combat psychiatrist. More common has been the acting out of conflicts by young men with histories of prior adjustment difficulties, a syndrome which, when it occurs in combat, we have previously described as "pseudo combat fatigue." However, careful reading of reports from other wars indicates that even this difference may be largely influenced by differing psychiatric attitudes and diagnostic criteria rather than by differences in the patients.

Classical combat fatigue has been reported less often in Vietnam than in previous wars. It is important to note, however, that combat fatigue, which undoubtedly has occurred more often than has been reported, has been effectively treated by general medical officers who are more psychiatrically sophisticated than their predecessors in previous wars.

One of the most significant differences affecting psychiatric problems in Vietnam combat is the rotation policy. Certainly, the morale factor and general importance of the small group's influence on the individual continue to be significant; however, the uniquely individual quality of each man's adjustment in Vietnam is unprecedented. Individual survival for one year is the goal of each man, and almost all combat zone behavior, both adaptive and maladaptive, can be understood motivationally as related to insuring this survival or making it easier.

Some problems which appear to be more common in Vietnam have stimulated considerable publicity, such as drug use and rebellious or violent behavior. In some cases these behavioral problems may represent "hidden" psychiatric casualties. Although people basically do not differ from generation to generation and from war to war, certainly military policies and type of combat do differ; more important, social attitudes and value changes are reflected in the problems of combat psychiatry.

John K. Imahara, M.D."

There are many so-called psychiatric casualties in Vietnam who are never processed

'John K. Imahara, M.D. is a Staff Psychiatrist, Santa Clara Mental Health Services, San Jose, California.

through medical channels. These are the hundreds of soldiers who become administrative or disciplinary casualties. When their behaviour becomes overly deviant or disruptive-being AWOL, showing disrespect and disobedience, acting aggressively or violently, or taking drugs they are removed from their units and confined to a military stockade. The effects on the young soldier are those of anger, fear, anxiety, despair, and bewilderment.

My tour of duty in Vietnam was spent as Chief of the Installation Stockade Mental Hygiene Consultation Service, the site of the "worst prison riot in the modern history of the United States Army" in August of 1968. Upon my arrival two weeks after the riot, the Longbinh Jail was in shambles. From this unfortunate and chaotic incident came many insights and constructive changes.

One was cognizant of the intense hostility expressed by the black soldier toward the military as an oppressive institution and toward the whites as the oppressor. Many blacks think, for example, that they get a disproportionate share of the combat missions. To increase their sense of fraternity and solidarity, and to preserve their individuality, these "soul brothers" subscribed to certain gestures, ornaments and modes of behavior that were sometimes known to intimidate white soldiers. Many blacks who were confined as troublemakers expressed a wish to be separated from the military. Even if one sometimes felt that their charge of prejudice was a distortion, it could not be denied that for many Negro soldiers this was a highly emotional issue that often led to deviant behavior.

Of major concern to commanders and mental health personnel in Vietnam was the widespread use of drugs. Not infrequently explosive situations arising from the combination of drugs, available weapons, and stress necessitated confinement of the passive resistive marihuana smoker, the paranoid methamphetamine injector, the hyperactive amphetamine user, the AWOL emaciated opium injector, and the moody individual who takes barbiturates. The use of drugs in combination was common.

John A. Talbott, M.D.

Since I did not serve in wars prior to Vietnam, any comparisons I make regarding psychiatric casualties must rely on literature and personal communication.

It is my impression that there are far fewer psychiatric casualties in this conflict than heretofore. The official Army line attributes this to a 12-month rotation basis, superb medical care, and better educated and trained soldiers. However, it is my opinion that the factor frequently not mentioned, that may be of the most importance, is that psychiatrists and general medical officers are better trained to diagnose and treat traumatic neurosis today than they were 20 years ago. The concept that not all psychiatric disease is caused by internal stress, but may result from environmental, familial, and personality factors, has contributed to this change in attitude.

