Nervous in the Service
The benefits of World War II accrued as surely to clinicians as they did to the sykewarriors and opinion pollsters who evolved into the behavioral scientists of the postwar era. Experts who treated malfunctioning individuals and those who attempted to manage the mental state of entire populations could all claim loyalty to the practice of psychology. They pointed with pride to a common body of theoretical knowledge and insisted that its flexible application to both clinical and policy purposes validated psychology's status as a universal science. The experts surveyed in chapters 2 and 3 spent the war years guiding wartime policy around mass emotional currents that threatened to obstruct military victory and contaminate democracy by undermining the cohesiveness of civilian and military spirit. Their reward for effective service was a place in postwar public policy for themselves and their research, as we shall see in chapters 5 through 8. War brought access to policy-makers, and access to policy-makers inspired visions of altering the exercise of power.
The experts whose work is described in this chapter provided services deemed equally crucial to the war effort. Although the subject of their tasks was different, the ultimate goal was not. Clinicians were just as centrally concerned with morale, and their activities also promoted a highly subjective conception of effective warfare rather than one that emphasized, for example, superior technology. As specialists in individual treatment, they took pains to show exactly how their work furthered collective aims and, in the process, pushed work designed to instill men-
tal hygiene and health far beyond its initial, clinical uses. According to psychiatrists Edward Strecker and Kenneth Appel, "Psychiatrists employ their skill in trying to mend broken personalities. They attempt to reassemble the fragments; fit them together; remobilize the morale....
A nation has a living personality. The national personality is the cross section of the personalities of all the citizens. It is a reliable barometer of the condition of the national morale." Throughout the war, clinicians spent their time administering tests, formulating diagnoses, and experimenting with a range of psychotherapeutic techniques designed to help mentally anguished soldiers recover a degree of military usefulness in spite of the terrible strains of war. "Morale does not grow on trees," clinicians Strecker and Appel proclaimed just as boldly as pollsters and sykewarriors. "It must be made."
Their record in "making morale" had dramatic results during the war and after. Clinical tasks multiplied, the ranks of clinical professionals surged, and clinical theories about what caused mental troubles were fundamentally reformulated, along with corresponding treatments. War on a mass scale was probably the only thing that could have made clinical treatment possible on a mass scale. It achieved what clinicians prior to World War II had never even dreamed of attempting on their own: a comprehensive "normalization" that altered the subjects and purposes of clinical work by reorienting theory and practice away from mental illness and toward mental health.
This chapter describes how the military's tangible requirements inspired such normalization and argues that it shaped clinicians' history both during World War II and long after. The normalization process was radical. In hopes of ensuring the mental stamina of the fighting forces, millions of ordinary men were brought into the orbit of clinical applications for the first time. In the short run, the outcome appeared misguided, even disastrous. Instead of improving Americans' war readiness, clinical technologies exposed an epidemic of emotional instability and betrayed the weakness of democratic resolve. In the long run, however, wartime clinical practice earned benefits for almost everyone involved. By acquainting huge numbers of ordinary people with professional healing and emotional self-management for the first time, it served as a foundation for the "growth industry" of the postwar years and lengthened the menu of services available to a rapidly expanding consumer market. War proved that more things, relationships, and experiences could alleviate mental troubles than anyone had previously
imagined. And it demonstrated why taking charge of citizens' mental health was such a major obligation of a modern, democratic state.
Who They Were and What They Did
Clinicians were the war's most visible psychological experts. Not only did their numbers exceed those of their policy-oriented counterparts, but their immediate clientele—literally millions of soldiers—eclipsed the relatively small group of war managers and policy-makers whose needs governed the path of experts with more conventional social scientific inclinations. One-third of the psychiatrists in the United States volunteered immediately to serve in the massive effort to screen every single one of the fifteen million recruits to the armed forces. But this amounted to a mere three thousand people, less than 2 percent of all U.S. doctors (who numbered around 180,000 in 1940) and less than 3 percent of military physicians.
It was clear early on that a critical shortage of psychiatrists would hobble the effort unless a crash course in mental medicine were provided to the military's general medical personnel. Twenty-five psychiatrists comprised the military's entire psychiatric staff when the United States entered the war, but another twenty-four hundred medical officers were rapidly trained in the treatment of emotional disorders, along with a wide assortment of allied professionals, from clinical psychologists to social workers and nurses. One-quarter of the country's trained psychologists, to take only one example, served in the military by the end of the war years. And the numbers of clinicians increased dramatically as a result of military requirements. In 1940 a bare 272 members of the American Psychological Association (less than 10 percent of the entire membership) had been employed in clinical capacities of any kind, and among these, very few were assigned major psychotherapeutic tasks. By July 1945 seventeen hundred psychologists were working for the military, a significant number of them in clinical capacities. War had offered many of them their first opportunities for clinical training and practice, persuading them that the field of individual treatment was the place to be in the future.
Because of psychiatry's medical origins, experts involved in clinical tasks appeared much less controversial at first than experts assigned to propaganda or intelligence operations, whose delicate tasks were almost
always shrouded in secrecy. Indeed, before the shocking results turned information about the military's mental state into top-secret data, clinical experts proudly broadcast their plans to mount screening and treatment programs in the name of humanitarianism as well as effective management. Properly supported and implemented, clinicians argued, they could increase military efficiency by selecting out individuals who were identified, in advance, as psychological drags on the war effort and dealing quickly with cases of mental breakdown after the fact. While clinicians shared with the experts discussed in chapters 2 and 3 a commitment to advancing national security and the skillful conduct of war by the U.S. military, their historical reputations marked them as virtuous healers rather than skillful manipulators. Years spent caring for the sick and unfortunate had offered psychiatrists precious insights into the general human condition, argued Alan Gregg, director of the Rockefeller Foundation's Medical Science Division. "By showing us the common rules, the uniform limitations, and liberties all human beings live under because they are human, psychiatry gives us a sort of oneness-with-others, a kind of exquisite communion with all humanity, past, present, and future. It is a kind of scientific humanism that frees us from dogma and the tyranny of the mind, a relief from the inhuman straitjacket of rigid finality of thought." According to William Menninger, who led the military's psychiatric effort during the war, Gregg's call to reveal the transcendent existential truths standing behind clinical experience was "a credo for every psychiatrist."
Because of the memory that 69,394 men (around 2 percent of all those examined) had been rejected from the World War I military, the first priority was a screening program for inductees. Robert Yerkes's notorious World War I intelligence testing program also came to mind as an unsettling reminder. Even though it had not been comprehensively administered, Yerkes had found a 50 percent rate of mental defectiveness among inductees and 60 to 70 percent of the rest demonstrated very low levels of intelligence: the average white, native-born soldier scored a mental age of thirteen. This amounted to a virtual epidemic of feeblemindedness among the young men who were to be the country's first line of defense. In 1940 psychiatrists faulted their World War I counterparts for being insufficiently rigorous in their preemptive screening. They had relied too heavily on physical exams and symptoms, and psychiatrists were called in only on a referral basis, when some other military gatekeeper suspected the existence of a mental problem. When psychiatrists did have the chance to investigate, they
complained that military bureaucrats frequently ignored their recommendations and labeled clinicians "nutpickers" or "nutcrackers." Psychiatrists accused the World War I armed forces of harboring attitudes toward their profession that were "colored by a mixture of prejudice and ignorance."
Without a doubt, the World War II screening effort would have to be a substantial improvement, and early indications were positive. "The Selective Service System seems to be fully awake to the importance of psychiatric considerations," reported one professional committee with great satisfaction. Designed and run by psychiatrist Harry Stack Sullivan, director of the prestigious William Alanson White Psychiatric Foundation, the program was incorporated into the 1940 Selective Service Act upon the express request of President Roosevelt, who was worried about the projected high costs of psychiatric hospitalization. The screening process itself entailed a series of four to five thorough psychiatric examinations, beginning at the local draft board level. Each exam was supposed to last fifteen to twenty minutes so as to avoid "the ridiculous business of staring at people for a moment and pulling a few out of the line for further study." According to the plan, standardized interviews would elicit detailed information about registrants' family backgrounds and emotional profiles with such questions as "Do you suddenly get so mad you don't know what you're doing?" All screening interviews would be conducted in private.
