as follows : Meanwhile, those of us trying to do a conscientious job of examination at that time were operating upon the most inconsistent, unverbalized premises. The operational base for our crystal-ball gazing was predicated on some sort of faith in ourselves that we could detect in a person the inability to withstand the rigors of military life and that he would be a neuropsychiatrie casualty. In retrospect I now know how much of

[15]

this was nonsense. In the first place I had no idea what the rigors of military life consisted of except: I didn't like it; the salt and pepper on this salad came from smatterings of knowledge about the psychodynamics of authority. It didn't mean much in this period of time, I repeat, because hardly anyone got rejected by our boss unless he had previously been hospitalized for mental illness. We found out later that even this was not too consistent a criterion for later performance in the army. T h e fact that the selection boards were never advised about the consequences of the procedures which they were following further handicapped t h e m : " T h e medical men needed some means of learning instead of sending a m a n into a void from which no word ever returned." Many of our respondents agreed with the following retrospective appraisal: On reflection my inclination is that we rejected too many individuals and did so not on the basis alone of symptomatic disability but perhaps more out of the conviction that the military people were unwilling to make any adjustment in administration to utilize persons with some emotional difficulties. On the other hand, I think that our group also rejected too many men out of the conscience that we would have some part in creating a heavier taxpayer's obligation for psychiatric care. It is generally conceded that such extra-clinical concerns played too large a role in the rejection of certain men. At the same time, they further illustrate the tendency of psychiatrists to question the extent to which purely clinical considerations are applicable to the job at hand. Such doubts are expressed in various ways and are based on different arguments. T h e point made in the following excerpt was mentioned by several writers: It has also been my feeling that the rejections for psychoneuroses as manifested by anxiety in certain physiologic symp-

[16]

toms under stress, both before entry into service and in service, were based on misconceptions. Anxiety is after all a normal response to situations of stress. Anyone applying or appearing before a board for examination is bound to be in a situation that is not only stress-producing but a very unusual one for them. Questions concerning current symptoms of stress in the past are bound to be answered in the affirmative by all except the most non-introspective people. The point of view expressed below goes a step further, leading to the formulation of a basic hypothesis: As far as the selection of military personnel is concerned, I have very serious doubts that there is any very close correlation between psychiatric nosology and liability to maladjustment in the service. My doubt about this is largely based on my industrial experience where I became quite convinced that a straight psychiatric diagnosis was of very little value in selecting people for employment. Thus, while the screening procedures in World War II were predicated on the theory that even a person with a "potential psychoneurosis" should be rejected, many psychiatrists now recognize that there is a much less definite relation than was previously thought to exist between the "neurotic potential," or even overt neurosis, on the one hand and performance on the other. This point is made more specific in this quotation: "Some compulsiveness makes an individual better adapted to military life and, of course, it is often said this makes for good citizens in civil life." However, the subtleties involved here are not to be underestimated: My experience with seamen indicated that many of them volunteered for that service because their neurotic pattern was served by it. They would have broken down in the Army— indeed some of them had. The dynamics of some of the most successful men in the service give a picture of those who feel

[17]

most comfortable in a group where the responsibility is shared or delegated or where there is none to speak of, and where there is provision for the expression of hostility which is not only acceptable but praiseworthy. The passive homosexual types have, in my opinion, been the least able to adjust. Several of our respondents agree with the more generalized formulation of one of their colleagues who states that "superior performance according to certain standards may itself be a neurotic expression." It is on the basis of such considerations that one of our respondents arrived at the conviction that the psychiatrist should seek to eliminate only those persons with "conflicts which make it impossible for them to be in any armed service," rather than to disqualify people merely because of a diagnosis of "neuroses or even . . . pre-psychotic symptomatology." This recommendation is amplified by another writer: The idea that psychoneurosis is a disqualifying diagnosis is of course a bad thought. It is my impression that many severe compulsive-obsessive neurotics may make excellent soldiers, whereas people with free floating anxiety and hysterical mechanisms can only be utilized under special conditions and not for general duty. Looking back on their experience in induction stations, many of the writers stressed that the screening effort "was to elicit negative rather than positive data." One psychiatrist commented on this situation as follows: I believe that there would have been many more men accepted if the emphasis were less on negative features and defects and more on the positive factors in the individual. We need to leam how to assess individual morale, character, integrative potential, ego strength, sense of responsibility and a healthy degree of compulsiveness. In other words, even if an individual

[18]

has a psychoneurosis, it depends upon his total character structure as to how he may function with it. There was rather general agreement among the group on the following suggestion as to how to shift from a negative to a positive emphasis in a screening examination: To my way of thinking, the history of the individual—that is to say, the history of his school, work and social adjustmentis far more important than is the evidence of tension during a medical examination. This kind of reaction may be entirely within the limits of health and is certainly not necessarily evidence of a badly integrated personality. This conclusion was succinctly presented by another writer: We have come to the conclusion that our standards during World War II were far too high and that rejection should be on the basis of demonstrated incapacity to adjust to civilian life, rather than on any diagnostic cross section label that we might use. Most of the excerpts presented thus far have been focused primarily on problems of screening for military service. Our letter to the psychiatrists referred as well to the problem of premature separations. The replies indicate that, with minor exceptions, the opinions expressed about rejections obtain equally for premature separations. In delineating the difficulties of screening, the psychiatrists emphasized administrative pressures, particularly frequent changes in personnel policy; deficiencies in the training and experience of psychiatric personnel; an undue reliance by the psychiatrists on clinical symptomatology with too little awareness of the importance of motivation, the whole personality, and reality factors; and, finally, the absence of an effective system in the military organization for providing limited assignments for handicapped persons. All of these factors which played so large a part in confounding selec[19]

tion policy would be duplicated in a study of premature separations. There was no consensus on the question of what the figures mean, but most of the psychiatrists warned that the conditions of screening underline the necessity for caution in generalizing about the meaning of the available statistics. Few psychiatrists ventured a definite answer to whether the figures do, or do not, support the theory that certain regions of the country have a higher than average incidence of emotional instability. Many felt that even if their personal experience had been greater than is usually afforded the clinician, it was still insufficient to permit them to reach a definitive conclusion. They were more assured about other aspects of the screening process, particularly those directly related to their own experience. As we have seen, they were quite outspoken about three aspects of the screening procedure—the basic philosophy of screening as a means of reducing, if not eliminating, potential breakdowns in military service; the overemphasis on the clinical symptomatology in screening; and frequent changes in the levels of performance for which they were screening men. T h e most striking conclusion which can be drawn from their replies relates to their present attitude toward psychiatric screening as a personnel selection device. In place of their initial enthusiastic belief early in World War I I that they could contribute to the efficiency of the Armed Forces by rejecting large numbers of individuals with varying degrees of neurotic disturbance, the vast majority now holds that, with the tools available to them at present and under the actual conditions of rapid examinations, they cannot perform such screening effectively. They now believe that instead of attempting to keep as many "vulnerable" people

[20]

out of the service as possible, only those individuals with a clear history of psychotic behavior and those with very severe neuroses which are certain to interfere with performance in a military environment should be kept out of the service. This change in attitude is as complete as it is striking. Closely related to this basic revision of their philosophy of screening is their new attitude toward reliance on clinical symptomatology in the screening process. Our psychiatric respondents now believe it to be an error to search for negative factors that might possibly interfere with a man's successful performance as a soldier. They have come to recognize that every man has one weakness or another and it is more than likely that these weaknesses are, willingly or unwillingly, intensified under the stress of the screening examination. Most psychiatrists now feel that although it remains important to give considerable weight to indications of weakness in a man's past, even more importance should be ascribed to evidences of strength. In general, they hold that men who have made a reasonable adjustment in civilian life should be able to make a reasonable adjustment in military life. Although some might fail in the transition, it would not be possible to identify them during a short—or even a longer—screening interview. Finally, our psychiatrists now believe that an adequate screening system must be based on explicit assumptions about manpower reserves and, further, must be geared to realistic standards of performance that will be required of men who are accepted. Otherwise, screening will be blind. During World War II the performance standards were altered not once but several times, from full combat for all to limited service for some, with many intermediate gradations. Even in the absence of other difficulties the fluctuat[21]

ing objectives and policies of the Army's personnel management system were sufficient to prevent the development of an effective screening system.

