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Debriefing Following Combat

Chapter 11

DEBRIEFING FOLLOWING COMBAT

RONALD J. KOSHES, M.D.*; STEPHEN A. YOUNG, M.D.†; AND JAMES W. STOKES, M.D.‡

INTRODUCTION

THE HISTORY OF POST-TRAUMA DEBRIEFING

TYPES OF DEBRIEFING

After-Action Review

After-Action Debriefing

Historical Group Debriefing

Civilian Critical Incident Stress Debriefing

Critical Event Debriefing

Psychiatric Debriefing

Large Group Debriefing

End-of-Tour Debriefing

PSYCHIATRIC DEBRIEFING TASKS

Predebriefing

Debriefing

Postdebriefing

ISSUES AND PITFALLS OF DEBRIEFING

IMPLEMENTATION OF PSYCHIATRIC DEBRIEFING

SUMMARY AND CONCLUSION

*Chief Psychiatrist, The Center for Mental Health, Washington, D.C. 20020; Guest Scientist, Division of Neuropsychiatry, Walter Reed Army

Institute of Research, Washington, D.C.; Assistant Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences,

Bethesda, Maryland; President, Society of American Military Psychiatrists

†Major, Medical Corps, U.S. Army; Department of Psychiatry, Walter Reed Army Medical Center, Washington, D.C.; formerly Chief of

Psychiatry, Gorgas Army Hospital, Panama

‡Colonel, Medical Corps, U.S. Army; Chief, Combat Stress Actions Office, Department of Preventive Health Services, Academy of Health

Sciences, Army Medical Department Center and School, Fort Sam Houston, Texas 78234-6133
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Burdell Moody Killed in Action 1968

Burdell Moody, with U.S. Army Artist Team #4, starkly portrays a squad returning to base camp in

Vietnam, carrying the body of one of their soldiers. Perhaps the most stressful aspect of combat for a soldier,

other than pondering his own death, is the death of another, especially a member of his own unit.

Witnessing death is a critical event in the life of any soldier and his unit, one warranting immediate

debriefing to lessen the likelihood of developing post-traumatic symptoms in the future.

Art: Courtesy of US Center of Military History, Washington, DC.
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Debriefing Following Combat

Emergence of post-traumatic stress disorder

(PTSD) as a clinical condition presupposes the experience of an overwhelming trauma and consequent biopsychosocial adaptation. By the criteria of

the Diagnostic and Statistical Manual, 4th ed.1 (DSMIV), the individual must reexperience the event,

perhaps through intrusive recollections, distressing dreams, and avoidance of stimuli associated

with the event, and may have persistent symptoms

of increased arousal manifesting as hyperalertness,

vigilance, and irritable behavior. The symptoms

must last for at least 1 month. The stress of combat

does not inevitably result in PTSD; debriefing following combat is an intervention that appears to

interrupt the causal connection.

Often, at some later point in life, the person

exposed to trauma, be it a natural disaster, terrorism, war, or other highly emotionally charged lethal or life-threatening events, will reexperience

feelings associated with the original trauma because of an environmental or emotional trigger. In

the case of war, PTSD can occur in as many as 15%

of those individuals exposed to combat.2

 In natural

disasters, terrorists attacks, and devastating industrial accidents (the so-called civilian critical incidents—CCI), PTSD rates are more variable, depending on the meaning attributed to the stressor

and the possibility of legal damages.

Trauma, however severe, is likely to be an organizing factor in a person’s life, defining for the

individual adaptation that can be both attributed to

and dated by the event. Perhaps the most useful

intervention is the help provided by families, friends,

church groups, military units, and others in stabilizing the individual in the community, allowing

for the ventilation of feelings, and validating the

role of the individual in the communities to which

he or she belongs.3

Psychological trauma following civilian critical

incidents has been similarly studied. Erikson4 documented the importance of tending to basic needs of

survivors when the dam on Buffalo Creek broke

and devastated a whole Appalachian community.

Long-term distress was exacerbated when families

were separated, homes relocated, and roads were

built without direct community involvement. As a

result, rescue workers learned the importance of

enlisting survivors in their own recovery process, a

principle that has been utilized in CCI training and

actual experience.

For combat, various models have been proposed

and studied to reduce the incidence of PTSD and

other acute psychiatric reactions. Most models rely

on the assumption that unit cohesion, training, and

leadership are important in helping soldiers adapt

to traumatic or adverse conditions. The decreased

incidence was striking in subsequent psychiatric

casualties experienced by an elite paratrooper unit

when compared to ordinary combat units in the

Israeli Army during the 1973 Yom Kippur War.5

Significant differences in the units highlight the

role of trust toward the immediate commanders,

unit identity, and professional soldiering knowledge.2,5 Moreover, the community support and

effective integration of soldiers returning from battle

into their units or homes appears to have the greatest influence on the development of long-term psychiatric sequelae.6–9

INTRODUCTION

THE HISTORY OF POST-TRAUMA DEBRIEFING

One process by which individuals can reduce

untoward effects of trauma (eg, natural disasters,

war, civil unrest) is called debriefing.10 Simply put,

the individual or group meet at the request of a

larger supervisory body to begin a process of integrating the trauma into their individual and group

experiences. Debriefing is a process that has been

described by mental health workers attendant to

natural disasters,10 terrorism,11 combat,12 and military accidents.13,14 It involves a structured meeting

designed to allow for ventilation of feelings, fears,

and the telling of stories of the traumatic event. It is

not the end, but rather the beginning, of the healing

process during which the reentry of individuals

into the community at large is facilitated.

The concept of group debriefing grew out of the

work of S.L.A. Marshall15 during World War II

when he attempted to record accounts of small unit

military operations for historical purposes. Marshall

noted that when a person could describe what happened to him during a harrowing experience this

served not only an abreactive purpose but allowed
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274

colleagues to correct misperceptions and render

social support. This appeared to decrease the development of combat stress reactions. Marshall

observed that these historical debriefings or “reconstructions” restored unit cohesion and readiness to return to combat. He considered this one of

his most important contributions to the U.S. Army.

Marshall continued to conduct official historical

debriefings for highly selected units throughout the

Korean and Vietnam conflicts. To the knowledge of

the authors, the technique was not used at that time

by clinical mental health personnel.

In 1978, the debriefing process was incorporated

by Navy psychiatrists in developing the Special

Psychiatric Rapid Intervention Teams (SPRINT),

which have been discussed in Chapter 9, U.S. Naval

Psychiatry). In the 1980s, the U.S. Army’s 7th Medical Command in Heidelberg, Germany used debriefing techniques on their Stress Management

Team deployments in response to a number of

terrorist attacks. A joint U.S. Navy-U.S. Army

team deployed to the Persian Gulf to assist the

U.S. Navy frigate Stark after it was damaged by an

Iraqi Exocet missile.12 The air show disaster at

Ramstein Air Force Base in Germany also required

extensive debriefing of survivors, witnesses, and

caregivers.

Critical incident stress debriefing (CISD) has also

been utilized in the civilian world.16 Some volunteer CISD teams are now active in most of the

United States and in other countries including

Canada, Great Britain, the Netherlands, Norway,

and Australia. These teams respond to critical incidents involving police, fire, and emergency medical

departments. Some governmental and nongovernmental agencies have their own debriefing teams

and policies.

During and after the U.S. invasion of Panama

and the Persian Gulf War, U.S. Army mental health

teams conducted a number of unit debriefings, although there was no formal doctrinal mandate or

training program. With the deployment to Somalia

in January 1994 of U.S. Army division mental health

and combat stress control detachment teams, critical event debriefings became common practice. They

were conducted following deaths in a unit from

enemy action, accident or suicide, or after other

distressing events involving deaths of civilians or

mass casualties of multinational force allies at U.S.

medical facilities.

U.S. Army critical incident debriefings have been

conducted following training deaths at the National

Training Center (NTC) in California and the Joint

Readiness Training Center (JRTC) in Louisiana; the

Green Ramp disaster at Pope Air Force Base in

North Carolina; the mass murder followed by a B52 bomber crash at Fairchild Air Force Base in

Washington state; and many other traumatic incidents. The U.S. Navy’s SPRINT teams continue to

deploy on call, as have U.S. Air Force teams. U.S.