The screening program assumed psychiatrists' ability to identify "predisposed" individuals and thus predict mental trouble, two skills that would, experts claimed, save the government much time and expense. It was widely publicized that psychiatric services and disability payments to veterans had cost close to $1 billion between 1925 and 1940 and it was estimated that each psychiatric casualty during World War II would cost at least $30,000. If only screening were properly implemented, "human values will be conserved; a great burden of unnecessary disability compensation payments, hospitalization expenses, and pensions will be avoided—and the prestige and effectiveness of psychiatry, greatly expanded." Every physician working for a local draft board, after all, would necessarily come into enlightening contact with psychiatry, most of them for the first time. For physicians unfamiliar with psychiatric diagnoses, guidelines for questioning were provided, including strict instructions that problematic candidates be immediately referred to the psychiatric member of the nearest medical advisory board.
Predisposition was a psychiatric concept with roots in nineteenth-century medicine. By 1940 large-scale socioeconomic events like the depression had moved the concept away from a narrow, genetic meaning and neo-Freudians, including Sullivan himself, were stressing the power of culture to shape and reshape human behavior. During the interwar period, a great deal of discussion revolved around ameliorating the detrimental social conditions—childhood delinquency, sexual perversion, unemployment, and so forth—that could enhance the biological predisposition of individuals to mental troubles.
As understanding of predisposition broadened, so too did psychiatric comprehension of the condition to which it pointed: mental illness. In contrast to the narrow criteria employed during the World War I effort, psychiatric disability was defined very broadly in World War II. At the inception of the draft in November 1940, Selective Service System Medical Circular No. 1 recommended summary disqualification of individuals displaying symptoms of any one of eight types of psychiatric handicap. Stupidity, serious personality disorders, substance abuse, and organic brain disease were four of the officially sanctioned grounds for psychiatric rejection. Physicians without psychiatric training were reminded that "these conditions are likely to escape notice unless one is particularly looking for them." They were also told to immediately refer individuals exhibiting the following "deviations" to the nearest psychiatrist: "instability, seclusiveness, sulkiness, sluggishness, discontent, lonesomeness, depression, shyness, suspicion, overboisterousness, timidity, sleeplessness, lack of initiative and ambition, personal uncleanliness, stupidity, dullness, resentfulness to discipline, nocturnal incontinence, sleep walking, recognized queerness, suicidal tendencies either bona fide or not, and homosexual proclivities." Draftees who expressed any discomfort at all about undressing in the presence of examiners were considered potentially unsuited to the conditions of military life and were therefore subject to disqualification. "Fatigue, increase in use of alcohol or tobacco, tendency to show increasing irritability, increase in profanity, decrease in neatness, being at odds with officers, and desire for transfer" were shortly added to the long list of offenses deemed worthy of discharge.
Psychiatric screening did not live up to its architects' hopes. It probably could not have done so, given the breadth of the screening criteria and the drastic shortage of trained personnel. With millions of men flooding into the military, it was simply impossible to conduct the program as it had been designed, and one or two quick exams, lasting a
minute or two at most, was the rule. So overwhelming were the practical problems that psychological tests were eventually designed for use with inductees and trainees that were entirely self-administered and scored in a minute or less. Questions too varied from place to place, and time pressures often reduced what was supposed to be a serious probe to yes or no answers to questions such as "Do you think you had a happy childhood?" and "Do you wet your bed?" Results too were inconsistent. One psychiatrist might judge manic-depressive candidates eminently qualified for military service while another routinely rejected all who divulged vegetarian dietary habits.
Frustrated by logistical hurdles, Harry Stack Sullivan quit his Selective Service post in 1942. Others also regarded the screening effort as "little more than a farce" and concluded that the constraints under which psychiatrists were operating were likely to impair their professional reputations as well as military effectiveness. "Under such circumstances psychiatric screening was bound to be a hit-or-miss affair in which the hapless psychiatrist had to spice his knowledge and experience with large sprinklings of hunches and fortune-telling."
Equally serious were the disagreements that surfaced among psychiatrists themselves about the recognizability of predisposition or the qualities necessary in a good soldier. Did the military's well-known sensitivity to signs of predisposition present unexpected opportunities to malingerers, who exploited psychiatric concern to avoid military service? Could the very aggressiveness that made mental patients unmanageable prove a distinct asset in combat? Was homosexuality, surely among the most common forms of perversion in men, really such a blight on military discipline, and did it, when discovered, merit automatic discharge and criminal prosecution? Such controversial questions were responses to wartime imperatives, but they also threatened psychiatrists' hard-earned authority to predict, not to mention treat, mental trouble.
The overall results of psychiatric screening and examination were both militarily alarming and publicly contentious. A total of 1,846,000 recruits were rejected from the armed forces for "neuropsychiatric" (NP) reasons, a full 12 percent of all recruits and a full 38 percent of all rejections. (No other justifications for military rejection approached NP deficiency; only "musculo-skeletal" and "eye, ear, nose, throat" came close with 17 and 10 percent, respectively.) An additional 550,000 or so men who survived their initial exam were eventually given NP dis-
charges, a full 49 percent of all discharges for mental and physical defects. Of these, 386,600 were "honorable" medical discharges based on a range of diagnoses, especially "psychoneurosis." Another 163,000 were "dishonorable, administrative discharges for reasons including psychopathic personality, drug addiction, alcoholism, and homosexuality. The total number of individuals formally disqualified from military service because of psychological malfunction was 2.5 million, a number dramatic enough to provide convincing evidence that rampant emotional disturbance constituted a threat to national security.
More detailed statistics were just as staggering. Of the casualties severe enough to require evacuation during the major U.S. campaign in the Pacific, at Guadalcanal in summer and fall 1942, 40 percent were psychiatric. In a six-month period in 1944, combat divisions in Europe experienced a psychiatric casualty rate of 26 percent; with intensive combat, this figure jumped to 75 percent. Resentment also materialized around the disproportionately high rejection rates of Native Americans (40 percent) and black Americans (53 percent). Leaders of these communities often accused psychiatrists of racial bias and demanded easier entrance into the military. Psychiatric discharges were also 10 percent higher in the Women's Army Corps than they were among male soldiers, but no protest about gender bias was mounted. Indeed, alarm over the potential masculinization of female recruits insulated disproportionately stringent psychological screening and discharge practices from criticism. Other citizens grew impatient with all the talk about neurosis. They were convinced, as some military officials were, that perfectly capable men were using the excuse of mild or nonexistent maladjustment to remain safe at home.
By 1943 the military considered such attitudes serious enough to do two things: order a major study to calm mounting objections to psychiatric screening and censor information about rejection rates and the mental state of soldiers. Most clinicians believed public opinion on matters of mental health and illness was dreadfully ignorant, and they admonished that too few men were being screened out of the military, rather than too many. The backlash nevertheless forced them to rethink their role. Clinicians had mobilized for the patriotic purpose of assisting the U.S. military, only to find their good intentions and diligent work overshadowed by their exposure of mental problems in millions of ordinary men.
With such grim statistics and with the military's continuing need
for massive infusions of manpower, it is not surprising that the initial enthusiasm for avoiding mental troubles entirely by screening them out slid gradually into an emphasis on effectively treating men who showed signs of mental trouble. During the first two years of the war, psychiatric casualties had been summarily discharged; they were given a diagnosis, but treatment was discouraged because "the official point of view of the Army toward psychiatric illness was a mixture of fatalism and disinterest; treatment was discouraged." By 1944 the army's Neuropsychiatric Consultants Division, headed by William Menninger (the first psychiatrist ever elevated to the rank of brigadier general), was downplaying the Selective Service emphasis on screening and lobbying to overturn the policy of therapeutic skepticism. Aggressive treatment programs, William Menninger argued, would allow psychiatry to display its powerful healing capabilities and shine up its tarnished image.