[22]

Ill

Why Did Men Break A L T H O U G H very large numbers of men were rejected for military service because of emotional instability even early in the war, the Army soon found that a large proportion of the men who had been accepted were breaking down in training or in combat. Their first conclusion was that the screening process was a failure since it was permitting so many "vulnerable" people to be accepted. But as the war progressed, and more particularly after the end of the war, it became increasingly clear that this conclusion was based on too narrow a concept of the relationship between personality and breakdown. Very few among our group of psychiatrists agree with their colleague who holds that: War probably created very few neurotic illnesses but condensed into the short space of a few years crackups, most of which would probably have occurred under civilian circumstances as well, but spread out over twenty-five or more years of the lives of the same 18 million individuals. The now more generally accepted opinion was formulated by one of them in these terms: From present knowledge, psychoneurotic breakdown in service does not appear sharply predictable at the time of induction. This, I believe, relates to a general over-estimate of the extent to which psychoneurotic breakdown is predetermined by predisposing factors as compared with the extent to which it is in reality determined by precipitating factors. There has been a striking change from the formerly held belief that a clear-cut distinction can be made among men

[23]

as between "the weak and the strong" to the current opinion that "every man has his breaking-point." This attitude developed gradually during World W a r I I and has become increasingly accepted since the end of the war. T h e conviction, gained in retrospect by many psychiatrists, that during World War I I too much stress was placed on negative factors in the personality and too little on positive supports has made them shift from attempting to discover causes for breakdown in the individual to studying the balance between stresses and supports: " I think we have to pay attention to all of these factors and increase the supports and diminish, insofar as possible, those policies and procedures which actually or potentially constitute stresses." One of the lessons learned by psychiatrists who had had direct acquaintance with men in combat was that: . . . many of the outstanding combat soldiers were hostile, emotionally insecure, extremely unstable personalities who might well be termed clinically ''psychopaths," whatever that may imply, who fully enjoyed the opportunity of taking out hostilities directly in a socially acceptable setting of warfare and who in the absence of such an outlet not infrequently end up in penitentiaries.

An even more striking formulation was provided by another writer, who stated that "there are a good many instances where men have been heroes on the basis of a neurotic or even of a psychotic disorder." Reflecting their awareness that a too narrow concept of personality was inadequate for the study of breakdown, an increasing number of psychiatrists sought to make allowance not only for personality factors but also for the "intensity and duration of stress." This approach was particularly relevant for an understanding of those who broke in combat, as [24]

can be seen from the quotation below, though a less extreme example of stress would be sufficient: I also feel strongly that any type of personality, no matter how well-balanced, will react if the stress becomes unbearable. I have examples in mind of good physical and emotionally balanced types who were in ninety days of combat in Italy with practically no sleep. T h e difficulties in assessing factors of stress were pointed out by one writer who said: The chances and the fortunes of war are such that some luckymen may go through such experiences repeatedly and come through unscathed; whereas another lad had both his legs shot off in the first five minutes of his first engagement, and this a relatively quiet and minor one. With this degree of variation in external stresses even in the same action, we have to be extremely careful in our efforts to decide whether a breakdown was due to something quite specific about the way in which a particular stress fitted a particular personality weakness. This statement also reflects an inclination on the part of many psychiatrists toward a more refined concept about neurotic personality traits. They came to emphasize the "specificity" of neurotic reactions rather than general pathology: ". . . the concept of specific vulnerabilities seems more accurate than a concept of general emotional instability." One psychiatrist put it in these terms: "Psychoneurosis is a very personal and individual affair that can be dealt with by only one generalization, and that is to individualize the understanding and treatment of the person, whether in military or civilian life." And another put it thus: Does not a study of wastage and conservation have to grow inductively out of a painstaking review of the many specific ways in which the very particular stresses of modern war fit

[25]

into the specific qualities of different personalities, so that the same stress may actually protect some personalities while causing explosive disintegration in others? T h e same writer gave the following illustration: There are circumstances in which combat stress is an actualization of the worst nightmares of childhood. We carry into our adult years many of the fantastic, terror-ridden stormcenters of childhood; and whenever external events approximate close enough these old, fantasy-ridden terrors, anyone can break. I believe, furthermore, that this accounts for the infantile quality of the transitory, psychotic manifestations of some of the stormier combat-induced breakdowns. In considering the problem of stress some of our psychiatrists recognized the necessity of distinguishing among groups of people in terms of the kind of stress situations to which they were exposed. " I t is necessary to clarify certain general groups because the stresses differ in each case. There were those who broke down early in service and there was the group who maintained marginal adjustment until the stress was increased, i.e., by going overseas and certainly by first combat experience." Although combat was generally recognized as representing the most severe kind of stress, several of our respondents who had been acquainted with men subjected to prolonged isolation gave considerable weight to this factor: T h e incidences of breaks also paralleled the uses which were made of the men in the service. If troops were in situations which permitted no activity and there was a mass sense of frustration, the incidence of breaks was much higher than when the men were engaged in activities which had some meaning and which gave them a sense of accomplishment. We saw this demonstrated in . . . troops who sat for from eighteen months to two years in Iceland and did exactly nothing from [26]

their point ot view and then when we attempted to get them into combat condition had to completely rebuild the division. Under circumstances of isolation and boredom, leadership, always important, was considered crucial: I did not feel that combat was as likely to bring out psychoneurotic behavior as boredom and lack of purpose. I remember one island in the South Pacific which was never attacked by the Japanese and on which the executive officer was more ar less of a martinet. The men developed an extraordinarily wide range of symptoms. I saw boys with hemianesthesia, anesthesia of a quarter of the body, gun barrel vision, legs in extension which could not be flexed—in short, the richest collection of gross hysterical symptoms I have ever seen. I felt very :ertain at the time and feel more certain now that the number sf neurotic individuals would have been gready decreased either with good leadership or if the island had been attacked jnce in a while by the enemy. Although some non-combat situations created stress of unusual order, this was not to deny the tremendously tieightened stress of combat: The last group I would consider are those who were exposed to combat for long periods. It is in this group that, I believe, the most normal personalities are to be found, or at least the aersonalities best able to withstand physical and emotional ¡tress. The solution here is, of course, relatively simple and lies not so much with psychiatric evaluation as with "common sense" directives and regulations in regard to the period of :ime a man is subjected to combat stress. Over and above all the other factors of stress, fear of ieath was considered most important: \1 though the combat neuroses form a miscellaneous group .vhen one deals with them as a composite, generalizations :onceming their etiology can probably be made. Personally, I ivould favor a formulation very much in the terms Meerloo

[27]

made, which has to do with the conflict between the fear of death and the social urge to remain part of the group and do one's duty. T h e particular conditions under which combat took place were also thought to be important: The second example of this was the units who were cut off and pinned down in combat, unable to defend themselves and unable to strike back but having to sit and take from their point of view a great deal of punishment without the possibility of retaliation. Units so involved in combat almost universally presented us with many psychiatric casualties, in contrast to units similarly constituted, similarly led, similarly trained, but in the open, as it were, and able to strike back at the enemy who harassed them. I am confident that the French army would never have been able to man the Maginot Line and sit passively through a war even if this technique had been tactically used. It was psychiatrically impossible. This writer summarized his notion of the impact of combat upon the individual by saying that "the level of adaptability could be measured in terms of the duration plus certain other factors of the service." Several psychiatrists warned against the assumption that the development of a neurosis under combat can be interpreted simply as a means of escape: The combat neurosis cannot generally be considered a means of escape in itself. I think that when the cases are carefully analyzed one finds that it is when the soldier begins to feel that there is no way out of the situation except death that he becomes most vulnerable to psychiatric breakdown. There seemed to me to be some undertone of suicide in a great many of the combat neuroses, and it is when the suicidal urge begins to creep in that the patient begins to project the urge and the environment becomes even more terrifying than it already is. That is, when the chips are down and the choice is between dying and doing one's duty, the psychiatric breakdowns are

