"THE CULT OF THE PATIENT"
Conscription leads to all males of a certain age ending up in the military at some stage, regardless of their suitability. Most conscripts would avoid the military like the plague if they had had any choice in the matter.
Some young men look at National Service as an opportunity to do 'interesting things' for two years, and a chance to 'grow up' and maybe sow their wild oats before settling down to tertiary education.
Others leave the country, or as Conscientious Objectors, opt to sit in prison for seven years instead of doing National Service. Others accept the inevitability of National Service, and not wanting to emigrate or go to prison, decide to try and survive their National Service by keeping a low profile, never volunteering for anything, and just making the best they can out of an unpleasant situation.
Others, usually less mature and less organised than those mentioned above, put no thought into National Service and how to survive it until suddenly they are caught up in the organisation, at which stage it is very difficult to get out. It was from this group that most of the patients seen at the Psychiatry Wards of 1 Military Hospital were drawn.
I met many youngsters in the army, who were patients when I saw them, who had survived their lives that far by hiding in the twilight of mainstream society, but when they found themselves in the army, someone had switched the floodlights on and they had no shadows in which to hide.
Very few people who ended up as psychiatric patients at 1 Military Hospital had unbroken records of mental health before their induction into the army (with the possible exception of those who suffered from Post Traumatic Stress Disorder.) Most seemed to have some history of distorted family relationships or some previous psychiatric treatment.
Imagine the situation; YOU are eighteen years old, and YOU suddenly find that basic training is a nightmare, and YOU are very unhappy about it. Other people are in the same boat, and they moan and complain, but they all seem to get on with each other, whereas YOU can't make friends.
Some people have various medical problems, but at the intake medical before the start of basic training YOU were pronounced fit and labelled 'G1 K1' - a potential 'lean mean fighting machine'.
"But hang on chaps," YOU try to say, "That doesn't sound like me. I'm a 'lounge lizard', a 'couch potato'. I like wine, women and song. I like sex and drugs and rock 'n' roll. I don't want to go crawling around in the dirt, practising trying to kill someone who has never done anything to me personally. There's been some terrible mistake! You've got the wrong man. Come on, let me go home!"
But no-one will listen. They've heard it all before. "Get back in your platoon!" they bellow at you!
"LET ME OUT OF THIS PLACE!"
There are some people who may need help and support to get through basic training, often because they have 'inadequate personalities', and cannot become 'part of the team' that is necessary to survive basic training.
Some people can be helped, but only if they are amenable to this. Many decide from the start that they don't want to adapt to the army; they want out!
From very early on in basic training, recruits are told what their rights are; and of the availability of the 'welfare' (Social Work) services, medical services, and Chaplain services. It is in these directions that recruits turn to extricate themselves from their nightmare of basic training.
Very soon they find that the Social Workers are over- worked, and are limited in what they can achieve. The Chaplains often (sweeping generalisation) suggest 'prayer' as a plan of action, which is usually seen as insufficient by someone wanting to get out of the army.
The Doctors are the best bet, because they have the best access to Psychiatry. But the doctors are overwhelmed by just about everyone wanting temporary respite in the form of 'light duty', which will prevent them from running around and doing push ups and other important aspects of preparing to defend the country against the Communist hoards.
MANIPULATIVE SUICIDE ATTEMPTS
The best way to draw attention to yourself, and to jump the queue of the 'sick, lame and lazy' is to make a suicide attempt. No matter how minor, army regulations stipulate that all people who attempt suicide must automatically be referred to the Department of Psychiatry. The army is very sensitive about attempted (and successful) suicides, which indicates low morale in the conscripted army, and results in questions being asked in Parliament.
An attitude we often came across was "Unless you (a) discharge me from the army, (b) stop me from standing guard duty, (c) transfer me to the closest unit to my home, (d) arrange that I can get a sleep out pass so that I can go and sleep at my parents /girl friend's house every night, I will (a) kill myself, (b) pretend to attempt to kill myself, and then you'll be sorry! This was often simple blackmail.
People who had been happily on AWOL would often make a suicidal gesture as the Military Police walked up to their front door, or else when they have had their holiday, they spontaneously report to psychiatry 'feeling depressed or suicidal', in an attempt to ease their way back into the unit without repercussions.
One patient actually admitted that he had been advised by his brother in law, who had been a Lieutenant during his national service, that he should try to return from AWOL by reporting to the Psychiatry Department.
"ITS YOUR JOB TO GET ME OUT OF THIS MESS"
Everyone knows that Social Workers and Psychologists and possibly Psychiatrists are 'bleeding-hearted do-gooders', whose vocation in life is to help people who are in trouble or distress.