By March 1945 the practice of automatically discharging soldiers with NP diagnoses was terminated. Determined not to let the disappointments of the early war stand as setbacks, William Menninger pushed military clinical practices in directions ever more sensitive to social context, abandoning as unhelpful, or at least insufficient, the notion that individuals could be conclusively categorized as either predisposed to mental trouble or not. The war's progress had transformed mental troubles into transitory and relative phenomena, with a number of possible outcomes. At one extreme was descent into more or less permanent mental disturbance and incapacity of the variety familiar on the wards of state hospitals. At the other was return to normality. William Menninger suggested that, if caught early in the form of simple maladjustment, mild mental trouble would rarely lapse into severe mental illness. It was due to this belief—that prompt treatment would arrest deterioration and probably guarantee recovery—that psychotherapy came into its own.
Efforts therefore shifted from screening soldiers to educating vast numbers of military clinicians in up-to-date methods of psychiatric diagnosis and treatment. Trained psychiatrists worked in induction centers, basic training camps, and in hundreds of general military hospitals at home and overseas; ten hospitals were devoted exclusively to NP casualties. Some were assigned to combat units. Most of the people who had direct contact with soldiers, however—48,000 medical officers and 872,000 nonmedical officers—had no previous psychiatric training. Consultants, whose job it was to spread psychiatric knowledge around
as liberally as possible, were in the vanguard of the treatment campaign, responsible for developing and maintaining high and consistent clinical standards throughout the military.
Personnel shortages gave psychiatrists the reason they needed to proselytize, which they did with missionary zeal. Here was an opportunity to place general psychiatric principles at the center of all medical education and practice and correct the woeful errors of doctors ignorant of psychological factors by introducing them, and impressionable medical students, to "the anatomy and the physiology of the personality." Exasperated too that their fees lagged behind those of other physicians, many psychiatrists seized the opportunity war presented to raise the prestige of psychiatry within medicine. They agreed with Alan Gregg, a Rockefeller Foundation officer and one of psychiatry's biggest professional boosters, when he declared that it was high time for "radical change."
[Psychiatry's task] derives in part from the incomprehension of all the rest of medicine which has gone so heavily technical and specialized that the psychiatrists are the only people left who are likely in many instances to insist upon a comprehensive view of the patient. . . . I come to the conclusion that unless psychiatry could be spread as a leaven in the lump of medicine and throwing most of its emphasis not upon madhouse material but upon the psycho-pathology of everyday life, psychoneuroses and behavior abnormalities, we would have to work in vain for any substantial improvement in the physician's comprehension of his patient.
The army sponsored various efforts to shore up the numbers of military psychiatrists (including schools of military neuropsychiatry at Brooke General Hospital at Fort Sam Houston in Texas and at Lawson General Hospital in Atlanta) by offering intensive introductory courses. But chronic shortages of qualified faculty brought pleas to private organizations to fund visits by civilians in order to improve the sophistication of military clinicians. The Rockefeller Foundation, which had allocated over $10 million of its medical research funds to psychiatry in the decade before the war, willingly shipped in a crew of "visiting firemen" to lecture on diagnostic procedures and demonstrate case conferences. Gregg hoped they would convert their students to the messianic view that "the convergent rays of psychiatry, psychoanalysis and psychology now flood the conduct of man with light as it has never before been illuminated."
The combination of advocates' enthusiasm and wartime necessity
succeeded in increasing the profession's status and numbers. As of 1944, psychiatry was accorded a division of its own in the army's Office of the Surgeon General, ranking on a par with surgery and medicine. By the end of the war, twenty-four hundred physicians were working as military psychiatrists, a number equal to the total membership of the American Psychiatric Association in 1940. A majority had no prewar psychiatric training. William Menninger estimated that the military trained more psychiatrists in a few short years than all U.S. medical schools could have produced in a decade.
Personnel shortages also temporarily curbed rivalries between psychiatrists and nonmedical clinicians who specialized in mental troubles, especially clinical psychologists. William Menninger was a tireless advocate for clinical teamwork. He adapted the innovative models tried before the war in his family's Topeka, Kansas, clinic (which would become a national hub of interdisciplinary training after the war) and agitated for resources with which to train clinical psychologists as well as psychiatric social workers and nurses. Not content with a traditional division of labor that would have left psychologists in charge of testing, he encouraged them to participate in activities limited to psychiatrists before the war: diagnosis and even the practice of psychotherapy.
If the war generated a spirit of professional cooperation, the professions nevertheless remained unequal; psychiatrists were to supervise all others who ventured into the sacred territory of individual treatment. Because their subordinate position during World War I had produced much tension and little collaboration, psychologists resisted working within the medical corps under psychiatric authority. Psychological testing, of course, remained an important—and relatively autonomous—function assigned almost exclusively to psychologists. Psychologists recalled that, more than any other single activity, military testing had paved the way for professional advances in the past. Because it "brought psychology, down from the clouds" during World War I and "transformed the 'science of trivialities' into the 'science of human engineering'" in the interwar period, psychologists in World War II persuaded the military early on to locate administrative responsibility for testing in the Army Adjutant General's Office, where it was insulated from psychiatric interference.
Testing programs were intended to accomplish important administrative goals; their clinical value was secondary, at least at first. By war's end, nine million men, almost 15 percent of the country's entire male population, had taken military General Classification Tests. Designed
as basic job placement tools and measures of trainability, these tests included exercises in reading comprehension, basic arithmetic, mechanical knowledge and aptitude, and so forth. Exercises in sentence completion included items such as:
Always __________________ the salute of those under you.
1. approve 2. seek 3. appreciate 4. watch 5. return
It was clear in 1942 that victory over Japan would be an _____________ victory indeed if it were coupled with a United Nations defeat in Europe at the hands of Germany.
1. important 2. appalling 3. empty 4. officious 5. indirect
In 1944 alone, sixty million standardized tests were administered to twenty million individuals in the military for the purpose of efficiently sorting men into the two thousand occupational and training categories that existed in the military. Military testers avoided using terms like "intelligence" and "IQ" to describe what they were doing (semantic choices such as these had drawn much controversial attention to their World War I predecessors) even though the results correlated neatly with educational background.
It was exactly such unglamourous administrative personnel work that psychologists' applied roles in mass institutions before World War II had prepared them to do. Leaders of the personnel effort emphasized the significance of this brand of psychological management by calling testers "the working architects and builders of the modern Army" and their tests "war weapons, although the roar and bang of machinery is absent from the silent room in which they work." But the tide was already moving away from classification and toward new areas of applied work in which tests figured prominently. The momentum of war itself swept psychologists away from administration and into the clinical picture in significant numbers, where personality inventories and projective tests become more common features of the therapeutic process, similarly valued for their time-saving attributes.
The appearance of symptoms of mental trouble in countless soldiers and the serious problems these posed for the fighting efficiency of the U.S. military were the most compelling reasons why psychologists tried to make their tests promote individual healing as well as military efficiency and also took on new diagnostic and interviewing tasks previously monopolized by psychiatrists. Skyrocketing breakdown rates (NP admissions in the United States went from 31.2 per thousand per
year in January 1942 to 68.9 per thousand per year in August 1943) prompted the military to set up a training program in clinical psychology at Brooke General Hospital, alongside the School of Military Neuropsychiatry. Five other training centers were envisioned but never materialized. There were not enough psychiatrists to serve as teachers.
In spite of logistical obstacles to their training, psychologists rose to the challenge before them. According to a 1944 report by Robert Sears (one of the authors of the important Frustration and Aggression ), psychologists throughout the military were quietly taking case histories or even conducting psychotherapy, learning as they went, sometimes with little or no formal training. One administrator in the Veterans Administration agreed. "This was therapy and it was called 'therapy'—recourse was rarely had to the euphemism 'counseling.'" They did it because it was necessary at the time, but intelligent psychologists could certainly see that individual treatment was the wave of the future. In 1946 a survey of every psychologist and psychologist-in-training who had served in the military showed a striking movement toward clinical work during the war years. Hundreds of them had practiced psychotherapy for the first time and many intended to return to school for further training in this field.
Blurring the division of labor between psychiatrists and clinical psychologists did more than permanently alter the balance of power between these two professions, although it did that too. It contributed to normalization, the dramatic shift in the subject and aims of clinical expertise. Before 1940 psychological testers worked to achieve the managerial goals of mass institutions like businesses or schools, performing the administrative tasks required in the interest of scientific management, educational progress, and operational efficiency. While most psychiatrists prior to the war worked in the institutional context of state hospitals, they believed firmly that their most profound loyalty was to individual patients and the alleviation of their mental troubles. Psychology's historical bond with reformist social science and psychiatry's origins in medicine undoubtedly had much to do with this difference in disciplinary identity.
