Aware of the shortage of psychiatrists in the armed forces, Rees had begun to build up a list of potential recruits before war had been declared. Bennet, an analytical psychologist and friend of Jung, was ultimately sent to India where he organized psychiatric services for the army in South East Asia. The return of the British Expeditionary Force from Dunkirk in June brought with it large numbers of troops suffering from psychological and functional somatic disorders.
The spectre of shell shock loomed. To forestall this potentially damaging development, No. The influence of Rees can be seen in many of the psychiatrists sent to work at Bishop's Lydeard. Responsible for research and teaching at the Tavistock from , J A Hadfield became clinical director of the neurosis division with the rank of Lt Colonel, while other appointments included Miller, Alan Maberly and Geoffrey Thompson.
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Major Adrian Stephen, the psychoanalyst and brother of Virginia Woolf, was posted there and taught on the military psychiatry course for medical officers. Without any particular therapeutic protocol, No. Conventional wisdom suggested that after a short period of rest, servicemen should be rapidly re-introduced to military life by graded physical exercise and occupational therapy to prevent the development of functional symptoms. In the quarter to June , for example, only 39 16 per cent of discharged patients were returned to duty in the same medical category, and 71 per cent were invalided from the forces.
The introduction of group and occupational therapy woodwork, sign writing and other handicrafts saw improved results, though this may have been simply the effect of screening before referral to Bishop's Lydeard and the introduction of stricter discharge criteria designed to keep men in the armed forces so that they did not become a burden on the pension system. As a result, in the quarter to September , patients However, the introduction of psychiatric units overseas to treat those with a good prognosis saw the return-to-duty rate fall to Because Bishop's Lydeard could not cope with the growing number of servicemen suffering from war neuroses, Hollymoor Hospital at Northfield in Birmingham was transferred to the military in April Under its first superintendent Lt Colonel J D W Pearce, a Tavistock-trained psychiatrist, 22 it was divided into hospital beds and training wings beds : the first for physical treatments of the acute phase and the second to rehabilitate servicemen who had partially recovered.
Based at the Tavistock before the outbreak of war, Bion had begun a training analysis with Rickman but not yet qualified. Faced with a regulated, hierarchical institution and patients who might be sent back to combat if they recovered, they decided to run the training wing of the hospital through a series of large leaderless groups, sometimes containing between and patients. This, they believed, would devolve a measure of autonomy and make patients aware of their responsibility for intra-meeting conflicts and by inference for their well-being.
Bion and Rickman were not the founders of group therapy, which had been practised on a limited scale in the UK and United States. He claimed a success rate of 87 per cent either discharged cured or improved , 26 and later set up outpatient groups. Although these results were published in the British Medical Journal for 14 February , Bion and Rickman did not refer to them.
In an attempt to loosen institutional ties during the pre-war period, T P Rees, medical superintendent at Warlingham Park, a large asylum, had introduced the concept of a hospital club whereby responsibility for its management was devolved to patients.
Mental Health and Social Policy, 1845-1959
Major Michael Foulkes, a Frankfurt-trained psychoanalyst, was the prime mover in the second Northfield experiment. Posted to Hollymoor in April to run a ward in the training wing, he obtained permission from the new commanding officer, Lt Colonel R J Rosie, to run small groups on his free afternoons. Breakdown in combat, Foulkes argued, followed the fracture of links with peers so that these relationships became a source of strain rather than mutual support.
Much has rightly been made of the role of military medicine in serving Weberian notions of modernity, the tendency for social institutions to be brought under unified and routine systems of administration. Often they were forced to act covertly or to find sympathetic commanding officers who would turn a blind eye to what some regarded as interventions likely to undermine morale or discipline.
At other times, by contrast, the military authorities took advantage of their ambiguous position in the sense that they could serve as a patient's advocate in the absence of organic symptoms and objective signs to circumvent regulations. With eight to ten members, the groups run by Foulkes were more manageable than those of the first Northfield experiment.
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They met once a week for ninety minutes, though some patients were also seen individually. There was scarcely a case which did not benefit, whilst in a large proportion of the patients the improvement was considerable and sometimes astonishing … the improvement was genuine and sustained. Yet no objective measures were recorded, no controls tested and no follow-ups undertaken to establish how permanent were the changes identified. It would not have gone down well with the military authorities had clinicians admitted that soldiers mentally scarred by combat were unlikely to return rapidly to their pre-service level of functioning.
Internal reports compiled by military psychiatrists and therapists working at Northfield were less optimistic about outcomes than published accounts. Whilst the First World War had demonstrated that the nation's fittest and bravest could succumb to mental breakdown, 40 this lesson had largely been forgotten by The principle was re-established during the Second World War that everyone, if subjected to intense stress of combat, would ultimately cease to function. No longer could a line be drawn between those who were regarded as constitutionally inferior and those considered innately healthy.