Everyone also knows that most psychologists and psychiatrists are 'raving whackos' themselves, and that Schizophrenia means that you have a 'split personality', which means that 'at times you are happy and at other times you are sad.'
"I could manage that if it would get me out of this mess!"
The plan of action for many unhappy National Servicemen was:
(a) I will fake mental illness
(b) If I am unsuccessful in this, I will at least be seen by 'shrinks', whose job it is to find something wrong with me, which will get me out of this mess.
Psychiatry, although not as sophisticated yet as many of the other medical specialities, is much more structured than many lay people realise. (See Kaplan & Sadock, 1985). Some patients present a very confusing picture, where they report symptoms that they are experiencing, but add in a couple of others for good measure, which contaminates an otherwise clear diagnosis. Often, admission to a ward was to enable the staff to differentiate the real symptoms from the improvised, 'jazzed up' version.
We had to sort through the maze the patient presented, and often found that they were just ordinarily maladjusted kids who didn't have the social skills to survive basic training without drawing unwanted attention to themselves.
If we then offered the support to help the person complete basics, patients would often get nasty, accusing us of missing severe problems which they could not begin to describe to us, and it was our job to identify their problem, and having done so to 'board' (discharge) them out of the army.
Sometimes their families would support them with this, with parents threatening to write to members of Parliament, or accusing us of being incompetent, of failing to identify long lasting 'very severe' problems, which had supposedly only started since their son had started with the army.
Others parents would say that their child 'needed a bloody good hiding', and hope that the army would knock them into shape. (More below)
The mental health professionals very often would like to help people who are in distress, but there are factors which motivate against the desire to do what one can to get anyone who asks out of the army.
Firstly, a 'Medical Discharge' can damage a person's future prospects. A 'G5' theoretically prevents a person from being employed in the Civil Service or any partially state controlled bodies, which together amount to 60% of employment opportunities in South Africa. The rationale is simple: If you're not mentally healthy enough to complete military service, even as a G4 K4, then you are not going to be capable of holding down a job in the civil service. There could also be problems in the private sector; a personnel manager interviewing a prospective employee asks "Tell me, son, what did you do during your National Service?"
"I got exempt," says the candidate.
"Oh, why?" asks the personnel manager with raised eyebrows.
"I pretended to be schizophrenic," says the candidate. "There's nothing wrong with me really, but I sure fooled them."
The personnel manager then thinks (a) this chap is a loony, and (b) If he's going to malinger in the army, how do I know that he will not malinger when he's working for me? Will I be able to depend on him when the going gets tough?
Secondly, there will be the social side effects, the label of mental illness which could count against the person, stigmatising him, and which he will never have the opportunity to shake off.
Thirdly, the majority of National Servicemen are just doing their time, making the best they can of a bad situation. They have to stand guard, which no-one likes. The boredom is mind killer. There are a finite number of soldiers at each unit. That guard duty has to be done by someone is not negotiable. Each 'would-be' patient who we use our influence to exempt from guard duty, would just place an additional burden on those in his unit who have not complained, who are just trying to survive 'doing their bit'!
Fourthly, possibly related, is the notion of setting a precedent, and inviting 'copy cat' presentations; "Jones wandered around the base stark naked talking to his dead father, and now he's out of the army" (Forget that he's in civilian psychiatric hospital.) Next day three platoons of soldiers are found walking around stark naked, talking to Jones's dead father. "Can't you organise a bus to take us all to the Psychiatry department?" a distraught imaginary Regimental Sergeant major asks with tears in his eyes.
Fifthly, there is the problem of 'Crying wolf'. The psychiatrists recommendations are not always implemented by the administrative superiors. If we try to exempt too many people, eventually we will no longer be taken seriously, and then we will not be able to help the people who really need it. It was as though we could only help a finite number of people, so we could only choose to help the most deserving cases.
ONCE ON THE WARD - STAY THERE!
Patients were only admitted to the ward temporarily, with the idea that they were being admitted for observation or treatment, and that they would be returned to their unit as soon as this process had been completed.
Most of the patients saw this differently. Even though they were in a military hospital, the contrast between being on the ward, and being back at the unit, especially if they were busy with basic training at the time, would be breath- taking.
In the ward, patients slept in until about 7 am - by which time most South Africans are up and about. They had to make their own beds but there were staff to do other domestic duties. They could spend their days doing pretty much what they wanted, with minimal pressure on them. They did not wear uniforms, but wore dressing gowns, which few seemed to object to. They could have visitors most nights, and many were allowed to go home over weekends. No one shouted at them, and they could watch TV in the evenings. They could make as many telephone calls as they could afford.