Being drawn into diagnosis and treatment during the war made psychologists appreciate and identify with the ideal of personal mental health to a greater extent than they had in the past. This in turn helped them realize that administratively useful activities like testing could double as therapeutic aids; by the end of the war, projective personality
and other psychological tests were being utilized to encourage self-reflection in individuals as well as provide information to military policy-makers.
Psychiatrists, on the other hand, became more aware than ever that their roles as healers and guarantors of military efficiency might be at odds. A myriad of morale-related responsibilities and the expectation that they treat men who broke down in order to return them to duty made it clear to psychiatrists that their first duty was to the military institution—and not necessarily to the mental health of the soldiers in it. Psychiatrists, according to Harry Stack Sullivan, had to absorb the lesson that their role was similar to other wartime experts.
The Public expects a considerable human cost in war, and it hasn't much native sympathy for people who can't stand the gaff. It is the Army's business first and foremost to win the war. Considerations of needless human cost are relevant only to the extent that precaution will not hamper the war effort. Medical men are peculiarly obtuse to this. They simply have not learnt to put first things first. . . . The war calls on psychiatry to be practical. No one expects it to be perfect.
Winning the war was the first priority. Humanitarian concerns were acceptable as long as they did not obstruct victory.
War and the Production of Normal Neurosis
Thus sensitized to how their own most important professional obligations were being shaped by the wartime context, clinicians were quick to see social factors at work in the production of the mental troubles they treated. Their conclusion? Individuals who became psychologically unbalanced were responding quite normally to an abnormal environment. "The situations of war, for the civilized man," reasoned psychiatrists Roy Grinker and John Spiegel, "are completely abnormal and foreign to his background. It would seem to be a more rational question to ask why the soldier does not succumb to anxiety, rather than why he does." William Menninger went so far as to call war a "pathological outpouring of aggression and destructiveness [that] might well be regarded as a psychosis."
That mental breakdown was to be expected under extreme conditions may have appeared obvious in retrospect, but it was not at first. It took time and effort to determine that men in combat units snapped in far greater numbers than did those serving in noncombat capacities and
that symptoms in the air forces differed systematically from those in the ground forces. These were patterns that predisposition simply could not explain. The sheer numbers of cases seen by military clinicians—NP admissions alone totaled one million, representing 850,000 individuals—finally led them to view the typical psychiatric casualty not as an intrinsically predisposed or mentally disordered individual but as a perfectly ordinary person under incredible strain—an "Everyman." "It became obvious that the question was not who would break down, but when ."
Psychiatrists did not discard entirely their conviction that the mental troubles of given individuals were configured in highly personal ways, conditioned especially by family background and childhood experience. They could not have done so and remained clinicians, after all. Dispensing with the study of individual mental health would have eviscerated the very basis of psychological treatment and left them no option but to become social engineers.
While few clinicians embraced this label explicitly, the movement toward an environmental understanding of wartime breakdown pushed the concerns of clinical professionals in decidedly social directions. According to William Menninger, the essence of the clinical task was to treat the whole personality in the context of the whole environment. This assignment was enormous, to say the least. Human personality consisted of "everything we are, have been, and hope to be," and environment was nothing less than "everything outside ourselves, the thing to which we have to adjust—our mates and our in-laws, the boss and the work, friends and enemies, bacteria and bullets, ease and hardship."
Mental health was present when the struggles within and between personality and environment could be routinely managed through adjustment; mental disturbance occurred when this effort overwhelmed the individual. It stood to reason that unusually forceful conflicts in either the personality or the environment—such as war—could throw mental health out of balance. Psychiatric methods would therefore have to be closely coordinated with theory and research in the social and behavioral sciences. Only a socially sensitive clinical vision could encourage the type of wise policy-making that would produce a postwar environment hospitable to mental health.
Such views clearly anticipated the activist ethos of postwar clinical work and the innovative community psychology and psychiatry movements, whose leaders were World War II clinicians like William Men-
ninger (see chapter 9). In the meantime, revealing the precise causes of mental trouble in any given case became a delicate balancing act between individual psychological patterns (determined by personal history) and changing levels of environmental hardship (in the immediate context of war). Since war was constantly acting upon the soldier and the soldier's circumstances, mental health and illness could no longer be considered fixed states.
Clinical vocabulary reflected the discovery that mental troubles could appear in the most normal of men and displayed the concomitant etiological emphasis on social factors. "War neuroses" clearly tied neuroses to war and "stress" implied that mental pressures were largely external. "Operational fatigue" (used in the air forces), "combat fatigue" (used in the navy), and "combat exhaustion" (used in the army) suggested that the weariness experienced by soldiers was somehow occupationally induced. On the other hand, clinicians who prided themselves on their terminological precision often derided such terms as useless and misleading. "Operational fatigue," they complained, was not even an accurate description. Because it had nothing to do with fatigue, individuals suffering from it would not recover with rest. It was nothing but a "wastebasket diagnostic term."
The statistical picture that emerged from clinicians' diagnostic choices also fostered the impression that most mental trouble was due to the war. Ninety percent of all hospitalized cases were classified as psychoneuroses and personality disorders, relatively minor troubles in the world of mental disorder. Only 6 to 7 percent conformed to the psychotic profile of the traditional mental patient. The label "psycho-neurotic" was used extensively because it functioned as a summarizing term for a number of more specific classifications, denoting a diversity of emotional reactions: anxiety, fear, hostility, guilt, depression, and physical manifestations like nausea and vomiting when they appeared as recurring psychosomatic symptoms.
Clinicians attempted to distinguish one particular "reaction" syndrome from the next with great care and the result pushed patterns of psychiatric classification away from the neurological emphases of the past, toward encompassing a wide variety of normal mental troubles. Several diagnoses, for example, were grouped under the category "transient personality reactions to acute or special stress," which emphasized the immediate pressures operating on the suffering individual, the absence of past psychological problems, and the likelihood of complete recovery in the future. Transient personality reactions were defined as
follows in the army's official Nomenclature and Method of Recording Diagnoses: "A normal personality may utilize, under conditions of great or unusual stress, established patterns of reaction to express overwhelming fear or flight reaction. The clinical picture of such reactions differs from that of neuroses or psychoses chiefly in points of a direct relationship to external precipitation and reversibility. In a great majority of such reactions, there is an essentially negative historical background." A majority of more specific diagnostic labels in this and other general categories of mental disorder—from "acute situational maladjustment" to "anxiety reactions"—appeared to share a definite relationship to the individual's actual experience. War transformed clinical nomenclature.
In sum, clinicians diverged sharply from their traditional preoccupation with illness and abnormality, fixating instead on the normal. Immersed in managing the psychological symptoms of individuals, they nevertheless came to appreciate their own great potential to prevent the slide toward illness and irrationality in mass populations, exactly as nonclinical experts did. War taught them that their historical commitment to treating mental illness at the point of insanity and gross disability was terribly reactive and extremely inefficient. Why wait around for people to deteriorate into pathetic mental cases? Far more forward-looking would be a professional ideology of early intervention in cases of mental trouble, even systematic environmental design with an eye toward producing mental health—presumably so that mental illness would dissipate to a point where it required only minimal professional attention.
While it was not in clinicians' power to redesign the wartime environment so that mental trouble could be prevented entirely (i.e., end the war), they did begin to make suggestions that sounded remarkably like those of their policy-oriented counterparts. John Appel, head of the Mental Hygiene Branch in the Psychiatry Division of the army's Office of the Surgeon General, led much of the effort to reform the military's overall environment through policy changes that would have an impact on personal well-being. In the name of clinicians' twin duties to individual soldiers' mental health and military efficiency, he called for fixed tours of combat duty. Knowing exactly how much time they could expect to spend in combat would both increase soldiers' efficiency and decrease their rates of mental breakdown. The indefinite tours that were routine in the war's early years had, John Appel observed, depleted human resources to the point of utter uselessness. A
policy of limiting combat to 120 days was finally adopted in the spring of 1945.