Army doctrine 17,18 establishes critical event

debriefings as doctrinally appropriate after especially traumatic events. Allied countries have also

accumulated extensive experience with military

debriefings following critical incidents and difficult tours of duty.

A number of models or types of debriefings have

evolved from this extensive experience. These include (but are not limited to) the types summarized

below:

• After-Action Review (AAR)

• After-Action Debriefing (AAD)

• Historical Group Debriefing (also called

Historical Event Reconstruction Debriefing—HERD)

• Civilian Critical Incident Stress Debriefing

(CISD)

• Critical Event Debriefing (CED)

• Psychiatric Debriefing

• Large Group Debriefings

• End-of-Tour Debriefings

After-Action Review

After-action review (AAR) is the standing operating procedure for all U.S. Army teams and small

units following any training exercise. The training

cadre bring the team together immediately after

each training event and have them talk through

what happened. The cadre share their own observations. The product is positive lessons learned,

not blame. Further, AARs may bring together the

leaders of all the participating small groups to give

the wider perspective and derive lessons learned on

command control, communication and coordination. All U.S. Army leaders are expected to conduct

their own AARs routinely, without cadre, when

conducting their own training exercises. They are

TYPES OF DEBRIEFING
275

Debriefing Following Combat

encouraged to continue this practice in real world

missions, including combat.

The AAR is designed for nonlethal training, and

focuses cognitively on the operational lessons

learned. It does not explicitly encourage emotional

ventilation or sharing of feelings and reactions.

However, effective leaders and supportive cohesive teams do recognize, and work through, the

sometimes intense feelings that arise. Mental health

personnel are not normally present at AARs, except

in their own training. However, it is valuable for

the mental health personnel supporting combat units

in field exercises to be transported to the AARs of

units that have experienced simulated critical incidents, to hear what the combat units do, be seen,

and exercise the ability of command to get them to

units to assist after real traumatic events.

After-Action Debriefing

After-action debriefing (AAD), in U.S. Army

doctrine, is an extension of the routine AAR.

The after-action debriefing process shares the after-action review’s concerns with details of what

happened. It goes further by actively encouraging

the team members to share and even talk out their

emotional responses to the event. After-action

debriefings should also be routine during training,

operations other than war, war, and following any

difficult or unpleasant event. Doing after-action

debriefing routinely will make them second nature

following any especially traumatic event. The objective of after-action debriefings following traumatic incidents is to promote “healing” by opening

up, “cleaning and draining” any unpleasant or

painful memories.17(pp6-6,6-7)

Exhibit 11-1 lists the key steps of the after-action

debriefing process. More detailed guidance on how

to lead an AAD is also available.17(Appendix A) The

critical components for leader actions are shown in

Exhibit 11-2. The AAD is led by the small unit’s own

leader(s). Mental health personnel, chaplains, and

other trusted outsiders who were not participants

in the event would attend only by invitation, and

purely as observers. Furthermore,

Combat stress control/mental health personnel

should always be notified whenever serious psychological trauma has occurred in a unit. They can

assist command in assuring that the after-action

debriefing process is done correctly.17(p6-7)

The mental health personnel might intervene

subtly during the processes only if they saw that the

AAD was ending without having reached a generally positive outcome on issues of guilt, blame,

anger, or other disruptive emotions. More often,

they would be available to the team members afterwards, who would know that they now shared

comprehensive knowledge of the event.

EXHIBIT 11-1

KEY STEPS IN AN AFTER-ACTION DEBRIEFING

• Explain the purpose and ground rules to be used during the debriefing at the outset.

• Involve everyone in verbally reconstructing the event in precise detail.

• Achieve a group consensus, resolving individual misperceptions and misunderstandings and restoring

perspective about true responsibility.

• Encourage expression (ventilation) of thoughts and feelings about the event.

• Validate feelings about the event as normal and work towards how they can be accepted, lived with, atoned.

• Prevent scapegoating and verbal abuse.

• Talk about the normal (but unpleasant) stress symptoms unit members experience and which may recur for

a while, so they, too, can be accepted without surprise or fear of permanence.

• Summarize the lessons learned and any positive aspects of the experience.

Reprinted from US Department of the Army. Leaders’ Manual for Combat Stress Control. Washington, DC: DA; September 1994.

Field Manual 22-51: 6-7.
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276

EXHIBIT 11-2

LEADER ACTIONS TO OFFSET BATTLE FATIGUE RISK FACTORS

Leader Actions

Conduct small team after-action debriefings after every difficult action (in training and in combat). An afteraction debriefing is an extension of after-action reviews which are routine in training. Reconstruct what

really happened so that the team benefits from the lessons learned. At the same time, this releases bottledup emotions and inner conflict that can lead to decreased unit cohesion, battle fatigue, and perhaps even to

PTSD. This is the purpose of the after-action debriefing. Feelings of anger and mistrust may go away on their

own once the soldier sees how things looked to the others. At least the feelings are out in the open and can

be dealt with honestly. Soldiers’ natural emotions of loss and grief come out, too, when buddies are wounded

or killed in combat. Guilt or shame may come out when soldiers make mistakes. Such soldiers can be

comforted and helped to put things into perspective by the rest of the team. The mistakes can be

acknowledged and forgiven or atoned for. When conducting the after-action debriefing, the leader must

1. Select a location that is relatively safe from enemy attack.

2. Set the ground rules.

3. Reconstruct the action from everyone’s memories.

4. Share thoughts and reactions to the action.

5. Encourage talk about any physical or mental signs of battle fatigue anyone may be having if the action

was a high stress event.

6. Bring the focus back to the mission after the feelings have been recognized and ventilated.

7. Use after-action debriefings to orient new unit members. These debriefings familiarize them with the

unit’s most recent history, introduce them to the veterans’ roles and personalities, and acquaint them

with the unit’s Tactical Standing Operating Procedure (TSOP). It also helps when merging survivors

of two units into one, with or without other new replacements.

Adapted from US Department of the Army. Leaders’ Manual for Combat Stress Control. Washington, DC: DA; September 1994.

Field Manual 22-51: A-7–A-9.

Civilian Critical Incident Stress Debriefing

Civilian critical incident stress debriefing (CISD)

is the debriefing format developed by Mitchell and

used and taught by the Critical Incident Stress Foundation. Its key points and the seven phases of the

debriefing are summarized in Exhibit 11-4. The

CISD was designed for brief, traumatic incidents

involving preexisting civilian teams, but is also

usually applicable to ad hoc groups. The debriefer

does elicit thoughts, reactions, and symptoms after

a relatively brief survey of each participant’s perspective on the “facts” of the event. The debriefer

also provides some education at the end. The CISD

format has been learned and used by military

debriefers in military contexts.

Critical Event Debriefing

For the Somalia deployment, a prototype pocket

card was developed and fielded to facilitate trainHistorical Group Debriefing

Historical group debriefing (also called, historical event reconstruction debriefing—HERD), patterned after the work of S.L.A. Marshall, involves

all participants of a preexisting unit in processing a

brief (up to several days) chronological reconstruction of a significant event. That event may, but need

not, involve traumatic events. Shalev,19 in Israel,

has revised the original S.L.A. Marshall protocol

and demonstrated its therapeutic effectiveness in

traumatic military unit settings where more “clinical” approaches often encounter resistance. This

technique may be less suited for ad hoc groups,

such as random survivors of an accident, because it

concentrates on filling out a timeline of fact that

random “victims” might not care about and does

not explicitly work through thoughts and reactions

that strangers might be unwilling to share. Exhibit

11-3 (adapted from Shalev’s work) summarizes the

historical reconstruction technique.
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Debriefing Following Combat

EXHIBIT 11-3

HISTORICAL EVENT RECONSTRUCTION DEBRIEFING: SUMMARY OF

S.L.A. MARSHALL’S DEBRIEFING TECHNIQUE

1. Debriefings are conducted as soon as possible after the action.

2. Prior to the debriefing session, the debriefer collects information about the unit’s background, structure

and role in the battle, and the outcome of the action.

3. The participants are told that the debriefing consists of a chronological reconstruction of the event in its

most minute details (to understand and learn from the action, not as fault-finding).