"We're in den! We're safe here! You can't touch us here!"
Time spent in hospital counted as National Service. Soldiers in detention barracks had the length of their sentence added on to the end of their National Services, called 'extra days'. They would have to stay on in the army for that time, while the rest of their intake, who had started with them 'cleared out'. The temptation to try to stay on the wards as long as possible, if not for the duration of National Service, was tremendous.
To stay on the ward, the patients had to be careful to be seen as being deserving of treatment. If they did not show some improvement, and there was no evident psychopathology, they might be seen as uncooperative, and discharged. If they improved too much, they might be considered to have been relatively cured, and returned to their unit. The role that they had to play was to be seen to be improving slowly, with occasional minor relapses, and making enough 'therapeutic insights' to keep their therapists happy.
When seeing one of my patients on the ward, I would usually start off a session asking 'How are things going?' Often they would answer that they thought that they were starting to cope, but they usually meant that they were starting to adjust to being in the ward, and did not imply that they were starting to adjust to being in the military.
Some patients really enjoyed playing the role of being a psychiatric patient, and all the things that they could get away with under the banner of being disturbed. Some were found to be sitting on the 'Do not walk on the grass' sign in the middle of an area of lawn under cultivation. They seemed to be playing with the idea; "We're mad so we can get away with anything."
Patients also exchanged information about the patient role, and in some cases shared medication. ("If I take these pills I might get better in which case they'll send me back to basic training.")
A mystique developed surrounding the psychiatric panels, which the staff saw as getting the know the patient. One patient told me that he was expecting to be asked "the hundred questions" as though there was a set number of standard questions.
TRANSFERS CLOSER TO HOME
Not all of the patients were holding out for a G5. Some would have been quite happy with a transfer closer to home, no more guard duty, and a 'sleep out pass' which would enable them to return home each night. Unless there were psychiatric, psychological or social work reasons - or pure medical reasons - a person stood virtually no chance of this. There are very low military presences at the big population centres like Johannesburg, Cape Town and Durban. It was very difficult to arrange transfers to these areas, because of the large number of 'deserving' applicants for very few positions. Small wonder people try to create problems which might help them to be sent closer to home; and malingering becomes an understandable response.
This all sounds very cynical, but it would probably be fair to say that sixty percent of the patients we saw had no actual psychiatric or psychological problems, (no illness other than being unhappy and distressed) but we would have to give them the benefit of the doubt until we were satisfied that there were no genuine problems, at which stage we could expect the patients to retaliate against us personally in which ever way they could.
With continual vigilance for malingering, and the effect of this on our trust of patients, job satisfaction was very limited in trying to treat people most of whom were not ill.
We did see people with genuine psychiatric and psychological problems, but these probably occurred no more than in the general population, and our management of such patients was straight forward.
It is the 'Secondary Gain' to be obtained from being admitted to a psychiatric wards which I think makes the patients described below different from those seeking psychiatric and psychological help in a civilian population.
UNCOMPLICATED ADJUSTMENT PROBLEMS - INTAKE/BASICS
Most of the people who were seen by the Department of Psychiatry initially presented with problems during their basic training, and this was the time during which the department was at its busiest.
The most common complaint was "I can't handle this anymore. I'm going to crack!" or its Afrikaans equivalent; "Ek kan dit nie meer hanteer nie. Ek gaan crack." Most of these were sorted out within their unit, by the Social Worker, the Doctor or the Chaplain, but some still managed to get as far as the Department of Psychiatry. The usual approach to such presenting problems was to separate those who 'could not' from those who 'would not.'
Where the 'medical/welfare' staff at the unit were unsure of the extent of the problem, or the ability of a young recruit to adjust, they would refer them to us. Some of these were straightforward malingerers, but some were more interesting.
Most conscripts didn't seem to think more than a day or two at a time, or didn't seem to until then, but the idea of three months of initial basics seemed to some to be sufficient cause to take their lives, or at least make an attempt to signal their distress.
"Patient referred by unit SWO (Social Work Officer) for evaluation possibly leading to him being boarded down to G3. Presenting reason is that he is Gay. Other reason is that he is scared of his rifle, and he is feeling overworked. Social work reason is that his mother is ill with cancer. I find no psychiatric grounds to have him boarded down, but have referred him to Capt. Annette V.'s adjustment group."