Other measures geared to preventing mental trouble through environmental adjustment included improving leadership training, boosting group cohesion, establishing rest camps, and feeding soldiers good food. These reforms should sound familiar. Very little of consequence distinguished their clinical advocates, who were devoted to environmental tinkering, from the psychological experts who operated on a policy level and were examined in chapters 2 and 3. Even though the details of their daily work remained rather different, the war advanced the integration of their overall perspectives.
There were, of course, genuine differences in orientation. Clinical theories and skills were especially suited to engineering the internal, psychological environment, and it was here that clinicians excelled. For example, while clinicians were just as dismayed as nonclinical experts to learn that the average soldier did not understand the political aims of the war, their greater familiarity with the interior landscape of irrational drives and unconscious motivations allowed them to respond more hopefully to this piece of distressing news. According to William Menninger, psychiatric interviews brought military clinicians to the same unfortunate conclusion that pollsters in the Army Morale Division's Research Branch had reached. "Only a small proportion of the entire armed force was capable of feeling an emotional urge toward the real purpose of American participation in World War II."
William Menninger and others involved directly in mental breakdown and recovery, however, drew on their clinical experiences and determined that there were worse things than not knowing what the war was all about. They pointed out that gut-level loyalties to buddies, automatic obedience to unit leaders, and hatred of the enemy were more important to military cohesion and the will to fight than was comprehension of the evils of fascism or the virtues of liberal democracy. "The Atlantic Charter, The Four Freedoms and postwar aims do not stir the soldier to his best efforts; only good morale within his own small group and the hope of getting home soon can do that," wrote Roy Grinker and John Spiegel, two psychiatrists who served in the Tunisian campaign in 1943. "Fortunately," they added, "strong intellectual motivation has not proved to be of the first importance to good morale in combat." If rational moral was weak morale, then it followed that emotion—not reason—was the source of military strength. "The will to fight must be forged out of the fiery furnaces of fear and
aggressiveness; if we are to win. We have to win this war with our hearts as well as our heads and hands. Ideas alone are too pallid."
The following sections briefly describe two particular areas of wartime clinical work: self-help literature designed by experts for mass consumption and the wartime practice of psychotherapy with mentally troubled soldiers. Although they employed clinical experts in different capacities, both advocated emotional management on the individual level as an indispensable element in effective military functioning and eventual victory. The process of normalizing clinical ideas and experiences, apparent in each case, provides the basis for the postwar developments that will be explored in chapters 9 and 10.
Self-Help: Emotional Preparedness as Military Strategy
The clinical drift toward prevention surfaced in preventive efforts to promote psychological self-help among normal soldiers. Advice was geared to the personal management of emotions under stress—fears and resentments, in particular—and much attention was paid to the distinction between normal and abnormal reactions in an effort to reassure soldiers that a certain amount of trepidation was to be expected as they adjusted to military life. Advice was typically packaged in the form of lectures to new recruits, short pamphlets or easy-to-read books, and popular films. In these efforts, science always gave way to simplicity. The point was to "show the men that the army was interested in their feelings" and help them adjust, not to exhibit the fine points of psychological knowledge (figs. 4-10).
Edwin Boring, a prominent psychologist involved in the war effort, thought such wartime self-help literature so successful that he predicted the postwar years would expand the market for such products into radio, television, and movies and change the emphasis from controlling negative emotional states to attaining contentment and peace of mind: Fear in Battle (an actual example of wartime self-help literature, discussed below) would be transformed into "How to be Happy —at every drug store" (his prophetic fantasy of where the future might lead). The dissemination of psychological knowledge through popular channels, Boring speculated, would "increase personal maturity, help social tolerance and progress, and enlarge the democratic communal base of thinking."
Boring's glowing review of the genre, however typical of the period's extravagant optimism and abiding faith in the democratic consequences
of true science, was also self-interested. He was coeditor of Psychology for the Fighting Man, one of the most important efforts in the self-help category. The brainchild of the Emergency Committee in Psychology, the book was part of psychologists' consciously organized effort to "sell" the notion of their professional contribution to the U.S. military. Marjorie Van de Water, a professional journalist who specialized in popular science writing, was hired to turn the sometimes obscure language of experts into prose the average GI could easily read and understand.
Numerous checklists were included, for example, offering simple instructions about what to do or think in a variety of situations. Staying awake, speeding the training process, and recognizing "mental danger signals" were each considered in turn, along with other situations common in military life. The experts had numerous tips for soldiers worried about "how to fight fear" or confused about "how to win friends in foreign lands." Among them were seeking physical contact with friends, trying hard to understand strange customs, and suppressing disapproval of behavior they thought too bizarre to respect. Although Boring
privately derided this how-to style as "soft and popular," and one reviewer dismissed the condescending "birds, bees, and flowers" tone of the book, there was no arguing with the project's success. The book was published in 1943 after sections were serialized; it eventually sold around 400,000 copies at 25 cents apiece.
Authored collaboratively by fifty-nine experts and more than 450 pages long, the book covered a range of topics, including a number that were not strictly clinical. Its general purpose was to bring up-to-date psychological knowledge to the masses and explain to ordinary soldiers the challenge of ensuring satisfactory psychological resources for military purposes. "The Army has a perpetual problem of psychological logistics," the authors noted, "a problem of the supply of motives and emotions, of aptitudes and abilities, of habits and wisdom, of trained eyes and educated ears. How does it get the mental materiel to the right places at the right time?" The rationale for psychological personnel testing was painstakingly explained in the book, as were the basics of vision and hearing, propaganda, and psychological warfare.
Most of the book, however, concentrated on loaded topics of great concern to individual soldiers: morale, food, sex, neurosis, panic, and personal adjustment. How to cope with sexual deprivation was a major subject and on this, as on other topics, the book's tone veered unsteadily between authoritative prescription and empathetic reassurance. If masturbation became a regular habit, or a preferred form of sexual activity, the authors counseled, "it is definitely abnormal." "If it is only resorted to as a temporary outlet," they added, it could do little mental or physical harm. Prostitution could also seriously hamper military efficiency, the experts warned, and no true sexual satisfaction could be found in promiscuous contacts. But adjusting to the sexual strains of military life was no simple matter either. Everything from unusual fantasies to homosexuality could be understood as a normal response to abnormal circumstances, at least sometimes. They were inappropriate, but they were also likely to be temporary. On masturbation, prostitution, and other sexual topics, Psychology for the Fighting Man tried to balance clear instructions and friendly reassurance. "It is not easy for a man to get his sexual life into wise and proper adjustment."
Homosexuality was a major, ongoing preoccupation for clinical experts throughout the war years, and their work on the topic was not by any means limited to the self-help literature. Because homosexuality was considered a special threat to military discipline and good morale, anyone with such proclivities was automatically rejected from the armed
forces. But since few homosexuals announced themselves upon induction, subsequent revelation of homosexuality was an official pretext for the psychiatric hospitalization and dishonorable discharge of thousands of soldiers and sailors.
But clinical opinion about homosexuality changed decisively during the war years and the shift bolstered the view that mental health experts were the very incarnation of modern enlightenment. The prewar consensus held that homosexuality was nothing but depraved sexual behavior in otherwise ordinary people. By 1945 clinical research made it appear that homosexuals had unique psychological profiles; in other words, they were not ordinary people. The military's practical response to homosexuals simply had to change, according to some clinicians. "The crude methods of the past have given way to more humane and satisfactory handling of the problems of the homosexual. No longer is it necessary to subject cases that are so definitely in the medical field to the routine of military court martial." Because it involved psychological identity, homosexuality ought to be treated with compassionate psychotherapy rather than criminal penalties. Sexual deviance was no simple matter of wicked behavior; hence, punishment could not fix it. Only experts with a grasp of the personality as an integrated whole could hope to illuminate—let alone alter—the psychological processes implicated in the production of homosexuality.