[28]

most frequent. . . . At any rate, a major factor in the maintenance of high incentive has to do with the relationships to the buddies in the outfit. Although to a great extent the buddies and the commanding officer represent the socializing forces in the immediate environment, socializing forces as provided by the family often give a pull in the opposite direction. Further indication that the simple escape explanation is inadequate is suggested by the following, where it is pointed out that frequently the breakdown came after the man was withdrawn from combat: It should be recognized that a very large number of psychiatric casualties occur after the combat is over and the men are returned to a rest area. It is at this time that the men must be kept fully occupied, and somehow be kept in trim for further fighting. They need resocialization in order to get away from the destruction of battle and their loss of socializing forces, and this must be carried out in some appropriate area. I have the feeling that if the Americal Division had not been sent to the Fiji Islands to recuperate from Guadalcanal the number of combat casualties would have been much lower. However, this was unavoidable at the time because there was no other outfit to protect the island. Just as a man cannot be kept in combat too long, there are also limits on how long he can be kept out of combat and be expected to get back into it. At the beginning of the war only the exceptional psychiatrist recognized that, although military service was stressful for the individual, there were also many supports within it. Yet this is an important consideration: The military service does provide a sense of security for many individuals but it is set at a rather low level for those with families. It does give opportunity for advancement. It should give a man much more feeling of being treated like a human being than was oftentimes true—and it should be possible for the soldier or sailor to get a much more thoroughgoing sense of the value to his country of his contribution. [29]

As the psychiatrists came to know military life more intimately, they placed increasing importance on motivation as a barrier to breakdown. "Motivation is one of the critical factors and probably is ultimately the most important factor which determines whether or not an individual succeeds at a given task." Another remarked: "From my point of view psychiatric thinking has a great deal to contribute to personnel management. Certainly throughout the war we were very much concerned with motivation." But it is conceded that we are here confronted with a rather elusive problem: Perhaps one of the most important and most difficult factors to elicit is that of motivation. . . . Some studies in the Air Force indicated that there was little discriminable difference in the histories and personality characteristics of pilots who had had to be grounded because of "fatigue" and those who were still flying, with the single exception that those who were still in combat seemed to have a much higher motivation for flying. Many letters called particular attention to the support which the individual got from his immediate small group: I believe that group morale and group performance . . . has more to do with the ordinary breakdown under ordinary circumstances than any other factor. The importance of belonging to and having someone belong to one's self, combined with approval and support, is a big factor in personal adjustment. My wartime impressions have made me think that this interchange has more to do with security and personal adjustment than we theorists have been allowing in the past. One writer put it very sharply by stating that "whatever type of selection is done, a great number of the deficiencies of the individual soldier can be overcome by factors that make for good unit morale." Continuing, the writer stated: Morale is well defined in the terms Alex Leighton used in a paper early in the war. It has to do with the willingness of [30]

the individual to sacrifice his own needs for the good of the unit and the unit's ideals. If the officers keep this definition in mind it often serves as a guide to the establishment of decent morale in a unit. In seeking to understand which factors contributed to and which detracted from group morale, the psychiatrists placed major stress on the quality of leadership manifested by all those in charge, from the platoon leader to the division commander: "I always felt that the leadership factor was far more important and as a matter of fact responsible for the motivational factors to a considerable degree." Another said: One can list such motivating factors as loyalty to one's own immediate group, loyalty to successively higher echelons in the military organization. This in turn brings up the whole problem of leadership and its role in maintaining group morale. It was a well known fact during World War II that certain company commanders had high NP casualty rates, others had low ones. Several psychiatrists stressed the importance of the leader's treating his men as individuals: The military were too much preoccupied with "bodies" and not enough with individuals. One of the most important qualities in a good platoon leader, or any leader, was consideration for his men as individuals—group failure was very directly related to leadership— or rather the lack of it. One reason why a man became so dependent on his leader is well formulated below: If a man gives up his own initiative in serving in the army and is no longer able to provide for his own welfare, he expects that the group leader will strive for the best interests of the individuals in the group insofar as is possible under the circumstances. Actually one of the most difficult problems [31]

in preserving decent unit morale is that the commanding officer or other superior authorities are apt to be concerned with their own welfare, and the men feel the discrimination. They feel that they do not have a proper deputy taking care of them. An officer who looked out for his men as much as he did for himself rarely had difficult morale problems. However, this is usually considered to apply only in combat, and it is just as important during the training process and in many of the trivial things that occur in the army. O n e writer placed almost all the responsibility for breakd o w n on defective leadership: T r u e breaks occurred in our observation, first, when there was defective leadership. . . . T h e experience which I had repeatedly was of seeing in some organizations very high incidence of emotional symptoms and in others continued efficient and effective functioning of personalities of no better structure, so far as I could determine, than those seen in the first organization. . . . This, of course, was the old psychiatric picture of the father surrogate and the family support. T h e following statement sums u p the opinion of a large n u m b e r of our respondents: My thinking has undergone some change in this regard during the past ten years. I have seen some startling examples of people who might have been considered to have a low threshold of instability manifestation, who, with good leadership and good fortune, adjusted well to difficult circumstances. I have a feeling that while there may be a genetic factor in preparing the soil for breakdown, yet in many cases, environmental situations were the greatest determinants. T h e leadership of Negro troops represents a special problem. Some of the obvious difficulties are suggested by the following q u o t a t i o n : It is not necessary to elaborate upon the difficulties in utilizing colored troops as they were utilized in the second World War.

[32]

I could never understand why it was that the southern whites were usually picked out to be the commanding officers. Where there were mixed officers there were also great difficulties. O n e of the most serious situations we saw had to do with very intelligent college graduate colored men who were in companies commanded by relatively uneducated white men. These colored men were usually held down by the white officer who did not like their ability to interfere with the officer's prestige among the troops. T h e colored soldier under these circumstances was apt to become quite paranoid and refuse 10 do any more duty. Finally, several writers called attention to the fact t h a t breakdowns often were caused less by the stress of military life t h a n by reports of what was happening at h o m e : I n our effort to set up some basis of prediction we were inclined to think more in terms of emotional breakdown as related to the military stress alone. Later I had some reason to doubt this assumption and I suspect that many of the breakdowns and instances of so-called military ineptitude came not so much from rigors of camp life as they did from the pressures and doings at home. Another psychiatrist put it tersely: " W e had a way of saying that as many casualties were caused on Guadalcanal by the mail from home as through enemy bullets." While we are still lacking a comprehensive theory of motivation, the increasing recognition of the role of group morale and leadership in preventing breakdown has led m a n y psychiatrists to speculate about some of the factors which tended to affect adversely the motivation of soldiers in World W a r I I . Several emphasized the difficulties that were the inevitable result of the attempt to transform a large number of civilians into soldiers: T h e military regression to authoritative methods is accepted reluctantly and incompletely; and individuality is always re-

