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."[84] 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."[85]
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." [86] 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.[87] 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."[88]
Figure 11. A military psychiatrist in the Philippines interviews
a patient in his outdoor office during World War II.
Figure 12. Hypnosis was one of the psycho- therapeutic
techniques used on soldiers during World War II.
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."[89] Five to eight days later, another 20 percent of the men were sent back to their units.[90] 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. "[91] 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-
Figure 13. World War II neuropsychiatric casualties in New
Guinea, ready for their evacuation to the United States.
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.[92] 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."[93]
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."[94] 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." [95] 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."[96] 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.[97]
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.[98]
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."[99] 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.[100] 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."[101] 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.[102]
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."[103]
The course of the war had borne out the truth of Alexander's view that "the real difficulties of democracy ... are emotional."[104] 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."[105] 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.[106]
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.