Psychology for the Fighting Man managed to present both old and new views on this topic, capturing this fascinating change of attitude in progress. Soldiers were counseled that meeting heterosexual needs through homosexual behavior was understandable, even if it was also degenerate. Normal soldiers with such impulses should fight hard to control them if they could (two practical rips from the experts were praying and concentrating on killing the enemy), but, whatever happened, they would probably be just fine once they returned home. On the other hand, the experts indicated that homosexuals were a recognizable type whose perversion—if forced upon unsuspecting soldiers—deserved court martial and prompt discharge. In the first case, homosexuality was a normal response to an abnormal situation. In the second, it constituted a distinct clinical syndrome: "Attempts to reform such men are almost always futile."
Belief in the possibility and desirability of reforming the self, although not necessarily applicable to sexual preferences and behaviors deemed deviant, was nevertheless at the core of most of the self-help effort. "Adjustment" was a term as likely to designate efforts to post-
pone or prevent mental breakdown through self-education and preparedness as it was the treatment of mental shock with professional techniques such as psychotherapy.
For obvious reasons, fear was an emotion especially in need of adjustment, and its management was a major theme in Psychology for the Fighting Man. The first step in the process of emotional management was reassuring explanation. Fear, according to the experts, was entirely natural and healthy when it was a response to actual external danger. Moreover, it was "nature's way of meeting in an all-out way an all-out emergency" and it was "useful in mobilizing all the body's resources." Whether in combat or in anticipation of combat, all soldiers who were honest with themselves experienced fear.
The process through which fear was normalized, it is important to note, depended on the sex-segregated nature of the combat experience, as well as the overwhelmingly male ranks of clinical experts themselves. Roy Grinker was one of a number of professionals who identified wartime contact with healthy young men experiencing stress as the key to clinicians' postwar gravitation toward normal psychology. Generalized fears had, after all, long been attached to the phenomenon of hysteria in women, an unappealing, if still fascinating, syndrome marked by extreme dependence, emotional superficiality, and a heavy dose of melodrama. Fear of combat, however, was uniquely masculine, and could therefore circumvent the taint of irrationality and abnormality that marked all the terrors clinicians treated in the female gender. Women felt "anxiety," rather than "fear," and the difference was crucial. Because the source of soldiers' combat fears was obvious and environmental, their feelings were normal and clinicians readily empathized with their nervousness. In contrast, women's feelings could be vague, difficult to explain, and farther from clinicians' own experience. They tended therefore to be interpreted as abnormal anxieties with purely intrapsychic roots. The purpose of the self-help literature, in any event, was to help soldiers strike a balance between permitting themselves to feel normal emotions (like fear) when it was safe to do so and strictly regulating them when it was not. Left unmonitored, fears could grow into anxieties, ceasing to be comprehensible emotional reactions to real peril and becoming states of chronic inner disturbance requiring treatment.
John Dollard, a member of the Yale Institute of Human Relations and a consultant to the Research Branch of the army's Morale Division, authored several self-help pieces on this particular topic, including a
short pamphlet, Fear in Battle, and the even shorter "Twelve Rules on Meeting Battle Fear." Both were intended to reassure men that fear was no cause for shame or embarrassment. Even extremely unsettling psychological experiences, Dollard advised, were perfectly ordinary amid the extraordinary circumstances soldiers faced. Emotional advice "will help any soldier with the guts to face the ordinary fact that everyone gets scared in battle."
Characteristic of advice on this and other topics, and of the normalization process in general, was the insistent refrain that insight—meaning psychological self-consciousness—was the most effective method and barometer of psychological self-mastery; practiced introspection was both technique and goal. Calm, rational understanding of self was a kind of emotional armament, as necessary to the effective prosecution of war as to the goal of individual self-defense and preservation. "Keep remembering that being scared makes you a smarter soldier—and a safer one," was Dollard's rule number 3. But such comforting words were hardly an adequate guide to soldiers facing tangible horrors on the battlefield. So Dollard also prescribed specifics on suppressing fear when necessary: "Make a wisecrack when you can" and "Never show fear in battle" were two of his recommendations. Nor did he neglect to remind soldiers to adopt regular habits of emotional communication. "Talk about being scared—any time you want to talk about it. Everybody gets afraid in combat. You're no exception, and neither are the rest of the men in your outfit. It's a common, every day battle experience for all normal men. It always has been—in every war in history. So there is no reason in God's world for not talking about it—during a lull in the fight, or afterward. And if you do, it helps next time—it helps every time."
Wartime self-help literature attempted to communicate several different things at once. Because it provided refreshing clarity and ready sympathy to countless individuals living without much of either, its appeal was not exactly mysterious. Moreover, it highlighted the potential helpfulness of clinical expertise to ordinary people. Soldiers who absorbed the lesson that they could take steps to prevent mental breakdown themselves were living proof that the meanings of war and of mental health were both rapidly changing. Owning up to feelings like fear was defined as key to managing the military's "mental material" precisely because victory in war required the active mastery of individual subjectivity. If they agreed to strive for a state of psychological insight, experts promised soldiers that, in return, they would help them fulfill
their patriotic duty, demonstrate their emotional enlightenment, and survive the war in body as well as in spirit.
Professional Help: The Psychotherapeutic Frontier Expands
Not all cases of wartime mental trouble, of course, could be efficiently managed by providing self-help literature or exhorting soldiers to circumvent breakdown by taking responsibility for their own emotional control. As the years wore on and psychological casualties mounted, the challenges clinicians had initially faced in screening predisposed individuals out of the military began to pale in comparison with treating masses of mentally troubled soldiers and returning them to health. Clinicians turned increasingly to psychotherapeutic means of accomplishing this task.
Before the war, psychotherapy had been associated largely with the elite office practice of psychoanalysis (the original talking cure) or with a range of techniques employed by psychiatrists functioning in the institutional context of state hospitals. In both cases, psychotherapy was an unusual experience for which the prerequisites were extreme wealth, avant-garde curiosity, or something close to insanity. Psychotherapy was not relevant to ordinary people. If anything, it was stigmatizing.
Wartime necessity permanently altered this pattern by normalizing psychotherapy. Clinicians' efforts to cope with anxieties and neurotic symptoms among soldiers introduced psychotherapeutic techniques to millions for the first time. Many of the somatic techniques used during the war had been used before with civilian mental patients—insulin injections, electroshock, and heavy sedation among them—and cases of severe (i.e., psychotic) disorder and total collapse were usually segregated and hospitalized, much as they had been before the war.
But the time and personnel pressures endemic to wartime clinical work, along with experts' obligations to serve the military's institutional need for a steady supply of dependable human resources, underscored "the necessity for therapy to adapt itself to a more or less inflexible military framework." This forced clinicians to devise a menu of creative psychotherapeutic alternatives and shortcuts "which give promise of returning a maximum number of men to duty within a minimum of time and with techniques which are feasible in the active theatres of combat."
For the most part, these techniques fell into the category of talking
cures, even if the talking was brief and, at times, chemically facilitated by various drugs (figs. 11 and 12). Individually and in groups, soldiers discussed their feelings, combat experiences, and personal histories. The primary goal of such treatment was to help mentally troubled individuals recoup their previous level of function and return to military service, but these practices also unquestionably encouraged new levels of psychological self-exposure and self-consciousness and insinuated that these characteristics were necessarily present in healthy individuals struggling to recover from momentary mental setbacks. The result was that basic definitions of clinical practice changed. From all appearances, larger and larger numbers of normal individuals benefited from psychotherapy and many more and varied activities proved therapeutic.
Psychotherapeutic treatment for the masses placed a premium on clinicians' time and energies. Treatment was as rapid as possible. The logistics of its provision, however, changed as the war altered clinicians' views of mental distress and its causes. For example, cases of combat breakdown were initially evacuated to hospitals in the rear because they were assumed to be limited to predisposed individuals who had escaped detection at the point of screening. Early in the war, when the emphasis was still on prediction rather than treatment, clinicians believed that predisposed men were unlikely to be militarily productive, once pushed beyond their low mental thresholds. As time passed, evidence mounted that mental breakdown was normal under the pressures of war and doubt was cast on the predictive value of predisposition. "Every person, no matter how strongly integrated," noted one psychiatrist, "has his breaking point when sufficient stress is applied."  Brief military service was all that was required to convince most other psychiatrists. Treatment of most combat mental cases subsequently evolved from trauma-oriented procedures to something more like psychological first aid.