[33]

affirmed by incapacity, illness, and separation. The military super-ego is a thin veneer that dissolved awfully fast. By some, this factor was traced back to our democratic traditions : The American soldier is an individual and his democratic citizenship habits will never be abandoned. Unless cognizance of this is taken in many ways there will always be a great percentage of separations. Others ascribed considerable importance to the Army's shortcomings in handling the problem of breakdown: It was my impression while I was in service, and still is, that the majority of the psychoneuroses which were so glibly diagnosed by us and disposed of from the service, were motivationally determined and resulted from confused policy, confused directives, and an inadequate grasp on the enormity of the problem by the higher echelons. However, several of our respondents pointed out that it is easier to recognize these shortcomings than to deal with them. Many writers placed considerable emphasis on "inequalities of sacrifice" between soldiers and civilians: Aside from combat conditions, the basic factors contributing to breakdown of susceptibles after induction were resentments over inequalities in sacrifice and vocational maladaptation. I do not suppose we can ever get away from the inequalities entirely, or even approach it, unless we were to go totalitarian ourselves. But, certainly, for many men the fact that their former fellow-workers on jobs at home were drawing down wartime wages and privileges was very provocative. Similarly: Another factor that is occasionally mentioned but seems to me of paramount importance in any consideration of conservation of manpower is the fact that the incentives are not equally [34]

lined up. A man who goes into service has the incentives of patriotism, possible honor, etc. However, against this are the facts that his medically rejected brethren are living at home with their families, are receiving high pay and are, in some instances at least, getting promotions. One respondent doubted that there would ever be any solution to this problem short of a major effort to equalize sacrifice through a National Service L a w : T o say it another way, I believe that in the future we will have just as much trouble as in the past unless we have a national service law where, if war comes, every individual, sick or well, must be in the national service and when he is sick his compensation is less than when he is well. I know this is radical and possibly an oversimplification of the problem, but it ought to be tried. T h e opinions presented above about why men break down in military service indicate how substantially the psychiatrists' approach to military problems broadened during and, particularly, since the war. From the narrow assumption that almost any type or degree of neurotic disturbance was a counter-indication for military service, the psychiatrists' concepts were expanded in several major respects. They came to realize that it was not sufficient to rule out every individual with symptoms of emotional disturbance and expect in this manner to insure against future breakdowns in the service. Instead, they feel that the clue to determining whether a neurosis would cripple a man or not depends primarily upon the specifics of his disability, which are usually impossible to evaluate in a short interview. Even more important was their broadened concept of the great variations of stress within the military environment. They also came to discard, in light of their experience, the assumption that military service produces only stress.

[35]

There are many supports within the system which provide protection for certain types of individuals. In particular, psychiatrists are now inclined to make greater allowance for the specific supports that a soldier receives from his immediate group and from a good leader. Thus, while personality strengths and weaknesses are important, equally important are the stresses and supports in the environment. Continued successful performance or breakdown depends to a large extent on the balance between the two. The common denominator for these changes in attitude is a shift from a concentration on neurosis and personality defects to a concern with motivation. Associated therewith is the shift from a predominantly clinical preoccupation to a broader concern with the problems connected with the management of men. However, most psychiatrists, like most other persons who are well informed and who have considered the matter, remain uncertain about how to identify and how to utilize constructively the key motivational factors. The material presented in this chapter illustrates how far psychiatrists have moved from the rather simple premise that they held early in the war, that breakdown was primarily a function of personality defects, to a more comprehensive view which includes in addition to personality such important factors as the stress and support balance in the environment, leadership, and group morale.

IV

Adjustment in Military and Civilian Life I N his letter to his colleagues, the staff psychiatrist asked them to comment on the possibility of comparing adjustment in military and in civilian life and to indicate what factors they considered unique in each. Our interest in such a comparison derived from the belief that the study of these two life situations might lead to a better understanding of the connection between the kind of situation confronting an individual and his ability to meet it; for different situations call forth different motivations which facilitate or impede the individual's efforts to meet the varying demands made of him. But a comparison of military life and civilian life is not only a comparison of life situations from the point of view of the individual. It also involves a comparison of two types of social environments. We have made no attempt to limit our respondents to a consideration of one or the other comparison, nor do we make a clear-cut distinction between them in our presentation of their comments. Some psychiatrists thought that the differences between the two environments were so great that it was not feasible to draw parallels: Having lived with the military for 3/2 years, I came to experience it as a way of life quite distinct from any type of institutional life that one can imagine, so that in making comparisons with civilian industrial life, I believe considerable

[37]

thought must be given to these tremendous differences. On the one hand, it may even make one question how valid comparisons can be between these two ways of life. Another said that the fear of sudden death in the military situation is paramount and that it precludes any parallel: There is a difference between the civilian and the military situation in the idea of sudden death which is such a bedfellow of the individual in the service. The projection of the average soldier's fears to this realistic possibility contributes to a basic underlying tension. I wonder how much discussion of this topic, on a reasonably realistic basis, has ever been attempted. It is a subject which I believe would benefit by clarification and discussion, rather than by hiding this deep-seated focus of fears. An important distinction was made by another writer who indicated the differences in the motivation for adjustment in civilian and military life: In the army you do not have the feeling of responsibility for integrating the misfit as in civilian life. After all, the person himself was frequently delighted to be considered unsuitable. In civilian life the motivation is entirely different. Although there is a certain amount of discipline imposed upon all people in civilian life, it is entirely different from that which confronts the soldier: The soldier is under an authority, must observe discipline from the time he enters the service until he is separated, while in civilian life, this situation may exist from, let us say, fifty to sixty hours a week to the other extreme of being relatively independent of this discipline. I believe that this is an important psychological factor to the men in the service, particularly the more mature and less acceptant and dependent. [38]

T h e soldiers' limited ability to take action about any disagreeable situation was also thought to be an important element in the comparison: The differences between military and civilian industrial life are very great so far as the newly inducted man is concerned. At home the individual knows what is expected of him, he can look forward to at least a few weeks or months of being in the same place. If he does not like what he is doing, there is some prospect for change, and most important, he has some say as to what he shall do. In the military organization he not only has lost most all his freedom, but this fact is emphasized to him in many ways, subtle and direct. Another writer stressed the "loss or suppression of individual initiative" and pointed out that "individuals will react in varying ways to the necessary military restrictions and loss of their identity." For some it may be very difficult to accept such abbreviation of their freedom and independence; for others not at all, as some psychiatrists point out, because the Army actually satisfies the dependency needs of certain individuals: There are some important differences, however, the most significant, perhaps, being the fact that in Military Service the individual has little need to exercise his own judgment and is, in effect, cared for in such a way as to satisfy many dependencyneeds which he may have. Not a few of the neuropsychiatric breakdowns which occurred in Military Service were brought about by elevation in rank to the greater responsibility of either the non-commissioned officer or officer status. A further difference between military and civilian life was seen in the comparatively greater freedom which a civilian has during his leisure time: The same man working on a production line in an industrial plant would look like his fellow workers while on the job, but

[39]

away from the job may drive a large and perhaps gaudy automobile, may dress as he believes a young banker would, smoke a large cigar and attain the feeling of great importance and thus, except for forty hours a week, indulge in whatever fancy he will or may. T h e same writer elaborates upon this distinction between the work and non-work hours of the civilian: The emotional support of his own personal life where, aside from the forty hours per week, he is king of his own castle, is vitally important in the maintenance of his total integrative system, regardless of the defensive techniques which he uses. There is available to the industrial worker the subterfuge, if you will, of living one life socially and another economically. This, to some personalities, is extremely important and, I think, extremely valuable. A corollary to this is the strain of living for twenty-four hours a day with the same group. This was suggested as an important factor unique to the military: My general impression about the comparison between military and industrial strains is that they are strikingly different. Going back again to my small group of premature separations, the strains which seemed to be most important in the precipitating etiology were separation from home and mother, and intimate twenty-four hour living with a small, too homogeneous, group. They had been able to avoid both of these strains in civilian life and upon discharge from the army again were able to get in situations where these strains didn't occur. Their adjustment both before and after military service was certainly marginal but didn't result in actual breakdown. T h e foregoing comments all point to the greater flexibility of the environment in civilian life which facilitates individual adjustment. Speaking of somewhat less stable people, one writer illustrated this point: In civilian life there usually is enough flexibility to enable most such people to maneuver around their neuroses. The Army on