4. All those who took part in the action participate in the session. No others are allowed to participate

(although new replacements to the unit can be allowed to listen if the veterans agree).

5. The debriefer emphasizes that all ranks are put aside during the session and all participants have equal

status as witnesses.

6. After initial “modeling” by the historical debriefer, the debriefing is led by the unit’s own commander.

7. The entire group takes part in the reconstruction of the action in all its details. Each soldier is encouraged

(but not forced) to add his own version to the other soldiers’ accounts.

8. All the information and all points of view on each stage of the action are collected from the participants.

9. Ambiguous information and contradictory statements are recorded by the interviewer as illustrating the

complexity of human interactions during an event.

10. Criticism and attempts to teach are discouraged. No open disbelief in any witness’s testimony is expressed

by the interviewer.

11. No attempt is made to reach agreement among participants. Premature conclusions and closure are

avoided.

12. The debriefer creates and maintains a congenial atmosphere and facilitates communication and openness

throughout the session.

13. Emotional reactions are recognized and validated, but are not emphasized. No deliberate psychological

intervention (eg, clarification, interpretation) is attempted by the debriefer.

14. The session is not limited in time, and continues for as long as it takes to reach the comprehensive

description of the event. It may adjourn temporarily for breaks, and resume after food and sleep.

Adapted from Shalev A. Historical Group Debriefing Following Combat: A Study of SLA Marshall’s Debriefing Techniques. Final

Report. [Coordinated by Department of Military Psychiatry, Walter Reed Army Institute of Research and Department of

Mental Health, Medical Corps, Israeli Defence Forces.] Jerusalem, Israel: Department of Psychiatry, Center for Traumatic

Stress, Hadassah University Hospital; 1992.

ing in debriefing techniques. The card drew extensively on the CISD 7-phase model, differing primarily in greater emphasis on filling in an unbroken

timeline in the Fact Phase. While calling for an

agreement on confidentiality (as in CISD), it

also reminds everyone of their obligations to

the Uniform Code of Military Justice if material

on violations of that code are raised in the debriefing. By agreement with Mitchell, this military

modification of CISD is being referred to as critical

event debriefing to avoid confusion over the

necessary differences in applying the CISD format

in the context of ongoing U.S. Army field operations and organizations. According to U.S. Army

doctrine,

When indicated, the unit should arrange for combat stress control/mental health personnel to conduct a critical event debriefing. Critical event

debriefings are similar to after-action debriefings

but differ in the following ways:

The critical event debriefing is led by a trained

debriefer who is not a member of the unit being
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278

EXHIBIT 11-4

CRITICAL INCIDENT STRESS DEBRIEFING: KEY POINTS AND PHASES

Points

The CISD should be conducted after an exceptionally distressing event.

The CISD is conducted by a specially trained team.

The participants are normal persons who have survived an abnormal, severe stressor.

Stress debriefing is not therapy or counseling. It is basic wise preventive maintenance for the human mind.

Phases

1. Introductory Phase: to introduce the team and explain the process.

2. Fact Phase: to reconstruct the event in detail, in chronologic order, as an unbroken “historical

time-line,” viewed from all sides and perspectives.

3. Thought Phase: to personalize the event and shift focus; to transition from factual to emotional focus.

Participants are asked to share what “thoughts” they had at key times.

4. Reaction Phase: to identify and ventilate feelings (emotions) raised by the event.

5. Symptom Phase: to normalize personal physical stress responses. The leader guides transition back

from emotional to factual focus, legitimizing participant’s physical symptoms and behavioral

reactions.

6. Teaching Phase: to reassure by educating that the feelings and stress symptoms are normal reactions

to abnormal conditions; they may last a while, but can be expected to resolve normally.

7. Reentry Phase: to complete and close the debriefing.

It is important to ensure that participants have follow-up options as individuals or as a group.

Adapted from US Department of the Army. Debriefer’s Guide to Critical Event Debriefing. Fort Sam Houston, Tex: Combat Stress

Actions Office, Department of Preventive Health Services, Army Medical Department Center and School; 1993: 1–4.

vertising them as a reimbursable long-term

disability. To do the latter invites malingering. It also subtly encourages those who do

have real but not disabling post-traumatic

symptoms to magnify them. This will be especially likely if they have other psychological

issues or grievances which the symptoms also

address, such as feeling unappreciated for the

sacrifices suffered or guilt at having left their

buddies.

(3) As with the treatment of acute battle fatigue,

it is essential that all persons involved in

preventive or treatment interventions for

PTSD express positive expectation of normal

recovery. At the same time, they must indicate that continuing or recurring symptoms

can and should be treated, still with positive

expectation of rapid improvement. They

should advise that post-traumatic stress

symptoms may recur in the future at times

of new stress. Successful treatment after future episodes should deal with the ongoing,

new stressors as much as with the past

trauma.17(p 6-8)

debriefed; the after-action debriefing is led by the

small unit’s own leader.

The critical event debriefer explicitly defers issues

of operational lessons learned in order to focus on

the stress aspects and stress responses; the afteraction debriefer does seek to capture relevant operational lessons learned in positive terms.17(pp6-7,6-8)

U.S. Army doctrine17 also cautions leaders regarding preventive intervention after traumatic stress.

(1) The analogy between PTSD preventive interventions and traumatic wound surgery suggests a cautionary warning. If the surgery is

not done skillfully, it can cause more harm

than good, leaving dead tissue and bacteria in

the wound. It may cut away tissue that did not

need to be sacrificed, or realign the broken

bones incorrectly. The same is potentially

true for poorly executed after-action debriefings or critical event debriefings.

(2) The problem for early prevention efforts is to

forewarn of possible post-traumatic stress

symptoms without glamorizing them or ad-
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Debriefing Following Combat

Case Study 1: The Medic and the Resuscitation

In the evening of 28 February 1991 (the cease fire

ending the Persian Gulf War had gone into effect at 0800

hours that morning), as two cavalry units were moving into

captured territory, the headquarters troop was establishing camp for the night. They had moved their vehicles into

a coil, which is a circular defensive arrangement with

tanks and fighting vehicles facing outward. The men were

digging foxholes in front of their vehicles. One young

soldier, a member of a fighting vehicle crew, was digging

his foxhole when his vehicle commander called him back

to his vehicle. The soldier turned, shouldered his shovel,

and stepped on an unexploded Dual Purpose Improved

Conventional Munition (DPICM), which exploded. The

soldier was carrying rifle grenades in a bandoleer across

his chest. These exploded as well. The soldier was in all

probability killed outright.

Two young medics (both inexperienced and just out of

school), who had only a few months earlier joined the unit,

and only a few weeks before joined this particular troop,

tried to resuscitate the soldier. The resuscitation was

gruesome. As they tried to ventilate the soldier, air

escaped from his cheek, so someone put a hand there.

Then air escaped from his chest, then his abdomen, and

finally even from one eye socket. The medics continued

their efforts for approximately 20 minutes at which time a

physician from the medical troop arrived, assessed the

situation as hopeless, and called off the resuscitation.

Two days later a combat stress control (CSC) team

was asked to see one of the medics because he was

clearly troubled by what had happened. The team members responded that they would see him, but that if he was

obviously distressed there was probably significant distress in others who had been involved in the resuscitation, as well as the soldier’s comrades, and his immediate

chain of command. The team proposed assembling all

involved to do a debriefing and reconstruction of the

accident and resuscitation, along with relevant events

before and after. The chain of command agreed.

The group was assembled in the open air and arranged

cots in a circle for everyone to sit on. The briefing was

begun with the suggestion that for the purpose of reconstructing events, ranks be set aside and that all participants be accorded the status of equal witnesses.

In the course of the debriefing, the details of the

resuscitation were presented. The medic the team had

been asked to see twice got up and stood in the center of

the group, with his eyes focused far away from the group,

and described what he had seen and done during the

resuscitation. The other medic contributed details as well.

The soldier’s vehicle commander described the events

leading up to the accident. The soldier’s friends initially

expressed reservations about the competency of the

medics and whether all that could have been done had in

fact been done. At that point the distressed medic stood

back up in front of the group and provided graphic details

of the resuscitation. It was then obvious to the dead

soldier’s friends who had not seen the accident and the

resuscitation efforts that the medics had done all that

could be done. The medics had done more than the

soldier’s friends could imagine themselves doing. As he

recounted the resuscitation, the medic became less distressed and gained confidence and self-assurance. Concerns of the soldier’s friends over the quality of the

resuscitation quickly receded.