It was 1943 when psychiatrists were sent to combat areas for the first time. Altering the geographical location of clinical work directly reflected the recognition that clinical efforts should be aimed at the normal neurosis produced in ordinary people under the abnormal conditions of combat. According to Grinker and Spiegel, psychiatrists with combat experience in North Africa, "The realities of war, including the nature of army 'society,' and traumatic stimuli, cooperate to produce a potential war neurosis in every soldier. When predisposition is combined with adequate stimuli of a certain type or degree, a neurotic breakdown is precipitated, which constitutes an illness and requires treatment."
After 1943 the first stop for mentally wounded soldiers was a clearing station close to the front, where they were immediately sedated so that they could sleep. After adding some good food and a bath to a decent interval of rest, 40 percent of these cases had recovered sufficiently to be returned to combat by the third day. Those who did not bounce back so quickly proceeded to the second stop for combat casualties, an "exhaustion center." Here, patients were sedated again, then offered some form of very brief psychotherapy, often in combination with drugs like sodium pentothal, which was administered for the sole purpose of speeding up the therapeutic process through "narcosynthesis." Five to eight days later, another 20 percent of the men were sent back to their units. Not only were these new procedures efficient from the military point of view (many of these cases would previously have been removed from active service altogether only to languish in costly and labor-intensive hospital settings), but they seemed to indicate that timely application of clinical attention to relatively mild instances of mental trouble significantly affected the outcome. Many recovered sufficient mental balance to continue military service: many in combat duty, others in noncombat capacities. The rest were evacuated (fig. 13).
Of course, important theoretical differences remained in how clinicians understood and treated war neuroses. Freudian psychology would emerge from the war as the dominant paradigm among clinicians. Partisans, like psychiatrists Roy Grinker and John Spiegel, considered predisposition (by which they meant past history, especially childhood socialization patterns and familial relationships) to be highly relevant in the precipitation of mental trouble and the determination of a given individual's neurotic symptoms. Yet they also embraced the position that the traumas present in the wartime environment had a direct bearing on mental breakdown. "Sick or well," they argued, "every combat soldier reacts to the stresses of the harsh realities of war according to how his previous psychological patterns have prepared him, and he reacts only to the proper quantifies of specific stimuli to which he is sensitized. In other words, in our opinion, the neuroses of war are psychoneuroses. " Insisting that all war neuroses were psychoneuroses was simply another way of saying that war was mentally unbalancing not in and of itself but because it mobilized old, often unconscious, emotional conflicts residing in the individual psyche, conflicts that were the most fundamental and authentic sources of mental symptoms. The ultimate point of psychotherapy was to untangle the knots tying previous psychological patterns to current psychological reactions. Clearly, the the-
oretical balance between psychological history and current circumstance meant that the job of delivering long-lasting psychological relief combined a detective's investigatory zeal with a counselor's patient wisdom. Psychotherapy entailed highly disciplined effort, painstaking insight, and a lot of time.
These were luxuries unavailable during the war. Grinker and Spiegel, along with other clinicians, sometimes regretted that the therapies they recommended—from food and sleep to brief talking cures—were inadequate to do the job of real emotional healing. Keenly aware that wartime pressures forced them to place superficial Band-Aids over deep mental wounds, they bemoaned their own habit of providing short-term "covering" techniques rather than long-term "uncovering" ones. Like their policy-oriented counterparts, however, World War II clinicians accepted without question that shortcuts were essential. The point was not to achieve perfect mental health and insight, or scientifically validate clinical services, but fortify the military's flagging psychological resources. Clinicians agreed that temporarily interrupting the most immediate source of neurosis—namely combat danger or fear of
it—was a first step in the process of emotional healing. Other, more ambitious steps would simply have to wait.
In the meantime, clinicians made creative use of the resources available to them. Like food and rest, everything from vocational training to good weather was eventually drafted into clinical service and relabeled "therapeutic." Clinicians could and did explain exactly why satisfying work and hot meals were psychologically beneficial and, as we have seen, they used their authority to back efforts to humanize military life in the name of preventing mental trouble. In the end, however, they knew it was not self-evident that such undertakings required their unique clinical talents. Common sense might be as much a resource as clinical expertise, and far less expensive, if the overall goal were to make the military a more hospitable place to spend time. Grossly overreaching therapeutic frontiers threatened to undermine their authority. Extending therapeutic frontiers within reason, however, could legitimate a larger sphere of operation.
In contrast to food and sleep, the practice of individual psychotherapy remained clinicians' singular contribution. Exclusively associated with clinical experts, psychotherapy claimed to alleviate mental anguish directly by establishing a helpful relationship between a troubled individual and a trained psychotherapist. The clinical theory underlying much wartime psychotherapeutic practice was Freudian in at least a rough sense, and psychodynamic approaches reached their zenith in the postwar years. Even though time and staff shortages precluded the practice of anything resembling classical psychoanalysis, clinicians held fast to an analytical version of the therapeutic relationship, however abbreviated by war. Only a deliberate professional effort, infused with insight, could successfully release whatever repressed emotions were at the root of soldiers' dysfunctional symptoms and strengthen their capacity to adjust more adeptly to the stresses of war.
Even this supposedly unique professional relationship, however, threatened at times to dissolve in the face of simple common sense. Indeed, therapists themselves were often the first to point out that em-pathetic attention was usually helpful to troubled people, whether offered by professionals, friends, or family members. Because so few non-psychiatric clinicians had any meaningful psychotherapeutic training before the war, military psychotherapists were generally advised to rely on intuition in their daily practice. "If [the therapist] is sincere, sensitive and open-minded in regard to himself as well as to the flier, he will instinctively take the right psychotherapeutic path," wrote Grinker and
Spiegel in an effort to reassure those with little or no previous experience in this area. But if sincerity and open-mindedness were the keys to effective psychotherapy, why limit its practice to a small number of highly paid professionals? "It is well," Grinker and Spiegel added as an afterthought, "if [the therapist] has a definite notion of precisely which path he is taking and how he means to accomplish his objective, which is to strengthen the ego in its struggle with anxiety."
World War II was a moment of important professional transition for psychotherapeutic experts. It offered them the difficult challenge of proving they had something unique to offer at the same time that it offered them an unprecedented opportunity to try that something out on a new mass audience. Hampered by wartime shortages of time and staff and constrained by their own inexperience, clinicians tried to demonstrate that psychotherapy was delicate enough to require specialized skills yet not so delicate as to be confined to extreme cases of mental breakdown. Its benefits were palpable enough to merit the extension of psychotherapy to large numbers of people for many reasons in short periods of time, but only experts could achieve positive results. Amateurs, they warned, were prone to do terrible damage.
By normalizing the content and extending the subject of clinical expertise, the war redefined psychotherapy in remarkably expansive terms. According to psychiatrist Lawrence Kubie, a consultant to the Office of Scientific Research and Development and an ardent proponent of clinical emphasis on prevention, "psychotherapy embraces any effort to influence human thought or feeling or conduct, by precept or by example, by wit or humor, by exhortation or appeals to reason, by distraction or diversion, by rewards or punishments, by charity or social service, by education or by the contagion of another's spirit." According to such definitions, virtually any human relationship could qualify as psycho-therapeutic. It is understandable that this drastic extension of psycho-therapeutic territory was confusing and failed to resolve outstanding questions about what alterations psychotherapy actually induced or who should be allowed to practice it. These controversial issues would consequently continue to be hotly debated throughout the postwar decades.
Their abilities as preventive emotional healers were matters of supreme belief among clinicians at the war's end. "As a result of our experience in the Army," William Menninger concluded with some satisfaction, "it is vividly apparent that psychiatry can and must play a much more
important role in the solution of health problems of the civilian."  It was an article of collective faith that psychotherapeutic treatment was reliable science, not hit-or-miss art. It brought "a systematic body of knowledge" to bear on wartime mental troubles with excellent practical results that were "more a matter of training than an accident of personality." In part, clinicians were simply jumping on the same scientific and technological bandwagon that had proved so auspicious for other wartime experts. In part, their extreme therapeutic optimism resulted from the genuinely novel opportunities war had offered them: to minister to mass populations under conditions that forced them to renovate the conceptual and practical tools of their trade, meeting the immediate and urgent needs of ordinary people under extraordinary pressure.