[40]

the other hand confronts them with rigid and inflexible situations which in one form or another make it impossible to escape. A simple example is a youngster seen recently at Fitzsimmons, who had a true compulsive Wanderlust. All his life he had had to change friends, his social associations (both men and women), studies, jobs, kinds of work, home, cities. If he did not change, enormous emotional tension would begin to build up in him. As soon as he changed, he could relax again and become happy, peaceful, content, and productive for a time. The Army blocks all such change. The result was a series of explosive episodes, first disciplinary in nature, and then a tension of nearly psychotic proportions. I do not doubt that in the long run his neurosis would have caught up with him in civilian life also. But he would probably have remained well for ten, fifteen, or twenty-five years. In seeking to pinpoint the particular conditions which exist in civilian life that make it possible for an individual with pronounccd neurotic traits to establish a tolerable adjustment, several writers placed considerable weight on the opportunity for a man to change his job: In civilian life a man can change his job and thus very often avoid breaking down. Sometimes his inability to change his job is an expression of his emotional handicap. I am under the impression that many who had to be hospitalized in the service returned home and went to work, not to a hospital. They also pointed out that industry generally expects less of a man than does the military: Surely industry tolerates an individual being a little ill and expects less performance from him than from a person who is well. The person who is a little ill does not necessarily get fired for it and his abilities are utilized. A similar thought was expressed by one writer who said that "one can lose job after job and finally sink to a level of tolerable existence in civilian life, whereas in army life it is [41]

cither court martial or hospital if one does not fit." Another stressed that " . . . the need for discipline and group morale is somewhat greater in the military than in our industrial establishments." Since individuals are under surveillance twenty-four hours a day in the Army and only eight hours a day in industry, men with emotional disabilities are more likely to be noticed in the Army: It would appear to us that emotional disabilities are more apt to be noticed and action taken by others in the rather close confines of military life, even while in training and on home soil, than would be the case in civilian life. There is ample reason for removing a man with such a disability from the military service. However, a similar reason would not necessarily cause such action in a civilian occupation or cause treatment to be sought at a clinic or mental hospital. In the preceding chapter we quoted several discussions of the question of emotional dependency as a factor contributing to breakdown in the Army. We may now add a few considerations about the civilian background of men whose pronounced dependency needs were severely frustrated in Army life. One point of view is expressed below: As to the men who broke down in service and were prematurely discharged, with one exception all of my patients broke down before being moved to overseas areas. While my numbers were very limited, the men were so strikingly similar that I felt my impressions might be somewhat significant. With very few exceptions the men showed a very high degree of emotional dependency on their mothers. They came from homes that were closely knit to a degree which I would regard as pathological. In other words they were probably quite comparable to the nostalgic group of the Civil War. In addition to the family dependency, particularly maternal, they pretty

[42]

uniformly gave a history of only a marginal membership in normal adolescent gang activities and I felt there was a causal relation between both of these factors. They were childishly dependent but they were unable to transfer that dependency to the Army organization, I presume to a considerable extent because their dependency had been directed toward a woman. And they had never learned the techniques of give and take in a closely knit gang of people of the same sex such as the small units of the army tend to be. T h e same point is made in the following quotation: I had the impression that most of those people who broke down in the service were over-dependent on someone in the family, were unaccustomed to being on their own, had had to make few changes in their own lives, and they were just barely able to compensate in civilian life. When they got into military service, they found everything quite impersonal, they were treated frequently in a deliberately irritative way and so reacted with illness or behavior disorders. This writer remarked on the need of a weak individual for the support of family and friends: Many individuals can maintain a reasonably good adjustment so long as their environment is simple, few demands are made upon them, and the familiar supports of family and friends surrounding them is not withdrawn. As soon as they are taken out of the familiar surroundings, the weaknesses begin to appear. T h e differences among men in their reliance upon family ties and the consequent differences in their military adjustment require special consideration, according to one writer: However, this does not lead us to any generalized rule. One sees that in the regular army almost all the men come from very poor homes and often broken homes, or have been raised in orphanages. These men have enlisted in the army to find a new home, and settle into it very well and make the army

[43]

the center of their lives. Apparently there is a very great difference in this respect between the regular army and the men inducted into the army. This may lead us to say that for some men more steps must be taken to make the army the center of their lives if they do not have stable family lives to fall back on. The remarks cited so far have dealt with the differences between military and civilian life. Our respondents emphasized the marked differences between the two situations in terms of personal freedom, in the routine of daily living, in possible techniques of escape from disagreeable or pressure situations, and in the support offered by others. Some psychiatrists, however, thought that there were significant parallels, but they are decidedly in a minority. One said: The more I see of military life the closer I see it allied to big business operations. Certainly those who are exposed to the actual danger of combat constitute but a small proportion of those who are in the military service. The main difference that I see is the relative absence of free will and choice that the civilian worker has, but I also think that this supposed free will and choice in civilian life is somewhat more limited than the average individual would like to believe. Starting from a different basis another writer arrived at a similar conclusion: I think the old truism that "the best civilians make the best soldiers" shows through quite well in industry where we find a rough parallelism in the fact that our military non-coms are now our shop stewards and shop foremen, some of the more aggressive are shop executives, while our "yard birds" and "sad sacks" continue to cluster the compensation rolls. In fact, I have been amazed at the number of individuals injured in compensation accidents who speak of collecting a pension for some service-connected disability (usually pes planus, etc.) as a result of the last war.

[44]

One psychiatrist felt that the parallels were sufficiently clear that they should be made the basis for formulating policy: If we could break down this idea that "you're in the Army now" and that there everything is different, we could accomplish a great deal. Granted that leadership is not perfect in industry, yet under that system the breakdown rate is lower than in the military, and many lessons may be learned. I suggest: take what has worked in civilian life and see how it has been modified in the military for success or failure, rather than to think of applying lessons from the military to civilian life. Although many suggestions were contained in these replies to our questions, it is quite clear that the points of similarity and difference between military and civilian life have yet to be analyzed. Here is one of the important tasks for further research which could lead to a better understanding of the factors which contribute to or detract from successful performance in both areas.

[45]

V

How Can Manpower Be Saved I T WAS inevitable that when a man began to reflect upon his experiences during World War II, he would think of changes in military organization and policy that might have at least mitigated those problems which he encountered. The psychiatrists, prompted by our letter, pointed out many changes which they believed might lead to the more effective utilization of manpower. Their suggestions relate to a wide variety of problems and policies, but they can be differentiated as to those which bear upon the personnel system as a whole, and those which relate specifically to the fields of screening, military training and indoctrination, and personnel assignment and utilization. It must be recalled again that psychiatrists are first and foremost clinicians, whether in civilian life or in uniform. Many of those who responded had had considerable experience with, and consequently acquired rather extensive knowledge about, one or more facets of the management of military manpower. However, no one of them was ever in a position to see the personnel problem in all of its aspects. The various recommendations which are detailed below must therefore be considered as merely suggestive; they do not represent a balanced appraisal of alternative policies by senior staff officers. With respect to the personnel system in general, one psychiatrist felt that much would be gained if "the older military traditions could be set aside anu more realistic utilization of manpower in terms of total effort were at-