One condition in Vietnam that is assuredly different is the degree of complaining and dislike for this particular war. In my contacts, with physicians who have served in World War II or Korea, I heard none of the stories that most of the psychiatric patients voiced in Vietnam. Almost without question, all nonpsychotic individuals who appeared at the mental health clinics complained of being in Vietnam and wanted to get out immediately. Although this was labeled a psychiatric problem, in my estimation it constituted a widespread sociologic phenomenon.

One condition that seems to be as high, if not higher, in Vietnam is alcoholism. The number of senior NCO's and officers with serious drinking problems, the number of auto accidents involving intoxicated soldiers, and the number of persons with delirium tremens is appallingly high.

William Hausman, M.D.'

As a career Army medical officer until my retirement in 1966, I had firsthand experience

8 John A. Talbott, M.D. is Director, Community Psychiatry, St. Luke's Hospital Center, New York. William Hausman, M.D. is Professor and Head, Department of Psychiatry, University of Minnesota.

with military psychiatry in the early part of the Korean campaign and subsequently made two brief visits to Vietnam in 1964-65.

Before commenting on the supposition that there are differences between Vietnamese psychiatric casualties and those in other wars, it should be observed that the diagnosis "combat fatigue" is, in fact, not a diagnosis at all but rather a euphemistic term specifically intended to avoid a psychiatric "label" that might reinforce a soldier's symptoms on the battle field or establish in him a more chronic pattern of neurotic response to stress thereafter.

Another fact of particular relevance to this question is that the pattern of symptoms has consistently varied among combat psychiatric casualties from war to war. Both Edwin Weinstein and Albert Glass have observed this phenomenon and have described the process, early in the war, wherein the pattern of symptoms for a given unit, and later for a given campaign, becomes established as the combat period continues. In earlier periods of any war one sees a more diffuse set of behavioral symptoms, and it is only later that anything resembling a syndrome begins to emerge. Certainly the "shell shock" phenomenon of World War I was not evident in World War II, where patterns of anxiety reactions and "three-day schizophrenia" were more commonly described on the various fronts. These patterns, in turn, were influenced by the various techniques for management of psychiatric casualties, by the length of time that men had to remain in the combat area, and by the availability of rest and recuperation facilities.

For all the above reasons it becomes very difficult to compare the meaningful combat psychiatric casualty rate from war to war. If one seeks reasonable comparability, the Korean war, fought on the mainland of Asia, with a well-established rest and recuperation policy and tours of fixed length, comes closest to the Vietnamese situation. On the other hand, the society from which soldiers come to Vietnam is significantly different in many respects from that of the United States in the early 1950s. One aspect of this change in social values, particularly among our younger people, is evidenced by the greatly increased use of drugs by soldiers in Vietnam.

Peter Bourne, M.D.1

Casualties of a psychiatric nature in Vietnam are fewer than in any previous war and have remained about the same as for a comparable stateside military force. Not only is the over-all incidence low, but the clinical patterns also differ significantly from previous wars. Only 5 per cent of psychiatric admissions in Vietnam have been diagnosed as "combat fatigue," while 40 per cent or higher are classified as character and behavior dis

10 Peter Bourne, M.D. is Director, Mental Health Unit, Atlanta Southside Comprehensive Health

Center.

orders. Hysterical conversion reactions, once common in previous wars, are now extremely rare and have been replaced by verbal expression of emotional suffering that the G.I. experiences.

Perhaps a word should be said about the new breed of general medical officers. These young physicians, serving for the most part as battalion surgeons who have entered the service immediately after internship, are well education and competent to treat basic psychiatric illness as well as many minor psychologic disturbances. By receiving such treatment at an optimal point in the medical evacuation chain, the number of individuals who become labeled as psychiatric casualties is diminished.

As long ago as 1946, T.F. Main, a British army psychiatrist, described his experience in using a mental hospital as a therapeutic agent. He was one of the earliest to use the term "therapeutic community,' community," which he described as "an attempt to use a hospital not as an organization run by doctors in the interests of their own greater technical efficiency, but

Reprinted from Hospital & Community Psychiatry, a journal of the American Psychiatric Association, Vol. 19, No. 9, September 1968, pp. 21-26, with permission of publisher and author.

