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CHAPTER 2
PSYCHOTHERAPY IN A MILITARY SETTING
Army Background of Psychoneurotic Cases The cases to be described in this book were all treated at Welch Convalescent Hospital. Patients arrived at this installation after having been evacuated from combat theatres to the United States. Each patient had passed through a number of hospitals and had received a variety of treatments before reaching Welch Hospital. NP treatment was undertaken with a knowledge of, and allowance for, any existing or pre-existing organic pathology. This was the end of the line. At this point the final therapeutic effort within the military service was made and the decision was taken as to whether the soldier was to be returned to duty, usually in a limited capacity, or be given a medical discharge (CDD) to civilian life. In order that the special treatment problems posed in the handling of these soldiers may be clear to the reader, a brief resume of the typical patient's recent history previous to his arrival at this installation is in order. The typical patient had developed a psychoneurosis after a period of service in a combat area. Among the patients were men from the Anzio Beachhead, from Cassino, from St. La, from the Battle of the Bulge, and from other well-known battlefields of the Second World War
Their first treatment had been evacuation from combat. In each division there was a rest area some distance behind the lines. Many men would respond to a few days of relaxation, especially if their cases had been promptly noted. This, of course, had nothing to do with the predisposing factors but relieved the system from the continual stress of combat. The normally well-adjusted individual might improve rapidly. His body was no longer being submitted to a constant barrage of shells, noises, groans of the dying, sights of mutilated men, and the constant alertness of a "kill or be killed" soldier. The regenerative forces within the body were able to cope with the anxiety created. With a few days of rest and sleep the soldier appeared to be completely recovered. Sometimes medicinal sedation was prescribed if the patient could not sleep or rest. However though greatly improved by this rest, the soldier was not necessarily "cured." he could not then return for another three months of the same combat, The stress he had endured and the anxiety developed in his body had left their mark. He probably could not "take" as much as when he first entered battle even though he looked perfectly well. A few more weeks of the same kind of severe duty and he might return to the aid station in a more severe anxiety state which would last longer.
Treatment in Rear-Echelon Hospitals
If it appeared that he was too severely disabled to improve greatly from a few days' rest, he was evacuated to the rear, to a hospital equipped to give more intensive and longer treatment. If his disorder was a reactive depression, he might be given shots of insulin to increase the metabolic processes, or his anxiety might be relieved by narcosynthetic treatment with sodium amytal or sodium pentothal Grinker and Spiegel, 1944). Under a barbiturate narcosis, material which had been repressed might emerge. Pentothal, commonly called "walkie-talkie" by the soldiers, seemed to have the effect of bursting "the dam of the unconscious." The patient was able to re enact scenes involving great emotional stress, to relive painful combat experiences and to recall periods during which he was amnesic. This was called abreaction. It is a form of "getting it off your chest." The repressed conflict, like an infected boil, is "lanced" and the repressed pathogenic material released. This procedure proved especially effective with acute cases. Some times the Pentothal would relieve the anxiety, disclose the source of guilt in the depressed patient, or enable the hysteric to regain use of his paralyzed limb, stuttering voice, or impaired eyesight. Often though the, predisposing factors in the patient had been so strong or the significances so deep that he lost his symptoms only while under the influence of the drug. When he awakened they returned. The symptoms might or might not be cleared up after repeated use of the drug. In cases like this, deeper and more intensive psychotherapy was required.