For these and other reasons, the war produced a comprehensive reassessment of clinical terms. "Normal neurosis" became a conceivable clinical category only because the concepts of mental health and illness had themselves changed drastically, from qualifies inherent in or absent from individuals to a spectrum on which mental stability and instability were feats to be constantly achieved or avoided. Upbeat and hopeful, military clinicians had learned much about their own potential from their work with masses of ordinary soldiers. Not only could they treat cases of severe breakdown effectively, but they could prevent milder cases from deteriorating by intervening quickly and aggressively, nipping mental trouble in the bud. According to William Menninger, this reassessment was the war's most profound lesson, and it pointed very decidedly toward a larger jurisdiction for psychological experts.
If health is the concern of medicine, and if by mental health we mean satisfaction in life, efficiency, and social compatibility, then the principles of psychiatry must apply not only to each of us as individuals but to our social relationship with each other. The field of medicine must be recognized as inseparably linked to the social sciences and concerned with healthy adjustment of men, both individually and in groups.
Under less strained conditions than war, he seemed to be suggesting, clinical experts could improve significantly on their very laudable military record. Psychiatrist Henry Brosin was even more explicit about what clinicians could do when the fighting ended and they applied the lessons of military experience to civilian life. "Good mental health or well-being is a commodity which can be created under favorable circumstances," he promised.
In 1945 the mood of celebration among clinicians was the very same
that animated policy-oriented experts; so too were the doubts that lurked behind it. Surely the government and the public, grateful for clinicians' tireless, patriotic service, would see fit to ensure their future with generous infusions of training and research funds. Professional advance and the national interest were, in this case, fortuitously compatible and achievable through practical means. Postwar social order and stability rested on a foundation of mental health, a goal which was also, in Henry Brosin's terms, "a commodity." "National mental health," William Menninger concurred, "could be purchased if that were our aim." This consensus that augmenting clinical funding was tantamount to improving national well-being would shortly be displayed on the floor of the U.S. Congress, where government officials debated the details of a federally sponsored mental health effort that became the National Mental Health Act of 1946.
If money for mental health were not forthcoming, how would the massive social problems, just waiting to be caused by untreated veterans, be managed? Clinicians predicted that men destabilized by their wartime experiences might be mentally mutilated for life if left to their own devices, victimized by a pitiful and expensive epidemic of "pensionitis" (a syndrome of debilitating dependence upon the state allegedly caused by financially rewarding veterans' mental instability), or prone to criminal temptations. According to Daniel Blain, head of psychiatry for the Veterans Administration, the "ripples that emanate from each generating unit, each veteran, must not be vicious, antisocial, discouraging, hostilely aggressive. They must be kindly, warm, invigorating ripples that unite all of us." Even mild ripples of maladjustment increased the likelihood that unemployment, illiteracy, strikes, illegitimacy, and racial prejudice (to name only the most frequently mentioned scourges) would mushroom in the postwar era. With sufficient clinical infrastructure, clinicians and their advocates pledged, the country could rest assured that undesirable social conflict would be minimized and veterans would be mentally prepared to live as economically productive and law-abiding citizens. In 1944 Alan Gregg put it as follows:
There will be applications far beyond your offices and your hospitals of the further knowledge you will gain, applications not only to patients with functional and organic disease, but to the human relations of normal people—in politics, national and international, between races, between capital and labor, in government, in family life, in education, in every form of human relationship,
whether between individuals or between groups. You will be concerned with optimum performance of human beings as civilized creatures.
Behind this most ambitious vision of clinical responsibility for the general state of human civilization lay the same political uneasiness felt by policy-oriented experts. Clinical work, after all, had corroborated the growing body of nonclinical research demonstrating that democracy was seriously endangered by strong and unpredictable emotional currents, including ugly tendencies toward prejudice and conformity. By 1945 little or no sophisticated understanding was required to make the point psychoanalyst Franz Alexander had made ten months prior to the attack on Pearl Harbor: "It is no wonder that in the face of current world events one turns for explanation toward the psychiatrist, the specialist in irrational behavior."
The course of the war had borne out the truth of Alexander's view that "the real difficulties of democracy ... are emotional." Clinicians' daily responsibilities for shoring up soldiers' morale and group cohesion had taught them that reason could never compete with emotion when human motivation and behavior were involved. Primitive fears and immediate loyalties had done far more to keep the fighting forces fighting than had campaigns (most of them miserable failures) to persuade soldiers that preserving democracy and eradicating fascism were worth the highest sacrifice.
Demoralizing as this wartime lesson was, it hardly lowered the aspirations of clinicians, the most forward-looking of whom had predicted that "the day will come when [the] Cinderella of Medicine, Psychiatry, will be honored as a wise and bountiful Social Princess dispensing a largess of culture." The daunting lessons of war merely fueled their missionary vision. What were clinicians if not experts in emotional management? And was not a plan of conscious, emotional management democracy's best hope for survival? By the end of the war, most clinicians certainly thought of their professional obligations in the activist, liberal terms articulated so well by figures such as William Menninger, Harry Stack Sullivan, and Alan Gregg. They considered themselves custodians of a vital social resource—mental health—without which economic prosperity, democratic decision making, and intergroup harmony were implausible, perhaps impossible.
Although they could not have known it at the time, their future role as emotional managers was as fraught with political contradictions as
was that of their counterparts who imagined themselves as the enlightened social engineers of postwar society. To champion the individual in the process of striving toward psychological insight, as they did, and to insist that the essence and future of democracy lay in this momentous struggle, as they also did, was the historic task of those experts with a unique understanding of the human personality. Lawrence K. Frank, who had proposed before the war that society be treated as a "patient," was equally prophetic when he wrote in 1940,
We are, somewhat reluctantly, realizing that the democratic aspirations cannot be realized nor adequately expressed in and by voting and representative government; democracy, or the democratic faith, is being reformulated today in terms of the value and integrity of the individual, not as a tool or as a means, but as an end or goal for whose conservation and fulfillment social life must be reoriented.... Thus freedom for the personality may be viewed as the crucial issue of a democratic society, for which we must seek to develop individuals who can accept all the inhibitions and requirements necessary to group life, without these distortions and coercive, affective reactions.
Ringing defenses of democracy, converted into psychological rhetoric such as "freedom for the personality," were not the inherently liberating manifestos that Frank and most other World War II-era clinicians believed them to be. They were politically ambiguous. Labeling the individual precious and dignified was certainly nothing new in U.S. history. Calling for direct control of the psychological terrain—because it was the only effective means of safeguarding democratic potential and averting a menacing epidemic of blind conformity and authoritarianism—was new, at least as an explicit public ideal and purpose of government. World War II had shown that experts would have to manufacture democratic personalities because U.S. social institutions had failed to produce people who could be trusted with democracy's future.
Thus were the clinical hopes and dreams of prevention that emerged from the war based on a collapse of faith in the rational appeal and workability of democratic ideology and behavior. Some clinicians dedicated to shoring up the emotional basis of democracy in the postwar era (humanistic theorists and practitioners, for example) did so by consecrating the individual psyche as the ultimate source of value and turning self-regulation into an act as publicly virtuous as it was personally meaningful. Others (behaviorist theorists and practitioners, for example) dismissed such psychological individualism as a foolish dream and insisted that only scientific expertise could be trusted as an incorruptible source of authority and control. Humanists wanted to actualize the per-
fect self. Behaviorists were more modest; they merely wanted to condition good behavior.
In spite of important tactical differences between clinical schools and tendencies, the postwar era they all envisioned was founded on the professionally unified project that emerged from World War II: to enlarge psychology's jurisdiction. As we shall see later, in chapter 9, important developments after 1945 grew out of the fundamental clinical lessons of world war. Clinical theory had to be grounded in normal psychology. Clinical services had to reach masses of ordinary people, coordinated and delivered by the state if necessary, so that normal neuroses could be treated before reaching a point that threatened social stability. And because human motivation brimmed with irrationality and resisted so stubbornly the call of reason, clinical experts would be indispensable guides in an era of social and emotional reconstruction. Democratic personalities would have to be remade from the inside out.