Dr. Schwartz is Assistant Professor of Psychiatry, Yale University School of Medicine, New Haven, Connecticut and Dr. Farmer is Senior Resident in Psychiatry, University of Tennessee College of Medicine, Memphis, Tennessee.

During the work described in this paper, Dr. Farmer was chief of the neuropsychiatric branch at the Naval Hospital in Newport, Rhode Island, and Dr. Schwartz was a staff psychiatrist there. The opinions expressed in this paper do not necessarily reflect the views nor receive the endorsement of the U.S. Navy Department.

as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the resocialization of the neurotic individual for life in ordinary society."(1)

Austen Riggs and others had followed similar principles in the 1920s and 1930s, but Main was the first to delineate the idea so clearly. The then-novel phrase implied simply that the healthy portion of the patient's personality was appealed to, nurtured, and allowed to mature within a growth- oriented milieu. Since that time, the therapeutic community concept has been developed, operated, and described by Jones (2-3), Caudill (4), Wilmer (5), and the Cummings (6), followed in recent years by Gill (7) and Quattlebaum (8).

The therapeutic community at the Naval Hospital in Newport, Rhode Island, was established as a study project in September 1965 and continued until July 1967, when both of

us left the Navy. We wanted to test certain hypotheses concerning military psychiatry. Various psychiatrists in the military services had expressed the belief that some factors inherent in a military setting might be detrimental to effective therapy. These factors include military rank, lack of confidentiality and privileged communication, the disrupting influences of rapid patient turnover, the inability to select patients on the basis of their psychopathology and motivation, and the turnover among the psychiatric staff. Some naval psychiatrists believed that inpatient treatment was feasible only at large treatment centers specially designed for that purpose. As a result of these attitudes, many units were being used most often merely as clearinghouses in which people poorly adapted for naval life were screened out of the service.

We wanted to see whether we could increase the efficiency of military psychiatric services. Specifically we wanted to examine the factors that were said to militate against the creation of a therapeutic community, and to see if patients still in the armed services could become more involved in their treatment. One task would be to find ways of minimizing the conflict that professional staff members perceived to exist between effective psychiatric practice and the demands of the military setting.

The physical plant and the administration of the psychiatric section were conventional. The service was housed in two temporary buildings joined by a narrow passageway. Both buildings were located some distance from the main hospital complex, yet within the confines of the hospital. One building was a traditional closed ward for severely ill patients, with the familiar restrictive para phernalia. Heavy screens covered the windows and doors. The doors were kept locked, and the nursing station was enclosed, keeping the staff isolated from the patients. After a few days of observation, seriously ill patients were usually transferred to the neuropsychiatric treatment center of the Naval Hospital in Philadelphia for comprehensive treatment and disposition.

The other building was an open ward for patients who were awaiting separation from the naval service or were returning for duty. Patients were routinely admitted to the closed ward and, after a brief period of observation,

were transferred to the open ward unless they were too disturbed.

Because of these physical and administrative arrangements, the patients on the open ward had little feeling for the hospital, little understanding of the treatment program, and little involvement with their comrades in the other building. Policies of the service were determined by a standard set of rules and regulations. Decisions about a patient, including discharge from the service, return to duty, and liberty status, were usually resolved between the physician and the patient involved. Although the medical corps staff and other professionals were sometimes consulted, there was usually little over-all staff involvement in decision-making, and almost no patient involvement in decisions that had to be made by and for other patients. The patients rarely understood the staff members' rationale and felt that decisions frequently were made in an inconsistent and arbitrary

manner.

Patient-staff conflict often retarded the formation of a therapeutic alliance, and patients often felt that the professional staff acted like the "bad parents" of their youth. Ward medical officers, particularly on the open ward, were continually plagued with patients' antisocial behavior, including theft, unauthorized absences, fighting, and wearing of civilian clothes or improper uniform, as well as suicidal gestures such as wrist-slashing. Patients showed little concern about keeping the wards clean; they performed very poorly on the work details, which were supervised by the hospital security department with almost no communication between the psychiatrists and the security officers.