The dead soldier’s chain of command raised another

issue before the group. By regulation, the soldier could

have been granted emergency leave to go home to visit

his wife and new baby just before the ground war had

begun, but he had decided to stay with the unit and go to

war with his friends. After some discussion, the group

consensus was that he had made the correct decision to

stay with his group even though they were all sorry that he

was dead.

One other issue was raised by the group. The soldier

had been wearing a rifle grenade bandoleer when he

stepped on the DPICM. The explosion of those grenades

probably contributed to his injuries. The fact that he was

carrying these grenades at all had been a concern to

some of his friends and to his chain of command. He had

no compelling reason to be carrying them once the cease

fire went into effect, but no one had pushed him to give up

wearing the grenades. In retrospect, the participants

wished they had taken a firmer stance with respect to the

grenades.

By the end of the debriefing the participants had a

clearer view of the accident, its antecedents, and the

resuscitation. For the distressed medic, the debriefing

was clearly a turning point in terms of how he viewed

himself and how his comrades viewed him. By the end of

the debriefing he was clearly free of distress and his

comrades viewed him with new respect.20

Comment: This case report demonstrates the value of

group debriefing after an especially traumatic and gruesome event. It was clear from the participants that most

members of the unit, not just the distressed medic, had

been affected by the accident and subsequent death.

Clarifying the sequence of events and responses to them

allowed the unit to put the event into perspective, thus

facilitating the reintegration of the medic into the unit.

Psychiatric Debriefing

Psychiatric debriefing (as presented further in

this chapter) begins the debriefing process with an

education briefing about normal stress and the prevention of PTSD. This may be delivered to large

audiences. Groups of participants are then led by

psychiatrically trained debriefers in an active process of ventilation (abreaction), sharing, and normalizing of stress reactions. This includes further

interpretation and education about psychological

defenses (the adaptive and the maladaptive ones).

While participants are told that they are not “patients,” this technique comes close to being psychotherapy. It may be the most expedient method for

assisting a large, ad hoc group that will disperse after
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280

the debriefing and not have the protective benefits

of continuing in a cohesive, working organization.

Large Group Debriefing

Large group debriefing17 is an umbrella term for

expedient debriefings involving large numbers of

people (100 to 500 or more) where it is impossible to

actively involve everyone. The organizational leaders of the sub-elements of the group (for example

the platoon leaders, company commanders, first

sergeants) perhaps supplemented by natural leaders or “key players” from the enlisted ranks, review

and reconstruct the facts of the critical event or

longer operation while the remainder watch and

listen. Large group debriefings are of limited use

for critical traumatic events, except for further integrative processing after the most traumatized elements have been debriefed in their own smaller

groups. They can be very effective as end-of-tour

debriefings.

Case Study 2: Troop by Troop

An armored cavalry regiment fought effectively in the

ground offensive of the Persian Gulf War, but suffered

losses from friendly fire and from unexploded ordnance.

During and immediately after the battle it had the benefit

of an expert combat stress control (CSC) team that had

been requested by the regimental commander from the

corps. That team conducted several small group

debriefings during and after the campaign. On returning

to home base, one of the squadron commanders followed

the advice of the CSC team and conducted debriefings

with the entire squadron, a troop at a time. The squadron

commander, assisted by each troop’s commander, conducted debriefing reconstructions of the entire battle with

the assembled troops. Concerns that the process might

scapegoat or place guilt and blame on only a few individuals were unfounded. It was clear to all that the confusion

and fatigue of a rapid advance through desert winter

weather and the snowballing consequences of many

small glitches in communication, coordination, and alertness spread the blame. Further, it was clear that when

things went well, it wasn’t just one person doing the right

thing, but a whole series of correct and timely actions that

led to a good outcome.

Comment: Postcombat reconstructive debriefings are

something that not only mental health personnel but every

commander should have in his hip pocket and be ready to

use after any significant action.

End-of-Tour Debriefing

End-of-tour (or demobilization) debriefings summarize all the significant events in an entire, prolonged operation. It begins by soliciting

memories (good and bad), thoughts, and reactions

during initial alert and mobilization. When everyone has had their say on that, discussion proceeds step by step through the good and bad memories and lessons learned of the actual deployment,

the first days, middle and final phases of the operation, up to the present. The operation may or may

not have involved traumatic events, but is likely

to have caused many frustrations and perhaps

resentments that can be ventilated and not carried

home. The process should end with a positive sense

of closure.

These debriefing categories are not rigidly fixed,

and can merge into each other. The debriefing team

must choose the appropriate type and format for

the specific traumatic incident. For example, natural disasters may require different debriefing

styles than do combat or human-caused incidents.

Debriefings of impersonal, mass-casualty disasters

should differ from those for small but highly personalized or traumatic incidents. The characteristics of the participants should influence the choice

of format. Even in the same traumatic event,

debriefings conducted with surviving victims must

differ substantially from debriefings of the immediate response rescuers, or of the second-echelon

caregivers. Debriefings of senior leaders and their

staffs will differ from the debriefings of the junior

leaders and the troops. Debriefings of elite, cohesive, and “macho” units must differ from debriefings

of ad hoc assemblages of victims, rescuers, or survivors. End-of-tour debriefings (EOTD) that do not

involve traumatic events must differ from those

that do.

Available resources will often limit (but should

not dictate) the type of debriefings that can be

accomplished. Some of the factors that influence

the choice of debriefing format are the number of

experienced and partially trained debriefing personnel, access to safe and reasonably comfortable

facilities, the total number and internal organization of the population to be debriefed, the other

conflicting mission or treatment demands, and, especially, time.

The remainder of this chapter presents the first

and second authors’ experience in conducting

psychiatric debriefings and end-of-tour debriefings during and after the U.S. invasion of

Panama and the Persian Gulf War. Other information on debriefings is provided in Chapter 9, U.S.

Naval Combat Psychiatry, and Chapter 12, Postcombat Reentry.
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Debriefing Following Combat

PSYCHIATRIC DEBRIEFING TASKS

psychiatric debriefing of soldiers. This is because

soldiers can be negative about the command structure during the debriefing itself, and the work of the

mental health team may be seen as divisive and

undermining. A simple explanation of the facts

concerning the prevention of PTSD and the helpfulness in maintaining unit cohesion in the face of

trauma is usually all that is necessary.

Chaplains, mental health and social support services, emergency, and other medical personnel will

become involved in the debriefing process or its

follow-up, and it is necessary to educate and coordinate activities with them. When services are not

coordinated, other workers may label individual

soldiers as patients and thereby increase their psychiatric morbidity. This phenomenon was seen

most strikingly during World War II, when soldiers

were evacuated to the rear and developed prolonged emotional symptoms.25,26 This has been called

the “evacuation syndrome.”

Training of mental health staff is especially

important during this phase prior to the debriefing.

Mock debriefings may be helpful in providing staff

an opportunity to practice interventions that

encourage the expression of feelings and discourage the tendency to overemphasize the reaction

to the trauma. In the experience of the authors,

staff training is ongoing and involves mock

debriefings, follow-up information, and dissemination of data on the efficacy of psychiatric

debriefings. Work of this nature is likely to decrease the incidence of worker burnout as well as

provide for more effective delivery of care.27 Ideally, members of a debriefing team should first

observe a real debriefing led by an experienced

debriefer; second, lead a debriefing while being

observed and mentored by an experienced debriefer;

and, finally, observe and mentor a new debriefer.

This is the “see one, do one, teach one” method.

However, this ideal requires a steady succession of

local traumatic events which will not always be

available for training.

Debriefing

When the debriefing begins, it is essential that

commanders provide an introduction to lend credibility to the event. A model that has proven beneficial includes the large group setting initially for

relaying information about the risk factors for the

development of PTSD and potential problems assoPredebriefing

A model of community consultation which had

been developed in the wake of the Korean conflict is

useful in setting the stage for the psychiatric debriefing.21 Because the debriefing is intended to

initiate the reintegration process, the mental health

personnel must make contact with the command

structure of the unit being debriefed.