[46]

tempted." Another thought we could learn much from the way in which the British handled their personnel: Very early, as the British did, we should have been asked to classify men for various degrees of stress subject to up- or down-grading on the basis of subsequent experience. To my mind this is the most important factor in preventing waste of manpower. Certainly industry hires for a type of job and the military should do likewise, not only on the basis of experience and skill but also in terms of emotional and personality stability and capacity for various types of adjustment. Much the same point of view was expressed by the following writer: The point I am stressing is that the recognition of capacities and defects and the attempt to utilize personnel in such a way that their incapacities can be kept from making them a complete loss is the essence of getting along with them. Recognizing the importance of motivation, one psychiatrist suggested that the point system could well have been instituted at the beginning of the war rather than at the end: That is, men from the start should have known that the longer overseas service and the more combat they had seen, the sooner they would get out of the service. And if it were impossible to predict when men could get out of the service such as happened in the last war, they could at least know that they would be given priority. The point system needed further revision overseas. Five additional points for each batde was not sufficient. The same writer elaborated on the question of incentives: I doubt that combat pay is as important to the soldier as the knowledge he should have that, if he survives a certain amount of combat, he will be able to return home. I think that the incentive to get into combat should be that the men in combat will have less time overseas than those who do not have com[47]

bat duty. Further, that going overseas should have its reward of less stay in the army than the men who never go overseas. This should apply to officers as well as to the enlisted men. A suggestion of how such an incentive system might work was presented: It is rather obvious that the reward for breaking down was too high in the last war; that is, men were let go on until they felt that there was no escape from perpetual combat except being killed, wounded, or going crazy. During the last war it was surprising to note how men could pull themselves together and hold out for another six months when they knew that if they could endure another six months they would then go home. As far as I know, the CBI was the only theatre in which the men understood that they would be out for but two years from the time they left home. It might be interesting to study the differences in psychiatric casuality rates in India as against the South Pacific. A further constructive solution is suggested below: In handling psychiatric casualties overseas a similar feature could be utilized. That is, if the men could go back to combat they could continue to gain points which would eventually get them out of the army. If they just remained overseas they would also get points, but not as many as if they went back into combat, whereas if they returned home to duty they would gain far less points and therefore not get out of the army and back to their families as fast. This could not be applied to very serious psychiatric casualties who would have to be discharged anyway. I think it could go far in reversing the feeling that a neurosis was an asset in relieving one from combat and overseas duty. It could be set up in a non-punitive system because it would be just what did happen to the servicemen at home, that is, they did not get out of the army as fast. Closely allied to the "reward for failure" alluded to above is the problem of "secondary gains." One writer included the following warning:

[48]

T h e secondary gains of any illness which may develop are numerous. If the individual knew that he would have to contribute his time and energy whether he was sick or well or whether he was in uniform or out, the problem of secondary gain from illness would be much less. T o make the whole matter even more ridiculous, he can get a pension for a functional illness and thus be in a position from then on to be paid to remain ill. This makes the burden of the psychiatrist who tries to treat him overwhelming. T h e "dreadful replacement system" of the last war, as one writer called it, c a m e in for repeated criticism: I t seems to me that it was an unusually fine example of how military men could think of their soldiers in terms of materiel rather than personnel. Obviously it was the most impossible system as far as the morale of the men was concerned. T h e replacement depot policy also needs study for here men felt totally lost and many broke down long before they went into combat. When they reached such places as New Caledonia and were separated from everyone they knew, they waited around for weeks or months until they found themselves in a unit again. Apparently very little was done to help the men maintain themselves during this period of stress. It would also have been possible to rehabilitate many more men in the Pacific if a better replacement depot policy had been instituted. It was found impossible to send a recovered man to a replacement depot awaiting re-assignment because the anxiety and loneliness of this wait was too much for him. T h e same writer called attention to the importance of the method in distributing special rewards: O n e also gains the impression that the giving of medals and rewards of various types to rear echelon men and outfits should be avoided in general. It was quite a surprise to find out, on returning from the Pacific, that the men stationed in the States were far more bemedalled than most of the veterans from the Pacific. This may be an exaggeration on my part, but it was a general impression held by many of us. Similarly,

[49]

considerable hostility was aroused in many outfits I saw by giving medals to the commanding officers of outfits for the performances of their outfits. It may be warranted in some cases, but usually it arouses a lot of hostility on the part of the men if this is done in place of the unit citation. With respect to the specific subject of screening for induction, there was rather general agreement that it should be broadened rather than refined: The American Psychiatric Association's Committee on Military Psychiatry last year felt quite strongly that induction screening should be very coarse indeed, and that emphasis should be placed on psychiatric evaluation of inductees during the first weeks of their training. At least one has the advantage then of considerably more time to study questionable cases, and their reaction to life actually in the military structure can be illuminating. Another psychiatrist summed up his recommendations by saying that screening should be "reserved for those presenting serious evidence of psychiatric unfitness." He went on to explain that he thought the "pre-induction examination is without value as to predictability for military service, except in the weeding out of obvious mental defectives and of patients who are overtly psychotic." There was considerable enthusiasm for "the Navy's plan of taking people for a three months' trial." One respondent said: I still think the best plan would be to make the most superficial screening in local stations, sending all except the most grossly disabled to boot camps for a much more careful survey over several weeks with some sort of arrangement that those found wanting would be separated administratively and not on medical grounds. Several psychiatrists agreed that it was important to pav more attention to training and indoctrination: [ 50 ]

However, I suspect that the main problem relates to the established idea of how to train a man for military service. It is my belief that the two main principles, (1) absolute discipline, (2) mobilizing anger, discontent and irritability, lead to aggressive tendencies which are necessary for combat efficiency. These two principles, whether they are overtly believed in or not, play a large part in the conventional military training. T h e period of transition from civilian to military status seemed to several of our respondents to be of crucial importance : Most of our young people have been brought up in the last 25 years in an atmosphere in which self-expression has been cultivated. The military is the complete reverse. If one recognizes that many of our young folk cannot make a sudden reversal from this viewpoint of self-expression to that of complete discipline and that the people of high sensitivity cannot immediately accept repression and frustration without the likelihood of breaking, then I think one can begin to deal with the question of why so many have broken down. T h e danger of neglecting this period of early service is stated with great clarity in the following excerpt: I understand that a breakdown of a survey made during the second World War reveals that someplace between 30 and 45 percent of the men who were separated for psychiatric disability broke down within the first three months of induction. This surely gives us very clear leads as to what must be done in the way of indoctrinating the soldier into the army. I do not think the assumption can be made that it is just as good that these men break down in the first three months because they would surely break down under greater stress. I think that the period of induction into the army is apt to be one of the greatest periods of stress, and that if the soldiers could be prevented from breaking down during this period, the total number of breakdowns would diminish appreciably.

[51]

The rigidity of military personnel policy and attitudes seemed to be the cause of much difficulty and certain modifications were advocated by several of our respondents. One psychiatrist emphasized the fact that as long as the military adhered to the doctrine that there is "no place for duty in the Army for an individual with psychoneurosis," the inevitable result would be "the premature discharge of many thousands of men." In this regard, apparently, the Army and the Navy were equally inflexible, as can be seen from this quotation: The rigidity of naval regulations was a major handicap in trying to help the potentially neurotic sailor to adjust. Naval regulations are apparently written with the blithe assumption that all men are equal, that they are either well or sick, and that if well they can withstand an equal amount of pushing around. This resulted in one of two things—either the man who was having difficulty was surveyed out or else the Medical Officer had to write a survey which was necessarily not entirely accurate. Many of the officers and petty officers had a reasonably good understanding of the problem that the enlisted man faced. The higher the rank of the officer the less this understanding tended to be, although, fortunately, there were numerous exceptions to this general rule. The absence of an effective "limited service category" was felt to be a major shortcoming by many: It seems to me that one factor in the high losses of manpower in military life was the failure to develop a working limited service category. Limited service looks very well on paper but does not work out well, and much of this had to do with the rigidity of military administration. I know I was guilty along with many other doctors in discharging thousands of men just because there wasn't any place to put them. In spite of all the circular letters and directives, the old traditional attitude that the man was either fit or sick, that if he was sick [52]

he was sick enough to belong in the hospital, prevailed. I don't know if this tradition can change. That the problem of premature separation had aspects beyond the purely psychiatric was not missed by many of our respondents: Perhaps a little clarity might come into the thinking on the matter if it were admitted right off the bat that the NP problem was never entirely an NP problem. It was always an NP-administrative problem. I have seen hundreds of men discharged just because there was no place to send them, or because psychiatrists had no faith in limited service categories or re-assignments. One psychiatrist felt strongly about the way in which he and his colleagues were forced to make decisions "for the convenience of the service": When clinicians are in a position to stand their ground, the Army stops using medical channels as a sewer down which to flush all their waste material, and either finds some use for such personnel or tells them administratively that they are no longer needed. In sharp contrast with the experience of many American psychiatrists stands the following comment by a psychiatrist who served with the Canadians: I spent sometime overseas with a Canadian psychiatric hospital where I can assure you that separations were not as easily made. There was a mechanical factor here in that by this time a soldier had had a lot of time and effort spent on him in training, and he was a long ways from a quick return to productive industry. Many stated that a stone wall confronted them when they sought to aid the Armed Services in improving their techniques of managing personnel:

[53]

We all know quite well that the medical officer doesn't have sufficient wisdom to make definitive recommendations for the management of psychoneurotic individuals but at least he has the most of what little there is, and line officers should be willing to take their recommendations seriously rather than feel that their authority is being weakened. However, the psychiatrists thought that they could probably make a contribution in certain areas, for instance, in the training camps: I feel that possibly the psychiatrist in the Service might, to a great extent, have been used far more efficaciously in this sphere, i.e., detecting early evidences of lack of compensation and swinging personnel into fields of action which would be less exacting and which might have either slowed down or completely prevented the ultimate collapse of the individual's integration. Such a contribution would have necessitated a willingness on the part of the Army to work with the less well-adjusted which was often lacking: It was felt in our training camps that a mass of men was not needed and that there was not time to "fool around" with poorly-motivated, immature people. With very little evidence of maladjustment to service, and without too much effort to involve the waverers, they were unceremoniously cut off early in training. Furthermore, such help as psychiatrists were able to give required command support if it was to be effective: A vast number of these people could have been preserved for non-combatant duty had their personality problems, which were brought into action by myriads of external reasons, been subject to study and even minor psychotherapy by staffs of local base mental hygiene clinics, who, like personnel counsellors in industry, should have had some respect from the military. These clinics, properly staffed and well received by '54]

C.O.'s, did a remarkable job, when they were permitted, in saving men from separation. As the psychiatrists saw it, better assignment procedures were definitely indicated: In considering vocational placement, it is obvious that not everyone entering service can get the job for which he is best equipped or which he was able to handle in civil life no matter how much he suffered from illiteracy, mental retardation, or emotional disorder. But, I am quite sure that the army could make a much greater effort at suitable placement and replacement. The need for an improved assignment system had particular pertinence for those who came into the Army with special skills: A significant number of breaks occurred in well-integrated personalities who were, by virtue of the very structure of the military machine, unable to attain any acceptance or satisfaction and were in effect rejected at every turn. These were the so-called "miscast personnel", people with great talents, in many instances, highly trained skills, and excellent motivation, but who were utilized so poorly that these potential assets were completely dissipated. This occurred repeatedly in both enlisted and commissioned personnel. These suggestions about the changes which the Armed Services might make with respect to their personnel system in general and with respect to the particular policies which they followed in screening, training, and assignment procedures were tangential to the answers which the psychiatrists developed to the major questions which we had put to them about screening, breakdown, and a comparison of military to civilian life. Being tangential, they should not be considered psychiatric doctrine but rather the personal reflections of a number of thoughtful psychiatrists about the broad problems of military manpower policy.

[55]

VI

The Ineffective Soldier AS we have stated, our request of the psychiatrists for their retrospective opinions about certain aspects of the relation between psychiatry and the military services grew out of our plan to investigate the problem of the ineffective soldier during World War II. In this last chapter we shall summarize what we learned from their thoughtful communications and indicate the outline of our research plan. Perhaps the most important conclusion drawn by the psychiatrists from their own experiences during World War II is that the more or less explicit aim of the screening procedure—to identify and reject every individual with a psychoneurotic vulnerability—was in error because it is not possible to define "potential breakdown" with a sufficient degree of precision. In fact, the psychiatrists now adhere to the opposite conviction that screening should aim at rejecting only those with the most obvious evidence of emotional disturbance which would interfere with effective performance in the Armed Services. Secondly, the psychiatrists were unanimous in urging caution in making extended use of the statistical data bearing on either screening at induction or on the nature or degree of disturbance of soldiers who were separated prematurely from the service. They reached this conclusion on the basis of their personal experience with the radical changes which were made from time to time in personnel policies and administrative procedures, which would have [56]

to be taken into account before one could venture to interpret the statistical findings. The third point of significance was that, upon reconsideration, the psychiatrists concluded that there had been an overemphasis during World War II on the application of clinical concepts to matters of military service. In general, the writers now believe that in place of this concern with the nuances of diagnosis and etiology, much greater attention should be paid to the environment in which the soldier finds himself. The consensus was that the student of the problem of breakdown must pay more attention to the stresses and supports that exist in the environment if he is to understand the causes of successful and unsuccessful performance. This does not mean that the psychiatrists believe that it would be feasible to ignore the personality factor, but that they recommend a substantial shift in emphasis from that which prevailed during the last war. Furthermore, they questioned the search for parallels between conditions in civilian and military life since they were impressed more with the differences between the two than with the similarities. Their replies did suggest that consideration of the stresses and strains in military life which have no counterpart in civilian life may yield important clues to why so many broke down in the service. In light of their present conviction that the conditions prevailing in the military environment are significant determinants of how people perform, many psychiatrists suggested the areas in which the Armed Services might try to increase the supportive elements and minimize the stresses. They called attention specifically to the need for better and more mature leaders; for an improved rotation and replacement system; for an improved basic training system in which the awkward, tense, or fearful recruit is aided in his initial

[57]

adjustment. They place much stress on the importance of avoiding secondary gains from illness which were so prevalent during World War I I . One of the most important recommendations concerned the need for more appropriate incentives to encourage the serviceman to perform more effectively. The writers stated that they are no longer as confident as they were of the adequacy of personality theory as an instrument for military manpower management. They realize that the host of specific problems of personnel management that demand attention and solution during a major war cannot be adjudicated on the basis of personality theory alone. As a result of their reconsideration of the problem, they have replaced their former assurance with a new tentativeness. Their letters indicate that, although they think that they are somewhat closer to an understanding of the complex problems of military selection, utilization, and separation than they were in the midst of the war, they are still impressed with the extreme complexity of these problems and realize that as yet there is no adequate basis for definitive recommendations. They all recognize the need for a comprehensive and systematic approach which would make full use of the rich personnel records of World War II and take advantage of the perspective and greater objectivity that has been gained through the passage of time. Several of the writers offered specific research recommendations. They stated that "there is a definite need for a study of, not psychiatric disease, but psychiatric 'wellness.' " They felt that much could be gained from studying those who continued in service as well as those who broke down: Apropos of this question, what would one find if one made a study of those individuals in the military who did not break [58]

down? Perhaps one would discover a high incidence of emotional instability anchored by a type of character structure (strength of character) which forced them to carry on. Another recommendation to study those who succeeded as well as those who failed is suggested below: In assessing the problem of personality and environment (stress and morale) much will be lost if one measures either component area in terms only of failure. It is the personality and the stress-morale externals of the successful soldier in and out of combat about which we know too little. Some who had had first-hand experience with survivors of prisoner-of-war camps thought of a more specific instance of utilizing this approach—a "study of survival": " I believe that there has been insufficient study of those who survived the rigors of war and until this is done it will be exceedingly difficult to make valid statements about the causes of psychiatric casualties." An illustration of the feasibility of this approach is described in the following statement: We attempted one such study by doing careful psychiatric interviewing of the survivors from Cabanatuan Prison Camp in the Philippines. As a matter of fact we saw the men who had the greatest difficulty in surviving as they were all totally blind or partially blind from vitamin deficiency, and their survival was something of a miracle. What we were interested in was trying to find out how it was that these men managed to come through whereas the bulk of the men in the prison camp died. A few interesting facts emerged from this, mostly having to do with a very strong motivation to return home, sometimes for very contrasting reasons. I should think other such studies could be made which might lead us to further understanding of what makes it possible for men to survive under very adverse circumstances. One psychiatrist elaborated on how he would structure the problem of breakdown for systematic analysis: [59]