"Patient referred by sickbay doctor for psychological reasons which he did not feel able to discuss with the doctor. These turned out to be some general unhappiness about being so far from home. There was no evidence of underlying psychopathology."
"Patient, a signaller, seen for follow up at own request following suicide notes and being taken into unit sickbay until this appointment. Arrived earlier than expected and demanded to be seen straight away. No way! He showed me a suicide note and told me that he would shoot himself. He is worried about going to the Border and he hates Morse. He is G4 K4 and as such should not be sent away from easy access to a hospital. I told him that we can try to keep him in the PWV area, but he will just have to try to cope at his unit. I phoned Sister Tucker and told her of this in his presence and advised that he be discharged from the sickbay on his return to the unit."
"Phoned unit social worker who says there is no possibility of him going to a bush station, and she has recommended that he be posted somewhere in the PW area."
" ... Tense and frustrated at the lack of opportunity to play sport as well as not being given the opportunity to go on JLs. Strong dependent traits. I reported back to his concerned mother about his present state - that he is not mad!"
"On occasions heard a voice inside his head urging him to make up his bed. Spends most of his weekends sleeping. Parents transferred to Witbank - mines. Could we transfer him to Middelburg?" "Tends to be the butt of his corporal's aggressive jokes. ?? Transfer to Middelburg and a sleep- out pass. Vague somatic complaints and tension headaches. Mother says his functioning at home has improved; 'He is a different boy'."
YOU CAN TAKE A HORSE TO WATER, BUT ...
"Neil is still not open to therapy. He blames the army totally for his present difficulties. He openly admits that there are things that he is not prepared to discuss with me because there is nothing that I can do about them. He agreed to terminate, but I invited him to return if he ever finds problems that he wishes to discuss."
One patient we saw was a school friend of Glenn T.'s. John looked a little odd, with a coke-bottle physique, and low protruding ears. "He's a typical 'Funny Looking Kid'," Marius remarked, not unsympathetically. He was a qualified school teacher, who had become married within two weeks of reporting for National Service, a phenomenon which raised a gasp of desperation from the psychiatric panel. He and his wife thought it would be a good idea to do this, to assure John of his wife's support during his National Service.
John had always been troubled by back trouble. During basic training, he was not allowed to run, and when the whole platoon was being punished for the sins of one, instead of running, he was told to hold his rifle at arms length in front of him and rotate it. The R1 (FN.) rifle weighed about 7.76 lbs, and John stared to suffer. Soon after this he had a brief psychotic episode, the details of which escape me. He was seen by Major Coetzee B., who declared that he was malingering, and threatened him with 'trouble'.
John was predisposed to mental health trouble, which the stress of his basic training triggered. He had a disturbed family background, with a childish and sadistic father who would deliberately scare the children with ghost stories and the like, and at one stage exploded a firecracker in John's bath, which burned the boy. A psychotic feature he recounted was that he had been involved in dramatics at school, and seemed to have difficulty in separating himself from the roles he was playing, difficulty with ego boundaries. He had played the father in 'The Diary of Anne Frank', and at times got lost in the character, and would face his life in that role.
While on Ward 24, John thought through many of the problems he had experienced in his life before he had been called up. He described this experience as having a ravine full of dead, rotting cattle, and one at a time, he was removing and burying the carcasses.
John was given a medical discharge on psychiatric grounds, and spent several months recovering before returning to teaching. Some months after his G5, he contacted me, and invited me around to tea with himself and his wife. At the end of a rather uncomfortable conversation, John asked me if I could write a note to say that there wasn't really anything wrong with him, as he needed this to continue with his career in teaching. This was not something that I could do.
Glenn, prompted by this experience and others, expressed his frustration with National Service; that it grabs people who have managed to survive ordinary life, pushes them beyond their endurance, and then discards them, marking them as unfit for normal employment for the rest of their lives.
One recruit requested separate shower facilities from other recruits because he was embarrassed about his small penis. "It isn't particularly small," one of the doctors is alleged to have said. "Step outside and lets compare."
NICE TRY, ANYWAY
During one intake, when our department was so busy that we are barely coping with the number of patients that are being presented, one of the doctors did a clinical interview with a soldier of the new intake who was quite clearly schizophrenic. He had all the symptoms. A text book case! The Doctor mentioned the case briefly to the Marius the psychiatrist, who advised him not to present him to the full psychiatric panel, as the matter was cut and dried, and the guy was likely to be medically discharged - 'G5-ed'.