If possible, a working relationship with the command structure should be developed prior to any

trauma. The contact is intended to educate the

leaders of the group about the importance of psychological debriefing in the prevention of PTSD and

other sequelae of mobilization and reentry. The

process of command contact has been described in

Chapter 9, Command Consultation, in Military Psychiatry: Preparing in Peace for War,22 a companion to

this volume. This process applies whether the mental health team is organic to the higher headquarters

of the supported unit (for example, the mental health

section in a division) or is providing area support

(for example, the mental health section of an Area

Support Medical Battalion or U.S. Army CSC Detachment in the field or the Community Mental

Health Service or Departments of Psychiatry, Psychology or Social Work of a post’s Medical Activity

in garrison). The same skills have been practiced by

U.S. Army psychiatrists working in civilian homeless shelters. In this instance psychiatrists prepared

the shelter staff for the introduction of direct delivery of psychiatric services23,24 by building relationships with the shelter leadership over a 3- to 4-

month period. The objective of this approach is for

the commanders to give permission to soldiers (or

civilian workers, family members, and others) to

voice their concerns without fear of repercussions.

Their experience is validated as a necessary part of

their job during difficult circumstances.

Thus, predebriefing tasks are

• Preparing commanders.

• Conducting higher command or installation briefing.

• Maintaining liaison with chaplains and other

medical and mental health support agencies.

• Conducting mental health activity training.

Military authorities higher than the unit command structure or installation directly involved

may have to be briefed concerning the necessity for
War Psychiatry

282

ciated with reunions with families and communities. Of special importance is the message that the

feelings and symptoms, which can be emotional or

physical, are normal responses to an abnormal situation. Often this is enough to relieve the anxiety of

the soldiers affected.

If time permits, small groups of 8 to 10 participants can then be formed with one or two workers

from the mental health staff, who facilitate a discussion of events encountered by the soldiers.

The tasks of the debriefing are

1. Utilizing large-group setting for information sharing and discussion of normal reactions to trauma.

2. Utilizing small groups (8–10 participants,

2–3 facilitators) for exploration of issues (if

sufficient staff is available).

3. Maintaining confidentiality.

Confidentiality appears to be a major theme in

these discussions. During the small group sessions

soldiers may be reticent to describe their experiences because of possible repercussions. They have

to be assured that the purpose of the debriefing is

not to point out blame or to solve administrative

problems. Therefore, they can be encouraged to

share their feelings with impunity. Also, silence,

sometimes encouraged in therapy, is not helpful in

these groups. The facilitators have to be aggressive

and ask the soldiers to recall stories and hear about

their concerns. The time limit for the entire debriefing can vary from 90 to 120 minutes.

Common defenses during this phase may be denial, anger, and guilt, which have been described

elsewhere.28,29 As in the experience of any traumatic

event, the psychological mechanisms which mollify

the experience come into play almost immediately.

The debriefer must be aware that supporting these

defenses, by allowing for ventilation at an early

stage, can make the use of these defenses less important as time goes by.

Postdebriefing

It must be remembered that debriefing is the

beginning of a process of reintegration for soldiers

involved in combat or other trauma. Therefore, the

debriefers must set the stage for further supportive

work if needed, without predicting negative reactions or fostering dependency. This includes identifying and contacting individuals who show signs

of needing psychiatric referrals, without stigmatizing them. It includes continued consultation to

commanders who may require guidance in matters

such as giving passes, leaves, and reassignments.

It is also crucial that the administrative/clinical

head of the debriefing process debrief his or her

own staff. Feelings of anger, denial, and guilt present

in the soldiers can also be overwhelming for the

debriefers. Because war can be horrifying, involving the death and mutilation of friends, comrades,

and even family members, it is important to take

care of the workers involved in helping the soldiers

integrate the experience.

After-action reports also serve to organize one’s

thoughts, and serve as a “clinical” record of the

proceedings of the debriefing. They are extremely

useful in understanding some of the basic themes

experienced by soldiers and the data from afteraction reports can guide remarks in the opening

moments of the debriefing.

Thus, the postdebriefing tasks are

• Conducting follow-up and referrals as

needed.

• Conducting command/community consultations.

• Debriefing staff.

• Completing after-action reports.

ISSUES AND PITFALLS OF DEBRIEFING

There are several issues and pitfalls in debriefing. First is a lack of support on the part of the

command or leadership structure of the unit. This

is often due to misunderstanding of the value of

the debriefing to future readiness. The command may view the debriefer as creating problems

rather than preventing them or even of being

divisive and subversive. Because so many feelings

are part of the experience of trauma, and there

is a tendency to project blame onto leadership,

commanders can feel that their authority is being

undermined. Contact with commanders early

on alleviates the responsibility of blame from

them. When presented with the historical data

suggesting increased unit cohesion, and a decrease

in psychiatric symptomatology following debriefing, commanders are ready to utilize debriefing

services.
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Debriefing Following Combat

Debriefers may find that there is a tendency to

provide easy solutions and to assign blame for the

problems of the unit. It is easy enough to agree with

soldiers or victims that their commander’s lack of

leadership abilities was responsible for their waiting in the desert for 2 weeks without an assignment.

In fact, the assignment may have been beyond the

commander’s ability to influence, but angry feelings

are nevertheless present. An exploration of these

feelings is the proper intervention, rather than blaming the commander or encouraging that the unit

initiate an investigation into his ability to lead.

The timing of the debriefing is of vital importance. While certain groups may be too emotionally

and cognitively exhausted to process information,

immediacy is a factor in the theory and practice of

debriefing. Often, groups have already begun to

process the traumatic event in a destructive manner, and the large groups involved (eg, U.S. Army,

civilian communities) may act pro forma and without regard to long-term consequences by dispersing groups exposed to trauma in a rushed fashion.

Reflexive defenses start to work almost immediately as the individuals begin to deny and project

anger, so many groups can and should be debriefed

as soon as possible. The clinician has to assess if

they are able to do so at the time.

However, when debriefing is done too close to

the traumatic event, victims may feel further traumatized and vulnerable. A period of rest and regrouping is preferable (but in the “real world,”

sometimes not possible) prior to debriefing. Some

researchers feel that when a person is in a state of

physiological arousal (1–5 d) after the trauma, debriefing may be harmful.30 Others cite the tendency

of individuals and groups to form a “trauma membrane” (a mental scab) after about 3 days; prior to

then they may be eager and even driven to talk of

the event. After then they may avoid and resist

being reminded. In this formulation, 1 to 2 days

after the event is optimal for debriefing. This area

is controversial and will require further study. The

following case example shows how debriefing a

combat unit too soon might have caused an increasing psychiatric pathology. The case is disguised to

protect the anonymity of the unit.

Case Study 3: The Helicopter Crash

Company A, deployed to Saudi Arabia prior to the start

of Operation Desert Shield in 1990, suffered the loss of 15

of its 60 members during a helicopter crash. While on

nighttime maneuvers, part of the unit being transported by

helicopter crashed into the desert sands. All members on

board the aircraft were killed by the impact and badly

burned in the ensuing fire.

When the unit commander learned of the crash, he

informed his superiors and subordinates in the chain of

command. On orders from the senior commander, a

psychiatrist and social workers were sent within 4 hours to

gather the remaining soldiers in the unit and begin a

debriefing. During this period, the psychiatrist provided

information about stress-related psychiatric disability and

predicted the possibility of intrusive nightmares, thoughts,

and angry feelings. Soldiers at the meeting, which lasted

about 2 hours, were generally quiet, and appeared dazed

and startled. Others looked angry, while still others were

sad, immobile, and worried.

After the mental health personnel left, the soldiers met

independently in their barracks and discussed how angry

they felt towards the psychiatrist and social worker because of the invasion of privacy they felt. “They don’t even

know what we do, who we are, or how we feel,” some

members of the unit stated.

A follow-up on this unit revealed an increased incidence (compared with other units) of disciplinary actions,

and alcohol-related incidents 4 months after returning to

the United States.