The individual who was unable to adjust to the military service almost from the moment of induction and who was separated in the first three to six months, represented one kind of personality structure. I am sure that a somewhat different kind of personality structure would be observed in that group who were separated in the second six months of military service. A third group would represent that level of personality integration, for want of a better term, which tolerated and adjusted with the required adaptations to the military service up to the point of embarkation overseas, or possibly to the point of, say, three months overseas. These three groups might well be considered as levels of adaptation. The fourth group is that in which all of us like to think we belong, able to adapt ourselves to prolonged (that is, over three months) service overseas in an actual or potential combat zone. In the group of so-called "strong personalities," able to tolerate overseas service and combat, additional factors then entered into the picture clinically and, as you know, the dividing line of twenty-one days of combat was used somewhat empirically by medical officers with the infantry divisions. I do not like the term "psychoneurosis," however, to indicate or imply what is more accurately a level of adaptability. A similar methodological suggestion is made in this excerpt: We know that various divisions have been compared but I don't know of any systematic study. We found the procedure very useful as far as companies in a given division were concerned when the division had been subjected to similar stress. O u r own plan of research for The Ineffective Soldier has taken into account five m a j o r implications of the communications of the psychiatrists. First, the fact that a distinguished group of psychiatrists had so many serious doubts about the principles which guided the application of psychiatric theory to military manpower management during World War II supported our conviction of the importance of making explicit the

[60]

theoretical foundations of World War II policy and of the need for a comprehensive reevaluation of these policies. Secondly, their communications reinforced our own conclusion that great care would have to be exercised in using statistical data collected during the war. Since the way in which men were classified and evaluated frequently depended more on existing administrative exigencies than on clinical principles, only error and confusion could result from uncritical use of the gross psychiatric data. Thirdly, in their responses to our inquiry the psychiatrists emphasized that the individual's adjustment to the military environment depended not only on his personality strengths and weaknesses, but also on the stresses and supports of the specific military environment in which he found himself. This supported our belief that breakdown in the military service does not represent a single problem, but must be analyzed in terms of different kinds of military situations involving different orders of stress and support. Fourthly, the fact that the psychiatrists were uncertain about the analogies or differences between adjustment to civilian and to military life pointed to the need for clarifying this relationship. If the analogies between the two situations are many and close, then an evaluation of civilian experience would help to predict the behavior of the civilian turned soldier; if they are not parallel, there would be little reason to make the evaluation of civilian performance an important part of the selection procedure at induction. Finally, the wide variety of specific recommendations for improved personnel management contained in the letters of the psychiatrists suggested that it would not be possible to evaluate individual policies without considering them within the overall framework of the Armed Services' system of personnel management.

[61]

When we wrote to the psychiatrists we had already developed a tentative research plan which incorporated these points. Their replies helped us to complete this plan and encouraged us in the belief that we were on the right track, particularly as far as present psychiatric thinking on military manpower problems is concerned. One of our first steps had been to read the wartime annual reports of all the psychiatric consultants to the Surgeon General of the Army, as well as the comprehensive reports from the individual service commands and major theaters which contained much valuable information about the broad policies that were in operation in the Zone of the Interior and overseas during the war. Although the scientific literature is much too vast to have been reviewed in detail, we did acquaint ourselves with a considerable number of studies which held promise of helping us in formulating a plan for our investigation. We had the good fortune to profit from the significant controlled studies of Brill and Beebe and had an opportunity to learn in detail about their methodology. Through the assistance of our Advisor, Major General Howard Snyder, we had the unique opportunity of requesting several NATO countries to elucidate selected aspects of their military manpower policies and procedures which had direct pertinence for our own investigation. General Snyder was also instrumental in making it possible for us to review some of the more important studies which had been carried out during World War I I by the Office of the Inspector General and the Personnel Division of the General Staff, and which had a direct bearing on our work. Continuing close contact has been maintained with the Surgeon General of the Army and the members of his staff throughout the post-war period. This has enabled us to [62]

remain intimately acquainted with the current policies of the Army and the reasons for continuance of, or changes in, the policies and practices followed during World War II. These opportunities, and many more, have contributed substantially to the formulation of our research plan. Since our study of the ineffective soldier is set within the larger framework of the Conservation of Human Resources project, it is influenced by a central concern of that project—the factors determining the level of performance of individuals and groups. Particularly, the project is devoted to the study of means and ways of reducing the waste of manpower that now occurs in our society as a result of poor performance. While we are not concerned with detailed studies of personality, and even less with specific clinical problems and etiology, consideration must be given to these factors to the extent that they have a bearing on the broader issues of manpower utilization. Since we want to learn as much as we can about the determinants of performance under conditions of military life, we are exploiting the rich potential represented by two different, yet related bodies of material. The Armed Services destroyed many records after the war but they have retained large bodies of valuable information that have never been culled in an attempt to gain a more comprehensive understanding of ineffective performance during World War II. Although Menninger, Stouffer, and a few other investigators have sought to utilize the broad statistical data collected by the military during World War II, it is fair to say that no one so far has exploited them fully. In addition to the materials retained by the Armed Services, there are important bodies of relevant data within the Selective Service System and the Veterans Administra[63]

tion which can round out the picture of the flow of manpower from civilian to military and back again to civilian status. It has been our good fortune to secure the cooperation of all of these agencies: the Department of Defense, and particularly the Department of the Army; the Selective Service System ; and the Veterans Administration. We were therefore in a position to establish, within the limitations of the raw data, the major characteristics of various groups of soldiers. We have been able to develop representative samples of the significant groups of soldiers who were characterized by ineffective performance in the sense that they had to be separated prematurely from the service. In addition, we are seeking to ascertain the important objective characteristics in respect to which they differed from soldiers who did not break down while in service. In Part One of The Ineffective Soldier we are reconstructing the complex personnel problems faced by the Armed Forces, particularly the Army, during World War II, and their need to improvise personnel policies to meet constantly changing objectives. We are describing how public opinion and community attitudes helped to determine the adoption of certain personnel policies and the rejection of others. The concluding section of Part One outlines statistically the flow of manpower into and out of the Armed Services, and includes a statistical analysis of the men rejected for military service for neuropsychiatrie and related reasons. Part Two is devoted to the detailed analysis of selected groups. In order to reduce the variations resulting from changes in policy, in administration, and in the stresses of the military situation, we have selected for this analysis men [64]

who entered the service during one short period—the last four months of 1942. In the broad category of ineffective soldiers we have included men who were separated prematurely for various reasons: those who received medical discharges on neuropsychiatric grounds; those who were considered behavior problems and were separated without honor; and those who were judged unsuitable for military service because of low intelligence. In selecting these groups for detailed study we distinguished further among men who served in three major environmental situations: (1) those who served only within the United States; (2) those who had foreign service but were not in combat; (3) men with combat experience. Within these three categories subsidiary distinctions were made. The first group, for instance, was divided between those who were separated within the first six months and those with longer service. Through such groupings we believe that we can delineate more sharply than have other research workers the extent to which the stresses of the military environment contributed to breakdown and premature separation. In addition to this "situational analysis," we are analyzing special groups of men who were discharged because of psychosis, enuresis, homosexuality, or alcoholism. Finally, we are reviewing the case materials in order to discover whether there were significant differences between the groups who were separated on medical and on administrative grounds. In Part Three we are presenting the major implications of our analyses for military manpower policy, for medical policies and procedures, and for social policy in general. The development of material on both the pre-service background and the post-war adjustment of each man will en-

[65]

able us to extract from the study of ineffective performance in the military services conclusions that are important for the conservation of manpower in civilian as well as in military life.

[66]