The panel was about to finish early the next day, so the Marius suggested that the doctor present the schizophrenic patient - just for interest. During the interview, the Marius noticed that although the patient had all the symptoms, he was able to describe them too easily; that he was being more academic than subjective in the description of what he was suffering from.
Marius became suspicious, and called for a background report. The Social Worker phoned his mother, who said, yes, he had whole rows of psychology books on his bookshelf, and he was expecting to be discharged from the army within a week. Busted! Shame!
I assessed a patient referred to me by Camper Psychiatrist Larry G.. He had gone AWOL (Absent WithOut Leave) when crossing a road in Voortrekkerhoogte to go to the mess hall, and his girlfriend had arrived in her car to collect him. During my assessment, I tried to decide whether his way of expressing himself reflected creativity or disordered thought processes or some schizophrenic process lurking in the deep dark depths of his brain. To indicate his perceived incompatibility with the army - instead of saying 'like a fish out of water', or some other conservative idiom, he described his experience as being 'like a polar bear in Havana'. I decided that he was just trying to be creative. He had used LSD a couple of times which has given him this incredible understanding of himself, the universe and everything.
When I last heard of him, in a message given to me by another patient, he was out of the army, and in England.
NOTE: The "1984 South African Citizenship Amendment Act", which made many British and other Country's nationals into South Africans overnight, and hence liable for military service. I believe that such people had the option to renounce their newly imposed South African citizenship, and to so leave the SADF immediately. It was expected that they would be given a month or so to leave South Africa, or be called up again. I don't know of anyone who used this, but it was rumoured to be a frequent occurrence, as basics became more unpleasant. This was not an option open to 'born and bred' South Africans.
Grant was a pleasant lad, though inadequate and with particular concentration problems. He had floundered at school, but blamed the army for interfering with his career in broadcasting.
He seemed to have 'holes in his concentration'. He didn't seem to be able to hold more than one idea in his head at a time. There wasn't anything wrong enough with him to get him discharged, and he was confined to administrative duties, which of course he was useless at:
"At work where he has been for two weeks he has botched up most of the jobs that have been given to him. Sometimes he arrives unshaven, and he parks in no parking zones and disregards parking tickets. There was also apparently an incident where he refused to salute a Captain because she was a woman. He reported no recollection of this event."
"I confronted Grant with this information but he discounted it saying that he was only making beginners errors. He says that he was unfairly transferred from Kollot (media centre) because he did not have enough experience. He feels that his unit are picking on a whole lot of small and insignificant things."
"I noticed that Grant arrived late with some excuse, and parked his car on a yellow line directly under a 'No Parking' sign. I pointed this out to him, and he felt that his haste justified this. He gave me a book to sign that I had seen him, and he would have left it behind with me if I hadn't chased after him with it."
It was seen to be my job to try to find some way in which his employment could be beneficial to the SADF. Guard duty would have suited him - 'stand there and look dangerous', but he wasn't to be trusted with a rifle. Refer him to the Regimental strangler? There were manipulative elements, and it suited him to be useless to the army - 'You might as well let me go home!'
Rupert was 17 when I met him, a tall dark youngster who must have been one of the 'twilight kids' mentioned above. He wasn't good at coping, and didn't seem to be very interested in trying.
I felt quite protective towards him because he had annoyed Marius at a psychiatric panel, and Marius had raised his voice at him.
Rupert's father had left the family when Rupert was a young child, and gone to England, and his mother seemed to be deeply involved in a lesbian relationship.
I gave Rupert some cake on my birthday. He managed to get me a card in which he wrote 'Have a happy birthday and many more'. I liked him.
He was discharged back to his Signallers Unit eventually, where he continued to take chances. We eventually arranged a transfer to a unit closer to home, but he did not pay his Regimental Funds, and so this delayed the transfer taking place. He had the naive view that if you ignored things, then eventually they would go away. The army is geared to making sure that such things are not forgotten.
When he was finally transferred to a unit close to home he was given nothing to do and told to look busy.
"He was on orders for being late last Saturday morning. He gave the Officers a sob-story and told his peers that he had been out partying until all hours. They also have a suspicion that he is back on drugs again. He believes that his mother has thrown him out of the house."
He managed to do something which made his unit think that he might be a security risk, like being seen to give a 'black power' salute or something similar.
I probably got as much enjoyment out of trying to nurture him as he got help from me. He did come to see me in his own time, so it must have meant something to him, and couldn't just have been to get out of the military situation.
The last bizarre thing that he did was to suggest that a party should take place in his honour so that he would know how many friends he had. Things like that don't just happen; they have to be organised. No-one came, and he took it personally.
I wonder what he is doing now?