Comment: In effect, this intervention was a stress

briefing, not a debriefing. It may have inadvertently

“pathologized” rather than “normalized” the predictable

stress symptoms. Also, it lasted too long. The Critical

Incident Stress Foundation16 recommends brief (10–15

min) “defusings” immediately after the critical event to

normalize the immediate reactions and set the stage for a

debriefing in 1 to 3 days. A debriefing might have been

more effective if it had asked unit members to describe

how they were involved or heard about the crash and

encouraged them to share their feelings rather than listening to theories about stress.

Mental health staff can become overwhelmed by

the debriefing process. War, because of its intensity

and disregard for human life, may bring forth a

variety of feelings from those individuals who work

with combat veterans. The staff must have a period

of decompression themselves in order to put the

experience into perspective. Most individuals in

the helping professions would rather take care of a

problem when it arises; during the debriefing process, taking care of the problem involves a reticent,

supportive, and encouraging stance.

Thus, the issues and pitfalls of the debriefing

process are

• Lack of command understanding and support of the debriefing process.

• Tendency to assign blame.

• Tendency to provide “easy” solutions.

• Inappropriate timing.

• Failure to debrief mental health staff.
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284

IMPLEMENTATION OF PSYCHIATRIC DEBRIEFING

The following case studies are provided for illustration of key concepts in the process of psychiatric

debriefing. In Case Study 4, attention is paid to the

psychiatrist’s efforts at following the correct debriefing process. Although no relationship was

built with the affected unit prior to the trauma, the

psychiatrist used the medical facility as a familiar

site and medical demobilization as a familiar process to aid in developing rapport with the soldiers.

In Case Study 5, a disguised case example, the

importance of eliciting feelings is demonstrated.

Both examples are taken from military experience,

but may be adapted easily to the management of

civilian critical incidents. Case study 4, drawn from

the authors’ experience, is of a delayed post-trauma

and end-of-tour debriefing.

Case Study 4: Explosion in the Desert

Company B is a reserve unit of about 70 members

who were called to active duty in preparation for an

overseas military mission. Prior to deployment, the commander of the unit assisted soldiers in developing family

care plans, organized spouse groups, and rallied community support. Most soldiers were new to the unit and in

their 20s.

When the unit arrived at the deployment site, the

commander suffered an exacerbation of physical complaints that had been long-standing. He required hospitalization, evaluation, and eventually was given a medical

profile that restricted him from deploying with the unit.

The executive officer of the unit assumed command. The

first sergeant arrived late because of family problems and

was unable to assist in the reorganization and stabilization of the unit. Additionally, the unit, which was originally

scheduled to deploy within 3 days of arrival at the mobilization site, was delayed for departure by 2 weeks.

During this time, the chaplain assigned to the unit

noted high levels of stress and uncertainty about the

details of deployment in the unit. He reported high levels

of anxiety and apathy as calls to family members exacerbated unit members’ sense of helplessness in dealing

with family issues back home.

When the unit finally deployed, family members arrived

at the deployment site to wish the unit well. Although there

was a ceremony with speeches from political as well as

military officials, unit members reported feeling scared

and overwhelmingly sad about leaving.

Upon arriving in the war zone, the unit was housed in

temporary quarters awaiting its mission in the war effort.

Soldiers reported feeling useless and anxious about the

uncertainty of their jobs in the overall mission.

Two weeks after arriving, a fuel tank exploded and

nearly one half of the soldiers were killed and most of the

others were wounded. Most of the living and wounded

soldiers suffered ruptured eardrums and acute anxiety

reactions.

After the explosion, the soldiers were evacuated to a

safe area, given clothing (as some were in night clothes

and most uniforms had been destroyed), and were given

permanent housing. The surviving soldiers met briefly

with a “stress team” consisting of a chaplain, psychologist, and psychiatrist, who described some of the aftereffects to be expected from this tragedy and attempted to

elicit feelings and fears.

The Persian Gulf War ended so soon after the explosion that the surviving unit was redeployed to the continental United States without ever having been reconstituted to perform their mission. The psychiatrist at the

deployment site explained to the medical command the

need for debriefing and began training the mental health

staff in preparation for this task. Initially, there was not

much support for debriefing the soldiers because the

process was seen as another time commitment with

logistical problems for the hospital staff. As a compromise, the debriefing was streamlined and “married” to the

out-processing medical examination.

When the hospital command learned of the return of

Company B, there was already pressure from political and

installation officials to rapidly process the remaining soldiers for return to home in civilian life. A parade was planned

as was a reception by the post commanding general.

The soldiers were met at the airport by high-ranking

military officers and the chaplain originally assigned to the

unit. The soldiers were to be examined that evening and

returned home in the morning. However, because the

medical staff reemphasized the importance of rest and

debriefing, examinations were rescheduled for the following morning.

The debriefing almost did not occur. The debriefers

planned to meet the group after the medical examinations

for 15 to 30 minutes and break into smaller groups for 1

hour. Some officials said that the debriefing already

occurred in Saudi Arabia. In fact, the hospital commander

was told by a representative from the installation that the

examinations were taking too long, the doctors were not

working fast enough, and that “all these soldiers need is

a hug from their families ... so hurry up.”

The authors, as the debriefers, however, insisted upon

conducting the debriefing but were given only 30 minutes.

The meeting opened with introductory remarks describing

the usefulness of debriefing as well as the difficulties that

soldiers might face upon reentry into their communities.

One soldier said, “We don’t need this, we are all friends

and don’t want to talk.” Most were able to talk about their

feelings, however, which centered around anger and

helplessness. There were attempts to place blame on the

unit’s leaders as well as on those not injured in the attack,

or were absent at the time of the bombing. Soldiers

described various somatic complaints: hearing problems,

gastritis, muscle aches, and headaches. They said that

communication was poor in the war zone, they did not
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Debriefing Following Combat

know who had been killed, where the unit members were,

or who was in charge. A second lieutenant was given

command in the war zone and despite his eagerness and

enthusiasm, he was the object of some ridicule for not

being able to solve problems such as clothing and shelter.

They described especially their reaction to the stress

team. Many soldiers felt that the team was intrusive,

invasive, and offered solutions to problems too prematurely. They experienced the stress team as chiding them

for poor behavior in the face of a crisis.

After the debriefing, the staff met to talk about the

experience. Most had never participated in a debriefing

of this type. The overall sense was one of helplessness

and a need to place blame and find solutions. The

installation commander was blamed for hustling these

troops, the hospital commander for lack of support, the

soldiers for being inarticulate and childlike, and the staff

blamed itself for opening up emotional wounds. The need

for blame was again interpreted and at that time, the

process of debriefing was better understood.

One week later, an after-action report was forwarded to

the hospital commander and the Office of the Surgeon

General recommending training in debriefing and greater

support of this endeavor. After the soldiers of Company

B returned home, several of the soldiers made an official

protest regarding the rushed treatment they received

during the demobilization process. Many wanted to spend

time as soldiers in a nonthreatening environment after

combat, but were quickly returned to civilian life. As a

result, some actually had to be brought back onto active

duty to continue with psychiatric treatment and other

debriefing activities.

Comment: This case study highlights the importance

of communication with the command structure and the

role of debriefing soldiers who have been involved in

combat. Several pitfalls were avoided when the psychiatrist enlisted the support of the medical and administrative staff of the hospital to authorize the debriefing. The

debriefing of the mental health staff was essential in their

understanding the whole process of debriefing as well as

to clear any possible feelings of guilt and responsibility in

the endeavor.

The following case example, also drawn from the

authors’ experience, describes the importance of

team work in debriefing and demonstrates the effectiveness of debriefing in eliciting feelings and

emotions related to the combat situation. It involves a delayed post-trauma debriefing and endof-tour debriefing.

Case Study 5: After the Battle

When Company C returned from Saudi Arabia, one of

us (RK) was asked to debrief this reserve combat unit.

The debriefing was conducted 4 months after return from

the Persian Gulf. The unit was from the area adjacent to

the mobilization post, so the preparations for deployment

were familiar. The unit had begun preparations about 1

month prior to the start of the ground war by combat

training in the United States. Three weeks prior to the

ground war, the unit arrived in Saudi Arabia. They

continued their combat training and suffered some psychological hardship of having no mail and no phones

available for approximately the first 2 months.

Company C participated in the beginning of the ground

operation and actually preceded the infantry into Kuwait.