The professional staff was composed of four psychiatrists, one clinical psychologist, and a minimum of 12 corpsmen. Because of shortages, training needs, and other administrative problems, nurses were assigned only briefly to the service. Having such fleeting contacts with psychiatric patients, they often made errors in judgment in dealing with them. For the most part, the corpsmen did not seem to have much interest in their work. Many tried to leave the unit, some even volunteering for hazardous duty to do so. The staff friction that occurs normally when people work together filtered down to the patients, at times creating an uneasy ward atmosphere.

In reorganizing the service, we hoped to create an atmosphere that would minimize antisocial behavior and enable the physicians to work with the healthy part of each patient's ego. To show the patients how their present conflicts with authority figures recapitulated past conflicts, we sought to establish a microcosmic society within which patients could view themselves and their interactions with others, and could undergo relearning experiences. We wanted to help them develop self-respect by assuming more responsibility for themselves and their fellow patients. We thought it would be useful to let them observe the decision-making process and to take part in it; thus we hoped both to provide a model for responsible behavior and to let them experience it.

Our first step was to establish a daily group meeting, which all patients from both wards were required to attend. The psychiatrists, the psychologist, and the corpsmen were also present. These community meetings became the major treatment modality on the service, as well as the focal point of community life. To reinforce group interaction as the main therapeutic focus, we abolished individual interviews except for initial consultation, discharge planning conferences, and family meetings where indicated. However sick the patients, they were considered active members of the community, and were expected to take part in all meetings and ward activities, including work details, to the best of their ability. To help the patients become actively involved in their own treatment, we encouraged them to hold their own meeting once a week, which no staff members were allowed to attend.

We began at once to involve the corpsmen in treating the patients. They took part in the feedback sessions that the staff held daily; there the goals of treatment and the rationale behind various remarks and decisions were discussed. Soon we could detect the start of a coordinated treatment team.

We noted that most of the community feeling was centered among the closed-ward patients. We therefore decided to transfer patients from the open ward to the closed ward for a time. Thus both groups of patients would be compelled to interact continually with each other, and so develop into a more closely knit therapeutic community. At the same time, one of the psychiatrists moved his

office into a room on the closed ward and maintained intimate contact with patients and corpsmen throughout the day.

It soon became apparent that patients needed some positive way of measuring their progress. To replace the traditional progression of closed ward to open ward, we classified patients according to how much liberty they were permitted. The amount of liberty was based on the amount of responsibility each patient had demonstrated, to his own satisfaction and that of his fellow patients. We then decided to alter the rules so that patients in the higher liberty categories were eligible to work on details outside the unit.

Patients were expected to assume responsibility for their fellow patients. The staff encouraged them to take part in making decisions that affected all the patients who lived in the community. That required reeducating the corpsmen as well. They had to learn to act to catalyze and foster group interaction, and not to dominate the group or control the decisions. The psychiatric staff did not override the patients' decisions even if they disagreed with them, except when the safety of a patient or the maintenance of group cohesion was involved.

Patient-leaders emerged; they were the most responsible patients, regardless of their military rank. Patients and staff agreed to the establishment of a patient governing committee, to consist of three men elected by the patients. The committee, subject to control by the staff, was to arbitrate patient differences and handle routine administrative matters. The master-at-arms, traditionally the highest-ranking responsible patient, was now to be selected by the patients and staff on the basis of demonstrated responsible behavior. His decisions and actions were subject to ultimate review by the patient governing committee. If patients had grievances against him, they could discuss them with the committee. If patients did not adhere to procedures that had been agreed on, the masterat-arms could bring their delinquency before the committee, which had the power to impose sanctions. The sanctions included deprivation of liberty, banishment to a seclusion room, or lowering of the individual's liberty classification.

The major barrier to the development of the therapeutic community was the attitude