In addition to these drug treatments the hospitals in the rear echelon usually had a well-planned program of activities, athletics, recreation, movies, and reading, all designed to "get his mind off it" and to provide a stable environment in which the natural forces of recovery might have the greatest opportunity to operate. Psychologically important at this time were letters from home, good buddies, and sympathetic and understanding doctors and nurses after several weeks or months of reconditioning of this type the patient had improved enough so that he could be returned to limited service behind the lines. There he could be of military value yet not be subjected to the extreme stress of battle. If this could not be done, he had to be evacuated to the States for longer convalescent treatment. The more severe the breakdown, the farther back from the combat zone he was sent. And conversely, the farther removed he was from the battle area, the less chance there was of reconditioning him for combat again. If he could be revived in the rest area and returned in a few days, he might continue to give valuable service as a fighting soldier. After a few months away from combat, however, in the rear-echelon hospital, it became almost impossible to send him back to battle. By the time he had been evacuated to the United States he had developed intensive antagonism and resistance to any type of further military service and thought only in terms of going home to civilian life. During his stay in these hospitals every possible ego-building therapy was tried. Constructive and creative activities were emphasized. He was encouraged to paint, model, or build something in an arts and crafts shop. Occupational therapy is a special form of arts and crafts work in which skilled therapists prescribe types of interesting activities which develop not only the weakened spirit but also the weakened muscles in the paralyzed arm or leg of the hysteric (War Department, 1944). Confidence in his own accomplishments and achievements sometimes worked wonders. A neurotic soldier might lose a great deal of anxiety and make considerable progress because he found he could fashion a bracelet for his wife or girl friend. Still another type of treatment which was found effective in many cases was that of progressive relaxation (Jacobson, 1938; Fink, 1943). Here the patient was taught how to relax completely one set of muscles after another, until his entire body was free of tension and he could easily go to sleep. This kind of treatment was found especially useful with severe anxiety states, although it was also used effectively with other types of neuroses. All these therapies are valuable. They are often called Superficial, not because they are ineffective, but because they concentrate on freeing the man from the stress that started in battle and was being continued almost as a habit. These superficial treatments do not attempt to deal with the patient's unconscious conflicts. They are more directly related to his immediate environment as such they are more suitable for group application, the type of approach which necessarily must be followed with the vast majority of Army cases. This eclectic ego-building is the essential feature in the psychobiological concept of treatment as developed by Adolf Meyer (Lief, 1948).
Procedure in Welch Hospital
Our typical patient, therefore, arrived at Welch Hospital with a well-structured neurosis which had successfully defied many previous treatment efforts over an interval of from three months to a year. His motivation was only in terms of return home, and he was usually embittered by his frequent military transfers from one hospital to another. He nearly always exhibited strong hostility to the Army and to any further therapy. Often, indeed, he had not received thorough and competent treatment. Inefficiency and incompetent personnel are too common in a large wartime Army to require any explanation or apology. However, much of his bitterness was related to displaced guilt reactions over his inability to remain with his outfit in combat. After reaching Welch Hospital the patient was assigned through a receiving company to activities involving psychiatric, physical, and dental examinations with diagnosis and classification, accompanied by orientation into the activities of the post and his future role. Following this he was assigned to a treatment company for a period of from six weeks to several months during which his treatment included group therapy, recreational and educational activities, physical exercise, and sometimes individual psychotherapy. The companies (with the exception of the Special Treatment Company) averaged 100 to 125 men each during peak load and were staffed by a psychiatrist, a clinical psychologist, and one or two psychiatric social workers. At the termination of his stay, the decision as to his disposition was made by the psychiatrist of his company, and his orders, either return to duty or discharge to civilian life, were cut accordingly. Within the Hospital the more difficult cases which did not respond to group treatment were referred by their psychiatrists to Company F, the Special Treatment Company. Here their cases were considered for suitability for the types of individual therapy offered in this Company. If the therapists in Company F felt that the case merited such attention, and the case was treatable by their methods, the patient was accepted and his transfer was accordingly made. At times especially problematic cases were directly assigned to the Company even though prognosis was questionable. The main types of treatment utilized in the company were narcosynthesis hypnotherapy and progressive relaxation. However, the size of the group was not permitted
to exceed twenty to thirty, so that time would be available for individual help. Before turning to the consideration of individual cases, we shall in the next few chapters briefly examine psychotherapeutic theory and techniques which were utilized in the rehabilitation of these soldiers. This will give purpose and substance to the verbatim reports of treatment sessions and enable the reader to evaluate more critically the degree of success which was achieved.