One service member was injured in his face by fragments

but suffered minimal long-term effects. A second service

member was killed while he was attempting to clear bunkers

and apparently stepped on explosives. He lost a limb

immediately and then died two days later in the hospital.

When the participants of the debriefing were allowed to

comment freely, the following is a sampling of what they

said:

“After we got back home, it was hard to get back into

the flow of things. We had a terrifying experience for a

short period of time, but now we feel like we want to use

our time wisely.”

“The period after the war was perhaps more psychologically disturbing than the war itself, since we had so

much time on our hands and nothing really to do. We

played volleyball, ate beans and rice and were really

lonely. Phones were then available for the first time but

they were expensive to use and there were long lines.”

“We had trouble getting back into the flow, especially

changing from military to civilian life. We didn’t have any

drills for the first 2 months after we got home.”

“We tried to eat all the good food we had missed and

drink all the good alcohol we had missed for 6 months.”

“Although this unit returned to this country in May 1991,

this debriefing (September 1991) is only the third Reserve meeting we have held.”

“Routine matters like paying bills do not seem to

matter much.”

Comment: As the soldiers spoke, it was clear they were

describing the frustrations of reentry into usual military life

or civilian life. It was tempting for the team members to

help them with suggestions, but the team members resisted and allowed the soldiers to tell their stories.

“We were promised that we would have a job waiting

for us when we got back but some of us really had slots

waiting and not regular jobs, and some of us had to move

to another state.”

“The main problem was that for 4 to 5 months we had

one purpose and one purpose alone, then we came back

to civilian life and we had absolutely nothing to do. We

asked what is the meaning of life.”

“Many of us were angry, especially for the first 2

weeks.”

“After we were angry, nothing phased us. Overdue

bills would bring this kind of reaction—Gee, this is all

they’ve go to do?”

“There was poor attendance at Reserve drills for the

first drill or two in contrast to before combat where drill

attendance had been 95%.”

“Much of the equipment has not arrived back to the unit

even as of yet.”

“The morale was good up to the cease fire.”
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286

“The service member killed in combat was 21 or 22

years old. He was a college student who was going to be

a unit leader. He was a member of the company for about

a year. He was well-known and well-liked.”

“One of our members died in a street accident. It was

a case of ‘mistaken identity,’ although drugs may have

been involved.”

“Being without money was not a big deal because it

was expensive and there were long lines to buy things.

Being without mail for 2 months was very upsetting, we

could see no reason for having our mail come to us late.

We were simply told that there were not enough people to

sort the mail.”

“There were many problems with pay, both active duty

and reservists. The active duty had one pay system and

the reservists had another. Some of us got no pay at all,

some got double pay, and some of us had much more

taken out later than we had imagined.”

“Some of us felt, and still feel annoyed when people

walk up to us in shopping centers and ask if we killed

anybody. The support is strong but sometimes results in

constant nagging and asking questions that upset us.”

“Why did it take them so long to get us home? We

waited for 35 days to have our chance to get onto an airplane

and come home. One of our senators came to visit us but

he did not know where we had been or what we had done.”

“When we arrived in the desert, which took us only a

day to get there, we were treated warmly by the active duty

units, but when they left, they left us taking our equipment

and leaving us with no feeling that we had been appreciated because they left us there alone.”

“The activation process took too long. It created a

great deal of stress. We were within several hours of

home but we could not go there for more than a month. We

said good-bye to our families and then went just several

hours away and stayed there for a month, creating a lot of

stress that we could not deal with. We feel that we should

have had some psychological debriefing at that point.”

Comment: Many soldiers were angry concerning their

service in the Persian Gulf War. They spoke about the

inefficiencies they encountered and when returning did

not feel they were treated “special” for their efforts.

“One of our greatest stressors was not knowing one

day to the next what is going on. This was not due to our

leadership. The officers were also uninformed. We were

not informed. A major problem was communication. We

especially needed to improve communication between

active duty and reserve units.”

“The active duty often put us down, even though we

were in front of them in the battle.”

“Another major problem was false information.”

One service member said PTSD stands for “pissed,

tired, and sick of drills” without knowing he was very close

to the actual meaning of the symptoms of PTSD, and that

his anger, difficulty sleeping, and substance abuse were

early stages.

“The government got us geared up for high expectations for combat. We were not let down because we were

not in combat much and yet we had a great deal of energy

created within us and it had no where to go. We have not

yet found a way to release this energy. The energy is

stopped up inside of us. Working out or exercise helps a

little bit. We really don’t know what to do with the extra

energy.”

“Back home after combat, everything seems trivial.

Dealing with others is very difficult now.”

“Some people seem to hold it against us for going to

war, especially if we try to say anything about it. We don’t

want to hurt the feeling of those who didn’t go, yet some

of us are very mad at those 18 members of our unit who

lied about reasons for not being sent to war.”

“We are sick and tired of being compared to Vietnam.”

“Some people who watched the war on TV said ‘You

didn’t really fight a war, you just sat around in the sand.’”

“I am involved at home with my wife and child, I have

calmed down only a little bit.”

“I was just married and sent overseas 6 months after

I was married. It has been hard to get back into the

relationship since I got back, it just doesn’t seem right any

more. I have to get out of the house and I usually go

somewhere and drink.”

“People ask stupid questions like, ‘Did you kill anybody, or who was the first person you killed?’”

“We did our job, we are back in the real world, and it is

hard to get back into the flow of things.”

“Jobs and things that used to worry us, don’t really

seem that important any more.”

“Money is a problem. The military didn’t pay us as

much as we made on the outside. Some of us didn’t pick

up any help either.”

“Our unit still feels a little bit disorganized. We are

getting things done, but we don’t seem like we were before

we went to war.”

“We feel the reserve unit should stay together longer to

support each other.” (The group was encouraged to

exchange phone numbers and stay in close contact with

each other.)

“What pissed me off the most was getting ready to go

over there and then getting over there and feeling like we

didn’t get the job done completely and the fear we may

have to go back.”

“We need psychological debriefing before deployment.”

Comment: These sentiments are fairly typical of the

several dozen debriefings the authors conducted during

the demobilization phase of Operation Desert Shield/

Storm. The debriefing demonstrated that many personnel in a unit can experience significant and persistent

distress from the circumstances of the deployment and

return home, unrelated to any specific critical (life-threatening) event. Many of the problems discussed and the

persistent bad feelings they engendered could have been

prevented had the unit been encouraged and mentored to

conduct routine after-action reviews and after-action

debriefings throughout the entire deployment.

There is an interesting follow-up regarding Company

C. Approximately 9 months following the debriefing where

the above comments were made, two soldiers were killed

in automobile accidents that involved alcohol. Several

others had not yet procured jobs, while others had been

referred for alcohol and drug treatment. Another debrief-
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Debriefing Following Combat

ing of the reserve unit was requested. Comments from

this debriefing centered around the sense of helplessness

and abandonment by families, friends, and the community. A commitment was made to continue work with this

reserve unit, who found it helpful to have the opportunity

to express feelings and frustrations regarding the effects

of deployment on their lives.

Finally, the process of developing a multidisciplinary team prior to combat or trauma is described

in the following case, which involved a critical

incident psychiatric model debriefing.

Case Study 6: Death in the Jungle

Prior to any battle during Operation Just Cause, the

Chief of Psychiatry at the U.S. Army Hospital in Panama

assembled a crisis intervention team. The purpose of this

team was to provide immediate mental health intervention during and after disasters related to combat. The team

consisted of a team chief who was a military psychiatrist

trained in crisis intervention and debriefing. Virtually all

other military mental health providers in Panama were

included on the team (psychiatrists, psychologists, social

workers, nurses, and enlisted mental health specialists).

This all-inclusive concept was considered critical to ensure

that enough trained personnel were available when needed.

The second key element in staffing was to utilize U.S.

Army, U.S. Navy, and U.S. Air Force personnel. Training

accidents and natural disasters could affect any of the

three service populations. A team member from that

service could act as a valuable liaison, especially in the

initial phase of trust-building between the affected personnel and the crisis team members.

Finally, it was important to utilize enlisted personnel in

these interventions in order to promote the building of

rapport. Many affected enlisted individuals might have

difficulty relating to officers during a time of crisis.

Training in mental health interventions in combat and

natural disasters was conducted on an ongoing basis.