Furthermore, it was recognized that traditional hospital regimes, when applied to psychological disorders, robbed patients of their autonomy and could impede recovery. The more, it was argued, that could be done to restore self-confidence and a sense of personal responsibility the better. Posted to command Northfield's training wing at the end of , Major Harold Bridger, who had no formal training in psychiatry or psychology, set about introducing these ideas. The treatment of the neurotic patient, who suffers from a disturbance of social relationships, cannot therefore be regarded as satisfactory unless it is undertaken within a framework of social reality which can provide him with opportunities for attaining fuller social insight and for expressing and modifying his emotional drives according to the demands of real life.
Psychiatrists from the Maudsley Hospital were recruited to the war effort, being divided between two suburban units in London. Occupational and social psychiatry was their goal. However, he soon recognized that their value was limited given the general level of mistrust felt by patients towards doctors and well-established nature of symptoms. Formal instruction was abandoned in favour of discussion and the traditional barriers between doctors, nursing staff and patients were lowered, though not eliminated.
A form of therapeutic community evolved from clinical practice, rather than being theoretically-driven as in the first Northfield experiment. Having discovered the therapeutic effects of groups, Maxwell Jones extended the principle to the Effort Syndrome Unit as a whole. However, despite the urgings of Aubrey Lewis, Jones made little attempt to evaluate outcomes using statistical techniques.
The one area where psychotherapy was considered valuable even by military authorities was on the battlefield.
Abreaction, or the discharge of emotion attached to a repressed experience, had been practised at special treatment centres close to the front line during the First World War by William Brown and Frederick Dillon. To encourage recall Brown used light hypnosis and claimed to have returned 91 per cent of admissions to full duty. Other more sceptical doctors, such as William Johnson and Dudley Carmalt Jones, believed that abreaction, by re-traumatizing soldiers, interrupted a process of natural recovery. Nevertheless, this story of therapeutic success found its way into the official histories and it was widely proclaimed that 80 per cent of shell-shocked patients treated by forward psychiatry returned to operational duties with combat units.
The system was publicized by Thomas Salmon, who introduced these methods to the American army in Because of the large numbers admitted to these centres during battle, sedation and graduated exercise were the most common interventions. Re-education and brief focused therapy sometimes assisted by hypnosis were also practised.
This reflected his own interests in psychotherapy, having been a member of the Society for Creative Psychology and undertaken twice-a-week therapy. He estimated that 86 per cent of admissions were sent to convalescent depots where they were downgraded to non-combatant roles. Although papers in reputable medical journals proclaimed the efficacy of PIE, the private reports of military psychiatrists were modest in their claims. In reality, most soldiers worn down by the intense stress of combat were unable to go back to fighting units after treatment. For example, between July and September Major Burch returned only 6 per cent of admissions to their units, the majority being sent to rehabilitation centres or to base duties.
Captain Henson, RAMC, neurologist, who is producing a report on cases of exhaustion received by him. Preliminary analysis of cases received early on in operations shows that 43 per cent had previously been treated elsewhere for exhaustion, returned to duty and relapsed. Brigadier Sandiford had also visited No. Recruited into the air force on the outbreak of war, he was posted to the RAF Officers' Hospital, Torquay, to investigate the nature of breakdown among aircrew. The experience of treating men with no history of mental illness and who did not fall into the traditional asylum diagnoses led Gillespie to consider social and cultural factors in the causation and treatment of psychoneuroses.
With forty-three beds, much attention was spent on providing a therapeutic atmosphere: private rooms, a gymnasium and quality furnishings.
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Treatment was broadly-based including continuous baths, narcosis and ECT for the most disturbed patients and occupational leather work, carpentry and model making and individual therapy for milder cases. Following the suicide of Gillespie in October , Thomas A Munro, recently returned from military service in India, became the York Clinic's second director.
War and the Practice of Psychotherapy: The UK Experience 1939–1960
It became part of the NHS in when fifteen of the forty-one beds were allocated to the health service. The York Clinic had its own kitchen and chef … It was all not merely comfortable—it was charming. In , at the behest of the Ministry of Health, C P Blacker surveyed psychiatric out-patient facilities in England and Wales, comparing wartime usage with that for Sympathetic to psychodynamic approaches and having undertaken a brief training at the Tavistock Clinic, Blacker recognized that the psychotherapy profession faced a credibility gap with the public and medicine.
Analytic methods of psychotherapy are sometimes spoken of as if they were a decadent and modern fad.
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Indeed, in the clinic set up in London by Edward Glover and other psychoanalysts to treat those traumatized by air-raids had been forced to close because they had no patients. Most psychiatrists and psychologists recruited into the RAMC left the forces once peace was declared. Bion undertook a training analysis with Melanie Klein and, like Rickman, went into private practice.
Foulkes was appointed consultant psychotherapist at the Maudsley Hospital. Bridger trained as a psychoanalyst with Paula Heimann and became a key member of the Tavistock Institute of Human Relation's consultancy team working in industry and other large organizations.