Discussions were held on the main tenets of crisis intervention therapy, victimology, and command consultation.

Specific topics at such meetings included: the unique

psychodynamics of individuals who have had to face lifethreatening situations themselves, or who lost a friend to

sudden, violent death. Additionally, any actual disaster

interventions were reviewed with special attention to lessons learned.

Command sponsorship was especially important. Because the team was organized prior to any actual combat,

enough time was available to brief commanders about the

importance of mental health intervention during combat or

disasters. The previous state of haphazard referral promoted anxiety among commanders about the consequences of allowing mental health personnel into a disaster scene, and kept troops in need of help out of reach. In

order to ensure that command sponsorship became a

reality in Panama, a detailed proposal was forwarded to

the military command in Panama explaining the need for

the team and the critical importance of the command’s

formally incorporating the mental health mission.

During the early morning hours of 22 February 1990

(approximately 6 to 7 weeks after Operation Just Cause),

two helicopters flying a night training mission were lost in

a northern province of Panama. The night was moonless

and severe weather added to the difficult flying conditions.

Once the aircraft were reported missing, an intensive search

was begun. The search parties included personnel from the

same unit that had suffered the losses. Due to the triple

canopy jungle, poor weather, and wide search area, the

downed aircraft were not found for nearly 36 hours.

The searchers located the two helicopters destroyed

in the separate accidents that had caused the immediate

deaths of 11 U.S. Army soldiers. There were no survivors. The affected units included aviators (the air crew)

and infantrymen (the passengers). Due to the unexpected and massive nature of the tragedy, there was

considerable emotional fallout in the community. Notably, the disasters took place during a period of high

morale in the local population. The long-anticipated

invasion of Panama 2 months earlier had inspired a

feeling of a “job well done.” The community was much

better prepared for the potential loss of life during combat

than at the time of the above-described accidents.

As the situation developed over the 36 hours after the

accidents, it became clear that an aggressive mental

health intervention was needed. Local mental health

providers became aware of the tragedy later that day and

began immediate efforts to contact the commanders involved. This effort was hindered by the fact that many of

the affected individuals were involved in the search and

were unavailable and the commander of the infantrymen

involved had been killed in the crash. Nonetheless, by the

second day, the mental health team chief accompanied

those personnel tasked with identification of the dead. In

addition, team members, including a psychologist and five

enlisted behavioral science specialists, were on standby

status. Aggressive negotiations with commanders resulted in the team arriving at the unit barracks on Sunday

morning, 25 February 1990. After initial briefing interviews with the command, the team then held two group

sessions of approximately 90 minutes each with all available members of the affected units. The following sections describe the specifics of that intervention in these

areas: education, identification, process, and follow-up.

Education. The education process was begun with a

brief overview of the history of combat psychiatry. The

emphasis here, and throughout the intervention, was on

the normal responses to psychic trauma. The team

explained the evolution of thought in this area (eg, how in

previous conflicts soldiers suffering psychological symptoms in the face of trauma were sometimes evacuated

and treated like mentally ill patients). Team members

explained that modern day mental health providers think

of psychologic symptoms as a normal response to trauma,

and expect that most soldiers will recover fully. They were

pointedly told, “You are not patients.”

In addition, an explanation of the psychology of victims

was presented. Victimology classifies various levels of
War Psychiatry

288

individuals affected by a disaster primarily by psychologic

proximity to the event. This concept was very useful in

helping soldiers understand their affective responses, even

though many were not directly involved in the accident.

Team members also discussed the classic acute responses to trauma: anxiety, sleep disturbances, irritability, increased alcohol use, and somatic complaints.

This initial portion of the session (approximately 20

min) provided a cognitive framework for the soldiers to

begin thinking about their varied and intensely emotional

responses.

Identification. From the outset of the intervention, the

group was told that some people may need or want

individual attention. The soldiers and commanders were

given the location and phone numbers of the two military

mental health clinics several times throughout the day.

Additionally, the debriefing team members were instructed to watch for individuals who seemed especially

affected. During breaks, providers approached smaller

groups of soldiers and individuals with this idea in mind. A

small number of people were identified in this fashion and

later seen on an outpatient basis.

Process. Those affected individually were encouraged, at times, and even called on, to discuss the events

of the previous 2 days. Predictably, many of the group

members were feeling angry, guilty, or were in a state of

denial of symptoms. Team members were instructed to

allow discussion and be able to tolerate silences. Appropriate interpretations were made, especially in the areas

of displacement, regression, and denial.

The almost universal incidence of some degree of guilt

and denial warrants further description. A phenomenon

observed numerous times involved individuals inappropriately accepting responsibility for elements of the tragedy. This was consistent with Schwartz’s31 observation,

“The patient becomes unable to discern where his will

ends and fate begins.” While this construct allowed them

the solace of not having to face their powerlessness, the

accompanying guilt for action not taken was in some

cases overwhelming.

The presence of “survivor guilt” during acute crisis

reactions was evident in this group. Members showed

almost no denial of the actual events, but many initially

denied emotional symptoms, so called “inhibited grief.”

According to Raphael,3 inhibited grief is a common syndrome and “usually combines psychological numbing,

over control, and containment of all feelings related to the

death and the disaster.” This syndrome is generally

considered to be maladaptive and likely to be associated

with future impairment. Therefore, efforts were made to

gently confront and interpret this defense.

Follow-Up. One message that the crisis team emphasized was the availability of follow-up. Recognizing that

individuals integrate psychologic input at different

rates, the team members informed the soldiers that

some might have symptoms during the days and weeks

after the event. A mental health technician was placed at

the local troop medical clinic on a daily basis during the

week following the incident. The mental health clinic

phone numbers were posted in conspicuous places in

the unit work and living areas. A small number of individuals were identified and followed up via input from these

two sources.

An unexpected outcome in the area of follow-up

occurred several weeks later when another unit experienced a similar, but smaller scale event. The commander

of this second unit was referred to the crisis team by

command elements in the units involved in the incidents

described above. This can be taken as indirect evidence

of positive reaction to the first debriefing. Follow-up

efforts were limited by troop movement, denial within the

system, and by the inability of the providers to arrange onsite follow-up treatment groups over the days and weeks

that followed.

Comment: The psychiatric debriefing format illustrated

here begins with a general information and education

briefing for all participants. As this must establish the

debriefer’s credibility, and rapport for the subsequent

debriefing, the material must be properly focused for the

specific participants. It must not use technical jargon

which will turn them off. It is especially important that it

not pathologize the process or the participants, even by

inference. The identification of participants who may

need individual therapy must be done in low-keyed fashion, without creating an expectation that many will need

such care, without turning people who could manage on

their own into patients, and without spotlighting and stigmatizing those who do seek further mental health assistance. The ideal of stress debriefing is not to generate

referrals or follow-up cases, but rather to make them

unnecessary. However, a temporary increase of patients

who thereby gain mastery over acute stress symptoms is

clearly preferable to a delayed stream of chronic, difficultto-treat PTSD cases. The process phase of psychiatric

debriefing (unlike S.L.A. Marshall’s HERD or CED/CISD)

is less concerned with eliciting facts and more active in

eliciting participation in abreaction. It actively interprets

the psychological processes involved—here, too, the vocabulary used must be carefully calibrated for the participants and not alienate them with psychiatric jargon.

Follow-up must not be so aggressive as to create negative expectations of successful self and buddy care.

Debriefing in one of its several forms is an

important part of demobilization from any combat

situation or stressful operation other than war

(OOTW). Debriefing is crucial to quickly restoring

SUMMARY AND CONCLUSION

unit effectiveness and preventing post-traumatic

stress problems following critical (traumatic) events.

Research from management of mental health

issues in natural and manmade disasters, personal
289

Debriefing Following Combat

trauma, and war indicate that when a group is

allowed to ventilate fears, frustrations, and feelings about the event, and its individuals receive the

support of their comrades, the likelihood of PTSD is

decreased. The lessons learned from various armed

conflicts and disaster management are preparing

mental health practitioners to exercise preventive care for potentially large numbers of combat

veterans before they develop psychiatric symptomatology.

Acknowledgement

The authors thank COL Robert S. Brown, for help in preparing Case Study 5.

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